Name of Manual - Blue Cross and Blue Shield of Minnesota

Reimbursement / Reconciliation
Complication and Comorbidity
Defined
According to St. Anthony Publishing, a “complication” is a
condition that arises during a hospital stay and prolongs the length
of stay by at least one day in approximately 75 percent of the
cases. The same source defines “co-morbidity” as a preexisting
condition that, because of its presence with a specific diagnosis,
will cause an increase in length of stay by at least one day in
approximately 75 percent of cases. The condition must affect the
patient’s hospital care by requiring one or more of the following:
Clinical evaluation
Therapeutic treatment
Diagnostic studies or procedures
Increased length of stay
Increased nursing care and/or monitoring
Although there is a standard list of diagnoses that are considered
complications or co-morbidities, if the diagnosis does not require
one or more of the above services, it should not be listed as a
diagnosis. The physician must verify and document the conditions,
based on clinical findings and treatment in the record.
9-4 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (11/02/11)