Complications of Surgical and Medical Care
Learning Objectives
2. Identify complications of surgical and medical care
4. Explain the importance of documentation in relation to MS-DRGs for reimbursement
Abbreviations/Acronyms
HAP hospital acquired pneumonia
ICD-9-CM International Classification of Diseases, 9th Revision, Clinical Modification
ICD-10-CM International Classification of Diseases, 10th Revision, Clinical Modification
ICD-10-PCS International Classification of Diseases, 10th Revision, Procedure Coding System
MS-DRG Medicare Severity diagnosis-related group
TPN total parenteral nutrition
TURP transurethral resection of the prostate
VAP ventilator assisted pneumonia
ICD-10-CM Official Guidelines for Coding and Reporting
Please refer to the companion Evolve website for the most current guidelines.
Section II. Selection of a Principal Diagnosis
G. Complications of surgery and other medical care
When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the T80-T88 series and the code lacks the necessary specificity in describing the complication, an additional code for the specific complication should be assigned.
Section I. Conventions, general coding guidelines and chapter specific guidelines
C. Chapter Specific Guidelines
1. Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99)
d. Sepsis, Severe Sepsis, and Septic Shock
5) Sepsis due to a postprocedural infection
(a) Documentation of causal relationship
As with all postprocedural complications, code assignment is based on the provider’s documentation of the relationship between the infection and the procedure.
(b) Sepsis due to a postprocedural infection
For such cases, the postprocedural infection code, such as, T80.2, Infections following infusion, transfusion, and therapeutic injection, T81.4, Infection following a procedure, T88.0, Infection following immunization, or O86.0, Infection of obstetric surgical wound, should be coded first, followed by the code for the specific infection. If the patient has severe sepsis the appropriate code from subcategory R65.2 should also be assigned with the additional code(s) for any acute organ dysfunction.
(c) Postprocedural infection and postprocedural septic shock
In cases where a postprocedural infection has occurred and has resulted in severe sepsis and postprocedural septic shock, the code for the precipitating complication such as code T81.4, Infection following a procedure, or O86.0, Infection of obstetrical surgical wound should be coded first followed by code R65.21, Severe sepsis with septic shock and a code for the systemic infection.
2. Chapter 2: Neoplasms (C00-D49)
c. Coding and sequencing of complications
4) Treatment of a complication resulting from a surgical procedure
When the admission/encounter is for treatment of a complication resulting from a surgical procedure, designate the complication as the principal or first-listed diagnosis if treatment is directed at resolving the complication.
l. Sequencing of neoplasm codes
5) Complication from surgical procedure for treatment of a neoplasm
When an encounter is for treatment of a complication resulting from a surgical procedure performed for the treatment of the neoplasm, designate the complication as the principal/first-listed diagnosis. See guideline regarding the coding of a current malignancy versus personal history to determine if the code for the neoplasm should also be assigned.
r. Malignant neoplasm associated with transplanted organ
A malignant neoplasm of a transplanted organ should be coded as a transplant complication. Assign first the appropriate code from category T86.-, Complications of transplanted organs and tissue, followed by code C80.2, Malignant neoplasm associated with transplanted organ. Use an additional code for the specific malignancy.
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4. Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89)
5) Complications due to insulin pump malfunction
(a) Underdose of insulin due to insulin pump failure
An underdose of insulin due to an insulin pump failure should be assigned to a code from subcategory T85.6, Mechanical complication of other specified internal and external prosthetic devices, implants and grafts, that specifies the type of pump malfunction, as the principal or first listed code, followed by code T38.3×6-, Underdosing of insulin and oral hypoglycemic [antidiabetic] drugs. Additional codes for the type of diabetes mellitus and any associated complications due to the underdosing should also be assigned.
(b) Overdose of insulin due to insulin pump failure
The principal or first-listed code for an encounter due to an insulin pump malfunction resulting in an overdose of insulin, should also be T85.6-, Mechanical complication of other specified internal and external prosthetic devices, implants and grafts, followed by code T38.3×1-, Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, accidental (unintentional).
6) Secondary diabetes mellitus
(b) Assigning and Sequencing secondary diabetes codes and its causes
(i) Secondary diabetes mellitus due to pancreatectomy
For postpancreatectomy diabetes mellitus (lack of insulin due to the surgical removal of all or part of the pancreas), assign code E89.1, Postprocedural hypoinsulinemia. Assign a code from category E13 and a code from subcategory Z90.41-, Acquired absence of pancreas, as additional codes.
6. Chapter 6: Diseases of Nervous System and Sense Organs (G00-G99)
2) Pain due to devices, implants and grafts
See Section I.C.19. Pain due to medical devices
3) Postoperative Pain
The provider’s documentation should be used to guide the coding of postoperative pain, as well as Section III. Reporting Additional Diagnoses and Section IV. Diagnostic Coding and Reporting in the Outpatient Setting.
The default for post-thoracotomy and other postoperative pain not specified as acute or chronic is the code for the acute form.
Routine or expected postoperative pain immediately after surgery should not be coded.
(a) Postoperative pain not associated with specific postoperative complication
Postoperative pain not associated with a specific postoperative complication is assigned to the appropriate postoperative pain code in category G89.
(b) Postoperative pain associated with specific postoperative complication
Postoperative pain associated with a specific postoperative complication (such as painful wire sutures) is assigned to the appropriate code(s) found in Chapter 19, Injury, poisoning, and certain other consequences of external causes. If appropriate, use additional code(s) from category G89 to identify acute or chronic pain (G89.18 or G89.28).
9. Chapter 9: Diseases of Circulatory System (I00-I99)
c. Intraoperative and Postprocedural Cerebrovascular Accident
Medical record documentation should clearly specify the cause- and-effect relationship between the medical intervention and the cerebrovascular accident in order to assign a code for intraoperative or postprocedural cerebrovascular accident. Proper code assignment depends on whether it was an infarction or hemorrhage and whether it occurred intraoperatively or postoperatively. If it was a cerebral hemorrhage, code assignment depends on the type of procedure performed.
10. Chapter 10: Diseases of Respiratory System (J00-J99)
d. Ventilator associated Pneumonia
1) Documentation of Ventilator associated Pneumonia
As with all procedural or postprocedural complications, code assignment is based on the provider’s documentation of the relationship between the condition and the procedure.
Code J95.851, Ventilator associated pneumonia, should be assigned only when the provider has documented ventilator associated pneumonia (VAP). An additional code to identify the organism (e.g., Pseudomonas aeruginosa, code B96.5) should also be assigned. Do not assign an additional code from categories J12-J18 to identify the type of pneumonia.
Code J95.851 should not be assigned for cases where the patient has pneumonia and is on a mechanical ventilator but the provider has not specifically stated that the pneumonia is ventilator-associated pneumonia. If the documentation is unclear as to whether the patient has a pneumonia that is a complication attributable to the mechanical ventilator, query the provider.
2) Ventilator associated Pneumonia Develops after Admission
A patient may be admitted with one type of pneumonia (e.g., code J13, Pneumonia due to Streptococcus pneumonia) and subsequently develop VAP. In this instance, the principal diagnosis would be the appropriate code from categories J12-J18 for the pneumonia diagnosed at the time of admission. Code J95.851, Ventilator associated pneumonia, would be assigned as an additional diagnosis when the provider has also documented the presence of ventilator associated pneumonia.
19. Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88)
1) General guidelines for complications of care
(a) Documentation of complications of care
As with all procedural or postprocedural complications, code assignment is based on the provider’s documentation of the relationship between the condition and the procedure.
2) Pain due to medical devices
Pain associated with devices, implants or grafts left in a surgical site (for example painful hip prosthesis) is assigned to the appropriate code(s) found in Chapter 19, Injury, poisoning, and certain other consequences of external causes. Specific codes for pain due to medical devices are found in the T code section of the ICD-10-CM. Use additional code(s) from category G89 to identify acute or chronic pain due to presence of the device, implant or graft (G89.18 or G89.28).
(a) Transplant complications other than kidney
Codes under category T86, Complications of transplanted organs and tissues, are for use for both complications and rejection of transplanted organs. A transplant complication code is only assigned if the complication affects the function of the transplanted organ. Two codes are required to fully describe a transplant complication: the appropriate code from category T86 and a secondary code that identifies the complication.
Pre-existing conditions or conditions that develop after the transplant are not coded as complications unless they affect the function of the transplanted organs.
See I.C.21.c.3 for transplant organ removal status
See I.C.2.r for malignant neoplasm associated with transplanted organ.
(b) Kidney transplant complications
Patients who have undergone kidney transplant may still have some form of chronic kidney disease (CKD) because the kidney transplant may not fully restore kidney function. Code T86.1- should be assigned for documented complications of a kidney transplant, such as transplant failure or rejection or other transplant complication. Code T86.1- should not be assigned for post kidney transplant patients who have chronic kidney (CKD) unless a transplant complication such as transplant failure or rejection is documented. If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.
Conditions that affect the function of the transplanted kidney, other than CKD, should be assigned a code from subcategory T86.1, Complications of transplanted organ, Kidney, and a secondary code that identifies the complication.
For patients with CKD following a kidney transplant, but who do not have a complication such as failure or rejection, see section I.C.14. Chronic kidney disease and kidney transplant status.
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