Complications of Surgical and Medical Care



Complications of Surgical and Medical Care



Learning Objectives



1. Apply and assign the correct ICD-9-CM and ICD-10-CM codes in accordance with Official Guidelines for Coding and Reporting


2. Identify major differences between ICD-9-CM and ICD-10-CM related to complications of surgical and medical care


3. Identify complications of surgical and medical care


4. Assign the correct V/Z codes, E codes, and procedure codes related to complications of surgical and medical care


5. Explain the importance of documentation in relation to MS-DRGs for reimbursement



Abbreviations/Acronyms



















ICD-9-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



Section I. Conventions, general coding guidelines and chapter specific guidelines



C Chapter-Specific Guidelines



1. Chapter 1: Infectious and Parasitic Diseases (001-139)



b. Septicemia, Systemic Inflammatory Response Syndrome (SIRS), Sepsis, Severe Sepsis, and Septic Shock



10) 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 postprocedural infection


    In cases of postprocedural sepsis, the complication code, such as code 998.59, Other postoperative infection, or 674.3x, Other complications of obstetrical surgical wounds should be coded first, followed by the appropriate sepsis codes (systemic infection code and either code 995.91 or 995.92). An additional code(s) for any acute organ dysfunction should also be assigned for cases of severe sepsis.


(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 998.59, Other postoperative infection, or 674.3x, Other complications of obstetrical surgical wounds, should be coded first followed by the appropriate sepsis codes (systemic infection code and code 995.92). Code 998.02, Postoperative septic shock, should be assigned as an additional code. In cases of severe sepsis, an additional code(s) for any acute organ dysfunction should also be assigned.



Example


The patient was readmitted after undergoing surgery last week; the patient is being treated for postoperative sepsis, 998.59, 038.9, 995.91, E879.9 (T81.4xxA, A41.9, Y83.9).


2. Chapter 2: Neoplasms (140-239)



c. Coding and sequencing of complications



i. 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 subcategory 996.8, Complications of transplanted organ, followed by code 199.2, Malignant neoplasm associated with transplanted organ. Use an additional code for the specific malignancy.



Example


Hernia of colostomy with repair of parastomal hernia. The colostomy was performed 1 year ago during colon cancer resection. The patient is no longer receiving treatment, and the cancer was completely resected, 569.69, V10.05, E878.3, 46.42 (K43.5, Z85.038, Y83.3, OWQFXZ2).


3. Chapter 3: Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders (240-279)



a. Diabetes mellitus



6) Insulin pump malfunction



7) Secondary Diabetes Mellitus



6. Chapter 6: Diseases of Nervous System and Sense Organs (320-389)



a. Pain—Category 338



2) Pain due to devices, implants and grafts


    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 17, Injury and Poisoning. Use additional code(s) from category 338 to identify acute or chronic pain due to presence of the device, implant or graft (338.18-338.19 or 338.28-338.29).



Example


Patient presents with acute pain secondary to a displaced nail in the right femur, 996.49, 338.19, 729.5, E878.1 (T84.124A, G89.18, M79.604, Y83.1).


3) Postoperative Pain


    Post-thoracotomy pain and other postoperative pain are classified to subcategories 338.1 and 338.2, depending on whether the pain is acute or chronic. 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 338.


(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 17, Injury and Poisoning. If appropriate, use additional code(s) from category 338 to identify acute or chronic pain (338.18 or 338.28). If pain control/management is the reason for the encounter, a code from category 338 should be assigned as the principal or first-listed diagnosis in accordance with Section I.C.6.a.1.a above.


(c) Postoperative pain as principal or first-listed diagnosis


    Postoperative pain may be reported as the principal or first-listed diagnosis when the stated reason for the admission/encounter is documented as postoperative pain control/management.


(d) Postoperative pain as secondary diagnosis


    Postoperative pain may be reported as a secondary diagnosis code when a patient presents for outpatient surgery and develops an unusual or inordinate amount of 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.


    See Section II.I.2 for information on sequencing of diagnoses for patients admitted to hospital inpatient care following post-operative observation.


    See Section II.J for information on sequencing of diagnoses for patients admitted to hospital inpatient care from outpatient surgery.


    See Section IV.A.2 for information on sequencing of diagnoses for patients admitted for observation.


7. Chapter 7: Disease and Circulatory System (390-459)



c. Postoperative cerebrovascular accident


    A cerebrovascular hemorrhage or infarction that occurs as a result of medical intervention is coded to 997.02, Iatrogenic cerebrovascular infarction or hemorrhage. Medical record documentation should clearly specify the cause-and-effect relationship between the medical intervention and the cerebrovascular accident in order to assign this code. A secondary code from the code range 430-432 or from a code from subcategories 433 or 434 with a fifth digit of “1” should also be used to identify the type of hemorrhage or infarct.


    This guideline conforms to the use additional code note instruction at category 997. Code 436, Acute, but ill-defined, cerebrovascular disease, should not be used as a secondary code with code 997.02.



Example


The patient had a postoperative cerebrovascular accident, which was embolic in nature. The patient initially had been admitted for treatment of coronary artery arteriosclerosis with CABG (left internal mammary artery and two greater saphenous vein grafts from left were used). Cardiopulmonary bypass was used during the surgery, 414.01, 997.02, 434.11, 36.12, 36.15, 39.61, E878.2, E849.7 (I25.10, I97.820, I63.40, 021109W, 02100A9, 5A1221Z, O6BQOZZ).


17. Chapter 17: Injury and Poisoning (800-999)



f. Complications of care





2) Transplant complications



(a) Transplant complications other than kidney


    Codes under subcategory 996.8, Complications of transplanted organ, 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 subcategory 996.8 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.18.d.3) for transplant organ removal status.


    See I.C.2.i for malignant neoplasm associated with transplanted organ.



Example


A patient with a previous intestinal transplant presents with diarrhea, which has been diagnosed as acute graft-versus-host disease, 996.87, 279.51, 787.91, E878.0 (T86.858, D89.810, R19.7, Y83.0).


(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 996.81 should be assigned for documented complications of a kidney transplant, such as transplant failure or rejection or other transplant complication. Code 996.81 should not be assigned for post kidney transplant patients who have chronic kidney disease (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 code 996.81, 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.10.a.2, Chronic kidney disease and kidney transplant status.



Example


Patient with history of kidney transplant presents to the ER with gastroenteritis. His review of systems documents CKD and hypertension, 558.9, 403.90, 585.9, V42.0 (K52.9, I12.9, N18.9, Z94.0).



Example


Patient with history of kidney transplant presents to hospital in acute renal failure due to rejection, 996.81, 584.9, E878.0 (T86.11, N17.9, Y83.0).


3) Ventilator associated pneumonia



(a) 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 997.31, 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 041.7) should also be assigned. Do not assign an additional code from categories 480-484 to identify the type of pneumonia.


    Code 997.31 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.



Example


Patient was hospitalized last month and was on a ventilator for exacerbation of COPD. She presents to the hospital today with pneumonia, 486, 496 (J18.9, J44.9).



Example


Patient was recently admitted for an acute exacerbation of CHF for which she was placed on a ventilator. She presents to the hospital today with ventilator associated pneumonia. Sputum cultures were taken and this pneumonia was found to be due to MRSA, 997.31, 041.12, 428.0, E879.8, E849.7 (J95.851, I50.9, B95.62, Y84.8, Y92.239).


(b) Patient admitted with pneumonia and develops VAP


    A patient may be admitted with one type of pneumonia (e.g., code 481, Pneumococcal pneumonia) and subsequently develop VAP. In this instance, the principal diagnosis would be the appropriate code from categories 480-484 for the pneumonia diagnosed at the time of admission. Code 997.31, Ventilator associated pneumonia, would be assigned as an additional diagnosis when the provider has also documented the presence of ventilator associated pneumonia.



Example


Patient was admitted to the hospital in acute respiratory failure due to pneumonia. She is placed in the ICU intubated and on a vent for 120 hours. She is transferred to the floor after 3 days where she develops a high fever. The physician documents ventilator associated pneumonia due to pseudomonas aeruginosa, 518.81, 486, 997.31, 041.7, 96.71, 96.04, E849.7, E879.8 (J96.00, J18.9, J95.851, B96.5, Y84.8, Y92.230, OBH17EZ, 5A1955Z).


19. Chapter 19: Supplemental Classification of External Causes of Injury and Poisoning (E-codes, E800-E999)



Apply the General Coding Guidelines as found in Chapter 5 and the Procedural Guidelines as found in Chapter 6.



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.


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 086.0, 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 086.0, 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


Related posts:

  1. Diseases of the Skin and Subcutaneous Tissue: (ICD-9-CM Chapter 12, Codes 680-709, and ICD-10-CM Chapter 12, Codes L00-L99)
  2. Diseases of the Blood and Blood-Forming Organs: (ICD-9-CM Chapter 4, Codes 280-289, and ICD-10-CM Chapter 3, Codes D50-D89)
  3. Diseases of the Circulatory System: (ICD-9-CM Chapter 7, Codes 390-459, and ICD-10-CM Chapter 9, Codes I00-I99)
  4. Introduction to ICD-10-PCS

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Jun 14, 2017 | Posted by in GENERAL SURGERY | Comments Off on Complications of Surgical and Medical Care

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