Transcript Postprocedural condition

Postprocedural, Injury
& Poisonings
Chapters XIX and XX
HS317b - Coding &
Classification of Health Data
Purpose of Chapter XIX & XX

To explain causes of injuries, poisonings
and certain other consequences of
external causes.
 Frostbites,
burns, corrosions, complications of
trauma, complications of surgical and medical
care, sequelae of injuries
 Code site and then type of injury.
External Cause of Injury Code
Mandatory to use with codes in the range
of S00 – T98 Injury, poisoning and certain
other consequences of external causes
 U98.~ Place of occurrence mandatory with

in range of W00 – Y34
 Exception
 Codes
Y06 Neglect & abandonment
 Y07 Other maltreatment
 Transport accidents, legal interventions, acts of war
 Medical/surgical misadventures

Post-admit Comorbidity
Arises post-admission
 Satisfies comorbidity requirements

 Significantly
affects the treatment received
 Requires treatment beyond maintenance of
the preexisting condition
 Increases the length of stay by at least 24
hours

Should a complication of care arise which
is clearly so serious
 That
it consumes majority of resources
 Is responsible for greatest LOS

Assign it as both MRDx & diagnosis type 2
 When
is a Condition Classified as a
Post-Procedural Complication?
Early Complication

A condition arising within 96 hours of an
intervention is considered an early
complication.
 Cause/effect
relationship between the
condition and the intervention is assumed.
Late Complication

A condition arising after 96 completed
hours of the intervention and stated by the
physician to be due to the procedure is
considered a late complication.
 Cause/effect
established
relationship has been
Postprocedural condition

A significant condition arising after 96
hours of the intervention but before the
end of the 15th day post surgery with no
documented evidence of the condition
arising as a result of the intervention is
considered a post-procedural condition.
 Cause/effect
established
relationship has not been
Steps for determining post-procedural
conditions & complications
1.
Index look-up is the first step
•
Folio lookup: Obstruction – intestine –
postoperative K91.3
•
Folio lookup: postoperative wound infection
Infection - postoperative wound T81.4
•
•
Folio lookup: Pneumothorax
•
•
due to operative injury of chest wall or lung
J95.80
– – accidental puncture or laceration T81.2
If there is no lead term…
If there is no lead term for the condition,
look up all possible synonyms.
 When a lead term for the condition cannot
be located or when there is no applicable
“postoperative” subterm proceed to the
lead term “Complications”. Look for a
subterm for the specific procedure or for
the body system affected.

When there are two subterms: ‘T’
or ‘body system’

When there are two subterms for a
condition, one directing the condition be
coded to a T code and the other directing
that condition to a body system,
 Select
the T code when the condition is an
early complication
 Select the body system when the condition is
a late complication
Functional Disturbance

A disturbance of normal function of a body
system
i.e.: arrhythmia is a functional heart disturbance
 i.e.: malabsorption is a functional gastrointestinal
disturbance

Sandwiching Codes

When code title of postprocedural
condition/complication of surgery does not
fully describe the problem
 An
additional code to provide more detail
regarding the nature of the condition can be
assigned

This additional code would be assigned a
diagnosis type 3
When to apply an external cause!

Why?
 It
connects the complication/condition to the
intervention

When?
 If
it arises < 96 hours postprocedurally
 If it involves the operative wound
 If it involves a mechanical failure
 If it involves a misadventure
 If it is documented by physician
 If it involves organ failure or rejections
Complications
< 96 Hours
>96 Hours & < 15 Days >15 Days
Cause/Effect
Cause/effect
assumed
must be
+ External Cause documented by
physician
Yes then add
External Cause
If No just postprocedural code
Cause/effect not
assumed. If no
documentation
then code to
condition.
Acute Renal Failure

Patient develops acute renal failure within 96
hours of surgery
 N99.0
postprocedural renal failure + external cause
code

An early complication
 Occurs
either in operating room or during
postoperative monitoring period of 96 hours.
 Assume cause-effect relationship between surgery
performed & complication
 Assign external cause code

Patient develops acute renal failure within 15
days of surgery & documentation links the
surgery to the acute renal failure
 N99.0
postprocedural renal failure & external
cause code

A postprocedural/postoperative complication
 Occurs
> 96 hours following departure from O.R.
 Within 15 days.
 Physician documents it as
postprocedural/postoperative complication
 External cause required

Patient develops acute renal failure within
15 days of surgery & documentation does
not link the surgery to the acute renal
failure
 N99.0

Postprocedural renal failure
Postprocedural condition
 Occurs
> 96 hours & < 15 days
 No documented evidence of condition arising
as a result of, or due to, intervention
 No external cause required
Patient develops acute renal failure after 15
days following surgery & documentation
links the surgery to the acute renal failure
 N99.0 Postprocedural renal failure +
external cause code
 A late Complication

 Occurs
> 15 days following surgery
 Documentation links the surgery to ARF
 External cause required



Patient develops acute renal failure after 15 days
following surgery with no documentation linking
the surgery to the acute renal failure
N17.9 Acute renal failure, unspecified
Postprocedural condition
>
15 days
 No documentation to link surgery to ARF
 No external cause
 Not coded as postprocedural
Post-Procedural Signs and Symptoms

They should only be classified as
postprocedural conditions when the
physician’s documentation indicates:
 They
are still present on discharge
 They persist for at least 96 hours
 A more precise diagnosis has not been
identified as the cause of the sign or symptoms
 That the symptom is due to or a direct result of
the procedure
Patient experiences postoperative pain
following hip arthroplasty. No dislocation or
displacement noted on x-ray. Pain
management specialist is asked to follow up
T85.8 (2) other complications of internal
prosthetic devices, implants & grafts NEC
 M25.55 (3) pain in joint, pelvic region &
thigh
 Y83.1 (9) Surgical operation with implant of
artificial internal device as the cause of
abnormal reaction of the patient…

Exceptions – MI & strokes
-
-
If it occurs during postoperative monitoring
period of 96 hours code to I21.~ (2) +
external cause code Y83 or Y84
If it occurs > 96 hours no longer assume it
to be related to procedure
-
-
Unless stated by physician
I21.~ (2) with no external cause code
Stroke

It is undetermined whether this is a
complication of a surgical procedure or a
natural progression of a disease process.
Do not code as postprocedural
 Code stroke as diagnosis type 2.

If it occurs < 96 hours include external cause
 If it occurs > 96 hours no external cause needed.

Adverse reaction
versus
Poisoning
Adverse reaction/Toxicity may
occur when:
Correct substance prescribed by physician
was administered appropriately
 Code the adverse reaction – i.e.: T88.7
Unspecified adverse effect of drug or
medicament
 Code reaction/manifestation – i.e. L27.0
(3) Generalized skin eruption due to drugs
and medicaments
 Code External cause code from drug table

Poisoning when:
Not prescribed by physician
 Dosage altered from prescription
 Non-medicinal substance
 Self-medication with non-prescription drug
 Any medication taken with alcohol

Non Compliance

When a condition is documented as due to
noncompliance with therapy or selfdirected discontinuance of a drug
 It
is neither a poisoning nor an adverse affect
 It is coded to the manifestation followed by
Z91.1 Personal history of noncompliance with
medical treatment and regimen.
Code poisonings

Folio lookup to drug table
 Code
poisoning code
 Code manifestation as diagnosis type 3
 Code external cause code
 Code place of occurrence
Standard for coding poisoning
All drugs involved must be coded
 Presume it to be accident when not
documented as intentional/self harm
 Illicit drug poisoning classified as
accidental unless documented to be
suicidal or homicidal

Injuries
Code each injury to greatest degree of
specificity
 With multiple injuries

 Code

most severe/life threatening first
When two or more injuries equal in
severity
 Assign
the injury receiving treatment that
consumes the largest portion of hospital
resources first.
Current versus old injuries
Has the repair been completed?
 Has it occurred within the past 365 days.
 Flow chart – i.e.: tendon injury

<
14 days old, code as current injury
 > 14 days old & treatment completed, code as
old injury
 If initial treatment still underway, code as
current injury
Intra-cranial injury & Fx of skull
Code first to intra-cranial injury
 Follow with code for fracture
 i.e.: traumatic subarachnoid hemorrhage,
with closed fracture of base of skull.
Patient suffered a brief loss of
consciousness
 S06.610 – Traumatic SAH
 S02.100 – Fx base of skull

Open wounds
Include animal bites, cuts, lacerations,
avulsion of skin, puncture wounds with or
without penetrating foreign body
 Complicated

 Delayed
healing
 Delayed treatment
 Foreign body
 Major infection
Open vs Closed fractures
Documentation must support open fx.
 Bilateral injuries may be captured by using
the same code twice
 Fractures due to crushing injuries

 Code
Fx first
 Code crush injury as diagnosis type 3
 Applies to internal organ crushing injury also
Burns & Corrosions

Occur in degrees that relate to thickness
of the burn
degree – erythema, superficial
 Second degree – epidermal loss & blistering,
partial thickness burn
 Third degree – full thickness skin loss and/or
deep necrosis of any underlying tissue
 First
Standard Coding for Burns

Burns of one site that exhibit multiple
degrees
 Code

to more severe burn of that site
Multiple site burns
 Most
severe burn site is MRDx
 The larger body surface area takes precedence
as MRDx
 Assign separate codes for burns of each site
whenever possible

Mandatory to code
 Body
surface area
 External cause
 Place of occurrence

Admission for dressing change
 MRDx
Z48.0 Attention to surgical dressings
 Code burn as diagnosis type 3.
 Mandatory to include external cause & place of
occurrence
Classification based on MRDx

MCC 21 Injury, Poisoning and Toxic
Effects of Drugs
 CMG
811 Allergic Reactions
 CMG 813 Drug Reactions
 CMG 818 Complication of Treatment
Classification based on MRDx

MCC 22 Burns
 Factor
in determining CMG assignment is
extent of burn.
 Whether skin grafting or debridement done
CMG 831 Extensive Burns without burn
procedures
 CMG 830 Extensive burns with skin graft, wound
debridement or other burn procedures

Classification based on MRDx

MCC 25 SignificantTrauma
 Includes
fractures of skull, open Fx, multiple
Fx, SDH, etc
 Complexity not assigned (level 9)
 Anytime tracheostomy or gastrostomy
procedure done for Trauma assigned to CMG
650 Tracheostomy and Gastrostomy
Procedures for Trauma
Classification based on MRDx

Multiple or Bilateral injuries (joints) factor into
CMG assignment
 Joint Replacement Procedures for Trauma
 Thoracoabdominal Procedure for Trauma


If no: was Wound debridement or lower extremity procedure
for Trauma done
 If no - Multiple or Bilateral Joint Procedures
 If yes - CMG 350 Multiple or Bilateral Joint Replacement
 If no, then CMG 351 Joint replacement for Trauma
CMG 350 & CMG 351 located in MCC 8 Diseases and
Disorders of the Musculoskeletal System and Connective
tissue