Postprocedural, Injury

1
Postprocedural, Injury PoisoningsChapters XIX
and XX

• HS317b - Coding Classification of Health Data

2
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.

3
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
• Codes in range of W00 Y34
• Exception
• Y06 Neglect abandonment
• Y07 Other maltreatment
• Transport accidents, legal interventions, acts of
  war
• Medical/surgical misadventures

4
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

5

• 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?

6
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.

7
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 relationship has been established

8
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 relationship has not been established

9
Steps for determining post-procedural conditions
complications

• 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

10
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.

11
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

12
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

13
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

14
When to apply an external cause!

• Why?
• It connects the complication/condition to the
  intervention
• When?
• If it arises lt 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

15
Complications
lt 96 Hours Cause/Effect assumed External Cause gt96 Hours lt 15 Days Cause/effect must be documented by physician Yes then add External Cause If No just post-procedural code gt15 Days Cause/effect not assumed. If no documentation then code to condition.
16
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

17

• 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 gt 96 hours following departure from O.R.
• Within 15 days.
• Physician documents it as postprocedural/postopera
  tive complication
• External cause required

18

• 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 gt 96 hours lt 15 days
• No documented evidence of condition arising as a
  result of, or due to, intervention
• No external cause required

19

• 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 gt 15 days following surgery
• Documentation links the surgery to ARF
• External cause required

20

• 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
• gt 15 days
• No documentation to link surgery to ARF
• No external cause
• Not coded as postprocedural

21
Post-Procedural Signs and Symptoms

• They should only be classified as postprocedural
  conditions when the physicians 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

22
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

23
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 gt 96 hours no longer assume it to be
  related to procedure
• Unless stated by physician
• I21. (2) with no external cause code

24
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 lt 96 hours include external cause
• If it occurs gt 96 hours no external cause needed.
  

25

• Adverse reaction
• versus
• Poisoning

26
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

27
Poisoning when

• Not prescribed by physician
• Dosage altered from prescription
• Non-medicinal substance
• Self-medication with non-prescription drug
• Any medication taken with alcohol

28
Non Compliance

• When a condition is documented as due to
  noncompliance with therapy or self-directed
  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.

29
Code poisonings

• Folio lookup to drug table
• Code poisoning code
• Code manifestation as diagnosis type 3
• Code external cause code
• Code place of occurrence

30
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

31
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.

32
Current versus old injuries

• Has the repair been completed?
• Has it occurred within the past 365 days.
• Flow chart i.e. tendon injury
• lt 14 days old, code as current injury
• gt 14 days old treatment completed, code as old
  injury
• If initial treatment still underway, code as
  current injury

33
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

34
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

35
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

36
Burns Corrosions

• Occur in degrees that relate to thickness of the
  burn
• First 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

37
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

38

• 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

39
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

40
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

41
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

42
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