Ok, we're going to conclude our
discussions of Chapters 19 and 20 by
talking about the complications of
surgery and medical care. The
complications that occur only in other
(specific) body sites are classified in those
chapters, for example. a complication of a
GI procedure is going to be in the (codes in the)
Diseases of the Digestive System.
Complications that happen that affect
multiple sites or body systems that are
not classified anywhere else are going
to come to the T80 -T88 codes.
Intra-operative and post procedural
complication codes are found within the
body system chapters, with codes specific
to the organs and the structures of that
body system. So there's a lot of words
but I think as we look at some codes, it
will make more sense. When you're looking
for a sub term that indicates a "postoperative"
or an "iatrogenic" condition, you
may or may not find any sub terms and if
you don't, then start using complications
as your main term and then start looking
at the sub terms under complications to
help you find these codes. An iatrogenic
condition is a condition that results
from the treatment of another condition,
so there's two things going on there. Read
the instructional notes carefully, in
particular, the exclusion notes that
relate to complications because it might
be that the correct code would be in a
different chapter of the ICD-10. By
using these instructional notes, it can
help us prevent some of those mistakes.
Not all postcare conditions are
classified as a complication, so your
documentation has to state that whatever
is occurring is unexpected or it's
abnormal. There has to be a documented
relationship between the condition
that's being treated and the care that's
being provided and the doctor has to say
that it's a complication. We cannot make
those assumptions on our own. When you
have complications that are involving an
internal device, implant or graft,
that's going to be classified first. It's
important to distinguish between an
admission for complications and
admission for any routine or scheduled
aftercare follow up to procedure. As
I just said, we can't make assumptions
because of the legal ramifications of
complications to procedures. People sue
doctors. We never want to make those
assumptions when we're assigning codes.
We only want to code whatever the doctor
has said. At the beginning of the T80-T88
range, there are
instructional notes that tell the coder
to use an additional code for the
adverse effects. If you recall, the
adverse effect is in the code range T36-T50,
with a 5th or 6th character
"5" to indicate this is an adverse effect.
You're going to use an additional code
to identify whatever condition is
resulting from that complication as well
as any devices involved and
circumstances that are involved in this
particular code. Those "Y" codes are
external cause codes, so if you want to
look at those, look at your options there.
It might be helpful to help you remember
what options are there for coding.
Okay, the first guideline under
complications of care refers you to the
general coding guidelines for
documentation of complications. This is
just a restatement of what I said
earlier, that it has to be documented
that what we are presenting is a
complication and the doctors have said
it's a complication. Not
everything that happens after surgery is
a complication. So we have to get very
confirmed documentation that it is a
complication and there has to be a
cause-and-effect relationship between
the care that the patient is receiving
and that condition. If you have any
doubts, as to whether or not something is a
complication, you're going to always do a
query because of the ramifications of
you coding something that isn't a
complication. The next coding guideline
has to do with pain due to medical
devices. If you have pain associated with
a device that's left in a surgical site,
for example, a hip replacement or a knee
replacement, you're going to find those
codes in Chapter 19. But if you are
looking at codes for pain due to medical
devices, that's going to take you to the
T codes and you're going to look at
additional codes for the pain categories
G89 to identify if it's acute or
chronic pain due to the presence of that
device.
Here's an example of pain due to medical
devices. Chronic left breast pain
secondary to a breast implant so this
would have been a case where the device
was left in. We go back up here to Chapter
19, device left in is T85 complication of
breast implant. We're also going to code
the breast pain and the chronic pain.
These codes, standing alone, do not give
the reader much information but when you
combine the three codes, you now know
there's a complication, the complication
is pain and the pain is chronic. By using
those three codes, we tell the story.
There's also transplant complications
other than the kidney. They break out the
(Coding) Guidelines to separate a kidney
transplant versus other transplants.
T86 is for complications of transplanted
organs and tissues and those include
complications and
rejection. You only assign a transplant
complication code if the complication
affects the function of the transplanted
organ.
Two codes are required to fully
describe a transplant complication, the
T86 code and a second code that
identifies that complication. Any pre-existing
conditions that developed
after the transplant are not
complications unless they now affect
that transplanted organ. That's a lot of words
there so you're really going to have to
remember if you're coding a transplant,
that you're going to refer yourself back
to those guidelines and review them time
and again until you can remember them.
At the end of this section of the
guidelines, the coder is referred to other
chapters for more information, (such as).
information regarding removing a
transplant is found in the Z codes
Chapter 21 and codes related to
malignant neoplasm or cancer of a
transplanted organ takes you back to the
guidelines for Chapter 2 Neoplasms.
Now let's talk about kidney transplants.
Patients who have undergone a kidney
transplant can still have some form of
chronic kidney disease because the
kidney transplant doesn't always fully
restore kidney function. You're not going
to use the T86 complication code if the
patient still has
chronic kidney disease unrelated to the
transplant. The T86 code is only for
complications of a transplant, like for
rejection or failure. In this diagnostic
statement, the patient received a kidney
transplant two days ago. The transplant
appears to be failing. We will continue
to monitor the situation to determine
next steps. Complication for transplant,
kidney rejection is here and then the
transplant kidney status is also given (Z94.0).
The T86 code should not be assigned
for post kidney transplant
patients who have chronic kidney disease
unless the complication is documented.
This statement we've been given here. the
patient was admitted with chronic kidney
disease, stage 4. He received a kidney
transplant three years ago but full
kidney function was not restored. More than
likely, he's going to need dialysis.
We're going to code the chronic kidney
disease and the transplant status. We are
not going to use the T86 code because
this is unrelated to that transplant.
This is a chronic kidney disease that he
had before, still has it, and it is unrelated to the
transplant. There are complication codes
that include the external cause and I've
given you an example here where the
patient has a fractured right tibia
shaft. The physician went in, trying to fix,
trying to stabilize that bone and now
they're thinking there's an infection
internally at the fixation site. That is
a complication of the fixation device
and we're going to assign this code T84-
and also going to assign the traumatic
fracture of the tibia shaft.
Complication of care codes within the
body system chapters just show you
sometimes you can look through the
different body systems and usually
towards the back of the chapters, that
it starts talking about
intra-operative and post procedural
complications. This particular statement,
there was a spinal fusion. The
surgeon inadvertently punctured the dura.
i'm going to show you an image on the
next slide of what that is. That was
repaired and the fusion was completed. So
the coder is going to code the
accidental puncture of the dura and this
is one of those situations I've
mentioned to you throughout the semester
where the Alphabetical Index gets you in
the "neighborhood" but maybe not in the
exact "house" you want to be in, so I would
take this G97.48, knowing that that
5th character of an "8" is a
more non-specific code, so I'm going to
always look for a more specific code
when I can. In this case, I've been
told that the dura has been punctured, that is
pretty specific, so we're going to go to
the Tabular, go to the G97 category and
start looking at the codes to see if
there's anything more specific than a
code that has a 5th character of "8".
We notice that it does. There is a
code very specific to accidental
puncture of the dura G97.41 and that
would be the code that we would use. In
the next slide, I wanted to show you the
dura and what we're talking about. The dura
lies just over the spinal cord so it
shouldn't happen but it's
probably not hard to do to accidentally
puncture that when you're working on
this vertebrae, these bones.
I just wanted to show you that so you can
keep that in mind. Okay, that's all I have
for the complications. If you have any
questions, please post them in the
discussion board along with the path
that you've tried to find the answer and
i will attempt to help you. Thanks so
much.