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									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
     Codes  in range of W00 – Y34
     Exception
       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
     Significantlyaffects the treatment received
     Requires treatment beyond maintenance of
      the preexisting condition
     Increases the length of stay by at least 24
   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
     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   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   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
         •     – – 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
        i.e.: arrhythmia is a functional heart disturbance
        i.e.: malabsorption is a functional gastrointestinal
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
   This additional code would be assigned a
    diagnosis type 3
When to apply an external cause!
   Why?
     Itconnects the complication/condition to the
   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
< 96 Hours      >96 Hours & < 15 Days >15 Days

Cause/Effect     Cause/effect        Cause/effect not
assumed          must be             assumed. If no
+ External Cause documented by       documentation
                 physician           then code to
                Yes then add
                External Cause

                If No just post-
                procedural code
    Acute Renal Failure
   Patient develops acute renal failure within 96
    hours of surgery
     N99.0   postprocedural renal failure + external cause
   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
     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 &
 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
   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
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
 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 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.
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
 Code each injury to greatest degree of
 With multiple injuries
     Code   most severe/life threatening first
   When two or more injuries equal in
     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
 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
     Firstdegree – erythema, superficial
     Second degree – epidermal loss & blistering,
      partial thickness burn
     Third degree – full thickness skin loss and/or
      deep necrosis of any underlying tissue
Standard Coding for Burns
   Burns of one site that exhibit multiple
     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
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
       CMG 830 Extensive burns with skin graft, wound
        debridement or other burn procedures
Classification based on MRDx
   MCC 25 SignificantTrauma
     Includesfractures 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

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