Coding for Complications of Medical & Surgical Care - PowerPoint Presentation

1. Coding for Complications of Medical & Surgical CareBeth Burgess, MHA, RHIA, CCS

2. Documentation of Complications of Care Official Coding Guidelines Section I.B.16“Code assignment is based on the provider's documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.”

3. Documentation of Complications of CareMust be more than a routinely expected condition or occurrenceCause-and-effect relationship may be implicit e.g., complication due to the presence of an internal device, implant, or graft; complication due to a transplantNo time limitDoes not imply improper or inadequate careReference:AHA Coding Handbook: Chapter 33

4. Complications of Care: Coding First refer to main term for the condition and look for a subterm indicating a postoperative or another iatrogenic condition.Obstruction -intestine K56.609 -postoperative K91.30 Pneumothorax J93.9 -postprocedural J95.811

5. Complications of Care: Coding Refer to main term “Complication” and look for an appropriate subterm such as:Nature of complication Type of procedure Anatomical site or body system affected General terms (e.g., “mechanical”; “infection”; “graft”)Complication Complication -bariatric procedure -intraoperative -gastric band procedure K59.09 -cardiac arrest -during cardiac surgery I97.710 -during other surgery I97.711

6. Complications of Care: Code Sequencing Assign code for the complication FIRSTIf complication code lacks specificity, assign additional code(s) to further specify the complicationExample: postop wound infection of the back with abscess requires two codes:T81.4XXA, Infection following procedure, initial episode L02.212, Cutaneous abscess of backReferences:OCG Section I.B.7OCG Section II.G

7. Complication Coding Codes T80-T88 Specific body system complications

8. T- Codes for ComplicationsT80*Complications following infusion, transfusion and therapeutic injectionT81*Complications of procedures, NECT82-T85*Complications of devices, implants and grafts T86Complications of transplanted organs and tissueT87Complications peculiar to reattachment and amputationT88*Other complications of surgical and medical care, NEC

9. 7th Characters for T80-T85 and T887th character required to specify:Initial encounter (“A”) Under active treatment Does not matter if previously diagnosedSubsequent encounter (“D”)Routine care during healing or recovery; active treatment has been completedSequela (“S”)Complications or conditions that arise as direct result of the complication Reference:OCG Section I.C.19.a

10. Complications Following Infusion, Transfusion and Therapeutic Injection (T80)T80.0---Air embolism following infusion, transfusion and therapeutic injectionT80.1---Vascular complications following infusion, transfusion and therapeutic injectionT80.2---Infections following infusion, transfusion and therapeutic injectionT80.3---ABO incompatibility reaction due to transfusion of blood or blood productsT80.4---Rh incompatibility reaction due to transfusion of blood or blood productsT80.A---Non-ABO incompatibility reaction due to transfusion of blood or blood productsT80.5---Anaphylactic reaction due to serum following infusion, transfusion and therapeutic injectionT80.6---Other serum reactions (e.g., serum rash, sickness or urticaria)T80.8---Other complications following infusion, transfusion and therapeutic injectionT80.9---Unspecified complication following infusion, transfusion and therapeutic injection

11. Infection Following Infusion, Transfusion and Therapeutic InjectionT80.211-Bloodstream infection due to central venous catheterT80.212-Local infection due to central venous catheterT80.218-Other infection due to central venous catheterT80.219-Unspecified infection due to central venous catheterT80.22--Acute infection following transfusion, infusion, or injection of blood and blood productsT80.29--Infection following other infusion, transfusion and therapeutic injection

12. Examples of Infection Following Infusion, Transfusion and Therapeutic InjectionBacteremia due to infected port-a-cathT80.211A, Bloodstream infection due to central venous catheterIf sepsis also present, code A41.- as an additional diagnosis! OCG Section I.C.1.d.5Cellulitis secondary to tunneled catheter for temporary dialysisT80.212A, Local infection due to central venous catheterPeritonitis secondary to infected peritoneal dialysis fluidT80.29XA, Infection following other infusion, transfusion and therapeutic injectionCC Q2 2001 pp.11-12

13. Complication of Procedures, NEC (T81)T81.1---Postprocedural shock (e.g., cardiogenic, septic, hypovolemic)T81.3---Disruption of wound, NEC T81.4---Infection following a procedureT81.5---Complication of FB accidentally left in body following procedure (e.g., adhesions, obstruction, perforation)T81.6---Acute reaction to foreign substance accidentally left during a procedure (e.g., chemical peritonitis)T81.7---Vascular complications following a procedure, NEC (e.g., air embolism, phlebitis/thrombophlebitis, PE, DVT)T81.8---Other complications of procedures, NEC (e.g., subcutaneous emphysema, postop fistula) T81.9---Unspecified complication of procedure

14. Examples of Complication of Procedures, NEC Postoperative sepsis following appendectomyT81.4XXA, Infection following a procedure*Postop DVT due to recent surgeryT81.72XA, Complication of vein following a procedure, not elsewhere classifiedLoose cement fragments left in hip joint following THA, requiring return to surgery for exploration and removal of the fragments.T81.590A, Other complications of foreign body accidentally left in body following surgical operationCC Q4 2014 p.24

15. Coding Clinic Advice for Complications of Procedures NEC (T81) Postop retained cement fragments following hemiarthroplasty: T81.590-, Other complication of FB accidentally left in body following surgical operation.CC 4Q 2014 p.24Postop fistula: T81.83X-, Persistent postoperative fistula + appropriate code for site of fistula.CC 3Q 2017 pp.3-4Nonhealing surgical wound = T81.89X-, Other complications of procedures, NEC unless nonhealing d/t infection (T81.4XX-) or wound disruption (T81.3-).CC 1Q 2014 p.23

16. Complication of Devices, Implants and Grafts All are further subdivided by:Mechanical (e.g., breakdown, displacement, leakage) Infection and inflammatory reaction Other (e.g., embolism, fibrosis, hemorrhage, pain, stenosis, thrombosis)

17. Cardiac and Vascular Prosthetic Devices, Implants and Grafts (T82)Cardiac Heart valve prosthesisCardiac electronic devices CABGHeart valve graftArtificial heart VascularAortic graft Carotid artery bypass graftFemoral artery vascular graftOther vascular graftsDialysis catheterAV fistula

18. Examples of Cardiac and Vascular Devices, Implants and Grafts ComplicationsCerebral infarction due to embolism of prosthetic heart valveT82.817A, Embolism due to cardiac prosthetic devices, implants & graftsI63.40, Cerebral infarction due to embolism of unspecified cerebral artery AMI due to in-stent stenosisT82.855A, Stenosis of coronary artery stentI21.A9, Other myocardial infarction typeMalpositioned dialysis catheterT82.42XA, Displacement of vascular dialysis catheter

19. Genitourinary Prosthetic Devices, Implants and Grafts (T83)Urinary catheters (urethral, cystostomy, nephrostomy)Indwelling ureteral stentImplanted urinary sphincterElectronic stimulator deviceIntrauterine contraceptive device Penile or testicular prosthesisImplanted vaginal or urethral mesh

20. Examples of Other Complications of GU Devices, Implants and GraftsUTI due to Foley catheterT83.511A, Infection and inflammatory reaction due to indwelling urethral catheterUTI due to suprapubic catheterT83.510A, Infection and inflammatory reaction due to cystostomy catheterObstructed ureteral stentT83.192A, Other mechanical complication of indwelling ureteral stentMalpositioned nephrostomy tubeT83.022A, Displacement of nephrostomy catheter

21. Internal Orthopedic Prosthetic Devices, Implants and Grafts (T84)Joint prosthesisInternal fixation deviceElectronic bone stimulatorMuscle and tendon graft

22. Examples of Internal Orthopedic Devices, Implants and Grafts ComplicationsProtrusion of nail s/p ORIF left femurT84.195A, Other mechanical complication of internal fixation device of left femurInfected right knee prosthesisT84.53XA, Infection and inflammatory reaction due to internal right knee prosthesisPain due to electric bone stimulatorT84.84XA, Pain due to internal orthopedic prosthetic devices, implants and grafts

23. Other Internal Prosthetic Devices, Implants and Grafts (T85)Ventricular intracranial shuntNeurostimulators of nervous systemelectrode vs. generator GI prosthetic devices, implants and graftse.g., bile duct prosthesis; esophageal anti-reflux deviceIntraocular lensBreast prosthesis and implantsCranial or spinal infusion catheter e.g., epidural; intrathecal; subarachnoid; subduralIntraperitoneal dialysis catheterInsulin pumpArtificial skin graft & decellularized allodermis

24. Examples of Other Internal Devices, Implants and Grafts ComplicationsDKA secondary to insulin pump malfunctionT85.694A, Other mechanical complication of insulin pumpProtrusion of gastric neurostimulator leadT85.191A, Other mechanical complication of implanted electronic neurostimulator of peripheral nerve electrode (lead)Gastric neurostimulator generator pocket infection T85.734A, Infection and inflammatory reaction due to implanted electronic neurostimulator, generator

25. Coding Clinic Advice for Complications d/t Device, Implants and Grafts (T82-T85)Displacement of fallopian tube occlusion devices = T83.428-, Displacement of other prosthetic devices, implants and grafts of genital tract. – CC Q1 2018 p.5Prosthetic joint fracture = T84.01-, Broken internal joint prosthesis. Do not assign T- code for “periprosthetic” fracture. – CC Q4 2016 p.42Infected AV graft = T82.7XX-, Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts. -CC Q1 2015 p.3

26. T86.0-Complications of bone marrow transplantT86.1-Complications of kidney transplantT86.2-Complications of heart transplantT86.3-Complications of heart-lung transplantT86.4-Complications of liver transplantT86.5Complications of stem cell transplant*T86.81-Complications of lung transplantT86.82-Complications of skin graft (allograft) (autograft)T86.83-Complications of bone graftT86.84-Complications of corneal transplantT86.85-Complications of intestine transplantT86.89-Complications of other transplanted tissue (includes pancreas)T86.9-Complication of unspecified transplanted organs and tissuesComplications of Transplanted Organs & Tissue

27. Complications of Transplanted Organs & Tissue5th or 6th digit for transplant complication codes (excluding stem cell):Other complications of heart transplant also includes 6th digits:0 – cardiac allograft vasculopathy8 – other complication of heart transplant0Unspecified complication 1Rejection2Failure8Infection9Other specified complication

28. Transplant ComplicationsOfficial Coding GuidelinesSection I.C.19.g.3“Codes under category T86, Complications of transplanted organs and tissues, 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 category T86 and a secondary code that identifies the complication.” Includes malignancy of transplant organ (OCG Section I.C.2)

29. CKD in Kidney TransplantOfficial Coding Guidelines Section I.C.19.3“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 T86.1- should be assigned for documented complications of a kidney transplant, such as transplant failure or rejection or other transplant complication. Code T86.1- should not be assigned for post kidney transplant patients who have chronic kidney (CKD) unless a transplant complication such as transplant failure or rejection is documented. If the documentation is unclear as to whether the patient has complication of the transplant, query the provider.”

30. CKD in Kidney TransplantCoding Clinic 1st Quarter 2013: p.24If the provider documents that the patient has kidney transplant failure with chronic kidney disease, assign code T86.12, Kidney transplant failure, for complication of the transplanted kidney. Assign code N18.4, Chronic kidney disease, stage 4 (severe), for the CKD.

31. Cytomegalovirus s/p TransplantIf CMV involves a transplanted organ, assign complication code for transplant infection Do not code transplant complication if CMV does not involve the transplanted organ (e.g., CMV colitis following kidney & pancreas transplant). CC Q1 2003

32. Diabetes in Pancreas TransplantDo not code pancreas transplant complication for preexisting diabetesCoding Clinic 5th Issue 1993:“A patient who had a pancreatic transplant may still suffer from the complications of diabetes (eg, diabetic retinopathy or peripheral neuropathy due to diabetes.)“

33. Transplant Complications: Coding ClinicComplication Coding Clinic ABO IncompatibilityQ2 2012 p.6Post-transplant lymphoproliferative disorder (PTLD)Q4 2008 p.90Graft-vs-host disease Q4 2008 p. 97Postop lymphocele affecting renal function following kidney transplant Q3 2003 pp. 16-17UPJ obstruction of transplanted ureterQ1 2010 p.9Ureteral stricture in transplanted ureter Q3 1994 p.8Delayed graft functionQ2 2011 p.6

34. Examples of Transplant ComplicationAcute R pyelonephritis in a patient with R kidney transplant: T86.13, Kidney transplant infection N10, Acute pyelonephritisAcute hypoxic respiratory failure in a patient s/p lung transplant:T86.811, Lung transplant failureJ96.01, Acute respiratory failure with hypoxia Atrial fibrillation with RVR in a patient s/p heart transplantT86.298, Other complications of heart transplantI42.91, Unspecified atrial fibrillation

35. T87.0X-Complications of reattached upper extremityT87.1X-Complications of reattached lower extremityT87.2-Complications of other reattached body partT87.3-Neuroma of amputation stumpT87.4-Infection of amputation stumpT87.5-Necrosis of amputation stumpT87.8-Other complications of amputation stump -1 Dehiscence of amputation stump -9 Other (contracture, flexion, edema, hematoma)T87.9-Unspecified complication of amputation stumpComplications of Reattachment & Amputation

36. Examples of Reattachment and Amputation ComplicationsInfection of right leg amputation stumpT87.43, Infection of amputation stump, right lower extremity *unrelated to progression of underlying diabetic complicationNeuroma of amputation stump of left armT84.32, Neuroma of amputation stump, left upper extremityDehiscence of amputation stumpT87.81, Dehiscence of amputation stump

37. T88.0---Infection following immunizationT88.1---Other complications following immunization, NECT88.2---Shock due to anesthesiaT88.3---Malignant hyperthermia due to anesthesiaT88.4---Failed or difficult intubationT88.5---Other complications of anesthesiaT88.6---Anaphylactic reaction due to AE of correct medication properly administered T88.7--- Unspecified AE of drug or medicamentT88.8---Other specified complication of surgical & medical care, NECT88.9---Complication of surgical & medical care, NECOther Complications of Surgical & Medical Care, NEC

38. Body System ComplicationsAll include: Postprocedural hemorrhagePostprocedural hematomaPostprocedural seromaMost include:Intraoperative hemorrhage and hematomaAccidental puncture and laceration

39. Body System ComplicationsCategoryBody SystemCategoryBody SystemD78.-SpleenJ95.-RespiratoryE89.-MetabolicK91.-DigestiveG97.-NervousL76.-Skin & Subcu TissueH59.-Eye and AdnexaM96.-MusculoskeletalH95.-Ear and Mastoid ProcessN98.-, N99.-GenitourinaryI97.-, I99.-Circulatory

40. Other Circulatory System Complications (I97, I99)Postcardiotomy syndromePostmastectomy lymphedema syndromePostprocedural hypertensionCardiac functional disturbances* Cardiac insufficiencyCardiac arrestHeart failure Cardiac arrest*Cerebral infarction* *intraoperative vs. postoperative

41. Examples of Circulatory System ComplicationsPostop right middle cerebral artery infarction as a complication of cardiac surgery. I97.820, Postprocedural cerebrovascular infarction following cardiac surgeryI63.411, Cerebral infarction due to embolism of right middle cerebral arteryTamponade due to hemorrhagic pericardial effusion secondary to radiofrequency ablation for a-fibI97.618, Postprocedural hemorrhage of a circulatory system organ or structure following other circulatory system procedureI31.4, Cardiac tamponadeIntraop atrial flutter with RVR complicating AVR.I97.790, Other intraoperative cardiac functional disturbances during cardiac surgeryI48.92, Unspecified atrial flutter

42. Other Respiratory System Complications (J95)Acute pulmonary insufficiency following surgery (thoracic vs. nonthoracic)Chronic pulmonary insufficiency following surgery Postprocedural respiratory failure AcuteAcute on chronicPostprocedural pneumothoraxPostprocedural air leak Chemical pneumonitis d/t anesthesiaTransfusion-related acute lung injuryComplication of ventilatorMechanicalVent associated pneumonia

43. Tracheostomy Complications (J95.0-)HemorrhageInfection Malfunction (mechanical, obstruction, stenosis)Tracheo-esophageal fistulaOther

44. Examples of Respiratory System ComplicationsPseudomonas pneumonia secondary to infected tracheostomyI96.02, Infection of tracheostomy stoma J915.1, Pneumonia due to PseudomonasAcute postprocedural respiratory failure*J95.821, Acute postprocedural respiratory failure*not expected postop respiratory status; due to surgery not other condition such as AECOPD

45. Other Digestive System Complications (K91)Vomiting following GI surgery Postsurgical malabsorptionPostprocedural intestinal obstructionPostcholecystectomy syndromePostprocedural hepatic failurePostprocedural hepatorenal syndromeComplications of intestinal pouch (pouchitis)Retained cholelithiasis following cholecystectomyComplications of bariatric procedures

46. Complications of Artificial Openings of Digestive System (K94)ColostomyEnterostomyGastrostomyEsophagostomyUnspecifiedHemorrhageInfectionMalfunctionOther specified

47. Examples of Digestive System ComplicationsPostpolypectomy GI bleedK91.840, Postprocedural hemorrhage of a digestive system organ or structure following a digestive system procedure Abdominal wall cellulitis due to infected colostomyK94.02, Colostomy infectionL03.311, Cellulitis of abdominal wall

48. Postoperative IleusICD-10-CM Alphabetic index defaults to complication code. However, should be documented as a complication. If documented as a complication:K91.89, Other postprocedural complication/disorder of digestive system +K56.7, Ileus unspecified Do not code postop obstruction unless obstructive ileus has been documented as a postop complication.Reference: CC Q1 2017 p.40

49. Postop Intra-abdominal Hemorrhage due to CoagulopathyPostop coagulopathy and intra-abdominal hemorrhage due to Effient and ASA taken as prescribed following emergent ileocecectomy. Code as follows:K91.840, Postprocedural hemorrhage of a digestive system organ or structure following a digestive system procedureD68.32, Hemorrhagic disorder due to extrinsic circulating anticoagulantsT45.525A, AE of antithrombotic, initial encounterT39.105A, AE of aspirin, initial encounterSequencing of K91.840 & D68.32 is dependent on circumstances of admission. References: CC Q1 2016 p.15CC Q1 2016 p.14

50. Other Genitourinary System Complications (N98, N99)Complications associated with artificial fertilization Postprocedural kidney failure (not transplant)Postprocedural urethral stricturePostprocedural adhesions of vaginaProlapse of vaginal vault after hysterectomyPostprocedural pelvic peritoneal adhesionsResidual ovary syndromeUrinary stoma complications

51. Complications of Stoma of Urinary Tract Incontinent stoma – drains continuously to an external appliance that’s emptiedContinent stoma – urine accumulates in an internal pouch that’s emptied by inserting a catheter. CC Q4 2016 p.48Cystostomy (N99.51-)Incontinent External Stoma (N99.52-)Continent Stoma (N99.53-)HemorrhageHemorrhageHemorrhageInfectionInfectionInfectionMalfunctionMalfunctionMalfunctionOtherHerniationHerniationStenosisStenosisOtherOther

52. Examples of GU System ComplicationsSignificant hematuria due to TURBT, requiring readmission for CBI.N99.820, Postprocedural hemorrhage of a genitourinary system organ or structure following a genitourinary system procedureLaceration of ureter as a result of inadvertent transection during hysterectomy.N99.71, Accidental puncture and laceration of a genitourinary system organ or structure during a genitourinary system procedureS37.13XA, Laceration of ureterUTI secondary to prostatectomy.N99.89, Other postprocedural complications and disorders of genitourinary systemN39.0, Urinary tract infection, site not specified

53. Summary Complication must be indicated in documentation Cause-and-effect vs. temporal relationshipComplication codes may be found in Chapter 19 (T80-T88) or within specific body system chapters.Code first complication and add additional code for further specificity of complication when warranted.

54. Questions?

55. Thank you!beth.burgess@enjoincdi.com