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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 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