Hs317b Coding and Classification of Health Data

HS317b – Coding and Classification of Health Data Injury, Poisoning & External Causes Comorbidities

Post-admit comorbidity  This is a condition that arises post-admission  Satisfies the requirements for determining comorbidity o Significantly affects the treatment received o Requires treatment beyond maintenance of the pre-existing condition o Increases the LOS by at least 24 hours  When a significant complication occurs during the episode in which the operation or other care was given, it is most frequently assigned as an additional code with a diagnosis type 2.  Should a complication of care arise which is clearly so serious o that it consumes the majority of the resources o is responsible for the greatest length of stay o Assign it as both MRDx and diagnosis type 2

Post procedural condition  The condition appears in the physician’s documentation as a complication of the procedure  The condition is present at discharge  The condition persists post procedurally for at least 96 hours.

Diagnosis type 9 – External Cause of Injury Code  Mandatory to use with codes in the range S00-T98 - Injury, poisoning and certain other consequences of external causes  U98.~ Place of occurrence is mandatory with o Codes in the range of W00-Y34 o Exception . Y06 Neglect and abandonment . Y07 Other maltreatment syndromes . Transport accidents . Legal interventions . Acts of war . Medical/surgical misadventures

Post-procedural conditions and complications

Definitions

A Functional Disturbance  A disturbance of normal function of a body system o Example: . arrhythmia is a functional heart disturbance . malabsorption is a functional gastrointestinal disturbance

1 HS317b – Coding and Classification of Health Data Injury, Poisoning & External Causes

An Early Complication  a complication that occurs in the immediate post/peri-operative period o in operating room o during postoperative monitoring period of 96 hours  External cause code must be assigned (cause-effect relationship between surgery performed & specified complication)

A late Complication  A complication that occurs after 96 completed hours following patient’s departure from the OR subsequent to any surgical procedure  Documentation must specify it as postprocedural or postoperative on patient’s chart  An external cause required

A postprocedural condition  When there is no documented evidence of condition arising as a result of or due to intervention  Occurs > than 96 hours after the patient leaves OR/intervention room  Occurs < than 15 days post surgery  No external cause is required.

Steps for determining post-procedural conditions and complications 1. Index look-up is the first step 2. Whenever a complication of a procedure is not indexed or is not a synonym of an inclusion or indexed term proceed as follows: . Code to T80 – T88  Early complications of medical procedures  Mechanical complications . Code to the appropriate system chapter:  Late complications  Functional complications

Sandwiching Codes  When code title of post-procedural condition or complication of surgery does not fully describe the problem o Add an additional code to provide more detail regarding the nature of the condition  This additional diagnosis is assigned as a diagnosis type 3  Example: patient experiences severe postoperative pain following hip arthroplasty. No dislocation or displacement noted on X-ray. Pain management specialist is asked to follow up. o T85.8 (2) Other complications of internal prosthetic devices, implants and grafts NEC o M25.55 (3) Pain in joint, pelvic region and thigh

2 HS317b – Coding and Classification of Health Data Injury, Poisoning & External Causes o Y83.1 (9) Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient  Example: A patient develops pneumonia 6 days after a bladder neck suspension o J95.88 (2) Other post-procedural respiratory disorder o J18.9 (3) Pneumonia, unspecified

External Cause – Connecting the complication/Condition to the Intervention  Assigned external cause if: o Complication or condition arises < 96 hours post-procedure o Complication or condition involves the operative wound site o Organ failure or rejections occurs (regardless of timeframe) o Mechanical complication is involved (regardless of timeframe) o Medical misadventure is involved o Physician documents a causal relationship between condition & procedure  Optional if: o Disturbance of normal function of body system occurs > 96 hours post- procedure  Do not to supply external code when o Postgastric surgery syndromes (K91.1) o Postlaminectomy syndrome NEC (M96.1) o Postmastectomy lymphoedema syndrome (I97.2) o Postsurgical blind-loop syndrome (K91.2)

Myocardial Infarction occurring in the post-operative & peri-operative period  Code I21.~ (diagnosis type 2) + External cause code from either Y83 or Y84 . Y83 Surgical operation and other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure . Y84 Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure o If occurs during intervention o If occurs during post-operative monitoring period of 96 hours  Code I21.~ o If > 96 hours o No documented evidence of it being post-operative

T81.~ ~ Complications of surgical and medical care, NEC (See coding standards, Chapter XIX, page 196)  Classify complications of surgical procedures that are not identified within a specific body system chapter.  Post operative hemorrhage or hematoma  Accidental puncture and laceration during a procedure  Disruption of operative wound  Infection following a procedure

T88. ~ ~ Other complications of surgical & medical care, not elsewhere classified  Use to capture any complication of surgical & medical care  T88.0 – T88.7 codes assigned when capturing specified complications of immunization, administration of anesthetic or unspecified adverse effect of drug or medication.  T88.8~ codes assigned for complications due to any of the following: phototherapy, ultrasound therapy, electroshock therapy, local applications of fomentations, plasters, etc, Paraffinoma

Post-procedure Signs and Symptoms  Can only be classified as postprocedural conditions (Dx type 2) when physician documentation indicates: o They are still present at discharge o They persist postprocedurally for at least 96 hours o A more precise diagnosis has not been identified o That the symptom is due to or a direct result of the procedure.  Assigned an appropriate external cause

T86 Failure and rejection of transplanted organs and tissues  Use this when source of the organ/tissue is another person or animal o Do not use when original source of graft or flap is the patient himself/herself. It is not classified as a transplant  When the complication is infection, failure or absolute rejection

T82 – T85 Complications of Devices, Implants or Grafts  Mandatory to include external cause code  If infectious organism documented identify it with additional code (B95-B97)

Adverse reactions versus Poisonings

Adverse reactions, Allergic reaction, toxicity, etc  May occur when a substance is taken as prescribed by a physician o Correct substance was administered appropriately  Code adverse reaction  Code reaction/manifestation (diagnosis type 3)  Code external cause code from the drug table

Poisonings when  It is not prescribed by a physician  Dosage is altered from prescription  It is a non medicinal substance  Self medication with non-prescription drug  Any medication taken with alcohol  Drug overdose o Code poisoning code

4 HS317b – Coding and Classification of Health Data Injury, Poisoning & External Causes o Code manifestation (Diagnosis type 3) o Code external cause code o Code place of occurrence Poisonings  All drugs involved in the poisoning must be coded  Presumed to be accidental when not stated as intentional self harm  Illicit drug poisoning generally classified as accidental o unless clearly documented to be either suicidal or homicidal intent  Noncompliance with therapy or discontinuance of a drug. o It is not a poisoning. o It is not an adverse effect. o Code manifestation. o Code Z91.1 Personal history of noncomplicance with medical treatment and regimen

Injuries  Code each injury to the greatest degree of specificity  When there are multiple injuries o Code the most severe (or life threatening) first o 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 o Old Injury is one in which the repair has been completed. However, following the repair, functionality has failed to return and thus continuing treatment is required. o Current Injury is one for which the repair is proceeding or has yet to be completed. . Has it occurred within past 365 days . Skin, muscle or tendon injury  < 14 days old. o Yes – code to current injury  > 14 days old & treatment completed. o Yes – code as old injury  Is initial (planned) treatment still underway. o Yes – code as current injury.  Intra-cranial injury + fracture of skull o Code first to intra-cranial injury. o Follow this by an additional code for the fracture. o Example: . Traumatic subarachnoid hemorrhage with closed fracture of base of skull. Patient suffered a brief loss of consciousness  S06.610 Traumatic subarachnoid hemorrhage, without open intra-cranial wound, with brief loss of consciousness  S02.100 Fracture of base of skull, closed

 Injury to blood vessels due to fracture, open wound or other injury o Code additional code to indicate injury to the blood vessel

Open Wounds  Include animal bites, cuts, lacerations, avulsion of skin & subcutaneous tissue & puncture wounds with or without penetrating foreign body  Complicated o Delayed healing o Delayed treatment o Foreign body o Major infection

Fractures – Closed versus Open  Documentation must support open, otherwise classify as closed  “condyle”, “coronoid process”, “ramus”, and “symphysis” indicates the portion of the bone fractured, not the name of the bone involved.  Bilateral injuries may be captured by using the same code twice  Interventions: immobilization, reduction, fixation or even a combination  Fractures due to Crushing Injuries o Code fracture first (diagnosis type MRDx or type 1) o Code crush injury code as diagnosis type 3 o Applies to internal organ crushing injury also

Burns & Corrosions  Occur in degrees which relates to the thickness of the burn. o First degree – erythema only. Superficial o Second degree – involves epidermal loss and blistering. Also called partial thickness burn. o Third degree – involves full thickness skin loss and/or deep necrosis of any underlying tissue.  Burns of one site that exhibit multiple degrees o Code to most severe burn of that site  Burns of multiple sites o Most severe burn site is assigned as MRDx o In burns of multiple sites of same degree, the larger body surface area takes precedence as MRDx o Assign separate codes for burns of each site whenever possible  Mandatory to assign code that classifies extent of body surface area  Mandatory to assign external cause  Mandatory to code place of occurrence  Admissions for change of burn dressing. MRDx Z48.0~ Attention to surgical dressings and sutures.

6 HS317b – Coding and Classification of Health Data Injury, Poisoning & External Causes o Code appropriate burn code as diagnosis type 3. o Mandatory to assign external cause. o Mandatory to code place of occurrence.