HS317b - Coding & Classification of Health Information
Week 3 – Lab Session
External Cause: Postadmit comorbidities
Complications of medical care are not grouped to a specific Major Clinical Category. They are included in the MCC pertinent to a specific body system or to MCC 21 Injury, Poisoning and Toxic Effects.
Looking up codes
Postoperative vomiting following a caecectomy
Vomiting
-following gastrointestinal surgery K91.0
Postoperative wound infection following laparoscopic cholecystectomy
Infection
-postoperative wound T81.4
Sepsis of tracheostomy stoma
Sepsis
-tracheostomy stoma J95.01
Persistent postoperative cardiac arrhythmia
Arrhythmia
--no sub terms indicating postoperative, Postprocedural, post surgery, due to, following etc.
Search on the synonymous term Dysrhythmia
Dysrhythmia
-cardiac
--postoperative I97.8
Fistula postoperative
postoperative, persistent T81.82
– – specified site (see Fistula, by site)
Broken hip prosthesis
Complications
fixation device, internal (orthopedic) T84.9
– – infection or inflammation T84.6
– – mechanical T84.2show what is included by following links
– – – bones of limb T84.1
– – specified NEC T84.8
HS317b - Coding & Classification of Health Information
Week 3 – Lab Session
Scenarios:
A patient had a right total hip replacement (cemented) for bilateral primary osteoarthrosis; on the 3rd postoperative day the haemoglobin level was reported as 1-2 g/L and the doctor recorded anemia in the progress notes (haemoglobin was within normal range preoperatively); no treatment was given and the haemoglobin on discharge was unchanged; length of stay was not extended.
A patient was admitted for Dacran graft repair of a ruptured abdominal aortic aneurysm; on the 2nd postoperative day, the doctor recorded anemia in the progress notes and ordered 2 units of blood (haemoglobin was within normal range preoperatively).
An elderly patient was admitted for open reduction and internal fixation (plate and screw) of fractured right tibial shaft which was due to a fall down her stairs at home; on the 5th postoperative day, the doctor noted acute respiratory failure in the progress notes; the patient required continuous ventilation support for 30 hours.
Admitted for removal of internal fixation nail in the left radius that has extruded into the surrounding tissue.
A patient who had been discharged from day care surgery for inguinal herniorrhaphy is readmitted for evacuation of a postoperative wound hematoma.
Accidental laceration of bladder during abdominal hysterectomy. The bladder was repaired with sutures at the time of the hysterectomy.
Digitalis Toxicity
Ataxia due to Valium (taken as prescribed) and three martinis at a party at a friend’s house.
First and second degree burns of the buttocks (estimated at 8%); baby was intentially immersed in scalding water by her mother at home.
Excision of blisters and application of Flamazine dressing to buttocks