Postprocedural complications and disorders

The coding of postprocedural complications and disorders is explained in detail here and summarised diagrammatically following this section.

Postprocedural complications and disorders are conditions arising as a result of surgical or medical procedures. In the medical record they may be referred to as postoperative complications, postoperative disorders, following surgery or following a procedure.

The principle is to use codes which fully describe the condition and the procedure that caused it. Postprocedural complications and disorders can be coded in three different ways:

1. Use a code from the range T80–T88 followed by the external cause code from Y83-Y84 if doing so adds further information about the nature of the procedure

2. Assign a code for the condition itself, followed by the external cause code from Y83–Y84 to identify the procedure

3. Assign a code from the postprocedural disorders category at the end of the relevant body system chapter followed by the external cause code from Y83-Y84 if doing so adds further information about the nature of the procedure.

A coder must never assume a condition is a postprocedural complication or disorder unless it is clearly documented as such by the responsible

1. Coding complications of surgical and medical care, not

elsewhere classified (T80–T88)

The range of conditions in categories T80–T88 are often complications relating to certain procedures or internal devices such as complications of injections T80, internal orthopaedic devices T84, or other cardiac and vascular prosthetic devices T82, and all have specific index entries.

Example: Displacement of heart valve prosthesis



- device, implant or graft (see also Complications, by site and type, mechanical) T85.6

- - heart NEC T82.5

- - - valve (prosthesis) T82.0 Tabular List entry:

T82.0 Mechanical breakdown of heart valve prosthesis Breakdown (mechanical)

Displacement

Leakage due to heart valve

Malposition prosthesis

Obstruction, mechanical Perforation

Protrusion

Displacement, obstruction, etc. are all classed as mechanical complications of prosthetic devices as they prevent the prosthesis from functioning

correctly. Refer to the list of inclusions under the mechanical complication codes in the Tabular List, Volume 1.

Complications classifiable to categories T80–T88 can also be referenced under the lead term that describes the specific condition, with the appropriate modifier to indicate that it is the result of a procedure or treatment, e.g. ‘postoperative’, ‘following surgery’, ‘following infusion’.

Example: Phlebitis due to IV infusion



Phlebitis (infective) (pyemic) (septic) (suppurative) I80.9 - following infusion, therapeutic injection or transfusion T80.1 Tabular List entry:

T80.1 Vascular complications following infusion, transfusion and therapeutic injection

When there is no entry for either the specific condition or the appropriate modifier, the lead term Complications must be referenced.

Example: Displacement of hip prosthesis



- prosthetic device, graft or implant T85.9 - - joint T84.9

- - - mechanical T84.0 Tabular List entry:

T84.0 Mechanical complication of internal joint prosthesis

Rationale: The above condition can also be indexed under the lead term Displacement in the Alphabetical Index.

It is not necessary to add an external cause code from categories Y83–Y84 to a code from the range T80-T88 when the postprocedural condition is classified to a code that fully describes both the nature of the condition and the procedure that has caused it.

This rule applies both if the complication occurs during the same Consultant Episode on which the procedure took place, or on a subsequent Consultant Episode / subsequent readmission for treatment of the postoperative complication.

Example: Air embolism due to transfusion



- - infusion, therapeutic injection or transfusion - - - air T80.0

Tabular List entry:

T80.0 Air embolism following infusion, transfusion and therapeutic injection

Rationale: In the above example, the postprocedural condition is classified to a code that fully describes the nature of the condition and the procedure that caused it therefore it is not necessary to assign an external cause code.

Example: Postoperative haemorrhage five hours after a tonsillectomy



- postoperative T81.0 Tabular List entry:

T81.0 Haemorrhage and haematoma complicating a procedure, not elsewhere classified



Complication (delayed) (of or following) (medical or surgical procedure) Y84.9

- removal of organ (partial) (total) NEC Y83.6 Tabular List entry:

Y83.6 Removal of other organ (partial) (total)

Rationale: In the above example, the external cause code is required to add more specific information about the procedure causing the postprocedural complication as it is not implicit in the code title for T81.0.

Example: Patient readmitted with swab in-situ following cholecystectomy



- accidentally left during a procedure T81.5 Tabular List entry:

T81.5 Foreign body accidentally left in body cavity or operation wound following a procedure



Complication (delayed) (of or following) (medical or surgical procedure) Y84.9

- removal of organ (partial) (total) NEC Y83.6 Tabular List entry:

Y83.6 Removal of other organ (partial) (total)

Rationale: In the above example, the postprocedural condition is classified to a code that does not fully describe the nature of the procedure therefore it is necessary to assign an external cause code.

When assigning a code from categories Y83-Y84 with codes from categories T80-T88 a .8 or .9 code from categories Y83-Y84 must not be assigned because these codes do not add further detail about the nature of the procedure.

Postprocedural infections following insertion of prostheses,