Guidelines for Coding Complications of Medical & Surgical Care

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Coding for
Complications of
Medical & Surgical Care
 
BETH BURGESS, MHA, RHIA, CCS
 
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.”
 
Documentation of Complications of Care
 
 
 
Must be more than a routinely expected condition or occurrence
 
Cause-and-effect relationship may be implicit
e.g., complication due to the presence of an internal device, implant, or graft;
complication due to a transplant
 
No time limit
 
Does not imply improper or inadequate care
 
Reference:
AHA Coding Handbook: Chapter 33
 
 
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
 
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
 
Complications of Care: Code Sequencing
 
 
 
Assign code for the 
complication FIRST
 
If complication code lacks specificity, assign additional code(s) to further specify the
complication
Example: postop wound infection of the back with abscess requires two codes:
1.
T81.4XXA, Infection following procedure, initial episode
2.
L02.212, Cutaneous abscess of back
 
 
 
References:
OCG Section I.B.7
OCG Section II.G
 
Complication Coding
 
 
1.
Codes T80-T88
2.
Specific body system complications
 
T- Codes for Complications
 
7
th
 Characters for T80-T85 and T88
 
 
7
th
 character required to specify:
Initial encounter (“A”)
Under active treatment
Does not matter if previously diagnosed
Subsequent encounter (“D”)
Routine care during healing or recovery; 
active treatment has been completed
Sequela (“S”)
Complications or conditions that arise as direct result of the complication
 
Reference:
OCG Section I.C.19.a
 
Complications Following Infusion, Transfusion
and Therapeutic Injection (T80)
 
Infection Following Infusion, Transfusion
and Therapeutic Injection
 
 
Examples of Infection Following Infusion,
Transfusion and Therapeutic Injection
 
 
Bacteremia due to infected port-a-cath
T80.211A, Bloodstream infection due to central venous catheter
If sepsis also present, code A41.- as an 
additional
 diagnosis!
OCG Section I.C.1.d.5
 
Cellulitis secondary to tunneled catheter for temporary dialysis
T80.212A, Local infection due to central venous catheter
 
Peritonitis secondary to infected peritoneal dialysis fluid
T80.29XA, Infection following other infusion, transfusion and therapeutic
injection
CC Q2 2001 pp.11-12
 
 
Complication of Procedures, NEC (T81)
 
Examples of Complication of Procedures,
NEC
 
 
Postoperative sepsis following appendectomy
T81.4XXA, Infection following a procedure*
 
Postop DVT due to recent surgery
T81.72XA, Complication of vein following a procedure, not elsewhere classified
 
Loose 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 operation
CC Q4 2014 p.24
 
 
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.24
 
Postop fistula
: T81.83X-, Persistent postoperative fistula 
+
 appropriate code for
site of fistula.
CC 3Q 2017 pp.3-4
 
Nonhealing 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
 
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)
 
 
 
Cardiac and Vascular Prosthetic Devices,
Implants and Grafts (T82)
 
CARDIAC
 
 
Heart valve prosthesis
 
Cardiac electronic devices
 
CABG
 
Heart valve graft
 
Artificial heart
 
 
VASCULAR
 
 
Aortic graft
 
Carotid artery bypass graft
 
Femoral artery vascular graft
 
Other vascular grafts
 
Dialysis catheter
 
AV fistula
 
 
Examples of Cardiac and Vascular Devices,
Implants and Grafts Complications
 
 
Cerebral infarction due to embolism of prosthetic heart valve
T82.817A, Embolism due to cardiac prosthetic devices, implants & grafts
I63.40, Cerebral infarction due to embolism of unspecified cerebral artery
 
 
AMI due to in-stent stenosis
T82.855A, Stenosis of coronary artery stent
I21.A9, Other myocardial infarction type
 
 
Malpositioned dialysis catheter
T82.42XA, Displacement of vascular dialysis catheter
 
 
Genitourinary Prosthetic Devices,
Implants and Grafts (T83)
 
 
Urinary catheters 
(urethral, cystostomy, nephrostomy)
 
Indwelling ureteral stent
 
Implanted urinary sphincter
 
Electronic stimulator device
 
Intrauterine contraceptive device
 
Penile or testicular prosthesis
 
Implanted vaginal or urethral mesh
 
Examples of Other Complications of GU
Devices, Implants and Grafts
 
 
UTI due to Foley catheter
T83.511A, Infection and inflammatory reaction due to indwelling urethral catheter
 
 
UTI due to suprapubic catheter
T83.510A, Infection and inflammatory reaction due to cystostomy catheter
 
 
Obstructed ureteral stent
T83.192A, Other mechanical complication of indwelling ureteral stent
 
 
Malpositioned nephrostomy tube
T83.022A, Displacement of nephrostomy catheter
 
 
 
Internal Orthopedic Prosthetic Devices,
Implants and Grafts (T84)
 
 
Joint prosthesis
 
Internal fixation device
 
Electronic bone stimulator
 
Muscle and tendon graft
 
Examples of Internal Orthopedic Devices,
Implants and Grafts Complications
 
 
Protrusion of nail s/p ORIF left femur
T84.195A, Other mechanical complication of internal fixation device of left
femur
 
 
Infected right knee prosthesis
T84.53XA, Infection and inflammatory reaction due to internal right knee
prosthesis
 
 
Pain due to electric bone stimulator
T84.84XA, Pain due to internal orthopedic prosthetic devices, implants and
grafts
 
 
 
 
Other Internal Prosthetic Devices,
Implants and Grafts (T85)
 
 
Ventricular intracranial shunt
 
Neurostimulators of nervous system
electrode vs. generator
 
GI prosthetic devices, implants and
grafts
e.g., bile duct prosthesis; esophageal anti-
reflux device
 
Intraocular lens
 
 
 
 
 
Breast prosthesis and implants
 
Cranial or spinal infusion catheter
e.g., epidural; intrathecal; subarachnoid;
subdural
 
Intraperitoneal dialysis catheter
 
Insulin pump
 
Artificial skin graft & decellularized
allodermis
 
Examples of Other Internal Devices,
Implants and Grafts Complications
 
 
DKA secondary to insulin pump malfunction
T85.694A, Other mechanical complication of insulin pump
 
Protrusion of gastric neurostimulator lead
T85.191A, 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
 
 
 
 
 
 
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.5
 
Prosthetic joint fracture 
= T84.01-, Broken internal joint prosthesis. Do not assign T-
code for “periprosthetic” fracture. – 
CC Q4 2016 p.42
 
Infected AV graft
 = T82.7XX-, Infection and inflammatory reaction due to other
cardiac and vascular devices, implants and grafts. -
CC Q1 2015 p.3
 
Complications of Transplanted Organs & Tissue
 
Complications of Transplanted Organs & Tissue
 
 
5
th
 or 6
th
 digit for transplant complication codes 
(excluding stem cell)
:
 
 
 
 
 
 
Other complications of heart transplant also includes 6
th
 digits:
0 – cardiac allograft vasculopathy
8 – other complication of heart transplant
 
 
 
 
Transplant Complications
 
Official Coding Guidelines
Section 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)
 
 
CKD in Kidney Transplant
 
Official 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.”
 
 
CKD in Kidney Transplant
 
Coding Clinic 1
st
 Quarter 2013: p.24
If 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.
 
Cytomegalovirus s/p Transplant
 
 
If 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
 
Diabetes in Pancreas Transplant
 
 
Do 
not
 code pancreas transplant complication for preexisting diabetes
Coding Clinic 5
th
 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.)“
 
 
 
Transplant Complications: Coding Clinic
 
Examples of Transplant Complication
 
 
Acute R pyelonephritis in a patient with R kidney transplant:
T86.13, Kidney transplant infection
N10, Acute pyelonephritis
 
 
Acute hypoxic respiratory failure in a patient s/p lung transplant:
T86.811, Lung transplant failure
J96.01, Acute respiratory failure with hypoxia
 
 
Atrial fibrillation with RVR in a patient s/p heart transplant
T86.298, Other complications of heart transplant
I42.91, Unspecified atrial fibrillation
 
 
 
 
Complications of Reattachment & Amputation
 
Examples of Reattachment and
Amputation Complications
 
 
Infection of right leg amputation stump
T87.43, Infection of amputation stump, right lower extremity
*unrelated to progression of underlying diabetic complication
 
 
Neuroma of amputation stump of left arm
T84.32, Neuroma of amputation stump, left upper extremity
 
 
Dehiscence of amputation stump
T87.81, Dehiscence of amputation stump
 
Other Complications of Surgical & Medical Care,
NEC
 
Body System Complications
 
 
All include:
Postprocedural hemorrhage
Postprocedural hematoma
Postprocedural seroma
 
 
Most include:
Intraoperative hemorrhage and hematoma
Accidental puncture and laceration
 
Body System Complications
 
Other Circulatory System Complications (I97, I99)
 
Postcardiotomy syndrome
Postmastectomy lymphedema syndrome
Postprocedural hypertension
Cardiac functional disturbances*
Cardiac insufficiency
Cardiac arrest
Heart failure
Cardiac arrest*
Cerebral infarction*
 
*intraoperative vs. postoperative
 
Examples of Circulatory System
Complications
 
 
Postop right middle cerebral artery infarction as a complication of cardiac surgery.
I97.820, Postprocedural cerebrovascular infarction following cardiac surgery
I63.411, Cerebral infarction due to embolism of right middle cerebral artery
 
Tamponade due to hemorrhagic pericardial effusion secondary to radiofrequency
ablation for a-fib
I97.618, Postprocedural hemorrhage of a circulatory system organ or structure
following other circulatory system procedure
I31.4, Cardiac tamponade
 
Intraop atrial flutter with RVR complicating AVR.
I97.790, Other intraoperative cardiac functional disturbances during cardiac
surgery
I48.92, Unspecified atrial flutter
 
 
Other Respiratory System Complications (J95)
 
Acute pulmonary insufficiency
following surgery 
(thoracic vs.
nonthoracic)
Chronic
 
pulmonary insufficiency
following surgery
Postprocedural respiratory failure
Acute
Acute on chronic
 
 
Postprocedural pneumothorax
Postprocedural air leak
Chemical pneumonitis d/t
anesthesia
Transfusion-related acute lung injury
Complication of ventilator
Mechanical
Vent associated pneumonia
 
Tracheostomy Complications (J95.0-)
 
 
Hemorrhage
 
Infection
 
Malfunction 
(mechanical, obstruction, stenosis)
 
Tracheo-esophageal fistula
 
Other
 
Examples of Respiratory System Complications
 
 
Pseudomonas pneumonia secondary to infected tracheostomy
I96.02, Infection of tracheostomy stoma
J915.1, Pneumonia due to Pseudomonas
 
 
Acute postprocedural respiratory failure
*
J95.821, Acute postprocedural respiratory failure
*not expected postop respiratory status; due to surgery not other condition such as AECOPD
 
 
Other Digestive System Complications
(K91)
 
 
Vomiting following GI surgery
 
Postsurgical malabsorption
 
Postprocedural intestinal obstruction
 
Postcholecystectomy syndrome
 
Postprocedural hepatic failure
 
Postprocedural hepatorenal syndrome
 
Complications of intestinal pouch 
(pouchitis)
 
Retained cholelithiasis following cholecystectomy
 
Complications of bariatric procedures
 
 
Complications of Artificial Openings of
Digestive System (K94)
 
 
 
Colostomy
 
Enterostomy
 
Gastrostomy
 
Esophagostomy
 
 
 
 
 
 
 
 
Unspecified
 
Hemorrhage
 
Infection
 
Malfunction
 
Other specified
 
Examples of Digestive System
Complications
 
 
Postpolypectomy GI bleed
K91.840, Postprocedural hemorrhage of a digestive system organ or structure
following a digestive system procedure
 
 
Abdominal wall cellulitis due to infected colostomy
K94.02, Colostomy infection
L03.311, Cellulitis of abdominal wall
 
 
 
 
Postoperative Ileus
 
 
ICD-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
 
 
 
 
 
 
Postop Intra-abdominal Hemorrhage due
to Coagulopathy
 
 
Postop 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 procedure
D68.32, Hemorrhagic disorder due to extrinsic circulating anticoagulants
T45.525A, AE of antithrombotic, initial encounter
T39.105A, AE of aspirin, initial encounter
 
Sequencing of K91.840 & D68.32 is dependent on circumstances of admission.
 
References:
CC Q1 2016 p.15
CC Q1 2016 p.14
 
Other Genitourinary System
Complications (N98, N99)
 
 
Complications associated with artificial fertilization
 
Postprocedural kidney failure (not transplant)
 
Postprocedural urethral stricture
 
Postprocedural adhesions of vagina
 
Prolapse of vaginal vault after hysterectomy
 
Postprocedural pelvic peritoneal adhesions
 
Residual ovary syndrome
 
Urinary stoma complications
 
Complications of Stoma of Urinary Tract
 
 
 
 
 
 
 
 
 
 
Incontinent stoma – drains continuously to an external appliance that’s emptied
 
Continent stoma – urine accumulates in an internal pouch that’s emptied by inserting a catheter.
 
CC Q4 2016 p.48
 
Examples of GU System Complications
 
 
Significant hematuria due to TURBT, requiring readmission for CBI.
N99.820, Postprocedural hemorrhage of a genitourinary system organ or structure following a
genitourinary system procedure
 
 
Laceration 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 procedure
S37.13XA, Laceration of ureter
 
 
UTI secondary to prostatectomy.
N99.89, Other postprocedural complications and disorders of genitourinary system
N39.0, Urinary tract infection, site not specified
 
 
 
 
 
Summary
 
 
Complication must be indicated in documentation
Cause-and-effect vs. temporal relationship
 
 
Complication 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.
 
Questions?
 
 
 
 
Thank you!
 
 
 
beth.burgess@enjoincdi.com
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Proper documentation and coding of complications of medical and surgical care are essential for accurate classification and billing. Assigning codes based on the provider's documentation of the relationship between the condition and care is crucial. Complications must be clearly documented with a cause-and-effect relationship indicated. Code sequencing is important to ensure specificity, with additional codes used if needed. Refer to the official guidelines and resources for accurate coding of complications in healthcare settings.


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  1. Coding for Complications of Medical & Surgical Care BETH 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 Care Must be more than a routinely expected condition or occurrence Cause-and-effect relationship may be implicit e.g., complication due to the presence of an internal device, implant, or graft; complication due to a transplant No time limit Does not imply improper or inadequate care Reference: 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 -bariatric procedure -gastric band procedure K59.09 Complication -intraoperative -cardiac arrest -during cardiac surgery I97.710 -during other surgery I97.711

  6. Complications of Care: Code Sequencing Assign code for the complication FIRST If complication code lacks specificity, assign additional code(s) to further specify the complication Example: postop wound infection of the back with abscess requires two codes: 1. T81.4XXA, Infection following procedure, initial episode 2. L02.212, Cutaneous abscess of back References: OCG Section I.B.7 OCG Section II.G

  7. Complication Coding 1. Codes T80-T88 2. Specific body system complications

  8. T- Codes for Complications T80* Complications following infusion, transfusion and therapeutic injection T81* Complications of procedures, NEC T82-T85* Complications of devices, implants and grafts T86 Complications of transplanted organs and tissue T87 Complications peculiar to reattachment and amputation T88* Other complications of surgical and medical care, NEC

  9. 7thCharacters for T80-T85 and T88 7thcharacter required to specify: Initial encounter ( A ) Under active treatment Does not matter if previously diagnosed Subsequent encounter ( D ) Routine care during healing or recovery; active treatment has been completed Sequela ( 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 injection T80.1--- Vascular complications following infusion, transfusion and therapeutic injection T80.2--- Infections following infusion, transfusion and therapeutic injection T80.3--- ABO incompatibility reaction due to transfusion of blood or blood products T80.4--- Rh incompatibility reaction due to transfusion of blood or blood products T80.A--- Non-ABO incompatibility reaction due to transfusion of blood or blood products T80.5--- Anaphylactic reaction due to serum following infusion, transfusion and therapeutic injection T80.6--- Other serum reactions (e.g., serum rash, sickness or urticaria) T80.8--- Other complications following infusion, transfusion and therapeutic injection T80.9--- Unspecified complication following infusion, transfusion and therapeutic injection

  11. Infection Following Infusion, Transfusion and Therapeutic Injection T80.211- Bloodstream infection due to central venous catheter T80.212- Local infection due to central venous catheter T80.218- Other infection due to central venous catheter T80.219- Unspecified infection due to central venous catheter T80.22-- Acute infection following transfusion, infusion, or injection of blood and blood products T80.29-- Infection following other infusion, transfusion and therapeutic injection

  12. Examples of Infection Following Infusion, Transfusion and Therapeutic Injection Bacteremia due to infected port-a-cath T80.211A, Bloodstream infection due to central venous catheter If sepsis also present, code A41.- as an additional diagnosis! OCG Section I.C.1.d.5 Cellulitis secondary to tunneled catheter for temporary dialysis T80.212A, Local infection due to central venous catheter Peritonitis secondary to infected peritoneal dialysis fluid T80.29XA, Infection following other infusion, transfusion and therapeutic injection CC 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 procedure T81.5--- 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 appendectomy T81.4XXA, Infection following a procedure* Postop DVT due to recent surgery T81.72XA, Complication of vein following a procedure, not elsewhere classified Loose 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 operation CC 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.24 Postop fistula: T81.83X-, Persistent postoperative fistula + appropriate code for site of fistula. CC 3Q 2017 pp.3-4 Nonhealing 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 VASCULAR Heart valve prosthesis Aortic graft Cardiac electronic devices Carotid artery bypass graft CABG Femoral artery vascular graft Heart valve graft Other vascular grafts Artificial heart Dialysis catheter AV fistula

  18. Examples of Cardiac and Vascular Devices, Implants and Grafts Complications Cerebral infarction due to embolism of prosthetic heart valve T82.817A, Embolism due to cardiac prosthetic devices, implants & grafts I63.40, Cerebral infarction due to embolism of unspecified cerebral artery AMI due to in-stent stenosis T82.855A, Stenosis of coronary artery stent I21.A9, Other myocardial infarction type Malpositioned dialysis catheter T82.42XA, Displacement of vascular dialysis catheter

  19. Genitourinary Prosthetic Devices, Implants and Grafts (T83) Urinary catheters (urethral, cystostomy, nephrostomy) Indwelling ureteral stent Implanted urinary sphincter Electronic stimulator device Intrauterine contraceptive device Penile or testicular prosthesis Implanted vaginal or urethral mesh

  20. Examples of Other Complications of GU Devices, Implants and Grafts UTI due to Foley catheter T83.511A, Infection and inflammatory reaction due to indwelling urethral catheter UTI due to suprapubic catheter T83.510A, Infection and inflammatory reaction due to cystostomy catheter Obstructed ureteral stent T83.192A, Other mechanical complication of indwelling ureteral stent Malpositioned nephrostomy tube T83.022A, Displacement of nephrostomy catheter

  21. Internal Orthopedic Prosthetic Devices, Implants and Grafts (T84) Joint prosthesis Internal fixation device Electronic bone stimulator Muscle and tendon graft

  22. Examples of Internal Orthopedic Devices, Implants and Grafts Complications Protrusion of nail s/p ORIF left femur T84.195A, Other mechanical complication of internal fixation device of left femur Infected right knee prosthesis T84.53XA, Infection and inflammatory reaction due to internal right knee prosthesis Pain due to electric bone stimulator T84.84XA, Pain due to internal orthopedic prosthetic devices, implants and grafts

  23. Other Internal Prosthetic Devices, Implants and Grafts (T85) Ventricular intracranial shunt Breast prosthesis and implants Neurostimulators of nervous system electrode vs. generator Cranial or spinal infusion catheter e.g., epidural; intrathecal; subarachnoid; subdural GI prosthetic devices, implants and grafts e.g., bile duct prosthesis; esophageal anti- reflux device Intraperitoneal dialysis catheter Insulin pump Artificial skin graft & decellularized allodermis Intraocular lens

  24. Examples of Other Internal Devices, Implants and Grafts Complications DKA secondary to insulin pump malfunction T85.694A, Other mechanical complication of insulin pump Protrusion of gastric neurostimulator lead T85.191A, 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.5 Prosthetic joint fracture = T84.01-, Broken internal joint prosthesis. Do not assign T- code for periprosthetic fracture. CC Q4 2016 p.42 Infected AV graft = T82.7XX-, Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts. -CC Q1 2015 p.3

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

  27. Complications of Transplanted Organs & Tissue 5thor 6thdigit for transplant complication codes (excluding stem cell): 0 Unspecified complication 1 Rejection 2 Failure 8 Infection 9 Other specified complication Other complications of heart transplant also includes 6thdigits: 0 cardiac allograft vasculopathy 8 other complication of heart transplant

  28. Transplant Complications Official Coding Guidelines Section 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 Transplant Official 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 Transplant Coding Clinic 1stQuarter 2013: p.24 If 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 Transplant If 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 Transplant Do not code pancreas transplant complication for preexisting diabetes Coding Clinic 5thIssue 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 Clinic Complication Coding Clinic ABO Incompatibility Q2 2012 p.6 Post-transplant lymphoproliferative disorder (PTLD) Q4 2008 p.90 Graft-vs-host disease Q4 2008 p. 97 Postop lymphocele affecting renal function following kidney transplant Q3 2003 pp. 16-17 UPJ obstruction of transplanted ureter Ureteral stricture in transplanted ureter Q1 2010 p.9 Q3 1994 p.8 Delayed graft function Q2 2011 p.6

  34. Examples of Transplant Complication Acute R pyelonephritis in a patient with R kidney transplant: T86.13, Kidney transplant infection N10, Acute pyelonephritis Acute hypoxic respiratory failure in a patient s/p lung transplant: T86.811, Lung transplant failure J96.01, Acute respiratory failure with hypoxia Atrial fibrillation with RVR in a patient s/p heart transplant T86.298, Other complications of heart transplant I42.91, Unspecified atrial fibrillation

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

  36. Examples of Reattachment and Amputation Complications Infection of right leg amputation stump T87.43, Infection of amputation stump, right lower extremity *unrelated to progression of underlying diabetic complication Neuroma of amputation stump of left arm T84.32, Neuroma of amputation stump, left upper extremity Dehiscence of amputation stump T87.81, Dehiscence of amputation stump

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

  38. Body System Complications All include: Postprocedural hemorrhage Postprocedural hematoma Postprocedural seroma Most include: Intraoperative hemorrhage and hematoma Accidental puncture and laceration

  39. Body System Complications Category Body System Category Body System D78.- Spleen J95.- Respiratory E89.- G97.- Metabolic Nervous K91.- L76.- Digestive Skin & Subcu Tissue H59.- Eye and Adnexa M96.- Musculoskeletal H95.- I97.-, I99.- Ear and Mastoid Process Circulatory N98.-, N99.- Genitourinary

  40. Other Circulatory System Complications (I97, I99) Postcardiotomy syndrome Postmastectomy lymphedema syndrome Postprocedural hypertension Cardiac functional disturbances* Cardiac insufficiency Cardiac arrest Heart failure Cardiac arrest* Cerebral infarction* *intraoperative vs. postoperative

  41. Examples of Circulatory System Complications Postop right middle cerebral artery infarction as a complication of cardiac surgery. I97.820, Postprocedural cerebrovascular infarction following cardiac surgery I63.411, Cerebral infarction due to embolism of right middle cerebral artery Tamponade due to hemorrhagic pericardial effusion secondary to radiofrequency ablation for a-fib I97.618, Postprocedural hemorrhage of a circulatory system organ or structure following other circulatory system procedure I31.4, Cardiac tamponade Intraop atrial flutter with RVR complicating AVR. I97.790, Other intraoperative cardiac functional disturbances during cardiac surgery I48.92, Unspecified atrial flutter

  42. Other Respiratory System Complications (J95) Acute pulmonary insufficiency following surgery (thoracic vs. nonthoracic) Postprocedural pneumothorax Postprocedural air leak Chemical pneumonitis d/t anesthesia Chronic pulmonary insufficiency following surgery Transfusion-related acute lung injury Postprocedural respiratory failure Acute Acute on chronic Complication of ventilator Mechanical Vent associated pneumonia

  43. Tracheostomy Complications (J95.0-) Hemorrhage Infection Malfunction (mechanical, obstruction, stenosis) Tracheo-esophageal fistula Other

  44. Examples of Respiratory System Complications Pseudomonas pneumonia secondary to infected tracheostomy I96.02, Infection of tracheostomy stoma J915.1, Pneumonia due to Pseudomonas Acute 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 malabsorption Postprocedural intestinal obstruction Postcholecystectomy syndrome Postprocedural hepatic failure Postprocedural hepatorenal syndrome Complications of intestinal pouch (pouchitis) Retained cholelithiasis following cholecystectomy Complications of bariatric procedures

  46. Complications of Artificial Openings of Digestive System (K94) Colostomy Unspecified Enterostomy Hemorrhage Gastrostomy Infection Esophagostomy Malfunction Other specified

  47. Examples of Digestive System Complications Postpolypectomy GI bleed K91.840, Postprocedural hemorrhage of a digestive system organ or structure following a digestive system procedure Abdominal wall cellulitis due to infected colostomy K94.02, Colostomy infection L03.311, Cellulitis of abdominal wall

  48. Postoperative Ileus ICD-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 Coagulopathy Postop 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 procedure D68.32, Hemorrhagic disorder due to extrinsic circulating anticoagulants T45.525A, AE of antithrombotic, initial encounter T39.105A, AE of aspirin, initial encounter Sequencing of K91.840 & D68.32 is dependent on circumstances of admission. References: CC Q1 2016 p.15 CC Q1 2016 p.14

  50. Other Genitourinary System Complications (N98, N99) Complications associated with artificial fertilization Postprocedural kidney failure (not transplant) Postprocedural urethral stricture Postprocedural adhesions of vagina Prolapse of vaginal vault after hysterectomy Postprocedural pelvic peritoneal adhesions Residual ovary syndrome Urinary stoma complications

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