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When assigning a ICD-10-CM diagnosis code(s) for a surgical complication, report the code for the complication first, followed by any additional diagnosis code(s) required to report the patient’s condition. Example 1: Complication from a surgical procedure for treatment of a neoplasm. The complication is the listed first, followed by a code for the neoplasm or […]
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I have doubt regarding cast complication when a patient arrives hospital due to cast discomfort that created pain/ swelling/ in case too tight/loose after 2-3 days of closed reduction of radius fracture, what encounter do we use for the visit- initial or subsequent?
Can we apply the below concept? . please help
For complication codes, active treatment refers to treatment for thecondition described by the code, even though it may be related to an
earlier precipitating problem. For example, code T84.50XA, Infection and inflammatory reaction due to unspecified internal joint prosthesis,
initial encounter, is used when active treatment is provided for the infection, even though the condition relates to the prosthetic device,
implant or graft that was placed at a previous encounter.7th character A, initial encounter is used for each encounter where the
patient is receiving active treatment for the condition.
Kindly any one please convey your ideas. Thank you.
Regards,
Menaka.
For complication codes, active treatment refers to treatment for thecondition described by the code, even though it may be related to an
earlier precipitating problem. For example, code T84.50XA, Infection and inflammatory reaction due to unspecified internal joint prosthesis,
initial encounter, is used when active treatment is provided for the infection, even though the condition relates to the prosthetic device,
implant or graft that was placed at a previous encounter.7th character A, initial encounter is used for each encounter where the
patient is receiving active treatment for the condition.
Thanks
Menaka.
E11.9 (Type 2 dm without complications) should not be coded with E11.41 (Type 2 DM with diabetic mononeuropathy) correct? It is my understanding you should not code without complication and complications together.
Thanks!
My surgeon took a patient to the OR and completed partial colectomy of the transverse and descending colon. The patient began having cardiac issues and the operation had to be halted prior to any anastomosis or stoma creation. They covered his open abdomen with a negative pressure dressing and towels and placed a drain then an airtight seal.
The next day he was taken back to the OR – negative pressure dressings removed and abdomen explored. They performed partial omentectomy, created end colostomy and matured it. the abdominal wound was packed with wet Kerlix and ABD pads.
Should I use code:
Day 1:
44141 with -53 to indicate the discontinuance of the initial procedure?
44139 mobilization of splenic flexure (clearly documented in op note)
97607 for negative pressure dressing
Day 2:
44320-58 or 44141-52-58 for the colostomy creation for?
49255 for omentemtectomy day 2?
Thank you in advance
It is my understanding that when selecting the crohn’s or colitis with complication codes, the complication must be documented as being current/active.
For example, patient has a diagnosis of large and small bowel crohn’s. Several years back patient had a fistula that complicated his crohn’s disease; however, the fistula since been resected and the patient has been treated now for a couple of years with Remicade with no current/active complications of his crohn’s disease. Patient has had several follow up visits with no GI complaints and is doing well on treatment.
Question is, would the patient’s diagnosis for all current visits that are documented with no GI complaints and doing well on treatment still be considered crohn’s disease with complication?
If anyone can point me to any supporting documentation, that would also be very helpful.
It is my understanding that when selecting the crohn’s or colitis with complication codes, the complication must be documented as being current/active.
For example, patient has a diagnosis of large and small bowel crohn’s. Several years back patient had a fistula that complicated his crohn’s disease; however, the fistula since been resected and the patient has been treated now for a couple of years with Remicade with no current/active complications of his crohn’s disease. Patient has had several follow up visits with no GI complaints and is doing well on treatment.
Question is, would the patient’s diagnosis for all current visits that are documented with no GI complaints and doing well on treatment still be considered crohn’s disease with complication?
If anyone can point me to any supporting documentation, that would also be very helpful.
It is my understanding that when selecting the crohn’s or colitis with complication codes, the complication must be documented as being current/active.
For example, patient has a diagnosis of large and small bowel crohn’s. Several years back patient had a fistula that complicated his crohn’s disease; however, the fistula since been resected and the patient has been treated now for a couple of years with Remicade with no current/active complications of his crohn’s disease. Patient has had several follow up visits with no GI complaints and is doing well on treatment.
Question is, would the patient’s diagnosis for all current visits that are documented with no GI complaints and doing well on treatment still be considered crohn’s disease with complication?
If anyone can point me to any supporting documentation, that would also be very helpful.