2021年10月27日星期三

ICD-10 coding and external causes of medical complications

The concept of complication is another disease caused by the occurrence and development of major diseases and the intervention of diagnosis and treatment methods, which is called complication. In the work of disease coding, we often encounter the situation or complications after medical operation, including early complications and late complications of medical operation; There were mechanical and functional complications.

1、 Classification of medical complications

1. Some medical complications are not considered unique to the operation, such as postoperative esophagitis K20.

At this time, it should be classified according to clinical manifestations and classified into a disease code in the chapter of body system. These medical complications are usually delayed complications, have clear clinical manifestations and can be classified into a disease.

2. Some medical complications are classified into the post operation category specially set up in the chapter of body system. This situation is usually delayed complications that cannot be classified into a specific disease code.

Such as postoperative hypothyroidism e89.0. There are 9 categories of postoperative complications in ICD-10.

3. Some medical complications are classified as T80 ~ t88 surgical and medical complications.

This section mainly classifies some early medical complications and complications that cannot be classified into the system chapter, some of which belong to medical accidents.

2、 Code search method of medical complications

Direct search code. In the index of ICD-10, medical complications can usually be found by selecting "complications" as the leading word.

Example 1:

Lymphedema syndrome after mastectomy

Investigation: complications of surgical operation elephantiasis and lymphedema i97.2 after mastectomy

Example 2:

Dumping syndrome after gastrectomy

Investigation: complications of surgical operation dumping syndrome (after gastrectomy) k91.1

3、 Classification of external factors

The four external causes of medical complications in ICD-10 are classified by sections, and the leading words of the external cause codes of various complications are different. As shown in the figure:

Abnormal reaction or complication

Limited to the level of medical technology or objective conditions, medical complications that cannot be completely avoided after medical personnel have done their reasonable duty of care are no fault complications.

There are three situations in ICD-10:

First, medical complications that are not considered to be unique to the operation and have clear clinical manifestations are classified into chapter a00-r99 of body system;

Second, it often has delayed complications after operation, which are specially arranged in the chapter of body system;

Third, medical complications with unknown clinical manifestations, as additional codes or not classified elsewhere are classified as t66-t78 or t80-t88.

The external causes of such complications are attributed to abnormal reactions or complications, which are coded in the second index of "external causes of injury" in Volume III of ICD-10.

Example 1:

Esophageal pericardial fistula. Three years after left pneumonectomy for left lung cancer, B-ultrasound showed pericardial effusion. Electronic gastroscope showed that the esophagus was 30cm away from the incisor and an abnormal channel could be seen near the anterior wall.

Notes:

Esophageal pericardial fistula occurred in this patient 3 years after operation, which has clear clinical manifestations and cannot be considered as a unique situation of operation. Therefore, the complications are classified into the corresponding chapter of anatomical system, and the external cause is abnormal reaction or complications.

Code search: complication - removal of organs (part) (all) y83.6.

Example 2:

Amniotic fluid embolism, maternal vomiting, choking and coughing during cesarean section, massive bleeding of birth canal, ineffective rescue and death.

Notes:

In this case, the medical staff implemented complete preventive measures, closely observed and took correct measures to actively rescue during the operation, but unexpected and preventable death occurred due to the patient's condition or special constitution, which belongs to abnormal reaction or complication.

Code search: complications - surgery - specifically y83.8.

Harmful effects of drugs

For allergies or other diseases caused by proper use of correct drugs, the coding range of complications is a00-r99, T78. -, t80-t88.8.

In the t88 category, t88.0-t88.1 are complications of immunization and are classified as harmful effects of drugs. T88.2-t88.5 refers specifically to drug anesthesia accidents. Modern medical anesthesia mainly uses drugs to make patients produce reversible functional inhibition of central nervous system and / or peripheral nervous system, resulting in the loss of sensation, especially pain.

Intubation failure after anesthesia

Examination: complications anesthesia: intoxication difficulty or failure of intubation t88.4.

T88.8 covers the two categories of harmful effects of other specified drugs and agents and surgical and medical complications. Therefore, t88 has three residual categories, namely t88.7 and t88.8 constitute the residual category of harmful effects of drugs and agents, and t88.8 and t88.9 constitute the residual category of surgical and medical complications,

T88.0-t88.8 become a coding representation of the harmful effects of generalized "drugs".

The external cause code of harmful effects is found in "external causes of injury" in the second index of Volume III of ICD-10: reaction, abnormal medical operation y84.9 - biology, drugs and vaccines - see the list of biological and chemical agents, and then find "harmful effects used in treatment" in the last column of the third index "list of drugs and chemical agents" in Volume III, with the coding range of y40-y59.

an accident

Under the existing medical science and technology conditions, the complications that can be predicted, avoided and prevented, but can not be avoided due to the fault or fault of medical personnel, are fault complications, but in essence, they are an accident, and their occurrence is not the result of medical personnel's pursuit or laissez faire.

Complications with definite clinical manifestations are classified into the body system chapter a00-r99, and complications with unknown clinical manifestations, as additional codes or not classifiable elsewhere are classified into t66-t78 or t80-t88.

The external causes of such complications are accidents, which are coded in the second index "external causes of injury" in Volume III of ICD-10. Check: reaction, abnormal medical operation or complications y84.9 - accompanied by accidental (medical) accidents (see also accidental (medical) accidents) y69. Re check: accident (medical) accident, code range: y60-y69.

The patient, male, 70 years old, was hospitalized for lung cancer and underwent right lower pneumonectomy. The day after operation was special nursing, and the second day was secondary nursing. On the 5th day after operation, the drainage bottle came out and bloody fluid was drawn out. The patient complained of chest tightness and died on the same day.

Notes:

In this case, due to improper postoperative observation and nursing, the drainage bottle prolapsed, which has a certain relationship with the patient's death. It is an accident.

Code search: accidental (medical) accident - failure, failure, improper - insertion or removal of catheter or instrument y65.4. If the medical care measures of this case are properly standardized, the drainage bottle is normal, and the postoperative arrhythmia belongs to abnormal reaction or complication, which is classified as y83.6.

Complications of medical devices

One is mechanical failure during operation and use, and the other is infection, pain and wound nonunion caused by medical devices. For the coding of external causes of mechanical complications, check the leading word "event, harmful" in the second index "external causes of injury" in Volume III, and the coding range is y70-y82.

This section is used when it is neither an abnormal reaction or complication nor an accident. The responsibility for the damage event mainly belongs to the manufacturer of the product. If the prosthesis is loose after total hip arthroplasty, X-ray shows that the prosthesis sinks and the bone cement is broken.

Code search: event, harmful - device - orthopaedic surgery Y79, check Volume I, subheading Supplement 2, i.e. y79.2. The external causes of hematoma, infection, effusion, pain, delayed healing and other non mechanical complications caused by medical devices are coded in the second index "external causes of injury" in Volume III. The leading word "complications" is checked, and the coding range is y83-y84, which is classified as abnormal reaction or complication.

Infection after total knee arthroplasty, the patient had joint pus one year after operation.

Code search: complication - implantation operation, implantation - artificial - internal device y83.1. If this case is a recent postoperative infection (within 3 months after operation) and there is evidence that the aseptic technology is improperly used, it is an accident and classified as y62.0.

External cause coding of medical complications is an important supplement to the main diagnosis. It can not only describe the specific situation of complications, but also reflect the nature of complications.

Malignant tumor radiation colitis

Code search: colitis - due to radiation k52.0, then distinguish the nature of the radiation operation complications through external cause codes y84.2 and y63.2, that is, whether the occurrence of k52.0 is an abnormal reaction or complication of normal irradiation or an accident of excessive irradiation.

When encountering such codes related to medical complications, you should first clarify the discharge diagnosis and carefully read the discharge diagnosis on the first page of the medical record. If the discharge diagnosis written on the first page of the medical record is not clear, you need to read the inpatient medical record or course record to clarify the diagnosis. If you still can't clarify the diagnosis, you need to ask the doctor to clarify the discharge diagnosis. Secondly, make clear the categories of medical complications, and then code them according to the coding principle of complications. Only in this way can we ensure the accurate coding of such diseases.

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