The concept of is another disease caused by the occurrence and development of major diseases and the intervention of diagnosis and treatment means, which is called complication. In the work of disease coding, there are often situations and 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. Like postoperative esophagitis K20, some medical complications are not considered specific to the operation.
At this time, according to the classification of clinical symptoms, it is classified as all disease codes of the body system and intestine. These medical complications are usually delayed complications with clear clinical symptoms and can be classified as specific diseases.
2. Some medical complications are included in the postoperative classification specially set for the intestinal tract of the body system. This is usually a delayed complication that does not contain a specific disease code.
Postoperative hypothyroidism e89.0. ICD-10 has 9 categories to study postoperative complications.
3. Some medical complications are divided into T80 ~ t88 surgery and medical complications.
This part of the code mainly classifies early medical complications and complications that cannot be classified into system chapters, some of which belong to medical accidents.
2、 Medical complication code retrieval method
When searching the code directly, in the ICD-10 index, medical complications can generally choose "complications" as the leading language for search.
Lymphedema syndrome after mastectomy
Examination: complications - surgery - epithelioma and lymphedema - i97.2 after mastectomy.
Fall syndrome after gastrectomy
Examination: complications - surgical - fall syndrome (after gastrectomy) k91.1
3、 Classification of external causes
ICD-10 classifies the external causes of four kinds of medical complications by stages, and looks for the different leading words of the external cause codes of various complications. As shown in the figure:
Abnormal reaction or complication
Limited to the level of medical technology or objective conditions, even if the medical staff have done their reasonable duty of care, the medical complications that cannot be completely avoided are no wrong complications.
ICD-10 is divided into three cases.
Generally, it is not considered as a unique state of operation, and the medical complications with clear clinical symptoms are intestinal a00-r99 of the body system; Classified as.
Second, there are often delayed postoperative complications that are specifically set up in the body system and the intestine.
Third, medical complications whose clinical symptoms are unknown or cannot be classified as additional codes are classified as t66-t78 or t80-t88.
The external causes of such complications are abnormal reactions or complications. In the external causes of injury, the second index of Volume III of ICD-10, find and code the leading words reaction, abnormalities or complications of medical operation.
Esophageal pericardial effusion. Three years after left pneumonectomy for left lung cancer, cardiac ultrasound showed pericardial effusion. Electronic gastroscope showed abnormal channels on the front wall of 30 cm of esophageal incisors.
The patient developed esophageal sac effusion 3 years after operation, with obvious clinical symptoms, which is not considered to be a unique condition of operation. The complications entered the corresponding anatomical system intestine. In addition, they were caused by abnormal reactions or complications.
Code search: complications - organ clearance (partial) all y83.6.
Amniotic fluid embolism, maternal vomiting, cough and massive bleeding in the birth canal during caesarean section, ineffective after rescue and died.
In this case, the medical staff took perfect preventive measures, made close observation during the operation, and took correct measures for active treatment. However, due to the patient's condition, special physique and other reasons, unpredictable and preventable deaths, abnormal reactions or complications occurred.
Code search: complications - surgery - especially y83.8.
Harmful effects of drugs
Allergies or other diseases caused by correct use of drugs, and the code range of complications is a00-r99 and 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, especially drug anesthesia accidents. Modern medical anesthesia mainly uses drugs to inhibit the reversible function of the central nervous system and / or peripheral nervous system, resulting in the loss of senses, especially pain.
Intubation failure after anesthesia
Examination: complications - after anesthesia - difficulty or failure of intubation t88.4.
T88.8 covers the two main categories of harmful effects of other specific drugs and drugs and surgical and medical complications. Therefore, t88 has three remaining categories: t88.7 and t88.8 constitute the remaining categories of harmful effects of drugs and drugs, and t88.8 and t88.9 constitute the remaining categories of surgical and medical complications
T88.0-t88.8 become a code representation of the harmful effects of a wide range of "drugs".
The external causes of harmful effects were investigated through the external causes of damage, the second index of Volume III of ICD-10. Reference response, medical operation abnormality y 84.9 - list of biological, drug, vaccine biological and chemical agents, and the code range queried in the last column of list of drugs and chemical agents used in treatment in the third index of Volume III is y40-y59.
Under the current conditions of medical science and technology, it can be foreseen, avoided and prevented. However, due to the negligence or negligence of medical staff, the unavoidable complications are negligent complications, but they are essentially accidents. This is not the result of the pursuit and laissez faire of medical staff.
Complications with definite clinical symptoms were classified as body system intestinal a00-r99, and complications with unknown clinical symptoms that could not be classified as additional codes or elsewhere were classified as t66-t78 or t80-t88.
The external cause of this complication is accident. The investigation of "external causes of injury" in index 2 of Volume 3 of ICD-10 shows that reaction, abnormal medical operation or complication y 84.9 - accidental "medical" accident (see accidental "medical" accident) y69 is accompanied. Review: accident (medical) accident with code range y60-y69.
Arrhythmia after lung cancer surgery, patient, male, 70 years old, hospitalized for lung cancer, right lower pneumonectomy. After the operation, due to special care, it was changed to secondary care the next day according to the doctor's instructions. On the 5th day after the operation, the patient discharged the drainage bottle, the blood fluid was extracted, the patient complained about the thymus, and died on the same day.
This example is related to the death of patients caused by medical staff's postoperative observation, improper nursing and escape of drainage bottle. It is an accident.
Code search: accident (medical) accident - failure, failure, insertion or removal of wrong catheter or equipment y65.4 if the medical measures in this case are appropriate, the drainage disease is normal, and the abnormal reaction or complication of postoperative arrhythmia is classified as y83.6.
Complications of medical devices
One is mechanical failure during operation and use, and the other is medical device infection, pain, wound failure to heal, etc. Mechanical complications were encoding from outside, and the leading word "event, deleterious" was investigated in the third index second index "external cause of damage", with a code range of Y70-Y82.
This part is not used in case of abnormal reaction or complication or accident. The responsibility for damage events 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.