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Reader Question:

Identify The Appropriate Complications

Published on Fri Feb 10, 2012

Question: Our patient has returned home after a coronary artery bypass graft (CABG) for coronary atherosclerosis (CAD) of his native artery. He needs continued observation and assessment of the surgical incision on his leg with three areas of incisional separation but no signs or symptoms of infection. He is a little weak but no longer has chest pain. How should we code for him?

Kansas Subscriber

Answer: Code for this patient as follows:

  • M1020a: 998.32 (Disruption of external operation [surgical] wound);
  • M1022b: 414.00 (Coronary artherosclerosis of unspecified type of vessel, native or graft);

When your patient has a complication such as an infection or wound dehiscence following surgery, look to the codes for the complication, rather than the aftercare V codes. Complications affecting multiple sites or body systems are generally found in categories 996-999 (Complications of surgical and medical care). Complications affecting specific sites are classified in the appropriate ICD-9 chapter.

If you're considering using a postoperative complication code, remember these tips:

1. A postoperative complication must arise during or result from a procedure, but it can't be something you would routinely expect to occur.

2. There must be a cause-and-effect relationship between the procedure and the complication.

3. The physician must document the condition as a complication. You can't just see that there is incisional separation and code for it.

4. If the physician's documentation doesn't describe a complication well, discuss the situation with the physician. You can then document the physician's statement as communication or a verbal order.

5. If the complication code is too general and a specific code exists for the condition, assign an additional code for the specific condition -- but sequence the complication code first, followed by the specific condition code.

In your patient's case, the wound has incisional separation so you should code for it as an external disruption with 998.32.

Follow the complicated wound code with the CAD diagnosis because in this case the CABG treats the disease but doesn't cure it.

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