Orthopedic Coding Alert

Question: My surgeon saw a patient in consultation at the hospital. A portion of the documentation states "right thigh abscess status post femoralpopliteal bypass graft -- also with erythema, redness, and cellulitis as an extension from the medial thigh abscess." Should I report a post-op code in addition to the abscess code? The patient had an infection at the surgery site eight months ago, two months after the grafting.

Connecticut Subscriber

Answer: You may report the abscess diagnosis code (682.6, Other cellulitis and abscess; leg, except foot) without the post-op code in the situation you describe.

Rationale: First, the abscess diagnosis is sufficient to explain the reason for the consult. Second, ICD-9 official guidelines state several times, "As with all procedural or postprocedural complications, code assignment is based on the provider's documentation of the relationship between the condition and the procedure" (http://www.cdc.gov/nchs/datawh/ftpserv/ftpICD9/icdguide07.pdf). The surgeon does not specifically document that the surgery caused the abscess, so you shouldn't assume this is the case.

Tip: If the surgeon does document a direct link between the procedure and the infection -- even months after the procedure -- you may report a postoperative code, such as 998.59 (Other postoperative infection).