Wiki Complication and late effects of surgery

[Sandra Fender]

I really need some input on this:
we have a new pt in our office (internal med) , she is 19 and went in for her spleen to be removed ( don't know why) and durning the surgery her aorta was cut. She now has brain damage, urinary and bowel incontinence as well as other many other issuse. please let me know how you would code this.

Thank you
sandi

 

[erjones147]

Obviously, not enough here to be sure about any of this. I think you have A LOT of consultation to do with the provider before even beginning to code this.

I would INVESTIGATE (not just use) the following:

998.2 (accidental puncture during a procedure)
901.0 (injury to aorta)
787.60 (fecal incontinence)
788.30 (urinary incontinence)

"brain damage" would not be specific enough, imo. How is it manifesting? Intellectual disabilities? seizures? etc,

 

[mitchellde]

the puncture and the injury to the aorta would be the codes for the visit to address these as acute issues. After the initial, the brain "damage and other issues would be coded and thne add the 905-907 code for late effect from surgery.