Significant complications

Significant complications tracked on medicine units.--TOstryzniuk 20:35, 24 November 2009 (CST)

• NOTE: Dr.Dan Roberts had provided this list of “specific complications” that he wanted to track on medicine wards. These complications/acquired diagnosis are a most important to look for and code preferential to all other codes available for complication.----TOstryzniuk 17:17, 3 November 2010 (CDT)

• Complication/acquired DX code:

1. Central Line complication (requires transfusion or surgery)

• 86000 - Central Line Related Blood stream Infection (CLR-BSI) (see UPL for subcode 1-95 - not all subcodes apply and we have no rules to exclude any)
• 98003 Pneumothorax 2nd to central line insertion
• 98102 Hemothorax – 2nd to central line insertion
• 98201 Significant bleed - 2nd to central line - Femoral Artery/vein
• 98203 Significant bleed - 2nd to central line - Pulmonary Artery
• 98203 Significant bleed - 2nd to central line - subclavian arter/vein
• 98205 Significant bleed - tamponade 2nd to central line
• 98300 Stroke due to central line
• 98500 Ischemia 2nd to central line (swan ganz, IJ, Subclavian)
• 98900 Loss or broken guidewire with central line insertion
• 99000 Arterial insertion of venous central line (malpositioning of PA or IJ into carotid artery or LV).

2. DVT Art/Ven Embolus/Thrombus -do you just want just lower extremity DVT or any other type?

• 13200 (code by itself is mixed bag of Arterial or venous embolus or Thrombus)
• 13201 Femoral (lower extremity)
• 13202 Popiteal (lower extremity)
• 13203 Subclavian (upper extremity/thorax-armpit, collar bone area)
• 13204 Superior mesenteric (abdomin)
• 13205 Post Operative (anywhere in body)
• 13206 Internal Jugular (upper extremity/thorax –neck area)
• 13208 Axillary (upper extremity/thorax-armpit - collar bone area)
• 13209 Innominate (upper extremity/thorax -)
  • 13606 aortic – Excluded because this is generally a paradoxical embolization of DVT thrombus into the aorta. Our code is a mixed bag of arterial venous embolus or thrombus so don’t include for DVT.

3. Ulcers - Decubitus only

• 94500 Decubitus ulcer only (used without subcode if stage unknown)
• 94501 stage 1 surface reddening
• 94502 just under skin
• 94503 deep to muscle
• 94504 full layer to bone

4. HAP-Hospital Acquired Pneumonia

• 3800 (UPL subcodes 1-95 (exclude subcode 59, see below))
• 3600 (UPL subcodes 1-95 (Pneumonia if not sure if hosp or community acquired, exclude subcode 59))

5. Aspiration Pneumonia Aspiration (early presentation, documented aspiration)

• 3859 hospital acquired aspiration pneumonia
• 3659 Pneumonia Etiology not clear (not sure where acquired) (see discussion here)

6.Pulmonary Embolus

• 1300 Pulmonary Embolus (used without subcode if reason is unknown)
• 1301 Pulmonary Embolus- Septic
• 1302 Thrombic
• 1303 Post Operative
• 1304 Air
• 1305 Post Trauma-fat emboli – not included for medicine
• 1390 other reason (same as using 1300 when reason is unknown)

7. Cardiac Arrest

• • 10001 Unwitnessed Cardiac Arrest
  • 10002 Witnessed Cardiac Arrest

8. Stroke

• • 50501 CVA Post angiogram
  • 50502 CVA Post operative procedure
  • 50504 CVA Post anticoagulation therapy
  • 50505 CVA Intra-operative
  • 50506 CVA Post Partum
  • 50590 CVA 2nd to OTHER causes (original description in "other medical proedures)
  • 98300 CVA due to central line - No Article (also see Central line complications)

9. NG tube placement problems

• • 99101 Aspiration due to Malpositioning

10. Septic Shock

• • 4400 (UPL subcode 1-95)

11. Severe Sepsis

• • 4500 (UPLsubcodes 1-95)

12. Septicemia/Bacteremia/Fungemia

• • 4600 (UPL subcode 1-95)

13. Cystitis (Bladder Infection)

• • 5100

14. Esophagitis 2nd to infection

• • 6400 (UPL subcode 1-95)

15. Gastroenteritis

• • 6500 (subcode 1-95)

16. Neutropenic Enterocolitis

• • 6800 (UPL subcode 1-95)

17. Pseudomembranous Colitis (C-DIFF)

• • 7212

18. Post OP Surg Wound Infection

• • 8300 (UPL subcode 1-95)

19. Soft tissue abcess

• • 8400 (UPL subcode 1-95)

20. Soft Tissue Infection (includes Cellulitis)

• • 8500 (UPL subcode 1-95)

21. Ulcers - Lower Extremity & other

• • 94700

22. Tracheostomy (complications)

• • 77404 obstruction
  • 77405 malpositioning
  • 77406 bleeding (significant)
  • 77407 Fistula formation
  • 77408 site infection
  • 77490 any other complications

23. Pneumothorax (2nd to procedures)

• • 98001 2nd to pleural tap/thoracentesis
  • 98002 2nd to chest tube insertion
  • 98003 (see item #1 above - central line complication) 2nd to central line insertion
  • 98090 2nd to other procedure
  • 1101 Iatrogenic (the preference is to use code 980 which is more specific)

24. Hemothorax (2nd to procedures)

• • 98101 2nd to pleural tap/thoracentesis
  • 98102 (see #1 above - central line complication)
  • 98103 2nd to chest tube insertion
  • 98190 2nd to other procedures
  • 1001 Iatrogenic (the preference is to use code 981 which is more specific)

25. Mainstem intubation

• • 98600

26. Aortic dissection post angioplasty

• • 98700

27. Liver laceration post procedure (post chest tube or any other procedure)

• • 98800