Significant complications
There are a limited number of complication spots available. November, 2009, Dr.Dan Roberts had provided this list of “specific complications” that he wanted to track on medicine wards. These complications/acquired diagnosis are the most important to look for and code preferential to all other codes available for complication.
- 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.
- 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)
- 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)
- 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)
- 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)
- 6800 (UPL subcode 1-95)
17. Pseudomembranous Colitis (C-DIFF)
- 7212
18. Post OP Surg Wound Infection
- 8300 (UPL subcode 1-95)
- 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)
- 98600
26. Aortic dissection post angioplasty
- 98700
27. Liver laceration post procedure (post chest tube or any other procedure)
- 98800
- Template:Discussion Is there a difference between Significant complications ICU and Significant complications medicine, and is there a good reason for one? Collectors who switch back and forth will get confused. Ttenbergen 00:44, 2013 August 27 (CDT)