Sequencing for Complications
When coding for surgical complications, report the code for the complication first, followed by any additional diagnosis code(s) required to report the patient’s condition.
For instance, suppose a patient has postoperative bleeding. An exploratory laparotomy reveals that the source of the bleeding is a tear in the splenic capsule. In this case, you would report 998.11 Hemorrhage complicating a procedure for the postoperative bleeding, followed by 865.02 Capsular tears to spleen, without major disruption of parenchyma or mention of open wound into cavity for the spleen capsular tear.