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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.

John Verhovshek
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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

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