Surgical Complication Diagnostic Coding: Quick Tip

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  • December 26, 2018
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Surgical Complication Diagnostic Coding: Quick Tip

When assigning a ICD-10-CM diagnosis code(s) for a surgical complication, report the code for the complication first, followed by any additional diagnosis code(s) required to report the patient’s condition.
Example 1: Complication from a surgical procedure for treatment of a neoplasm. The complication is the listed first, followed by a code for the neoplasm or history of neoplasm.
Example 2: A patient becomes dehydrated because of the malignancy, and only the dehydration is being treated. Sequence the code for dehydration, first, followed by the code to report the malignancy.
Example 3: A patient has postoperative bleeding. When an exploratory laparotomy is performed, the source of the bleeding is found to be in a tear in the splenic capsule. Report D78.02 Intraoperative hemorrhage and hematoma of the spleen complicating other procedure for the surgical complication (postoperative bleeding), followed by S36.039A Unspecified laceration of spleen, initial encounter 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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