General Surgery Coding Alert

Reader Questions:

Check Documentation For Malfunction Specifics

Question: I would like to know the correct coding for malfunctioning of a port-o-catheter. I have been using V58.81. I wanted to know if there was a better or more specific code.

Washington Subscriber

Answer: This is considered either a -complication- or -malfunction- of the device, but there are different types of complications. Check your physician's documentation and choose one of the following:

- 996.1 -- Mechanical complications of other vascular device, implant, and graft

- 996.62 -- Infection and inflammatory reaction due to vascular device, implant, and graft (requires an additional code to specify the infection, such as sepsis)

- 996.74 -- Other complications due to vascular device, implant, and graft

- 999.31 -- Infection due to central venous catheter (requires an additional code to specify the infection, such as sepsis)

Once you select the correct primary code from those listed above, the secondary code would be E878.8 (Other specified surgical operation or procedure as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the operation).