T81.43XA or K65.1 as PDx ?
Patient with a history of Roux en Y gastric bypass transferred from an outside hospital where she presented twice in one week with c/o abdominal pain. CAT scan reviewed by Dr and discussed with Dr. of interventional radiology. CT reveals Intra-abdominal abscess probably from a perforated gastrojejunal anastomotic ulcer. Labs revealed leukocytosis and hypokalemia.
Esophagram - No delay in flow of contrast, possible stricture involving either the gastrojejunostomy anastomosis or proximal Roux limb. No contrast extravasation.
Pt underwent technically successful CT-guided drainage catheter placement into anterior abdomen abscess with aspiration of 250 mL of brown purulent fluid. Post aspiration CT shows decreased size in the anterior abdomen abscess.
Thanks !
Comments
It would depend on the providers documentation of whether the intra-abdominal abscess was related to the Roux-en-Y gastric bypass surgery. My thoughts would be to send a query to the provider to confirm. if it is confirmed as a complication then the code T81.43XA, Infection following a procedure, organ and space surgical site, initial encounter would be your PDX and lead to DRG 862 Postoperative and post-traumatic infections with MCC K65.1 Peritoneal abscess
Remember code assignment is based on the providers documentation of the relationship between the condition and the care, intervention or procedure, unless otherwise instructed by the classification regardless of the chapter the code is located in.
There must be a cause-and-effect relationship between the care provided and the condition and the documentation must support the condition is clinically significant.
it is not necessary for the provider to explicitly use the word complication.
I would also review Coding Clinic for ICD-10 CM/PCS 1st Quarter 2022 page 51 (regarding a serosal tear) it basically states that the provider does not need to use the word complication, that sometimes the providers documentation in the post-op note is sufficient to report a complication whether they agree or not, and that if something that occurs during a surgical procedure "alters the course of the surgery as supported by the medical record documentation , it should be reported as a complication. It also stated that the word complication does not imply inappropriate /inadequate care, and/or an unplanned outcome.
Thank you so very much for your help. Much appreciated.