Question 1

Patient was admitted for an open TAH (removal of uterus and cervix) due to symptomatic fibroids. The physician documented in the operative report that a complication had occurred in which the bladder was accidentally lacerated during the procedure and was repaired with suture.

Accepted Answer

D25.9 represents the symptomatic fibroids, the reason for the surgery. N99.71 is the code for accidental laceration of a pelvic organ during a procedure, which in this case is the bladder. 0UT90ZZ is the code for the total removal of the uterus, open approach. 0UTC0ZZ is for the total removal of the cervix, open approach. 0TQB0ZZ is the code for the repair of the bladder, open approach.

Question 2

Patient was admitted with an abscess caused by Streptococcus of abdominal surgical wound, initial encounter. Cultures were positive for Streptococcus spp. The abscess of the skin was incised and drained.

Accepted Answer

The correct coding includes T81.4xxA for the complication of the surgical wound, L02.211 for the abscess of the abdominal wall, B95.5 for the Streptococcus infection, Y83.9 for the surgical procedure as the cause of abnormal reaction of the patient, without mention of misadventure at the time of the procedure, and 0H97XZZ for the incision and drainage of the abscess.

Question 3

Patient had an outpatient surgical procedure this morning and was discharged in stable condition. Patient returns because of inability to void. A Foley catheter is inserted.Diagnosis: Postoperative urinary retention

Accepted Answer

N99.89 (Other postprocedural complications and disorders of genitourinary system, not elsewhere classified) is the correct diagnosis code for postoperative urinary retention. R33.9 (Unspecified urinary incontinence) is appropriate for the inability to void. Y83.9 (Surgical operation and other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the operation) correctly identifies the procedure as the cause of the condition. 0T9B70Z (Drainage of Bladder with Drainage Device, Via Natural or Artificial Opening) accurately describes the insertion of a Foley catheter.

Question 4

During a posterior lumbar fusion at L4 to L5 for spinal stenosis, the surgeon accidentally nicks the dura. The fusion was performed via an open posterior approach with fusion of the posterior column using morselized allograft. Patient has a history of asthma for which he takes meds prn.

Accepted Answer

- M48.06: code for spinal stenosis, which was the reason for the surgery
- G97.41: code for the complication of dural tear during the surgery
- J45.909: code for asthma, which the patient has a history of
- Y83.2: code for the surgical approach of open posterior approach
- Y92.234: code for the complication of accidental puncture or laceration during a procedure
- 0SG00K1: code for the procedure of posterior lumbar fusion at L4 to L5 using morselized allograft.

Question 5

Patient had an outpatient ERCP for extraction of a common bile duct stone. The patient developed acute abdominal pain and was admitted to rule out post ERCP pancreatitis.Impression: Post-ERCP pancreatitis

Accepted Answer

The correct codes are K91.89 (Other postprocedural complications and disorders of digestive system), K80.50 (Calculus of bile duct without cholangitis or cholecystitis, without obstruction), K85.90 (Acute pancreatitis, unspecified), Y83.8 (Other surgical procedures), and 0FC98ZZ (Endoscopic extraction of common bile duct). These codes accurately represent the patient's condition and the procedures performed.

Question 6

A patient had a kidney transplant 2 years ago but developed ESRD again because of transplant failure. The patient has been on dialysis for the past year. The patient is now complaining of SOB and edema and is admitted for fluid overload and hemodialysis. Dialysis is performed multiple times during this stay.

Accepted Answer

The answer of A patient had a kidney transplant 2...

Question 7

Patient with a history of a kidney transplant comes to the ER with gastroenteritis. His history is positive for CKD, stage 2, and hypertension.

Accepted Answer

The answer of Patient with a history of a kidney...

Question 8

To aspirate means to ____.

Accepted Answer

To aspirate means to inhale or breathe in a foreign substance, such as food or liquid, into the lungs. This can cause choking, respiratory distress, and other serious problems.

Question 9

Patient is admitted for treatment of primary liver cancer. Patient had a liver transplant 2 years ago. Patient has a past medical history of hypertension and COPD and is a former alcoholic, now in remission. Patient has been sober for 10 years.

Accepted Answer

The answer of Patient is admitted for treatment of primary...

Question 10

Codes under subcategory T86 are used ____.

Accepted Answer

Codes under subcategory T86 are used for both complications and rejection of transplanted organs.

Question 11

A patient had a partial pancreatectomy for chronic pancreatitis and has now developed postpancreatectomy diabetes mellitus along with diabetic nephrosis.

Accepted Answer

- E89.1: Postprocedural endocrine and metabolic disorder, unspecified
- E13.21: Other specified diabetes mellitus with diabetic nephropathy
- Z90.411: Acquired absence of pancreas
- Y83.6: Other specified surgical procedures and interventions, complications of procedure, not elsewhere classified.

The patient had a partial pancreatectomy (Z90.411) which resulted in postpancreatectomy diabetes mellitus (E13.21) and diabetic nephrosis (E89.1). The Y83.6 code is also included to indicate that the complications are a result of a previous surgical procedure. The correct code combination is C.

Question 12

Patient presents with pseudoaneurysm right femoral artery due to recent cardiac cath at another facility.

Accepted Answer

I97.89 is used for other postprocedural complications and disorders of the circulatory system, not elsewhere classified, which includes pseudoaneurysm following a procedure. I72.4 specifies the location of the aneurysm in the femoral artery. Y84.0 is for cardiac catheterization as the cause of the abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure.

Question 13

Patient with decreased visual acuity due to corneal graft rejection. Patient was admitted for cadaver keratoplasty (external) of the left eye with removal of the previous corneal graft.

Accepted Answer

The correct ICD-10-CM code for corneal graft rejection is T86.840. The procedure code for a cadaver keratoplasty with removal of the previous graft is 08R9XKZ.

Question 14

There is a time limit for complications to occur.

Accepted Answer

Complications can occur at any time during or after a medical procedure. There is no time limit for them to occur.

Question 15

The patient had an embolic cerebrovascular accident and was documented by the surgeon as being a postoperative complication. The patient initially had been admitted for treatment of coronary artery arteriosclerosis with CABG. The patient is taken to the OR for an open three-vessel aorta to coronary artery using greater saphenous vein. The left greater saphenous vein was harvested via percutaneous endoscopic approach. Cardiopulmonary bypass is performed during the surgery.

Accepted Answer

The patient has three diagnoses - coronary artery arteriosclerosis (I25.10), embolic cerebrovascular accident (I63.40), and postoperative complication (I97.820). The reason for the surgery is the treatment of coronary artery arteriosclerosis with CABG. The surgical approach involved an open three-vessel aorta to coronary artery using greater saphenous vein, and the left greater saphenous vein was harvested via percutaneous endoscopic approach. Cardiopulmonary bypass was performed during the surgery. Therefore, the correct ICD-10-CM code combination for this scenario is I25.10, I97.820, I63.40, Y83.2, 021209W, 06BQ4ZZ, 5A1221Z.

Question 16

Leakage of peritoneal dialysis catheter. Patient is on dialysis for end-stage renal disease. Peritoneal catheter was removed (percutaneous removal of infusion device from peritoneal cavity). Patient has a history of hypertension and type 2 diabetes with associated neuropathy.

Accepted Answer

The most appropriate codes for this scenario are T85.631A for the leakage of the peritoneal dialysis catheter, N18.6 for end-stage renal disease, E11.22 for the associated neuropathy, Z99.2 for the history of the condition, Y84.1 for the removal of the catheter, and 0WPG33Z for percutaneous removal of the infusion device from the peritoneal cavity. ICD-10-CM code I12.0 for hypertension and E11.40 for type 2 diabetes are also appropriate comorbid conditions. Therefore, choice B is the best option.

Question 17

The term dehiscence means ____.

Accepted Answer

The term dehiscence typically refers to a surgical wound that has opened up or split apart. It can occur for various reasons such as poor wound healing, infection, or improper stitching. A and C are not associated with the term dehiscence, while D is unrelated altogether.

Question 18

A patient is admitted with a urinary tract infection (UTI) resulting from E. coli. The patient has an indwelling Foley catheter after recent radical prostatectomy for prostate cancer. The coder queries the physician regarding the relationship of the UTI and the Foley catheter, and the physician documents that the UTI is caused by the Foley catheter. The patient is morbidly obese with type 2 diabetes, controlled with insulin. The patient is still under active treatment for the cancer.

Accepted Answer

The correct coding includes T83.511A for the infection and inflammation of a genitourinary prosthetic device, initial encounter, since the UTI is caused by the Foley catheter. N39.0 for the UTI itself. B96.20 for unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere, since the specific strain of E. coli is not mentioned. E66.01 for morbid (severe) obesity due to excess calories. E11.9 for type 2 diabetes mellitus without complications, controlled with insulin (Z79.4 indicates long-term (current) use of insulin). C61 for malignant neoplasm of prostate, indicating active treatment for prostate cancer. Y84.6 for the presence of the indwelling catheter.

Question 19

Complications affect only certain body systems.

Accepted Answer

Complications can affect multiple body systems and their interactions, leading to complex medical conditions.

Question 20

Patient was hospitalized 1 month before this admission. During that admit, she was diagnosed with COPD and placed on a ventilator for 2 days. She is admitted today with pneumonia.

Accepted Answer

J18.9 is the ICD-10 code for pneumonia, unspecified organism, which is the primary reason for the patient's current admission. J44.9 is the code for chronic obstructive pulmonary disease (COPD), unspecified, which is a relevant and active condition that affects the patient's treatment and care. The other codes in options A, C, and D are either too specific, not directly relevant to the current admission, or include conditions not mentioned in the provided information.

Quiz 26: Complications of Surgical and Medical Care