HS317b – Coding and Classification of Health Data
Injury, Poisoning & External Causes
Comorbidities
Post-admit comorbidity
 This is a condition that arises post-admission
 Satisfies the requirements for determining comorbidity
o Significantly affects the treatment received
o Requires treatment beyond maintenance of the pre-existing condition
o Increases the LOS by at least 24 hours
 When a significant complication occurs during the episode in which the operation
or other care was given, it is most frequently assigned as an additional code with a
diagnosis type 2.
 Should a complication of care arise which is clearly so serious
o that it consumes the majority of the resources
o is responsible for the greatest length of stay
o Assign it as both MRDx and diagnosis type 2
Post procedural condition
 The condition appears in the physician’s documentation as a complication of the
procedure
 The condition is present at discharge
 The condition persists post procedurally for at least 96 hours.
Diagnosis type 9 – External Cause of Injury Code
 Mandatory to use with codes in the range S00-T98 - Injury, poisoning and certain
other consequences of external causes
 U98.~ Place of occurrence is mandatory with
o Codes in the range of W00-Y34
o Exception
 Y06 Neglect and abandonment
 Y07 Other maltreatment syndromes
 Transport accidents
 Legal interventions
 Acts of war
 Medical/surgical misadventures
Post-procedural conditions and complications
Definitions
A Functional Disturbance
 A disturbance of normal function of a body system
o Example:
 arrhythmia is a functional heart disturbance
 malabsorption is a functional gastrointestinal disturbance
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HS317b – Coding and Classification of Health Data
Injury, Poisoning & External Causes
An Early Complication
 a complication that occurs in the immediate post/peri-operative period
o in operating room
o during postoperative monitoring period of 96 hours
 External cause code must be assigned (cause-effect relationship between surgery
performed & specified complication)
A late Complication
 A complication that occurs after 96 completed hours following patient’s departure
from the OR subsequent to any surgical procedure
 Documentation must specify it as postprocedural or postoperative on patient’s
chart
 An external cause required
A postprocedural condition
 When there is no documented evidence of condition arising as a result of or due to
intervention
 Occurs > than 96 hours after the patient leaves OR/intervention room
 Occurs < than 15 days post surgery
 No external cause is required.
Steps for determining post-procedural conditions and complications
1. Index look-up is the first step
2. Whenever a complication of a procedure is not indexed or is not a
synonym of an inclusion or indexed term proceed as follows:
 Code to T80 – T88
 Early complications of medical procedures
 Mechanical complications
 Code to the appropriate system chapter:
 Late complications
 Functional complications
Sandwiching Codes
 When code title of post-procedural condition or complication of surgery does not
fully describe the problem
o Add an additional code to provide more detail regarding the nature of the
condition
 This additional diagnosis is assigned as a diagnosis type 3
 Example: patient experiences severe postoperative pain following hip
arthroplasty. No dislocation or displacement noted on X-ray. Pain management
specialist is asked to follow up.
o T85.8 (2) Other complications of internal prosthetic devices, implants and
grafts NEC
o M25.55 (3) Pain in joint, pelvic region and thigh
o Y83.1 (9) Surgical operation with implant of artificial internal device as
the cause of abnormal reaction of the patient
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HS317b – Coding and Classification of Health Data
Injury, Poisoning & External Causes

Example: A patient develops pneumonia 6 days after a bladder neck suspension
o J95.88 (2) Other post-procedural respiratory disorder
o J18.9 (3) Pneumonia, unspecified
External Cause – Connecting the complication/Condition to the Intervention
 Assigned external cause if:
o Complication or condition arises < 96 hours post-procedure
o Complication or condition involves the operative wound site
o Organ failure or rejections occurs (regardless of timeframe)
o Mechanical complication is involved (regardless of timeframe)
o Medical misadventure is involved
o Physician documents a causal relationship between condition & procedure
 Optional if:
o Disturbance of normal function of body system occurs > 96 hours postprocedure
 Do not to supply external code when
o Postgastric surgery syndromes (K91.1)
o Postlaminectomy syndrome NEC (M96.1)
o Postmastectomy lymphoedema syndrome (I97.2)
o Postsurgical blind-loop syndrome (K91.2)
Myocardial Infarction occurring in the post-operative & peri-operative period
 Code I21.~ (diagnosis type 2) + External cause code from either Y83 or Y84
 Y83 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 procedure
 Y84 Other medical procedures as the cause of abnormal reaction
of the patient, or of later complication, without mention of
misadventure at the time of the procedure
o If occurs during intervention
o If occurs during post-operative monitoring period of 96 hours
 Code I21.~
o If > 96 hours
o No documented evidence of it being post-operative
T81.~ ~ Complications of surgical and medical care, NEC
(See coding standards, Chapter XIX, page 196)
 Classify complications of surgical procedures that are not identified within a
specific body system chapter.
 Post operative hemorrhage or hematoma
 Accidental puncture and laceration during a procedure
 Disruption of operative wound
 Infection following a procedure
T88. ~ ~ Other complications of surgical & medical care, not elsewhere classified
 Use to capture any complication of surgical & medical care
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HS317b – Coding and Classification of Health Data
Injury, Poisoning & External Causes


T88.0 – T88.7 codes assigned when capturing specified complications of
immunization, administration of anesthetic or unspecified adverse effect of drug
or medication.
T88.8~ codes assigned for complications due to any of the following:
phototherapy, ultrasound therapy, electroshock therapy, local applications of
fomentations, plasters, etc, Paraffinoma
Post-procedure Signs and Symptoms
 Can only be classified as postprocedural conditions (Dx type 2) when physician
documentation indicates:
o They are still present at discharge
o They persist postprocedurally for at least 96 hours
o A more precise diagnosis has not been identified
o That the symptom is due to or a direct result of the procedure.
 Assigned an appropriate external cause
T86


Failure and rejection of transplanted organs and tissues
Use this when source of the organ/tissue is another person or animal
o Do not use when original source of graft or flap is the patient
himself/herself. It is not classified as a transplant
When the complication is infection, failure or absolute rejection
T82 – T85 Complications of Devices, Implants or Grafts
 Mandatory to include external cause code
 If infectious organism documented identify it with additional code (B95-B97)
Adverse reactions versus Poisonings
Adverse reactions, Allergic reaction, toxicity, etc
 May occur when a substance is taken as prescribed by a physician
o Correct substance was administered appropriately
 Code adverse reaction
 Code reaction/manifestation (diagnosis type 3)
 Code external cause code from the drug table
Poisonings when
 It is not prescribed by a physician
 Dosage is altered from prescription
 It is a non medicinal substance
 Self medication with non-prescription drug
 Any medication taken with alcohol
 Drug overdose
o Code poisoning code
o Code manifestation (Diagnosis type 3)
o Code external cause code
o Code place of occurrence
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HS317b – Coding and Classification of Health Data
Injury, Poisoning & External Causes
Poisonings
 All drugs involved in the poisoning must be coded
 Presumed to be accidental when not stated as intentional self harm
 Illicit drug poisoning generally classified as accidental
o unless clearly documented to be either suicidal or homicidal intent
 Noncompliance with therapy or discontinuance of a drug.
o It is not a poisoning.
o It is not an adverse effect.
o Code manifestation.
o Code Z91.1 Personal history of noncomplicance with medical treatment
and regimen
Injuries
 Code each injury to the greatest degree of specificity
 When there are multiple injuries
o Code the most severe (or life threatening) first
o When two or more injuries equal in severity
 Assign the injury receiving treatment that consumes the largest
portion of hospital resources first
 Current versus old injuries
o Old Injury is one in which the repair has been completed. However,
following the repair, functionality has failed to return and thus
continuing treatment is required.
o Current Injury is one for which the repair is proceeding or has yet to be
completed.
 Has it occurred within past 365 days
 Skin, muscle or tendon injury
 < 14 days old.
o Yes – code to current injury
 > 14 days old & treatment completed.
o Yes – code as old injury
 Is initial (planned) treatment still underway.
o Yes – code as current injury.
 Intra-cranial injury + fracture of skull
o Code first to intra-cranial injury.
o Follow this by an additional code for the fracture.
o Example:
 Traumatic subarachnoid hemorrhage with closed fracture of
base of skull. Patient suffered a brief loss of consciousness
 S06.610 Traumatic subarachnoid hemorrhage, without open intra-cranial
wound, with brief loss of consciousness
 S02.100 Fracture of base of skull, closed

Injury to blood vessels due to fracture, open wound or other injury
o Code additional code to indicate injury to the blood vessel
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HS317b – Coding and Classification of Health Data
Injury, Poisoning & External Causes
Open Wounds
 Include animal bites, cuts, lacerations, avulsion of skin & subcutaneous tissue &
puncture wounds with or without penetrating foreign body
 Complicated
o Delayed healing
o Delayed treatment
o Foreign body
o Major infection
Fractures – Closed versus Open
 Documentation must support open, otherwise classify as closed
 “condyle”, “coronoid process”, “ramus”, and “symphysis” indicates the portion
of the bone fractured, not the name of the bone involved.
 Bilateral injuries may be captured by using the same code twice
 Interventions: immobilization, reduction, fixation or even a combination
 Fractures due to Crushing Injuries
o Code fracture first (diagnosis type MRDx or type 1)
o Code crush injury code as diagnosis type 3
o Applies to internal organ crushing injury also
Burns & Corrosions
 Occur in degrees which relates to the thickness of the burn.
o First degree – erythema only. Superficial
o Second degree – involves epidermal loss and blistering. Also called
partial thickness burn.
o Third degree – involves full thickness skin loss and/or deep necrosis of
any underlying tissue.
 Burns of one site that exhibit multiple degrees
o Code to most severe burn of that site
 Burns of multiple sites
o Most severe burn site is assigned as MRDx
o In burns of multiple sites of same degree, the larger body surface area
takes precedence as MRDx
o Assign separate codes for burns of each site whenever possible
 Mandatory to assign code that classifies extent of body surface area
 Mandatory to assign external cause
 Mandatory to code place of occurrence
 Admissions for change of burn dressing. MRDx Z48.0~ Attention to surgical
dressings and sutures.
o Code appropriate burn code as diagnosis type 3.
o Mandatory to assign external cause.
o Mandatory to code place of occurrence.
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