Clinical coding secrets (13)
By
Dr.Sedeek El Hakeem (MBBS, TQM, cert.CII, IFCE)
Today
I’ll present a new dose of Clinical coding secrets, I have been abstracted them
from my reading Australian Coding Standards and practicing Australian clinical
coding(ICD10AM,ACHI) at a private general hospital (150 beds) in KSA
Sequelae
of Injuries, Poisoning, Toxic Effects and Other External Causes
Definition
A 'sequela' of an
injury is a current condition that was caused by a previously occurring injury,
poisoning, toxic effect or other external cause.
Oesophageal stricture
due to previous ingestion of hydrochloric acid.
Classification
There is no time limit
as to when a sequela code can be used. The residual condition may be apparent
immediately following the acute phase, such as loose bodies in a joint due to a
previous fracture, or it may occur months or years later, such as scarring due
to previous tendon laceration.
A sequela of injury,
poisoning, toxic effect or other external cause may be documented in one of the
following ways:
• late (effect of)
• old
• sequela of
• due to previous injury, poisoning, toxic
effect or other external cause that occurred in a previous episode of care
• following a previous injury, poisoning,
toxic effect or other external cause that occurred in a previous episode of
care
As the underlying cause
is no longer current, a code for an acute injury, poisoning, toxic
effect or other external cause is not assigned.
An
admission for tendon repair following laceration of tendon of finger two weeks
ago is not a sequela as the laceration is still present and being treated.
The coding of sequelae
of injury, poisoning, toxic effects or other external causes requires three
codes:
• the residual condition or nature of the
sequela (current condition)
• the cause of the sequela (the previous condition)
• the external cause of the injury,
poisoning, toxic effect, etc
The
residual condition or nature of the sequela is sequenced first, followed by the
cause of the late effect.
Malunion following
fracture of radius caused by fall from ladder at home while painting house.
Codes: M84.03 Malunion of fracture, forearm
T92.1 Sequelae
of fracture of forearm and upper arm
Y86 Sequelae
of other accidents
An appropriate place of
occurrence code (Y92.-)
The sequelae diagnosis
codes for injury are:
T90.- Sequelae of injuries of head
T91.- Sequelae of injuries of neck and trunk
T92.- Sequelae of injuries of upper limb
T93.- Sequelae of injuries of lower limb
T94.- Sequelae of injuries involving
multiple and unspecified body regions
T95.- Sequelae of burns and frostbite
T96 Sequelae of poisonings by drugs,
medicaments and biological substances
T97 Sequelae of toxic effects of
substances chiefly nonmedical as to source
T98.- Sequelae of other and unspecified
effects of external causes
The external cause
sequelae codes are:
Y85.- Sequelae of transport accidents
Y86 Sequelae of other accidents
Y87.- Sequelae of intentional self-harm,
assault and events of undetermined intent
Y88.- Sequelae with surgical and medical
care as external cause
Y89.- Sequelae of other external causes
Further treatment of an
injury (eg removal of an orthopaedic pin) is not to be regarded as a sequela of
the original injury. These cases should be assigned to the appropriate Z code
describing the need for further treatment (eg Z47.0 Follow-up care involving
removal of fracture plate and other internal fixation device) with the
appropriate procedure code.
Today I have been presented
a new dose of Clinical coding secrets; I hope this dose will help you to sail
safely in the sea of clinical coding as you know coding translates medical
service into money
Next
time I’ll provide a new dose of Clinical coding secrets
For
more information contact me on
@dr8q
sedeeks2011@gmail.com
0582128676
