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.
EXAMPLE 1:
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is no longer current, a code for an acute injury, poisoning, toxic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.
EXAMPLE 2:
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.
EXAMPLE 3:
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
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