Exam 26: Complications of Surgical and Medical Care

What does DVT stand for?

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.

The term dehiscence means ____.

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

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.

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.

If the documentation is unclear whether the diagnosis was the result of a procedure or condition, a physician query should be initiated.

Mechanical complication of gastrostomy: __________

NSTEMI following laparoscopic appendectomy for acute appendicitis. Physician documents that the NSTEMI was due to the procedure: __________

Leaking silicone breast implant, initial visit: __________

Codes for complications may be located in the chapter for specified body sites.

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.

When looking for a complication code in the Index, the coder should first look under the ____________________.

Patient with acute osteomyelitis right femur due to infected right knee joint replacement, initial encounter: __________

Mechanical complications are related to ____________________ malfunctions.

Pneumonitis due to organism growing in ventilation (air conditioning) system: __________

Code only complications that occur within 2 weeks of a transplant surgery.

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.

Match each definition to one of the following items. -The decay of tissue

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.