Exam 25: Complications of Surgical and Medical Care

When no entry is found under the main term for the condition,the coder should refer to the main term ____________________.

To aspirate means to ____.

During a posterior lumbar fusion at L4-L5 for spinal stenosis,the surgeon accidentally nicks the dura.The fusion was performed via an open posterior procedure on the posterior column using morselized allograft.Patient has a history of asthma for which he takes meds p.r.n.

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.

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

Patient with an intestine transplant with diverticulitis of the intestinal graft: __________

What are some examples of procedures resulting in complications that occur during medical care and not during surgery?

Coding complications always imply that poor care has been delivered.

Patient has subclavian vein thrombosis due to PICC: __________

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

Iatrogenic is a term used to signify that a condition is a result of treatment.

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

A patient comes to the hospital with acute appendicitis and is taken to the OR for an open appendectomy.During the course of the surgery,the liver is accidentally lacerated and repaired.The patient recovers without any ill effects.__________

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

Mechanical complications are related to ____________________ malfunctions.

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

A patient comes to the hospital with chronic cholecystitis,and a laparoscopic cholecystectomy is performed.The patient's bowel function was slow to return,and on day 3 the patient developed a post-operative ileus.__________

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

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

What does DVT stand for?