b. Postoperative complications affecting a specific an atomical site or body system
are classified to categories 001-799 in the main classification. Complications affecting
more than one site or body system are classified to categories 996-999 of the chapter
on injury and poisoning. Of particular significance are the last three lines of the
exclusion note which state: "any condition classified elsewhere in the Alphabetic Index
when described as due to a procedure." An additional code, when possible, will be
used to specifically identify the anatomical site or the manifestation of the postoperative
complication. When multiple coding is used, sequencing of codes is important. A
postoperative complication may be principal diagnosis if it is the cause for readmission.
The codes from categories 996-999 take precedence in sequencing, when an additional
code is used for specificity.
c. Subcategories/subclassifications codes 996.0 -996.5 are specific for mechanical
complications resulting form various prosthetic devices or implants. They include
mechanical breakdown or obstruction, leakage, displacement, perforation, or protrusion
of the devices. Complications of a mechanical nature of internal prosthetic devices and
implants are classified to 996.0-996.5. Complications involving implants and internal
devices are classified to 996.7. The remaining codes in category 996 are for
physiological complications; for example, complications or rejections following organ or
tissue transplants with an accompanying code from category V42 to identify the specific
organ or tissue involved. (See principle XVI (Organ and Tissue Transplants) for correct
sequencing of codes.)
2. Medical Care Complications.
a. Subcategory codes 999.0 through 999.9 will be used when the diagnostic
statement specifies that condition as a complication resulting from medical care.
Carefully read the inclusion and exclusion terms.
b. Subcategory code 999.9 may be used alone to indicate a complication of
medical care when the specific condition is not mentioned by the responsible physician.
When possible, an additional code will be used for specificity to completely describe the
3. Complications vs. Aftercare.
a. Coding personnel should thoroughly review the record to ascertain whether the
condition requiring hospitalization was in fact a complication or aftercare.
b. An admission for aftercare is usually scheduled, whereas an admission for
complication of surgical or medical care occurs at the time the complication develops.
1. Read carefully the "excludes " note, Page 867 in Volume 1, ICD-9-CM.
DIAGNOSIS: Infection of surgical wound (Cesarean section 3 weeks ago)