March 2018

Coding Committee Update

R. Dale Blasier, MD, FRCS(C), MBA
Coding Committee Advisory Member

Complications of Spine Surgery in ICD-10

The ICD-10 tabular list of codes offers great granularity and variety in the description of complications which may occur associated with spinal surgery. The ICD-10 codes were initially developed for epidemiology but now have developed into a major mechanism for documenting medical necessity for medical or surgical treatment. Payers routinely consider ICD-10 codes in determining payment decisions for treatment of post-op complications.

Complication codes fall into several categories, these include:

Generic complications of any surgery
Complications after musculoskeletal procedures
Intraoperative and post procedural complications and disorders of musculoskeletal system
Intraoperative and postprocedural complications and disorders of nervous system
Other surgical complications

It is worthwhile to look at these complications, and where they reside within the ICD-10 codeset.

Generic complications of any surgery during or after a procedure are listed in T81-T86.

Because these are listed in the T-section – these are considered injuries and require a 7^th digit (usually “A”). The seventh digit “A” should be appended if the complication is under active treatment. The seventh digit “B” should be appended if the complication is healing routinely. The seventh digit “S” should be appended indicating a sequela or late effect of a complication. These complications include:

Shock T81.1
Disruption of external surgical wound T81.31X (i.e. dehiscence of skin)
Disruption of internal surgical wound T81.32X (i.e. dehiscence of fascia)
Infection T81.4XX. This covers a wide variety of possibilities:
- Intra-abdominal abscess following a procedure
- Postprocedural infection, not elsewhere classified
- Sepsis following a procedure
- Stitch abscess following a procedure
- Subphrenic abscess following a procedure
Wound abscess following a procedure
Retained foreign body T81.500 (i.e. instrument, sponge, unattached implant)
Vascular injury T81.7
Breakdown (mechanical) of internal fixation device of vertebrae T84.216
Breakdown (mechanical) of internal fixation device of other bones T84.218
Breakdown (mechanical) of other internal orthopedic devices, implants and grafts T84.418
Displacement of other internal orthopedic devices, implants and grafts T84.42
Infection and inflammatory reaction due to internal fixation device of spine T84.63
Complications of bone graft T86.83. There are several possibilities:
- T86.830 Bone graft rejection
- T86.831 Bone graft failure
- T86.832 Bone graft infection (Use an additional code to specify type of infection)
Infection and inflammatory reaction due to other internal orthopedic prosthetic devices, implants and grafts T84.7
Pain due to internal orthopedic prosthetic devices, implants and grafts T84.84

Complications after musculoskeletal procedure M96.0 – M96.6

These probably should be labelled “complications after spine treatment”, but they are not. These are listed in the M chapter and are considered diseases and do not require a seven digit. These include:

Pseudarthrosis after fusion or arthrodesis M96.0
Post laminectomy syndrome M96.1
Post radiation kyphosis M96.2
Post laminectomy kyphosis M96.3
Postsurgical lordosis M96.4
Post radiation scoliosis M96.5
Fracture of bone following insertion of orthopedic implant, prosthesis or bone plate M96.6

Intraoperative and post procedural complications and disorders of musculoskeletal system, not elsewhere classified M98.6

These complications describe injury to a musculoskeletal structure which result from a procedure which may or may not be musculoskeletal in nature.

Intraoperative hemorrhage and hematoma of a musculoskeletal structure M96.81
Accidental puncture and laceration of a musculoskeletal structure M96.82
Post procedural hemorrhage of a musculoskeletal structure M96.83
Post procedural hematoma or seroma of a musculoskeletal structure M96.84
Postprocedural hematoma of a musculoskeletal structure following a musculoskeletal system procedure M96.840
Postprocedural hematoma of a musculoskeletal structure following other procedure M96.841
Postprocedural seroma of a musculoskeletal structure following other procedure M96.842

Intraoperative and postprocedural complications and disorders of nervous system, not elsewhere classified G97

These are found in the G chapter. They are considered diseases and not injuries.

CSF leak from spinal puncture G97.0
other reactions to spinal lumbar puncture including headache G97.1
intraoperative hemorrhage and hematoma of a CNS structure complicating a procedure G97.3
intraoperative hemorrhage and hematoma of a CNS structure following a CNS procedure G97.31
intraoperative hemorrhage and hematoma of a CNS structure following other procedure G97.32
inadvertent durotomy during a procedure G97.41
puncture of other CNS organ during a CNS procedure G97.48
puncture of other CNS organ during other procedure G97.49
Postprocedural hemorrhage and hematoma of a nervous system organ or structure following a nervous system procedure G97.51
Postprocedural hemorrhage and hematoma of a nervous system organ or structure following other procedure G97.52
Other intraoperative procedural complications of the nervous system G97.81
Other postprocedural complications of the nervous system G97.81

Other surgical complications:

Acute blood loss anemia D62
Ileus K56.7
Acute embolism and thrombosis of unspecified deep veins of lower extremity (specific to involved vein) I82.40 (i.e. VTE. Codes differ according to which vein is involved)
Urinary retention R33.9

There is a wide variety of conditions described in ICD-10 which can be used to document post-op complications of spine surgery. They are not all described in this article. Often the language used to describe these conditions is not obvious, so it is hoped that exposure to the language of the conditions in this article will aid in the search for the correct ICD-10 code.

To access past Coding Corner articles in our Members' Only section of the website, please click here.

Chair: Barton L. Sachs Committee: Mathew D. Hepler, Past Chair, Advisory; William K. Koeck (C); Kathryn McCarthy Mullooly (C); Matthew E. Oetgen (C); Michael S. Chang; Walaa Elassuity; R. Dale Blasier, Advisory; John Frino