Surgical Diagnoses That Need Extra Detail in ICD-10-CM

Part 2 of 5

Sepsis after a procedure: T81.44X-

When sepsis is a complication of a procedure, report T81.44X- (sepsis following a procedure) with the 7th character for the encounter (A, D or S), then a code for the infection's organism if known. A bloodstream infection caused by a central venous catheter has its own code: T80.211-.

Organism codes still matter. For example, A41.54 is sepsis due to Acinetobacter baumannii.

Part 3 of 5

Parkinson's disease: G20 is no longer billable

G20 is now a category, not a code. Pick one of these, based on whether the patient has dyskinesia (involuntary movements) and fluctuations (the medicine wearing off between doses):

A surgeon placing a feeding tube for a Parkinson's patient may not record these details, even though the neurologist knows them. Code from the documentation for the encounter you're coding; if it doesn't say, query the surgeon rather than picking G20.C.

Part 4 of 5

Desmoid tumor by site: D48.110–D48.119

A desmoid tumor grows from connective tissue. It doesn't spread like a cancer, but it can grow into nearby tissue, most often the abdominal wall, shoulder or thigh. It used to be coded to D48.1; it now has its own codes by site.

Part 5 of 5

Family history of colon polyps: Z83.710–Z83.719

A family history of colon polyps can justify a colonoscopy sooner or more often than the usual screening schedule. The code now says what kind of polyp the relative had: