HIMP 2210 – Health Data Classification II

Exercise 13.4 – Post-Intervention Conditions

Scenario Dx Dx Dx Code(s)
Prefix Type Cluster S L E

1. This patient had undergone a M A T81.4

laparoscopic cholecystectomy three 9 A Y83.6
weeks previously. She is now admitted
with a postoperative wound infection.
A swab was taken for C&S which was
positive for a bacterial infection. The
patient was treated with intravenous
antibiotics.

2. This patient had been treated in this M A T81.4

hospital 4 weeks previously, when a 1 A U82.1
total abdominal hysterectomy was 3 A B95.6
performed. She has been admitted at 9 A Y83.6
this time with a postoperative wound
infection. Culture and sensitivity of the
infected area shows that it is MRSA.
The patient is placed in isolation and
treated with intravenous antibiotics.

3. This patient is admitted for removal M A T82.79

and replacement of an infected cardiac 9 A Y83.1
pacemaker. This had been implanted 6 2 B J18.9
twelve months previously. On the 2 nd 9 B Y83.1
hospital day the patient was taken to
1.HZ.55.LA-NL
the OR. Under general anesthesia the
1.HZ.53.LA-NL
internal fixed rate cardiac pacemaker
was removed through an open
approach. The area was thoroughly
irrigated and a new similar cardiac
pacemaker was then implanted. The
patient tolerated the procedure well.
Following the revision procedure, the
patient develops pneumonia and
remains in hospital for six more days.
4. The patient is admitted for a total M C18.9
colectomy with ileostomy for colon 2 A T81.4
cancer. On postop. Day 2, he develops 6 3 A A41.2
6 2 A T81.1

1
postoperative staphylococcus sepsis. 6 3 A R57.2
On post-operative day 4, he is 9 A Y83.3
transferred to the ICU with septic
shock following the procedure.
[CIHI page 156]

 Sepsis is classified as post procedural

 There is a ‘Use Additional code’ at T81.4 saying it is mandatory to assign an additional code to
provide specificity
o Therefore, mandatory to assign A41.2
o This is considered ‘additional information’ and therefore Diagnosis Type 3
 Post-procedural shock is found by going to Shock, surgical
o There is a ‘Use additional code’ note saying to identify septic shock
o This is mandatory