Created Feb 2015
Reviewed Dec 2019
In the case of coding a complication following a hemicolectomy with stoma formation which Y83.- external code should be assigned?
Y83.6 Removal of other organ (partial)(total) or Y83.3- Surgical operation with formation of external stoma or both?
I have been told to use the code higher in the ICD-10-AM Tabular List but I cannot find any written guideline on this.
Code assignment should be determined on a case by case basis. There are no guidelines in the ICD-10-AM classification for categories Y83–Y84 Surgical and other medical procedures as the cause of abnormal reaction, or of later complication, without mention of unintentional events at the time of the procedure that instruct coders to assign a code which is higher in the Tabular List of codes.
Clinical coders need to determine the nature of the complication for example, if the complication is because of (or related to) the stoma, then Y83.3- Surgical operation with formation of external stoma is the appropriate code to assign. However, if the complication is because of the hemicolectomy, then Y83.6 Removal of other organ (partial)(total) is the appropriate code to assign.