Intraoperative and postprocedural complications of the spleen
ICD-10 Codes (0)
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Updates & Changes
FY 2026 Updates
Deleted Codes
No codes deleted in this range for FY 2026
No significant changes for FY 2026
This range maintains stability with current coding practices
Historical Changes
- •FY 2025: Routine maintenance updates with minor terminology clarifications
- •FY 2024: Enhanced specificity requirements for certain code ranges
- •FY 2023: Updated documentation guidelines for improved clarity
Upcoming Changes
- •Proposed updates pending review by Coordination and Maintenance Committee
- •Under consideration: Enhanced digital health integration codes
Implementation Guidance
- •Review all FY 2026 updates for D78-D78 codes before implementation
- •Always verify the most current codes in the ICD-10-CM manual
- •Ensure clinical documentation supports the selected diagnosis codes
- +3 more guidance items...
Range Overview
The D78-D78 code range in the ICD-10 medical classification list is specifically designated for intraoperative and postprocedural complications of the spleen. These codes are used to document complications that occur during or after surgical procedures involving the spleen. The scope of these codes includes but is not limited to splenic injury, hemorrhage, and infarction that occur during or after a surgical procedure.
Key Usage Points:
- •Always code to the highest level of specificity.
- •Use additional codes to identify any associated conditions or complications.
- •The D78 codes are not to be used for conditions classified under other codes.
- •Ensure the documentation supports the use of D78 codes.
- •Remember to code separately any routine postoperative care.
Coding Guidelines
When to Use:
- ✓When a patient experiences a splenic injury during a surgical procedure.
- ✓When a patient has a postoperative hemorrhage of the spleen.
- ✓When a patient suffers from postprocedural infarction of the spleen.
- ✓When a patient has other intraoperative and postprocedural complications of the spleen.
- ✓When a patient experiences an unspecified intraoperative and postprocedural complication of the spleen.
When NOT to Use:
- ✗When a patient has a pre-existing splenic condition.
- ✗When a patient has a complication not related to the spleen.
- ✗When a patient has a complication from a non-surgical procedure.
- ✗When a patient's complication is better classified under another code.
- ✗When a patient is receiving routine postoperative care.
Code Exclusions
Always cross-verify the exclusion list with the patient's medical record to ensure accurate coding.
Documentation Requirements
Documentation for D78-D78 codes should be comprehensive, clearly indicating the nature of the intraoperative or postprocedural complication of the spleen. It should include the type of surgical procedure performed, the specific complication experienced, and any associated conditions or complications.
Clinical Information:
- •Type of surgical procedure performed
- •Specific intraoperative or postprocedural complication
- •Timing of the complication (intraoperative or postprocedural)
- •Any associated conditions or complications
- •Treatment provided for the complication
Supporting Evidence:
- •Operative report
- •Postoperative notes
- •Imaging reports
- •Laboratory results
Good Documentation Example:
Patient underwent splenectomy due to splenomegaly. Intraoperatively, patient suffered a splenic injury, which was managed with suturing.
Poor Documentation Example:
Patient had surgery, suffered a complication.
Common Documentation Errors:
- ⚠Not coding to the highest level of specificity
- ⚠Not documenting the timing of the complication
- ⚠Not including associated conditions or complications
- ⚠Not providing supporting evidence
Range Statistics
Coding Complexity
The coding complexity for the D78-D78 code range is considered medium due to the need to accurately identify the specific type and timing of the complication, code any associated conditions or complications, and ensure the documentation supports the use of these codes. Additionally, coders must always code to the highest level of specificity.
Key Factors:
- ▸Determining the specific type of complication
- ▸Identifying the timing of the complication
- ▸Coding any associated conditions or complications
- ▸Ensuring the documentation supports the use of D78 codes
- ▸Coding to the highest level of specificity
Specialty Focus
The D78-D78 code range is primarily used by surgeons, particularly those specializing in abdominal or general surgery. These codes are also relevant for hospitalists and other healthcare providers involved in postoperative care.
Primary Specialties:
Clinical Scenarios:
- • A patient undergoing splenectomy suffers an intraoperative splenic injury.
- • A patient presents with postoperative hemorrhage of the spleen following a laparoscopic splenectomy.
- • A patient experiences postprocedural infarction of the spleen after a splenic artery embolization.
- • A patient has an unspecified postprocedural complication of the spleen following a splenopexy.
Resources & References
There are several resources available for coders to reference when using the D78-D78 code range. These include the official ICD-10-CM guidelines, clinical reference sources, and educational materials.
Official Guidelines:
- ICD-10-CM Official Guidelines for Coding and Reporting
- American Health Information Management Association (AHIMA) Coding Guidelines
- Centers for Medicare & Medicaid Services (CMS) ICD-10 Provider Resources
Clinical References:
- American College of Surgeons (ACS) Clinical Guidelines
- UpToDate Clinical Database
Educational Materials:
- American Academy of Professional Coders (AAPC) Educational Resources
- AHIMA ICD-10 Training Materials
Frequently Asked Questions
Can D78 codes be used for complications from non-surgical procedures?
No, D78 codes are specifically for intraoperative and postprocedural complications of the spleen. Complications from non-surgical procedures should be coded separately using the appropriate ICD-10 codes.