Is it appropriate to assign an additional code to identify the specific complication when reporting a surgical complication?
Yes, it is appropriate to assign an additional diagnosis code. When assigning codes to describe complications of surgical and medical care (categories 996-999), use an additional code to identify the specific complication, if it provides information about the nature of the complication. When the complication code fully describes the condition, no additional code is required. For example, the instructional note at subcategory 996.7, Other complications of internal prosthetic device, implant, and graft, instructs the coder: “Use additional code to identify complication, such as: …venous embolism and thrombosis.” This advice is supported by the Official Guidelines for Coding and Reporting, Section I.C.17.f.1.b., which states, “Use additional code to identify nature of complication.”