Effective October 1, 2011, a new set of codes has been created for the complications of weight loss procedures: infection due to gastric band procedure (539.01); other complications of gastric band procedure (539.09); infection due to other bariatric procedure (569.81); and other complications of other bariatric procedure (539.89).
Bariatric surgery and gastric band procedures are very successful in most cases for weight reduction; however, there are some associated complications, such as infections and device malfunctions. Previously, in ICD-9-CM, complications of bariatric surgery were indexed to code 997.4, Digestive system complications.
Gastric banding or lap-band surgery is a surgical method to help obese patients reduce their weight by placing an adjustable band around the stomach, creating a smaller stomach from which to digest food. Gastric banding works by restricting the size of the stomach and slowing down digestion.
Complications can arise from the band itself, including but not limited to band leakage; band slippage; band erosion; and infection. In some instances the stoma can become obstructed. The opening of the stomach pouch created through the gastric banding procedure is referred to as a stoma. Because the stoma is significantly smaller than a typical stomach, it can become blocked if food is not chewed sufficiently. A blocked stoma can cause severe pain as well as the inability to ingest further food particles. If the stoma frequently becomes blocked, a surgeon may need to loosen the gastric band in order to prevent further obstructions.
Malabsorptive/restrictive surgeries (e.g., roux-en Y gastric bypass and biliopancreatic diversion) are invasive procedures that combine the creation of a small stomach pouch to restrict food intake and construction of bypasses of the duodenum and other segments of the small intestine to cause malabsorption (decreased ability to absorb nutrients from food). Surgical complications of malabsorptive surgery may involve anastomotic (staple line) leak or stricture, and infection. Another risk of gastric bypass is dumping syndrome, in which food is "dumped" from the stomach into the intestines too quickly, before it has been properly digested. Approximately 85% of patients who undergo gastric bypass have some dumping.
Symptoms include nausea, bloating, pain, sweating, weakness, and diarrhea. Dumping is often triggered by high-carbohydrate foods, and adjusting the diet often helps.
New category 539 Complications of bariatric procedures New subcategory 539.0 Complications of gastric band procedure New code 539.01 Infection due to gastric band procedure Use additional code to specify type of infection, such as: abscess or cellulitis of abdomen (682.2) septicemia (038.0-038.9) Use additional code to identify organism (041.00-041.9) New code 539.09 Other complications of gastric band procedure Use additional code(s) to further specify complication New subcategory 539.8 Complications of other bariatric procedure Excludes: complications of gastric band surgery (539.01-539.09) New code 539.81 Infection due to other bariatric procedure Use additional code to specify type of infection, such as: abscess or cellulitis of abdomen (682.2) septicemia (038.0-038.9) Use additional code to identify organism (041.00-041.9) New code 539.89 Other complications of other bariatric procedure Use additional code(s) to further specify complication
The patient is a 35-year-old male who was admitted to the hospital with abdominal pain and nausea and vomiting. A CT scan revealed fluid around the gastric band indicative of an infection. The provider documented that the patient had an infection of the gastric band. The patient received intravenous antibiotics, his condition improved and he was discharged on day five. How should the gastric band infection be coded?
Assign code 539.01, Infection due to gastric band procedure, for the gastric band infection.