Please provide clarification on the reporting of code 512.1, Iatrogenic pneumothorax. I understand the guideline for chapter 17, Injury and poisoning (800-999) regarding complications of care that states that "code assignment is based on the provider's documentation of the relationship between the condition and the procedure" (Section I.C.17.f.1.a). Does this guideline extend also to code 512.1, which is in the Respiratory System chapter? Does the provider need to document that the pneumothorax is a complication before assigning code 512.1?
If the provider documents iatrogenic pneumothorax or documents that the pneumothorax is due to a procedure, code 512.1, Iatrogenic pneumothorax, should be assigned. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following surgery are classified as complications. First, there must be more than a routinely expected condition or occurrence. In addition, there must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication.