Journal of AHIMA - July 2011

Coding Notes

Medical Devices Associated with
Adverse Incidents

SOME EXAMPLES OF codes for medical devices associated with adverse incidents in diagnostic and therapeutic use (Y70–Y82) include:

Y71 Cardiovascular devices associated with adverse incidents

Y71.0 Diagnostic and monitoring cardiovascular devices associated with adverse incidents

Y71.1 Therapeutic (nonsurgical) and rehabilitative cardiovascular devices associated with adverse incidents

Y71.2 Prosthetic and other implants, materials and accessory cardiovascular devices associated with adverse incidents

Y71.3 Surgical instruments, materials, and cardiovascular devices (including sutures) associated with adverse incidents

Y71.8 Miscellaneous cardiovascular devices associated with adverse incidents, not elsewhere classified

only for use if the documentation in the record specifies that the intent cannot be determined. (Coding Guideline I.C. 20.h. 1)

Late-effect external cause codes. Late effects are reported using the external cause code with the seventh character extension “S” for sequela. These codes should be used with any report of a late effect or sequela resulting from a previous injury. ( Coding Guideline I.C. 20.i. 1)

Cause of injury identified by the federal government (FBI) as terrorism. When the cause of an injury is identified by the federal government (FBI) as terrorism, the first-listed external cause code should be a code from the terrorism category (Y38). The definition of terrorism employed by the FBI is found at the inclusion note at the beginning of category Y38.

Use additional codes for the place of occurrence (Y92.-). More than one Y38 code may be assigned if the injury is the result of more than one mechanism of terrorism.

When the cause of an injury is suspected to be the result of terrorism, a code from category Y38 should not be assigned. Suspected cases should be classified as assault. (Coding Guideline I.C. 20.j. 1, 2) ¢

References

National Center for Health Statistics. “ICD-10-CM Official Guidelines for Coding and Reporting.”March 1, 2011. www. cdc.gov/nchs/data/icd9/10cmguidelines2011_FINAL.pdf.