Most Intra-operative & Post- procedural complications are included in Chapter 17 – Injury and Poisoning.

Anemia, document:

• Nutritional, specify:
  – Iron deficiency
  – Vitamin B12 deficiency
  – Folate deficiency (dietary or drug-induced)
  – Other (protein, megaloblastic)
• Hemolytic, specify:
  – Due to enzyme disorders
  – Sickle-cell disorders
  – Other hereditary or acquired
• Aplastic
• In other chronic diseases (specify the underlying disease)

Spleen document Intra-operative & Post-procedural complications, specify:

• Intra-operative (during) or Post-procedural (following)
• Hemorrhage, hematoma, accidental puncture or accidental laceration of the spleen
• Procedure on the spleen or other procedure

Intra-operative & Post-procedural complications are also included in other chapters based on specific site/system documentation.

•  Type
•  Site

General Documentation:

•  Type of pain:
  – Acute or chronic
  – Post-procedural (specify procedure)
  – Due to trauma
  – Neoplasm related (specify neoplasm and site)
•  Site specificity, when applicable
•  Laterality (right, left, bilateral), when applicable
•  Dominant or Non-dominant side, when applicable

Chronic Pain:

•  Central pain syndrome and Chronic pain syndrome are different than the term ‘chronic pain’ and will be coded based on your specific documentation.

Migraine, document:

•  With or without aura
•  Intractable or not intractable
•  With or without status migrainosus

Epilepsy, document:

•  Localization related or generalized
• Intractable or not intractable
• With or w/o status epilepticus

– Limited to breakdown of skin
– With fat layer exposed
– With necrosis of muscle
– With necrosis of bone

“Pain” is also included in other chapters based on specific documentation (site, not specified as acute or chronic).