Your 71-year-old male patient had surgery to remove a portion of his colon due to recently discovered colon cancer. He is noted to be morbidly obese with a BMI of 42. The surgeon’s operative report indicates that he left the wound open to heal by secondary intention. Treatment with a wound vac has also been ordered. OASIS M1342 is marked as “2” but there’s no indication of any complication. The colon cancer is documented as completely eradicated by the surgery and the patient will not undergo any further treatment for it.
Code the Scenario:
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Primary and Secondary Diagnoses |
M1025 Additional diagnoses |
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M1021a: Aftercare following surgery for neoplasm |
Z48.3 |
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M1023b: Morbid (severe) obesity due to excess calories |
E66.01 |
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M1023c: Body mass index (BMI) 40.0-44.9, adult |
Z68.41 |
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M1023d: Personal history of other malignant neoplasm of large intestine |
Z85.038 |
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M1023e: Acquired absence of other specified parts of digestive tract |
Z90.49 |
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Rationale:
- There’s no indication of any complication present in the surgical wound despite the fact that it’s healing by secondary intention. Use of a wound vac does not imply a complication. Z48.3 is the appropriate code for the surgical aftercare.
- The patient’s morbid obesity will impact his recovery, so it’s appropriate to code for this as a relevant comorbidity. Also assign the code for his BMI, in accordance with tabular instruction.
- The cancer is documented as eradicated and the patient is not undergoing any further treatment. Assign the code for personal history of malignant neoplasm instead of a code for active cancer in this situation.
- Finally, report Z90.49 to capture the removal of part of his colon.