Biloma pós-colecistectomia

"Como codificar biloma pós-colecistectomia?
 Estive a pesquisar o que é um biloma: uma coleção de bílis na cavidade abdominal.
 Mas não sei como codificar como complicação"

/Responde Fernando Lopes)
 
 
A acumulação de bílis na cavidade peritoneal, na sequência de uma colecistectomia, resulta habitualmente da deiscência de uma sutura ou de uma anastomose e essa complicação também deveria ser codificada.
A ICD-10-CM também prevê a codificação de complicações como a hemorragia, o hematoma, o seroma... mas não prevê o biloma.
Se só for referido o biloma deverá codificar-se deste modo:
 
Complication
    postprocedural 
          specified (NEC) 
                digestive K91.89


K91.89 Other postprocedural complications and disorders of digestive system 
Use additional code, if applicable, to further specify disorder 
Excludes2: postprocedural retroperitoneal abscess (K68.11)
 
Uma nota antiga do Coding Clinic acrescentava a codificação de outros transtornos das vias biliares (ver a seguir).
 
Fernando Lopes  
 
--------------------------------------------------------------------------
Postoperative biloma 
Coding Clinic, Second Quarter 1999 Page: 14         
 
Question:
This patient, who is one week status post laparoscopic cholecystectomy that was converted to an open cholecystectomy, was admitted for severe generalized abdominal pain associated with intractable nausea and vomiting. The CT scan of the abdomen reveals a biloma in the right subhepatic space.  A catheter was placed with ultrasound and fluoroscopic guidance for drainage.  How is postoperative biloma coded and what procedure codes should be assigned?
 
Answer:
Assign code 997.4, Digestive system complications, as the principal diagnosis. Assign code 576.8, Other specified disorders of biliary tract, as an additional diagnosis. Assign code 54.91, Percutaneous abdominal drainage, for the drainage performed.  Code 88.76, Diagnostic ultrasound of abdomen and retroperitoneum, may be assigned as an additional code for the ultrasound guidance.
 
Biloma, loculated bile leaks or an extraductal collection of bile within a confined capsular space, is a complication associated with abdominal trauma or abdominal surgery. The condition results from either an accessory duct entering the gallbladder bed directly or from the cystic duct stump. The presenting biliary symptoms include nausea and vomiting, abdominal pain and tenderness, and jaundice. If persistent leakage from the biliary system is present, endoscopic or percutaneous stenting of the bile duct or operative control of the leakage may be necessary.
 
Copyright 1984-2007, American Hospital Association ("AHA"), Chicago, Illinois.  Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.
--------------------------------------------------------------------------