What is the correct ICD-10 (International Classification of Diseases, 10th Revision) diagnosis code for an access site hematoma following a percutaneous coronary intervention (PCI)?

From the Guidelines

The correct ICD-10 diagnosis code for an access site hematoma following a percutaneous coronary intervention (PCI) is I97.620, which specifically denotes "Postprocedural hemorrhage of a circulatory system organ or structure following a cardiac catheterization." This code accurately captures the complication of hematoma formation at the vascular access site after a PCI procedure. When documenting this condition, it's essential to also code the original condition that necessitated the PCI, as noted in guidelines such as those from the American College of Cardiology/American Heart Association Task Force on Practice Guidelines 1. The hematoma occurs when blood leaks from the puncture site in an artery (typically femoral, radial, or brachial) and collects in the surrounding tissues. Key factors associated with vascular complications, including access site hematoma, as outlined in the ACC/AHA/SCAI Practice Guidelines 1, include the use of fibrinolytic or platelet inhibitor therapy, coexisting peripheral vascular disease, female gender, prolonged heparin use with delayed sheath removal, and older age. Proper documentation should include the location, size, and any interventions required to manage the hematoma, as these details may affect coding specificity and accuracy in the medical record. Monitoring post-PCI hematocrit for a decrease greater than absolute 5% to 6% is crucial, and computed tomography can confirm the diagnosis of retroperitoneal hematoma, with more than 80% of patients being treated conservatively with transfusions without surgery, as discussed in the context of managing complications after PCI 1. Given the potential for significant morbidity and the importance of accurate coding for both clinical and administrative purposes, using the specific ICD-10 code for access site hematoma is vital for ensuring that patient care and outcomes are appropriately tracked and managed.

From the Research

Access Site Hematoma Diagnosis Code

The correct ICD-10 diagnosis code for an access site hematoma following a percutaneous coronary intervention (PCI) is not explicitly stated in the provided studies. However, the studies discuss the complications and risk factors associated with access site hematomas after PCI.

Risk Factors and Complications

Some of the key points from the studies include:

• Access site hematoma is a common complication after PCI, with a frequency of 1.3% to 8.9% 2
• Risk factors for access site hematoma include female gender, low body surface area, higher femoral artery puncture, and use of glycoprotein IIb/IIIa inhibitors 3, 2
• Access site hematoma can lead to serious complications, such as retroperitoneal hematoma, which can cause abdominal pain, groin pain, back pain, and hypotension 3
• The incidence of retroperitoneal hematoma after PCI is 0.74% 3

ICD-10 Diagnosis Code

Although the studies do not provide a specific ICD-10 diagnosis code for access site hematoma, the code for "Hematoma of access site" is not mentioned. However, the code for "Hematoma of skin and subcutaneous tissue" is ICD-10 code M79.1, and the code for "Other complications of procedures, not elsewhere classified" is ICD-10 code T81.9 4, 2

Key Points

Some key points to consider when diagnosing and coding access site hematomas include:

• The location and severity of the hematoma
• The presence of any underlying conditions or risk factors
• The use of any medications or devices that may contribute to the development of the hematoma
• The need for prompt recognition and treatment to prevent serious complications 5, 6