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2025 ICD-10-CM code K94.20

Unspecified complication of a gastrostomy.

Refer to the official ICD-10-CM coding guidelines for detailed instructions on selecting the most appropriate code.Use the most specific code available to describe the complication. If the complication is not digestive system-related, another code should be considered.

Medical necessity for the treatment of a gastrostomy complication is typically established by documentation of symptoms, diagnostic findings, and the necessity of intervention to prevent further harm or improve the patient's condition.The documentation should clearly link the complication to the gastrostomy procedure.

The clinical responsibility for this code rests with the gastroenterologist or surgeon managing the patient's gastrostomy and any resulting complications.This includes diagnosis, treatment, and follow-up care.

IMPORTANT K94.29 (Other complications of gastrostomy) should be used if a specific complication is documented.Consider also codes from other chapters if the complication is not digestive-system related (e.g., infection codes).

In simple words: This code is used when there's a problem with a feeding tube placed directly into the stomach.The problem isn't specified, but it could be an infection, bleeding, leak, or the tube not working correctly.

This code classifies any unspecified complication arising from a gastrostomy procedure.A gastrostomy is a surgical procedure creating an opening (stoma) in the abdominal wall and stomach, allowing for direct feeding.Complications can include infection, bleeding, leakage, or dysfunction of the stoma or tube.

Example 1: A patient with a gastrostomy tube experiences significant bleeding from the stoma site.K94.20 is assigned, along with codes describing the bleeding (e.g., hemorrhage). Further investigation might reveal the cause of bleeding., A patient develops a localized infection at the gastrostomy site. K94.20 is used, supplemented by appropriate infection codes, to describe the complication.The infection needs treatment with antibiotics., A patient's gastrostomy tube becomes dislodged.K94.20 captures this complication, and further coding may reflect the reason for dislodgement, attempts at replacement, or resulting consequences.

Complete medical record documentation is essential for accurate coding.This includes the date of gastrostomy placement, details of the complication (type, location, severity), treatment provided (e.g., medication, surgery), and the patient's response to treatment.Imaging studies (if performed) should also be documented.

** This code is intended for unspecified complications.Always strive for the most specific coding possible.If the complication is related to the tube, consider additional codes specifying that. The information provided here is for general guidance only and should not be considered medical advice. Always consult the latest official coding guidelines and relevant clinical documentation.

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