2025 ICD-10-CM code T88.51
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Injury - Complications of surgical and medical care, not elsewhere classified (T80-T88) Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Hypothermia following anesthesia.
Medical necessity is established when hypothermia is a documented complication following anesthesia and presents with associated clinical symptoms or risks, such as prolonged recovery time, increased risk of infection, or cardiovascular complications.The level of intervention required would dictate the medical necessity of the treatment of hypothermia.
Anesthesiologist, surgeon, and possibly ICU physician depending on the severity and location of care.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- T88.5 Use additional code for adverse effect, if applicable, to identify drug (T41.- with fifth or sixth character 5)
In simple words: This code is for low body temperature after surgery due to anesthesia.It happens because of things like the anesthesia affecting body temperature control, the operating room being cold, or things done during surgery that cause heat loss.Doctors may use other codes to describe exactly what happened.
This code classifies hypothermia (body temperature below 36°C) occurring as a complication following anesthesia.It is often a result of a combination of factors including anesthesia-induced impairment of thermoregulatory control, a cool operating room environment, and surgical factors that promote excessive heat loss.Additional codes may be necessary to specify the underlying cause,any associated adverse effects, or the involvement of specific devices or circumstances.
Example 1: A 65-year-old male undergoing a total hip replacement develops hypothermia (core temperature 35°C) post-operatively due to prolonged surgery and inadequate warming measures during the procedure. , A 30-year-old female undergoing laparoscopic cholecystectomy experiences hypothermia (core temperature 34.5°C) post-anesthesia, likely related to exposure of the abdominal cavity during the procedure and low ambient temperature in the operating room., A 70-year-old patient with pre-existing cardiac conditions undergoes coronary artery bypass grafting (CABG). Postoperatively, the patient develops hypothermia (35.8°C) exacerbated by the cardiac effects of the anesthesia.
Pre-operative assessment including patient age, health status, and any factors increasing risk of hypothermia. Intraoperative notes detailing the type and duration of anesthesia, temperature monitoring throughout the procedure, warming measures used, and any fluid management. Post-operative temperature readings and monitoring. Documentation of any interventions for hypothermia.
** Hypothermia is a serious complication that can lead to increased morbidity and mortality.Active warming techniques are essential for prevention.The severity and treatment of hypothermia are dependent on the core body temperature and the presence or absence of associated symptoms.
- Payment Status: Active
- Specialties:Anesthesiology, Surgery, Critical Care Medicine
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center, Post-Anesthesia Care Unit (PACU)