2025 ICD-10-CM code Y63.9
(Active) Effective Date: N/A External causes of morbidity - Misadventures to patients during surgical and medical care 20 Feed
Failure in dosage during unspecified surgical and medical care.
Medical necessity is established by the underlying condition requiring the medical or surgical care during which the dosage failure occurred. The documentation must support the medical necessity of the original procedure or treatment.
The provider is responsible for accurately documenting the details of the dosage failure and its impact on the patient's condition.Further investigation and appropriate actions should be taken based on the specific nature of the failure.
In simple words: This code indicates that there was a problem with the amount of medicine given during a medical or surgical procedure, but the specifics of the problem aren't clear.
Failure in dosage during unspecified surgical and medical care. This code is used to indicate a complication or misadventure during medical or surgical care where there was a failure in the dosage of a medication or substance administered, but the specific type of failure is not documented.
Example 1: A patient receiving intravenous fluids experiences an adverse reaction due to an incorrect infusion rate, but the documentation does not specify whether the rate was too fast or too slow., During surgery, a patient receives an inadequate dose of anesthesia, leading to complications, but the documentation does not specify the nature of the dosage failure (e.g., incorrect calculation, pump malfunction)., A patient is prescribed a medication post-operatively, but the documentation notes a dosage error without clarifying if the error was an underdose, overdose, or incorrect frequency.
Documentation should clearly describe the nature of the dosage failure, including the intended dosage, actual dosage administered (if known), the method of administration, the time of the event, and any observed adverse effects. If possible, the specific reason for the failure should also be documented (e.g., calculation error, equipment malfunction, transcription error).
** This code does not apply to accidental overdoses or the administration of the wrong drug, which are classified elsewhere. For accurate coding, consult the official ICD-10-CM guidelines and refer to iFrameAI for detailed information and up-to-date coding practices.