2025 ICD-10-CM code Y83
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A External causes of morbidity - Surgical and other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure Chapter 20: External causes of morbidity Feed
Surgical operation and other surgical procedures causing abnormal patient reaction or later complications, excluding misadventures during the procedure.
Modifiers may apply depending on the specific complication and the services rendered in its management.
Medical necessity is established by the documentation demonstrating the presence of a clinically significant complication following a surgical procedure.The complication should require treatment or intervention beyond routine post-operative care.
The clinical responsibility includes documenting the post-operative complications, managing the patient's response, and implementing appropriate treatment strategies. The physician's role also involves accurately coding the condition for billing and reporting purposes.
In simple words: This code is used when someone has a bad reaction to surgery or develops problems after surgery, but the problems weren't caused by mistakes made during the surgery itself.
This code classifies instances where a surgical operation or other surgical procedure results in an abnormal reaction from the patient or subsequent complications.It specifically excludes misadventures that occur during the procedure itself.The focus is on adverse events that manifest after the procedure has concluded, not those directly attributable to immediate procedural errors or negligence.
Example 1: A patient undergoes a routine appendectomy.Post-operatively, they develop a severe allergic reaction to the suture material, requiring hospitalization and treatment. Code Y83 would be used to reflect the complication arising from the surgical procedure., A patient experiences a deep vein thrombosis (DVT) following a hip replacement surgery.This complication, while not directly caused by surgical error, is a consequence of the procedure and would be coded with Y83 in addition to a code reflecting the DVT itself., A patient undergoes a coronary artery bypass graft (CABG).Several weeks later, they develop a wound infection at the surgical site. This post-operative complication, unrelated to immediate intraoperative events, would warrant the use of Y83 along with the wound infection code.
Complete operative notes, post-operative progress notes, laboratory results (if applicable, such as allergy testing or blood work related to complications), radiology reports (if imaging was performed for diagnosis or treatment of complications), and any other relevant documentation supporting the existence and treatment of the complication.
** The seventh character for Y83 is not specified in the provided data.The appropriate seventh character (A, D, or S) should be appended to indicate the encounter status (initial, subsequent, or sequela) based on the patient's visit context.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Surgery, Internal Medicine, Cardiology (if cardiovascular complications arise), Infectious Disease (if infection is a complication)
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center, Office