2025 ICD-10-CM code T81
(Valid) Effective Date: N/A Injury, poisoning and certain other consequences of external causes - T80-T88 19 Feed
Complications of procedures, not elsewhere classified.
Medical necessity must be established by demonstrating the relationship between the procedure and the subsequent complication. The documentation should clearly support the need for additional care due to the complication.
The physician is responsible for documenting the specific complication and its relationship to the procedure.
In simple words: This code represents complications that can occur during or after a medical procedure, but are not classified under other specific codes.
Complications of procedures, not elsewhere classified. Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5).
Example 1: A patient develops a post-operative infection following a surgical procedure. This infection is not specific to the surgical site and is not otherwise classified., A patient experiences an adverse reaction to a medication administered during a medical procedure. This reaction is not classified under a more specific code., A patient develops respiratory distress following a diagnostic procedure. This distress is not due to a specific complication like pneumothorax and is not classified elsewhere.
Detailed documentation of the complication, the procedure that preceded it, and the causal relationship between the two. Any additional diagnoses or treatments related to the complication should also be documented.
- Specialties:Any specialty performing medical procedures.
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital,Ambulatory Surgical Center, and other places of service where medical procedures can be conducted.