2025 ICD-10-CM code Y62
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A External causes of morbidity - Misadventures to patients during surgical and medical care Chapter 20: External causes of morbidity Feed
Failure of sterile precautions during surgical and medical care.
Modifiers may be applicable to the codes used for the complications and procedures related to the failure of sterile precautions.Consult the appropriate coding guidelines for specific modifier usage.
Medical necessity is established by the presence of a postoperative infection or other complication directly attributable to the failure of sterile precautions during the surgical or medical procedure.The documentation should clearly link the failure of sterile technique to the adverse outcome.
The clinical responsibility for this code involves documenting the failure of sterile precautions and the resulting complications.This requires a thorough review of the procedural notes, surgical reports, and any subsequent treatment related to the infection or complication.
In simple words: This code is used when a medical procedure or surgery has complications because proper sterile techniques weren't followed. It's added to the main diagnosis to explain what went wrong.
This code classifies instances where sterile precautions were not followed during surgical or medical care, leading to adverse events.It encompasses situations where the lack of sterility resulted in infections or other complications.The code is used as a secondary code to provide additional information regarding the cause of a condition, and should not be the principal diagnosis.
Example 1: A patient undergoing a laparoscopic cholecystectomy develops a postoperative infection due to a breach in sterile technique during the procedure.Code Y62 would be used as a secondary code in addition to the infection code., A patient receiving a central venous catheter develops a bloodstream infection as a result of improper sterilization of the catheter insertion site.Code Y62 is used along with the infection code and the code for the catheter procedure., During an orthopedic surgery, a non-sterile instrument is used, resulting in a postoperative infection. Code Y62 is used to capture the failure of sterile precautions.
Complete operative notes detailing the procedure, including mention of any breach in sterile technique, should be available.Post-operative notes, laboratory results (culture reports), and any imaging studies related to the complication should also be documented.
** The information provided in the medical record must clearly establish the causal relationship between the failure of sterile precautions and the resulting complication(s).This may involve specific details about the breach in sterile technique and the subsequent infection or complication.
- Payment Status: Active
- Modifier TC rule: Not applicable to Y62 itself, but potentially applicable to the procedures and services related to the complications.
- Specialties:Surgery, Infectious Disease, Internal Medicine
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center