2025 ICD-10-CM code Y63.6
Underdosing and nonadministration of necessary drug, medicament, or biological substance during surgical and medical care.
Medical necessity for the originally prescribed medication, drug, or biological substance must be established. The impact of the underdosing or nonadministration event on the patient's treatment and overall clinical outcome should be clearly documented.
It is the clinician's responsibility to ensure accurate and timely administration of prescribed medications or biological substances during surgical or medical care. Any deviation, like underdosing or omission, should be clearly documented along with justification and any remedial actions taken.
In simple words: A necessary medication, drug, or biological substance was given at too low a dose or not given at all during medical or surgical care.
Failure in dosage during surgical and medical care specifically related to underdosing or nonadministration of a necessary drug, medicament, or biological substance.
Example 1: A patient undergoing chemotherapy receives a lower dose of a chemotherapeutic agent than prescribed due to a calculation error., A patient scheduled for a surgical procedure does not receive the pre-operative prophylactic antibiotic as ordered., A patient in the ICU requires a continuous infusion of insulin, but the infusion pump malfunctions, leading to a period of underdosing.
Documentation should clearly state the intended dose, the actual dose administered (if any), the reason for underdosing or nonadministration, the time and date of the occurrence, the impact on the patient (if any), and actions taken to mitigate adverse effects. Any contributing factors should also be documented, such as pump malfunctions, pharmacy errors, or documentation discrepancies.
** This code excludes accidental overdose and administration of the wrong drug (T36-T50).
- Specialties:Any specialty providing surgical or medical care.
- Place of Service:Any place of service where surgical or medical care is provided