2025 ICD-10-CM code Y84
(Active) Effective Date: N/A Complications of medical and surgical care - 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 (Y83-Y84) 20. External causes of morbidity (V00-Y99) Feed
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.
Medical necessity for the use of Y84 is established by demonstrating a clear causal relationship between the medical procedure performed and the subsequent abnormal reaction or complication experienced by the patient. The documentation must support the determination that the adverse outcome is a direct consequence of the procedure and not due to other unrelated factors.
The physician is responsible for documenting the specific medical procedure performed, the subsequent abnormal reaction or complication, and the causal link between the procedure and the adverse outcome. Proper documentation should clearly establish the timeline of events and rule out other potential causes for the observed condition.
In simple words: This code indicates a complication or bad reaction resulting from a non-surgical medical procedure, occurring some time after the procedure itself. It signifies that no problem was apparent during the procedure itself.
This code represents complications arising from medical procedures not classified as surgical, leading to an abnormal patient reaction or a later complication. It excludes misadventures during the procedure itself and explicitly notes the absence of any adverse incident at the time of the procedure.This code is used as a secondary code to indicate the cause of the condition, with the primary code representing the nature of the condition (often from Chapter 19: Injury, poisoning and certain other consequences of external causes (S00-T88)).
Example 1: A patient develops a rash a week after receiving an intravenous injection of a medication, indicating a delayed allergic reaction. Y84 would be used as a secondary code alongside the code for allergic dermatitis., A patient experiences nerve damage following a lumbar puncture. The nerve damage is documented as a direct result of the procedure, and Y84 is used as a secondary code with the primary code reflecting the specific nerve damage., A patient develops an infection at the site of a recent endoscopy. The infection is determined to be a consequence of the procedure, with Y84 used in conjunction with the appropriate infection code.
Documentation should include: 1. Details of the medical procedure performed (e.g., type, date, location). 2. Description of the abnormal reaction or later complication. 3. Evidence establishing the causal link between the procedure and the adverse outcome. 4. Timeline of events, including the onset of the reaction or complication relative to the procedure.
** It is crucial to distinguish between Y84 and codes that describe misadventures occurring during a procedure (Y60-Y69) or complications specifically related to medical devices (Y70-Y82). Y84 should only be used when there was no misadventure at the time of the procedure and the complication is not directly related to a device malfunction.
- Specialties:Any specialty performing medical procedures can potentially use this code. This includes, but is not limited to: Internal Medicine, Cardiology, Gastroenterology, Radiology, and various other medical specialties.
- Place of Service:Any place of service where a medical procedure is performed, such as "Office", "Inpatient Hospital", "Outpatient Hospital", "Ambulatory Surgical Center" etc.