2025 ICD-10-CM code Y84.2
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Complications of medical and surgical care - Other medical procedures Chapter 20: External causes of morbidity and mortality Feed
Radiological procedure and radiotherapy causing an abnormal patient reaction or later complication, excluding misadventures during the procedure.
Modifiers may be applicable depending on the specific circumstances. For example, if the procedure was performed in a different setting, or if specific additional services were provided, corresponding modifiers might be necessary.
Medical necessity is established by the need for the radiological procedure or radiotherapy, documented in the patient's medical record. This typically involves a clinical diagnosis warranting the procedure, as well as documentation of the patient's response to the procedure, indicating the appropriateness of coding Y84.2.
The clinical responsibility lies with the physician or healthcare professional who performed the radiological procedure or radiotherapy and the physician managing the resulting complications.This involves accurate documentation of the procedure, any adverse reactions, and subsequent follow-up care.
- Chapter 20: External causes of morbidity and mortality
- Y84 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
In simple words: This code is used when a patient has a bad reaction or develops a problem after an X-ray, radiation treatment, or similar medical procedure, but nothing went wrong during the procedure itself.
This ICD-10-CM code classifies instances where a radiological procedure or radiotherapy leads to an abnormal reaction in the patient or a subsequent complication.It's crucial to note that this code is only applicable when no misadventure occurred during the procedure itself.The code should be used in conjunction with another code specifying the nature of the condition resulting from the radiological procedure or radiotherapy. This code is used to indicate the cause of the condition, not the condition itself.
Example 1: A patient undergoes radiation therapy for cancer.Weeks later, they experience severe skin reactions at the radiation site. Code Y84.2 is used to indicate the radiation therapy as the cause of the skin reaction, along with a code describing the specific skin condition (e.g., radiation dermatitis)., A patient receives a CT scan with contrast. They experience an allergic reaction to the contrast media, manifesting as hives and shortness of breath.Code Y84.2 is used along with a code specifying the allergic reaction (e.g., anaphylactic shock)., A patient has a radiation treatment for a brain tumor. Months later, they develop cognitive difficulties. Code Y84.2 is used in conjunction with codes that specify the cognitive impairments (e.g., cognitive disorder due to other specified neurological condition).
Detailed medical records documenting the radiological procedure or radiotherapy, including the type of procedure, dosage, date, and location of radiation if applicable.Thorough documentation of any adverse reaction, including symptoms, onset, severity, and treatment provided.Radiological imaging reports and pathology results if applicable, and physician's notes detailing the patient's condition before, during, and after the procedure.
** This code should not be used if the adverse reaction or complication is a direct result of a misadventure during the procedure itself.In such cases, other codes from Chapter 20 would be more appropriate.Always ensure comprehensive and accurate medical documentation to support the use of this code.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Radiology, Oncology, other specialties involved in the management of radiation-related complications.
- Place of Service:Hospital inpatient, hospital outpatient, ambulatory surgical center, radiation oncology clinic.