T81.9XXA Unspecified complication of procedure, initial encounter

Instructional Notes:

T81.9XXA
Description: Unspecified complication of procedure, initial encounter
↓
T81.9
Description: Unspecified complication of procedure
↓
T81
Description: Complications of procedures, not elsewhere classified
Exclude2:
- complications following immunization (T88.0-T88.1)
- complications following infusion, transfusion and therapeutic injection (T80.-)
- complications of transplanted organs and tissue (T86.-)
- specified complications classified elsewhere, such as:
- complication of prosthetic devices, implants and grafts (T82-T85)
- dermatitis due to drugs and medicaments (L23.3, L24.4, L25.1, L27.0-L27.1)
- endosseous dental implant failure (M27.6-)
- floppy iris syndrome (IFIS) (intraoperative) H21.81
- intraoperative and postprocedural complications of specific body system (D78.-, E36.-, E89.-, G97.3-, G97.4, H59.3-, H59.-, H95.2-, H95.3, I97.4-, I97.5, J95, K91.-, L76.-, M96.-, N99.-)
- ostomy complications (J95.0-, K94.-, N99.5-)
- plateau iris syndrome (post-iridectomy) (postprocedural) H21.82
- poisoning and toxic effects of drugs and chemicals (T36-T65 with fifth or sixth character 1-4)
Use Additional Code:
- code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)
↓
T80-T88
Description: Complications of surgical and medical care, not elsewhere classified (T80-T88)
Exclude2:
- any encounters with medical care for postprocedural conditions in which no complications are present, such as:
- artificial opening status (Z93.-)
- closure of external stoma (Z43.-)
- fitting and adjustment of external prosthetic device (Z44.-)
- burns and corrosions from local applications and irradiation (T20-T32)
- complications of surgical procedures during pregnancy, childbirth and the puerperium (O00-O9A)
- mechanical complication of respirator [ventilator] (J95.850)
- poisoning and toxic effects of drugs and chemicals (T36-T65 with fifth or sixth character 1-4 or 6)
- postprocedural fever (R50.82)
- specified complications classified elsewhere, such as:
- cerebrospinal fluid leak from spinal puncture (G97.0)
- colostomy malfunction (K94.0-)
- disorders of fluid and electrolyte imbalance (E86-E87)
- functional disturbances following cardiac surgery (I97.0-I97.1)
- intraoperative and postprocedural complications of specified body systems (D78.-, E36.-, E89.-, G97.3-, G97.4, H59.3-, H59.-, H95.2-, H95.3, I97.4-, I97.5, J95.6-, J95.7, K91.6-, L76.-, M96.-, N99.-)
- ostomy complications (J95.0-, K94.-, N99.5-)
- postgastric surgery syndromes (K91.1)
- postlaminectomy syndrome NEC (M96.1)
- postmastectomy lymphedema syndrome (I97.2)
- postsurgical blind-loop syndrome (K91.2)
- ventilator associated pneumonia (J95.851)
Use Additional Code:
- code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)
↓
S00-T88
Description: Injury, poisoning and certain other consequences of external causes
Exclude2:
- birth trauma (P10-P15)
- obstetric trauma (O70-O71)
Notes:
- Use secondary code(s) from Chapter 20, External causes of morbidity, to indicate cause of injury. Codes within the T section that include the external cause do not require an additional external cause code
Use Additional Code:
- code to identify any retained foreign body, if applicable (Z18.-)