Cracking the Code
Complications from Medical or Surgical Care
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If a complication from medical or surgical care initiates a visit to the doctor’s office or an admission to the hospital, a complication code is reported as the primary diagnosis. We can locate the complication codes in the T80-T88 series of the ICD-10-CM codes. When documented, the code for the specific complication is also listed. Some of the complication codes include both the nature of the complication as well as the type of procedure that caused the complication. In this case, an additional external cause code is not required.
Regarding intraoperative and postprocedural complications, these codes can be found within the body system chapters with codes specific to the organs and structures of that body system, unless the complication is specifically indexed to a T code from Chapter 19. These codes should be sequenced first, followed by a code or codes for the specific complication, if applicable.