Complete ICD-10-CM coding and documentation guide for icd-10 coding for postoperative complications includes clinical validation requirements, medical necessity guidelines, and coding policies.
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Essential facts and insights about ICD-10 Coding for Postoperative Complications
Use ICD-10 code T81.4- for infection following a procedure, ensuring proper documentation in clinical notes.
Additional codes that may be used with this diagnosis
Type 2 diabetes mellitus without complications
Use if diabetes is impacting wound healing.
Essential hypertension
Use if hypertension complicates recovery.
ICD-10 codes for post-op complications include T81.4- for infections and T81.0- for hemorrhage or hematoma. These codes require specific documentation linking the complication to the surgery.
Document postoperative complications by explicitly linking them to the procedure, using terms like 'complication of surgery' and including clinical indicators such as lab results or imaging.