Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)
code(s) to identify the specified condition resulting from the complication
code to identify devices involved and details of circumstances (Y62-Y82)

Excludes2

  • 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)
  1. T81 Complications of procedures, not elsewhere classified

    Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)

    Excludes2

    • 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)

    The appropriate 7th character is to be added to each code from category T81

    • A - initial encounter
    • D - subsequent encounter
    • S - sequela
    1. T81.1 Postprocedural shock

      Inclusion term(s):

      • Shock during or resulting from a procedure, not elsewhere classified
      1. T81.10 Postprocedural shock unspecified

        Inclusion term(s):

        • Collapse NOS during or resulting from a procedure, not elsewhere classified
        • Postprocedural failure of peripheral circulation
        • Postprocedural shock NOS
      2. T81.11 Postprocedural cardiogenic shock

      3. T81.12 Postprocedural septic shock

        Inclusion term(s):

        • Postprocedural endotoxic shock resulting from a procedure, not elsewhere classified
        • Postprocedural gram-negative shock resulting from a procedure, not elsewhere classified
      4. T81.19 Other postprocedural shock

        Inclusion term(s):

        • Postprocedural hypovolemic shock
    2. T81.3 Disruption of wound, not elsewhere classified

      Inclusion term(s):

      • Disruption of any suture materials or other closure methods
      1. T81.30 Disruption of wound, unspecified

        Inclusion term(s):

        • Disruption of wound NOS
      2. T81.31 Disruption of external operation (surgical) wound, not elsewhere classified

        Inclusion term(s):

        • Dehiscence of operation wound NOS
        • Disruption of operation wound NOS
        • Disruption or dehiscence of closure of cornea
        • Disruption or dehiscence of closure of mucosa
        • Disruption or dehiscence of closure of skin and subcutaneous tissue
        • Full-thickness skin disruption or dehiscence
        • Superficial disruption or dehiscence of operation wound
      3. T81.32 Disruption of internal operation (surgical) wound, not elsewhere classified

        Inclusion term(s):

        • Deep disruption or dehiscence of operation wound NOS
        • Disruption or dehiscence of closure of internal organ or other internal tissue
        • Disruption or dehiscence of closure of muscle or muscle flap
        • Disruption or dehiscence of closure of ribs or rib cage
        • Disruption or dehiscence of closure of skull or craniotomy
        • Disruption or dehiscence of closure of sternum or sternotomy
        • Disruption or dehiscence of closure of tendon or ligament
        • Disruption or dehiscence of closure of superficial or muscular fascia
      4. T81.33 Disruption of traumatic injury wound repair

        Inclusion term(s):

        • Disruption or dehiscence of closure of traumatic laceration (external) (internal)
    3. T81.4 Infection following a procedure

      Inclusion term(s):

      • Wound abscess following a procedure
      1. T81.40 Infection following a procedure, unspecified

      2. T81.41 Infection following a procedure, superficial incisional surgical site

        Inclusion term(s):

        • Subcutaneous abscess following a procedure
        • Stitch abscess following a procedure
      3. T81.42 Infection following a procedure, deep incisional surgical site

        Inclusion term(s):

        • Intra-muscular abscess following a procedure
      4. T81.43 Infection following a procedure, organ and space surgical site

        Inclusion term(s):

        • Intra-abdominal abscess following a procedure
        • Subphrenic abscess following a procedure
      5. T81.44 Sepsis following a procedure

      6. T81.49 Infection following a procedure, other surgical site

    4. T81.5 Complications of foreign body accidentally left in body following procedure

      1. T81.50 Unspecified complication of foreign body accidentally left in body following procedure

        • T81.500 Unspecified complication of foreign body accidentally left in body following surgical operation
        • T81.501 Unspecified complication of foreign body accidentally left in body following infusion or transfusion
        • T81.502 Unspecified complication of foreign body accidentally left in body following kidney dialysis
        • T81.503 Unspecified complication of foreign body accidentally left in body following injection or immunization
        • T81.504 Unspecified complication of foreign body accidentally left in body following endoscopic examination
        • T81.505 Unspecified complication of foreign body accidentally left in body following heart catheterization
        • T81.506 Unspecified complication of foreign body accidentally left in body following aspiration, puncture or other catheterization
        • T81.507 Unspecified complication of foreign body accidentally left in body following removal of catheter or packing
        • T81.508 Unspecified complication of foreign body accidentally left in body following other procedure
        • T81.509 Unspecified complication of foreign body accidentally left in body following unspecified procedure
      2. T81.51 Adhesions due to foreign body accidentally left in body following procedure

        • T81.510 Adhesions due to foreign body accidentally left in body following surgical operation
        • T81.511 Adhesions due to foreign body accidentally left in body following infusion or transfusion
        • T81.512 Adhesions due to foreign body accidentally left in body following kidney dialysis
        • T81.513 Adhesions due to foreign body accidentally left in body following injection or immunization
        • T81.514 Adhesions due to foreign body accidentally left in body following endoscopic examination
        • T81.515 Adhesions due to foreign body accidentally left in body following heart catheterization
        • T81.516 Adhesions due to foreign body accidentally left in body following aspiration, puncture or other catheterization
        • T81.517 Adhesions due to foreign body accidentally left in body following removal of catheter or packing
        • T81.518 Adhesions due to foreign body accidentally left in body following other procedure
        • T81.519 Adhesions due to foreign body accidentally left in body following unspecified procedure
      3. T81.52 Obstruction due to foreign body accidentally left in body following procedure

        • T81.520 Obstruction due to foreign body accidentally left in body following surgical operation
        • T81.521 Obstruction due to foreign body accidentally left in body following infusion or transfusion
        • T81.522 Obstruction due to foreign body accidentally left in body following kidney dialysis
        • T81.523 Obstruction due to foreign body accidentally left in body following injection or immunization
        • T81.524 Obstruction due to foreign body accidentally left in body following endoscopic examination
        • T81.525 Obstruction due to foreign body accidentally left in body following heart catheterization
        • T81.526 Obstruction due to foreign body accidentally left in body following aspiration, puncture or other catheterization
        • T81.527 Obstruction due to foreign body accidentally left in body following removal of catheter or packing
        • T81.528 Obstruction due to foreign body accidentally left in body following other procedure
        • T81.529 Obstruction due to foreign body accidentally left in body following unspecified procedure
      4. T81.53 Perforation due to foreign body accidentally left in body following procedure

        • T81.530 Perforation due to foreign body accidentally left in body following surgical operation
        • T81.531 Perforation due to foreign body accidentally left in body following infusion or transfusion
        • T81.532 Perforation due to foreign body accidentally left in body following kidney dialysis
        • T81.533 Perforation due to foreign body accidentally left in body following injection or immunization
        • T81.534 Perforation due to foreign body accidentally left in body following endoscopic examination
        • T81.535 Perforation due to foreign body accidentally left in body following heart catheterization
        • T81.536 Perforation due to foreign body accidentally left in body following aspiration, puncture or other catheterization
        • T81.537 Perforation due to foreign body accidentally left in body following removal of catheter or packing
        • T81.538 Perforation due to foreign body accidentally left in body following other procedure
        • T81.539 Perforation due to foreign body accidentally left in body following unspecified procedure
      5. T81.59 Other complications of foreign body accidentally left in body following procedure

        • T81.590 Other complications of foreign body accidentally left in body following surgical operation
        • T81.591 Other complications of foreign body accidentally left in body following infusion or transfusion
        • T81.592 Other complications of foreign body accidentally left in body following kidney dialysis
        • T81.593 Other complications of foreign body accidentally left in body following injection or immunization
        • T81.594 Other complications of foreign body accidentally left in body following endoscopic examination
        • T81.595 Other complications of foreign body accidentally left in body following heart catheterization
        • T81.596 Other complications of foreign body accidentally left in body following aspiration, puncture or other catheterization
        • T81.597 Other complications of foreign body accidentally left in body following removal of catheter or packing
        • T81.598 Other complications of foreign body accidentally left in body following other procedure
        • T81.599 Other complications of foreign body accidentally left in body following unspecified procedure
    5. T81.6 Acute reaction to foreign substance accidentally left during a procedure

      1. T81.60 Unspecified acute reaction to foreign substance accidentally left during a procedure

      2. T81.61 Aseptic peritonitis due to foreign substance accidentally left during a procedure

        Inclusion term(s):

        • Chemical peritonitis
      3. T81.69 Other acute reaction to foreign substance accidentally left during a procedure

    6. T81.7 Vascular complications following a procedure, not elsewhere classified

      Inclusion term(s):

      • Air embolism following procedure NEC
      • Phlebitis or thrombophlebitis resulting from a procedure
      1. T81.71 Complication of artery following a procedure, not elsewhere classified

        • T81.710 Complication of mesenteric artery following a procedure, not elsewhere classified
        • T81.711 Complication of renal artery following a procedure, not elsewhere classified
        • T81.718 Complication of other artery following a procedure, not elsewhere classified
        • T81.719 Complication of unspecified artery following a procedure, not elsewhere classified
      2. T81.72 Complication of vein following a procedure, not elsewhere classified

    7. T81.8 Other complications of procedures, not elsewhere classified

      1. T81.81 Complication of inhalation therapy

      2. T81.82 Emphysema (subcutaneous) resulting from a procedure

      3. T81.83 Persistent postprocedural fistula

      4. T81.89 Other complications of procedures, not elsewhere classified

    8. T81.9 Unspecified complication of procedure

Abbreviations used here:

NEC Not elsewhere classifiable
This abbreviation in the Tabular List represents “other specified”. When a specific code is not available for a condition, the Tabular List includes an NEC entry under a code to identify the code as the “other specified” code.

NOS Not otherwise specified
This abbreviation is the equivalent of unspecified.