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. T88 Other complications of surgical and medical care, not elsewhere classified

    Excludes2

    • complication following infusion, transfusion and therapeutic injection (T80.-)
    • complication following procedure NEC (T81.-)
    • complications of anesthesia in labor and delivery (O74.-)
    • complications of anesthesia in pregnancy (O29.-)
    • complications of anesthesia in puerperium (O89.-)
    • complications of devices, implants and grafts (T82-T85)
    • complications of obstetric surgery and procedure (O75.4)
    • dermatitis due to drugs and medicaments (L23.3, L24.4, L25.1, L27.0-L27.1)
    • poisoning and toxic effects of drugs and chemicals (T36-T65 with fifth or sixth character 1-4 or 6)
    • specified complications classified elsewhere

    The appropriate 7th character is to be added to each code from category T88

    • A - initial encounter
    • D - subsequent encounter
    • S - sequela
    1. T88.0 Infection following immunization

      Inclusion term(s):

      • Sepsis following immunization
    2. T88.1 Other complications following immunization, not elsewhere classified

      Inclusion term(s):

      • Generalized vaccinia
      • Rash following immunization
    3. T88.2 Shock due to anesthesia

    4. T88.3 Malignant hyperthermia due to anesthesia

    5. T88.4 Failed or difficult intubation

    6. T88.5 Other complications of anesthesia

      1. T88.51 Hypothermia following anesthesia

      2. T88.52 Failed moderate sedation during procedure

        Inclusion term(s):

        • Failed conscious sedation during procedure
      3. T88.53 Unintended awareness under general anesthesia during procedure

      4. T88.59 Other complications of anesthesia

    7. T88.6 Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered

      Inclusion term(s):

      • Anaphylactic shock due to adverse effect of correct drug or medicament properly administered
      • Anaphylactoid reaction NOS
    8. T88.7 Unspecified adverse effect of drug or medicament

      Inclusion term(s):

      • Drug hypersensitivity NOS
      • Drug reaction NOS
    9. T88.8 Other specified complications of surgical and medical care, not elsewhere classified

    10. T88.9 Complication of surgical and medical care, unspecified

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.