Remember Second Dx Code for Some Anesthesia Shock
Question: During surgery, a patient who was under general anesthesia experienced a sudden drop in blood pressure. Notes indicate that the drop occurred due to “adverse effect/inhaled anesth.” What ICD-10-CM diagnosis codes are appropriate for this encounter? Alaska Subscriber Answer: You’ll need a pair of diagnosis codes for this encounter. First, report T88.2XXA (Shock due to anesthesia, initial encounter), as the patient is in shock from the anesthesia. “Shock caused by anesthesia is a critical condition marked by a severe and sudden drop in blood pressure due to the anesthetic agents used in surgery or medical procedures,” according to AAPC’s Codify. When this occurs, “the body's vital organs do not receive enough blood flow, resulting in symptoms such as rapid pulse, shallow breathing, dizziness, confusion, and even loss of consciousness.” In the notes under T88.2- (Shock due to anesthesia), ICD-10-CM instructs: “Use additional code for adverse effect, if applicable, to identify drug (T41.- with fifth or sixth character 5).” This leads you to the T41.- (Poisoning by, adverse effect of and underdosing of anesthetics and therapeutic gases) code set. For coding purposes, an adverse effect is “an undesired, harmful effect of a drug that has been correctly prescribed and properly administered,” per Codify. Look for more detail in the T41.- code set and you’ll land on T41.0X5A (Adverse effect of inhaled anesthetics, initial encounter), which you should list in addition to T88.2XXA. Chris Boucher, MS, CPC, Senior Development Editor, AAPC
