T81 (Complications of procedures, not elsewhere classified) compared with T88.53 (Unintended awareness under general anesthesia during procedure), from the official CMS tabular data. Both may be reported when both conditions are documented (Excludes2).
Distinct conditions — both may be reported.
“complication following procedure NEC (T81.-)”
An Excludes2 note means the excluded condition is not part of the code above it, but a patient can have both. Report both when both are documented.
Source: CMS ICD-10-CM tabular instructional notes
Yes, when both are documented. T88.53 carries an Excludes2 note covering T81: “complication following procedure NEC (T81.-)”
Excludes2 marks distinct conditions — both may be reported when both are documented.
| T81Complications of procedures, not elsewhere classified | T88.53Unintended awareness under general anesthesia during procedure | |
|---|---|---|
| Billing status | Non-billable header Report instead: T81.10XA, T81.10XD, T81.10XS, T81.11XA, T81.11XD | Non-billable header |
| Classification | S00-T88 — Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88) | S00-T88 — Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88) |
| Definition | Complications of procedures, not elsewhere classified is a non-billable ICD-10-CM category code (T81). | Unintended awareness under general anesthesia during procedure is a non-billable ICD-10-CM category code (T88.53). |
| 7th character | The appropriate 7th character is to be added to each code from category T81 | The appropriate 7th character is to be added to each code from category T88 |
| Use additional code | 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) | code for adverse effect, if applicable, to identify drug (T41.- with fifth or sixth character 5) 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 |
Derived from the official CMS ICD-10-CM tabular data (FY2026). Not billing advice; verify sequencing rules for the encounter. All data sources