AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2016 Issue 4; ICD-10-CM NEW/REVISED CODES
Unintended Awareness under General Anesthesia
Subcategory T88.5, has been expanded to uniquely identify unintended awareness under general anesthesia during a procedure (T88.53), and subcategory Z92.8, has been expanded to uniquely identify patients with history of unintended awareness under general anesthesia during a procedure (Z92.84). Although rare, a patient can become conscious during surgery and remember what occurred. This is referred to as “intraoperative awareness,” or anesthesia awareness, and is estimated to occur about 1 to 2 times per every 1,000 uses of general anesthesia. Although most patients do not experience pain, the experience can be bothersome, as...
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Article Overview
This article explains a diagnosis coding topic related to unintended awareness during general anesthesia, including how the condition is described in clinical documentation and how related ICD-10-CM categories were expanded. It is aimed at coders, billers, and clinical documentation staff who need to recognize when this anesthesia-related issue is reported and how the topic is represented in the diagnosis code set. The article also references guidance from the American Society of Anesthesiologists and frames the issue in the context of surgical care and postoperative documentation.
Why This Topic Matters
Accurate identification of anesthesia-related awareness events affects diagnosis reporting, documentation quality, and communication among clinical and coding staff.
What You Will Learn
- How unintended awareness under general anesthesia is discussed in clinical documentation
- How the topic is represented within ICD-10-CM categories and related history coding
- What general anesthesia awareness means in the context of surgical care
- Why this topic may be relevant to postoperative documentation and anesthesia-related reporting
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation specialists
- Billing staff
- Anesthesia-related clinical staff
Codes Discussed
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