ICD-10 Coding for Postoperative Hematoma(T81.0, T81.4)
Complete ICD-10-CM coding and documentation guide for Postoperative Hematoma. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Postoperative Hematoma
T81.0-T81.9Primary Range
Complications of procedures, not elsewhere classified
This range includes codes for complications following surgical and medical care, such as hemorrhage and hematoma.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| T81.0 | Hemorrhage and hematoma complicating a procedure, not elsewhere classified | Use when a hematoma is directly linked to a recent surgical procedure and requires intervention. |
|
| T81.4 | Infection following a procedure, not elsewhere classified | Use when a postoperative hematoma is complicated by infection. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for post op hematoma
Essential facts and insights about Postoperative Hematoma
Primary ICD-10-CM Codes for post op hematoma
Decision Criteria
clinical Criteria
- Presence of hematoma confirmed by imaging and linked to a procedure.
documentation Criteria
- Provider documentation must state 'due to' or 'resulting from' the procedure.
Applicable To
- Postoperative hematoma
- Post-surgical hemorrhage
Excludes
- Traumatic hematoma (S00-T88 with appropriate 7th character)
Clinical Validation Requirements
- Documented linkage to recent procedure
- Imaging confirming hematoma
- Symptoms such as pain or neurological deficits
Code-Specific Risks
- Misclassification if not linked to a procedure
- Overcoding minor hematomas
Coding Notes
- Ensure documentation clearly links the hematoma to the procedure.
T81.4 - Infection following a procedure, not elsewhere classified
Use when a postoperative hematoma is complicated by infection.
Applicable To
- Postoperative wound infection
Excludes
- Infections due to devices, implants, or grafts (T82-T85)
Clinical Validation Requirements
- Positive culture results
- Clinical signs of infection such as fever or purulence
Coding Notes
Ensure infection is documented as related to the procedure.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Infection following a procedure
T81.4Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Traumatic subdural hemorrhage
S06.36-Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Postoperative Hematoma to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code T81.0.
Impact
Clinical: Misrepresentation of patient condition., Regulatory: Non-compliance with coding standards., Financial: Potential for denied claims.
Mitigation Strategy
Educate providers on documentation requirements., Implement documentation templates.
Impact
Reimbursement: Incorrect DRG assignment leading to financial discrepancies., Compliance: Potential audit flags for overcoding., Data Quality: Inaccurate complication rates affecting quality metrics.
Mitigation Strategy
Only code as T81.0 if intervention is required or significant symptoms are present.
Impact
Coding minor hematomas as complications without sufficient documentation.
Mitigation Strategy
Implement regular audits and coder education.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Postoperative Hematoma, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Postoperative Hematoma
Use these documentation templates to ensure complete and accurate documentation for Postoperative Hematoma. These templates include all required elements for proper coding and billing.
Postoperative hematoma with infection
Specialty: SurgeryRequired Elements
- Linkage to procedure
- Symptoms and clinical findings
- Imaging results
- Intervention details
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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