2024 ICD-10-CM Diagnosis Code T41.3X6S
Underdosing of local anesthetics, sequela
- ICD-10-CM Code:
- T41.3X6S
- ICD-10 Code for:
- Underdosing of local anesthetics, sequela
- Is Billable?
- Yes - Valid for Submission
- Chronic Condition Indicator: [1]
- Not chronic
- Code Navigator:
T41.3X6S is a billable diagnosis code used to specify a medical diagnosis of underdosing of local anesthetics, sequela. The code is valid during the current fiscal year for the submission of HIPAA-covered transactions from October 01, 2023 through September 30, 2024. The code is exempt from present on admission (POA) reporting for inpatient admissions to general acute care hospitals.
This code describes a circumstance which influences the patient's health status but not a current illness or injury. The code is unacceptable as a principal diagnosis.
T41.3X6S is a sequela code, includes a 7th character and should be used for complications that arise as a direct result of a condition like underdosing of local anesthetics. According to ICD-10-CM Guidelines a "sequela" code should be used for chronic or residual conditions that are complications of an initial acute disease, illness or injury. The most common sequela is pain. Usually, two diagnosis codes are needed when reporting sequela. The first code describes the nature of the sequela while the second code describes the sequela or late effect.
Clinical Classification
Clinical Category is Poisoning/toxic effect/adverse effects/underdosing, sequela
- CCSR Category Code: INJ075
- Inpatient Default CCSR: X - Not applicable.
- Outpatient Default CCSR: X - Not applicable.
Clinical Information
Acupuncture Analgesia
analgesia produced by the insertion of acupuncture needles at certain acupuncture points on the body. this activates small myelinated nerve fibers in the muscle which transmit impulses to the spinal cord and then activate three centers - the spinal cord, midbrain and pituitary/hypothalamus - to produce analgesia.Adjuvants, Anesthesia
agents that are administered in association with anesthetics to increase effectiveness, improve delivery, or decrease required dosage.Anesthesia
a state characterized by loss of feeling or sensation. this depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures.Anesthesia and Analgesia
medical methods of either relieving pain caused by a particular condition or removing the sensation of pain during a surgery or other medical procedure.Anesthesia Department, Hospital
hospital department responsible for the administration of functions and activities pertaining to the delivery of anesthetics.Anesthesia Recovery Period
the period of emergence from general anesthesia, where different elements of consciousness return at different rates.Anesthesia, Cardiac Procedures
a range of methods used to induce unconsciousness; analgesia; and muscle relaxation during cardiac procedures.Anesthesia, Caudal
epidural anesthesia administered via the sacral canal.Anesthesia, Closed-Circuit
inhalation anesthesia where the gases exhaled by the patient are rebreathed as some carbon dioxide is simultaneously removed and anesthetic gas and oxygen are added so that no anesthetic escapes into the room. closed-circuit anesthesia is used especially with explosive anesthetics to prevent fires where electrical sparking from instruments is possible.Anesthesia, Conduction
injection of an anesthetic to inhibit nerve transmission in a specific part of the body.Anesthesia, Dental
a range of methods used to reduce pain and anxiety during dental procedures.Anesthesia, Endotracheal
procedure in which an anesthetic such as a gas or mixture of gases is inhaled through a tube into the lungs.Anesthesia, Epidural
procedure in which an anesthetic is injected into the epidural space.Anesthesia, General
procedure in which patients are induced into an unconscious state through use of various medications so that they do not feel pain during surgery.Anesthesia, Inhalation
anesthesia caused by the breathing of anesthetic gases or vapors or by insufflating anesthetic gases or vapors into the respiratory tract.Anesthesia, Intravenous
process of administering an anesthetic through injection directly into the bloodstream.Anesthesia, Local
a blocking of nerve conduction to a specific area by an injection of an anesthetic agent.Anesthesia, Obstetrical
a variety of anesthetic methods such as epidural anesthesia used to control the pain of childbirth.Anesthesia, Rectal
procedure involving the instillation of an anesthetic into the rectum.Anesthesia, Spinal
procedure in which an anesthetic is injected directly into the spinal cord.Anesthetists
persons trained and certified to administer anesthetics.Balanced Anesthesia
the use of several anesthetics together in small amounts, as opposed to a larger amount of one drug, to induce loss of sensation and loss of consciousness.Brachial Plexus Block
a blocking of neural conduction in the network of nerve fibers innervating the upper extremity.Cervical Plexus Block
a blocking of neural conduction in the network of nerve fibers innervating the neck and shoulder.Cryoanesthesia
anesthesia achieved by lowering either body temperature (core cooling) or skin temperature (external cooling).Electronarcosis
profound stupor produced by passing an electric current through the brain.Emergence Delirium
a form of delirium which occurs after general anesthesia.Intraoperative Awareness
occurence of a patient becoming conscious during a procedure performed under general anesthesia and subsequently having recall of these events. (from anesthesiology 2006, 104(4): 847-64.)Malignant Hyperthermia
rapid and excessive rise of temperature accompanied by muscular rigidity following general anesthesia.Treatment Refusal
patient or client refusal of or resistance to medical, psychological, or psychiatric treatment. (apa, thesaurus of psychological index terms, 8th ed.)Benzocaine
a surface anesthetic that acts by preventing transmission of impulses along nerve fibers and at nerve endings.Bupivacaine
a widely used local anesthetic agent.Dibucaine
a local anesthetic of the amide type now generally used for surface anesthesia. it is one of the most potent and toxic of the long-acting local anesthetics and its parenteral use is restricted to spinal anesthesia. (from martindale, the extra pharmacopoeia, 30th ed, p1006)Etidocaine
a local anesthetic with rapid onset and long action, similar to bupivacaine.Lidocaine
a local anesthetic and cardiac depressant used as an antiarrhythmia agent. its actions are more intense and its effects more prolonged than those of procaine but its duration of action is shorter than that of bupivacaine or prilocaine.Lidocaine, Prilocaine Drug Combination
a topical local anesthetic preparation that is composed of a mixture of lidocaine and prilocaine. it is used to provide anesthesia during minor surgery and for the treatment of premature ejaculation.Mepivacaine
a local anesthetic that is chemically related to bupivacaine but pharmacologically related to lidocaine. it is indicated for infiltration, nerve block, and epidural anesthesia. mepivacaine is effective topically only in large doses and therefore should not be used by this route. (from ama drug evaluations, 1994, p168)Prilocaine
a local anesthetic that is similar pharmacologically to lidocaine. currently, it is used most often for infiltration anesthesia in dentistry.Carboxylesterase
carboxylesterase is a serine-dependent esterase with wide substrate specificity. the enzyme is involved in the detoxification of xenobiotics and the activation of ester and of amide prodrugs.Penicillin G Procaine
semisynthetic antibiotic prepared by combining penicillin g with procaine.Procainamide
a class ia antiarrhythmic drug that is structurally-related to procaine.Procaine
a local anesthetic of the ester type that has a slow onset and a short duration of action. it is mainly used for infiltration anesthesia, peripheral nerve block, and spinal block. (from martindale, the extra pharmacopoeia, 30th ed, p1016).Propoxycaine
a local anesthetic of the ester type that has a rapid onset of action and a longer duration of action than procaine hydrochloride. (from martindale, the extra pharmacopoeia, 30th ed, p1017)Tetracaine
a potent local anesthetic of the ester type used for surface and spinal anesthesia.Trimecaine
acetanilide derivative used as a local anesthetic.
Coding Guidelines
Underdosing refers to taking less of a medication than is prescribed by a provider or a manufacturer's instruction. Codes for underdosing should never be assigned as principal or first-listed codes. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose, then the medical condition itself should be coded.
The appropriate 7th character is to be added to each code from block Poisoning by, adverse effect of and underdosing of anesthetics and therapeutic gases (T41). Use the following options for the aplicable episode of care:
- A - initial encounter
- D - subsequent encounter
- S - sequela
Code Edits
The Medicare Code Editor (MCE) detects and reports errors in the coding of claims data. The following ICD-10-CM Code Edits are applicable to this code:
- Unacceptable principal diagnosis - There are selected codes that describe a circumstance which influences an individual's health status but not a current illness or injury, or codes that are not specific manifestations but may be due to an underlying cause. These codes are considered unacceptable as a principal diagnosis.
Present on Admission (POA)
T41.3X6S is exempt from POA reporting - The Present on Admission (POA) indicator is used for diagnosis codes included in claims involving inpatient admissions to general acute care hospitals. POA indicators must be reported to CMS on each claim to facilitate the grouping of diagnoses codes into the proper Diagnostic Related Groups (DRG). CMS publishes a listing of specific diagnosis codes that are exempt from the POA reporting requirement. Review other POA exempt codes here.
CMS POA Indicator Options and Definitions
POA Indicator | Reason for Code | CMS will pay the CC/MCC DRG? |
---|---|---|
Y | Diagnosis was present at time of inpatient admission. | YES |
N | Diagnosis was not present at time of inpatient admission. | NO |
U | Documentation insufficient to determine if the condition was present at the time of inpatient admission. | NO |
W | Clinically undetermined - unable to clinically determine whether the condition was present at the time of inpatient admission. | YES |
1 | Unreported/Not used - Exempt from POA reporting. | NO |
Table of Drugs and Chemicals
The parent code T41.3X6 of the current diagnosis code is referenced in the Table of Drugs and Chemicals, this table contains a classification of drugs, industrial solvents, corrosive gases, noxious plants, pesticides, and other toxic agents.
According to ICD-10-CM coding guidelines it is advised to do not code directly from the Table of Drugs and Chemicals, instead always refer back to the Tabular List when doing the initial coding. Each substance in the table is assigned a code according to the poisoning classification and external causes of adverse effects. It is important to use as many codes as necessary to specify all reported drugs, medicinal or chemical substances. If the same diagnosis code describes the causative agent for more than one adverse reaction, poisoning, toxic effect or underdosing, utilize the code only once.
Patient Education
Anesthesia
What is anesthesia?
Anesthesia is the use of medicines to prevent pain during surgery and other procedures. These medicines are called anesthetics. They may be given by injection, inhalation, topical lotion, spray, eye drops, or skin patch. They cause you to have a loss of feeling or awareness.
What is anesthesia used for?
Anesthesia may be used in minor procedures, such as filling a tooth. It could be used during childbirth or procedures such as colonoscopies. And it is used during minor and major surgeries.
In some cases, a dentist, nurse, or doctor may give you an anesthetic. In other cases, you may need an anesthesiologist. This is a doctor who specializes in giving anesthesia.
What are the types of anesthesia?
There are several different types of anesthesia:
- Local anesthesia numbs a small part of the body. It might be used on a tooth that needs to be pulled or on a small area around a wound that needs stitches. You are awake and alert during local anesthesia.
- Regional anesthesia is used for larger areas of the body such as an arm, a leg, or everything below the waist. You may be awake during the procedure, or you may be given sedation. Regional anesthesia may be used during childbirth, a Cesarean section (C-section), or minor surgeries.
- General anesthesia affects the whole body. It makes you unconscious and unable to move. It is used during major surgeries, such as heart surgery, brain surgery, back surgery, and organ transplants.
What are the risks of anesthesia?
Anesthesia is generally safe. But there can be risks, especially with general anesthesia, including:
- Heart rhythm or breathing problems
- An allergic reaction to the anesthesia
- Delirium after general anesthesia. Delirium makes people confused. They may be unclear about what is happening to them. Some people over the age of 60 have delirium for several days after surgery. It can also happen to children when they first wake up from anesthesia.
- Awareness when someone is under general anesthesia. This usually means that the person hears sounds. But sometimes they can feel pain. This is rare.
[Learn More in MedlinePlus]
Medication Errors
Medicines treat infectious diseases, prevent problems from chronic diseases, and ease pain. But medicines can also cause harmful reactions if not used correctly. Errors can happen in the hospital, at the health care provider's office, at the pharmacy, or at home. You can help prevent errors by:
- Knowing your medicines. When you get a prescription, ask the name of the medicine and check to make sure that the pharmacy gave you the right medicine. Make sure that you understand how often you should take the medicine and how long you should take it.
- Keeping a list of medicines.
- Write down all of the medicines that you are taking, including the names of your medicines, how much you take, and when you take them. Make sure to include any over-the-counter medicines, vitamins, supplements, and herbs that you take.
- List the medicines that you are allergic to or that have caused you problems in the past.
- Take this list with you every time you see a health care provider.
- Reading medicine labels and following the directions. Don't just rely on your memory - read the medication label every time. Be especially careful when giving medicines to children.
- Asking questions. If you don't know the answers to these questions, ask your health care provider or pharmacist:
- Why am I taking this medicine?
- What are the common side effects?
- What should I do if I have side effects?
- When should I stop this medicine?
- Can I take this medicine with the other medicines and supplements on my list?
- Do I need to avoid certain foods or alcohol while taking this medicine?
Food and Drug Administration
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Code History
- FY 2024 - No Change, effective from 10/1/2023 through 9/30/2024
- FY 2023 - No Change, effective from 10/1/2022 through 9/30/2023
- FY 2022 - No Change, effective from 10/1/2021 through 9/30/2022
- FY 2021 - No Change, effective from 10/1/2020 through 9/30/2021
- FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020
- FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
- FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
- FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
- FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016. This was the first year ICD-10-CM was implemented into the HIPAA code set.
Footnotes
[1] Not chronic - A diagnosis code that does not fit the criteria for chronic condition (duration, ongoing medical treatment, and limitations) is considered not chronic. Some codes designated as not chronic are acute conditions. Other diagnosis codes that indicate a possible chronic condition, but for which the duration of the illness is not specified in the code description (i.e., we do not know the condition has lasted 12 months or longer) also are considered not chronic.