Perforation of esophagus

This code signifies a non-traumatic hole or tear in the wall of the esophagus, allowing its contents to leak into surrounding tissues. This can lead to serious complications such as mediastinitis, sepsis, and empyema. The perforation can be spontaneous, iatrogenic (e.g., during endoscopy), or due to underlying esophageal disease.

Use this code for spontaneous esophageal perforations, those resulting from medical procedures (iatrogenic), or perforations secondary to conditions like esophageal cancer or severe esophagitis. Documentation should clearly state the presence of an esophageal perforation and specify that it is not due to external trauma.

• Always review documentation to differentiate between traumatic and non-traumatic perforations; traumatic perforations are excluded.
• If the perforation is iatrogenic, an external cause code (Y92.11x for hospital, Y92.12x for outpatient, etc.) and a complication code (T81.2xxA for accidental puncture/laceration during procedure) may also be necessary.
• Consider sequencing this code as the principal diagnosis if it is the primary reason for the encounter and treatment.