Unintended awareness under general anesth during proc, subs

This code signifies a patient's experience of regaining consciousness or awareness during a surgical or medical procedure while under general anesthesia. This is an adverse event where the patient can recall events, sensations, or conversations from the procedure, despite being expected to be fully unconscious.

This code is used for follow-up encounters related to a previously documented episode of unintended intraoperative awareness. This includes subsequent evaluations, management of psychological sequelae such as PTSD, or treatment for any physical complications directly resulting from the awareness event.

• Ensure documentation clearly indicates this is a follow-up visit for a previously established diagnosis of intraoperative awareness.
• Do not use this code for the initial encounter where the awareness was first identified; a different encounter character is required for that.
• Always code any associated mental health conditions (e.g., PTSD, anxiety) or physical complications as secondary diagnoses.