ICD-10-CM diagnosis code
T88.52XA Failed moderate sedation during procedure, initial encounter
- Billable
- Yes, a complete code (FY2026)
Encounter (7th character)
This code is for the initial encounter: the patient is receiving active treatment for the condition (for example surgery, an emergency department visit or evaluation by a new clinician).
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Other codes in T88
39 complete codes in this category.
- T88.4XXAFailed or difficult intubation, initial encounter
- T88.4XXDFailed or difficult intubation, subsequent encounter
- T88.4XXSFailed or difficult intubation, sequela
- T88.51XAHypothermia following anesthesia, initial encounter
- T88.51XDHypothermia following anesthesia, subsequent encounter
- T88.51XSHypothermia following anesthesia, sequela
- T88.52XAFailed moderate sedation during procedure, initial encounter
- T88.52XDFailed moderate sedation during procedure, subsequent encounter
- T88.52XSFailed moderate sedation during procedure, sequela
- T88.53XAUnintended awareness under general anesthesia during procedure, initial encounter
- T88.53XDUnintended awareness under general anesthesia during procedure, subsequent encounter
- T88.53XSUnintended awareness under general anesthesia during procedure, sequela
Documentation tips
- Make sure the note supports every element of the title, “Failed moderate sedation during procedure, initial encounter”: each detail in it should be traceable to the history, examination or assessment.
- Code to the highest specificity the documentation supports. If a detail is missing from the note, add it to the note rather than choosing a less specific code by default.
- Check the Tabular List and official guidelines for instructional notes (“code first”, “use additional code”, Excludes1/Excludes2) that apply to T88.
The international WHO ICD-10 also has T88, with its inclusion and exclusion notes; titles and detail can differ from ICD-10-CM.
ICD-10-CM is developed by the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, and is based on the WHO ICD-10. Codes and titles are reproduced unchanged from the FY2026 code list (effective 1 October 2025). Their use here does not imply endorsement by CDC, HHS or the U.S. Government. Changes effective on or after 1 October 2026 may not be reflected yet; check the current release at cdc.gov or cms.gov before submitting claims.
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