T81.4 — Infection following a procedure
T81.4 is a non-billable header ICD-10-CM code for infection following a procedure. It cannot be billed on its own: choose one of the more specific child codes below. This code also requires a 7th character before it is complete.
This code requires a 7th character
The appropriate 7th character is to be added to each code from category T81
- A
- initial encounter
- D
- subsequent encounter
- S
- sequela
Excludes2 — not included here, but may coexist
The excluded condition is not part of this code, but a patient can have both. You may code both.
- bleb associated endophthalmitis (H59.4-)
- infection due to infusion, transfusion and therapeutic injection (T80.2-)
- infection due to prosthetic devices, implants and grafts (T82.6-T82.7, T83.5-T83.6, T84.5-T84.7, T85.7)
- obstetric surgical wound infection (O86.0-)
- postprocedural fever NOS (R50.82)
- postprocedural retroperitoneal abscess (K68.11)
Use additional code
Add a secondary code to capture the detail described below.
- code to identify infection
- code (R65.2-) to identify severe sepsis, if applicable
Code also
Both codes may be needed to describe the encounter fully. Sequencing depends on the reason for the visit.
- , if applicable, disruption of internal operation (surgical) wound (T81.32-)
Inclusion terms
Alternative wordings a physician may use in the chart for this same code.
- Wound abscess following a procedure
Other codes that can never be billed with T81.4
These codes carry an Excludes1 note pointing at T81.4. The conflict binds both ways, but ICD-10-CM only writes it down on one side — so you would not find this by reading T81.4 alone.
Risk adjustment
T81.4 does not map to an HCC and does not risk-adjust under CMS-HCC V28. That is normal — most ICD-10 codes do not. It still needs to be coded correctly; it just will not move a RAF score.
Code to one of these instead T81.4
6 child codes. Green means billable.
- T81.40Infection following a procedure, unspecified
- T81.41Infection following a procedure, superficial incisional surgical site
- T81.42Infection following a procedure, deep incisional surgical site
- T81.43Infection following a procedure, organ and space surgical site
- T81.44Sepsis following a procedure
- T81.49Infection following a procedure, other surgical site
Related codes at this level
Codes that share T81. If T81.4 is not quite right, the correct code is usually one of these.
- T81.1Postprocedural shock
- T81.3Disruption of wound, not elsewhere classified
- T81.5Complications of foreign body accidentally left in body following procedure
- T81.6Acute reaction to foreign substance accidentally left during a procedure
- T81.7Vascular complications following a procedure, not elsewhere classified
- T81.8Other complications of procedures, not elsewhere classified
- T81.9Unspecified complication of procedure
Questions about T81.4
- Is T81.4 a billable ICD-10-CM code?
- No. T81.4 is a non-billable header code. Code to a higher level of specificity using one of its child codes.
- Where does T81.4 sit in the tabular list?
- Injury, poisoning and certain other consequences of external causes (S00-T88), in the block Complications of surgical and medical care, not elsewhere classified (T80-T88).