T81.4

T81.4: Infection following a procedure

Non-billable headerICD-10-CM

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

Excludes2 inherited from the categories above T81.4

Not part of this code, but both may be coded when both are present.

Written on T81: Complications of procedures, not elsewhere classified

complications following immunization (T88.0-T88.1)
complications following infusion, transfusion and therapeutic injection (T80.-)
complications of transplanted organs and tissue (T86.-)
specified complications classified elsewhere, such as:
complication of prosthetic devices, implants and grafts (T82-T85)
dermatitis due to drugs and medicaments (L23.3, L24.4, L25.1, L27.0-L27.1)
endosseous dental implant failure (M27.6-)
floppy iris syndrome (IFIS) (intraoperative) H21.81
intraoperative and postprocedural complications of specific body system (D78.-, E36.-, E89.-, G97.3-, G97.4, H59.3-, H59.-, H95.2-, H95.3, I97.4-, I97.5, J95, K91.-, L76.-, M96.-, N99.-)
ostomy complications (J95.0-, K94.-, N99.5-)
plateau iris syndrome (post-iridectomy) (postprocedural) H21.82
poisoning and toxic effects of drugs and chemicals (T36-T65 with fifth or sixth character 1-4)

Other codes that can never be billed with T81.4

Their own Excludes1 notes name this code, so the conflict is not listed above.

O86.0Infection of obstetric surgical wound
R50.82Postprocedural fever

Risk adjustment

No CMS-HCC V28 category: this code does not change a RAF score.

Code history

Unchanged in every release from FY2024 to FY2027.

Code to one of these instead T81.4

6 child codes. Green means billable.