Not Valid for Submission
T81.4 is a non-specific and non-billable diagnosis code code, consider using a code with a higher level of specificity for a diagnosis of infection following a procedure. The code is not specific and is NOT valid for the year 2022 for the submission of HIPAA-covered transactions. Category or Header define the heading of a category of codes that may be further subdivided by the use of 4th, 5th, 6th or 7th characters.
The appropriate 7th character is to be added to each code from block Complications of procedures, not elsewhere classified (T81). Use the following options for the aplicable episode of care:
- A - initial encounter
- D - subsequent encounter
- S - sequela
Specific Coding for Infection following a procedure
Non-specific codes like T81.4 require more digits to indicate the appropriate level of specificity. Consider using any of the following ICD-10 codes with a higher level of specificity when coding for infection following a procedure:
Tabular List of Diseases and Injuries
The Tabular List of Diseases and Injuries is a list of ICD-10 codes, organized "head to toe" into chapters and sections with coding notes and guidance for inclusions, exclusions, descriptions and more. The following references are applicable to the code T81.4:
Inclusion TermsInclusion Terms
These terms are the conditions for which that code is to be used. The terms may be synonyms of the code title, or, in the case of "other specified" codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.
- Wound abscess following a procedure
Use Additional CodeUse Additional Code
The “use additional code” indicates that a secondary code could be used to further specify the patient’s condition. This note is not mandatory and is only used if enough information is available to assign an additional code.
- code to identify infection
Type 2 ExcludesType 2 Excludes
A type 2 excludes note represents "Not included here". An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.
- 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
Information for Patients
After any operation, you'll have some side effects. There is usually some pain with surgery. There may also be swelling and soreness around the area that the surgeon cut. Your surgeon can tell you which side effects to expect.
There can also be complications. These are unplanned events linked to the operation. Some complications are infection, too much bleeding, reaction to anesthesia, or accidental injury. Some people have a greater risk of complications because of other medical conditions.
Your surgeon can tell you how you might feel and what you will be able to do - or not do - the first few days, weeks, or months after surgery. Some other questions to ask are
- How long you will be in the hospital
- What kind of supplies, equipment, and help you might need when you go home
- When you can go back to work
- When it is ok to start exercising again
- Are they any other restrictions in your activities
Following your surgeon's advice can help you recover as soon as possible.
Agency for Healthcare Research and Quality
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Wounds and Injuries
An injury is damage to your body. It is a general term that refers to harm caused by accidents, falls, hits, weapons, and more. In the U.S., millions of people injure themselves every year. These injuries range from minor to life-threatening. Injuries can happen at work or play, indoors or outdoors, driving a car, or walking across the street.
Wounds are injuries that break the skin or other body tissues. They include cuts, scrapes, scratches, and punctured skin. They often happen because of an accident, but surgery, sutures, and stitches also cause wounds. Minor wounds usually aren't serious, but it is important to clean them. Serious and infected wounds may require first aid followed by a visit to your doctor. You should also seek attention if the wound is deep, you cannot close it yourself, you cannot stop the bleeding or get the dirt out, or it does not heal.
Other common types of injuries include
- Animal bites
- Electrical injuries
- Fractures (broken bones)
- Sprains and strains
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