ICD-10-CM Code T81.4

Infection following a procedure

Version 2020 Non-Billable Code

Not Valid for Submission

T81.4 is a "header" nonspecific and non-billable code code, consider using a code with a higher level of specificity for a diagnosis of infection following a procedure. The code is NOT valid for the year 2020 for the submission of HIPAA-covered transactions.

Short Description:Infection following a procedure
Long Description:Infection following a procedure

Consider the following ICD-10 codes with a higher level of specificity:

  • T81.40 - ... unspecified
  • T81.40XA - ... unspecified, initial encounter
  • T81.40XD - ... unspecified, subsequent encounter
  • T81.40XS - ... unspecified, sequela
  • T81.41 - ... superficial incisional surgical site
  • T81.41XA - ... superficial incisional surgical site, initial encounter
  • T81.41XD - ... superficial incisional surgical site, subsequent encounter
  • T81.41XS - ... superficial incisional surgical site, sequela
  • T81.42 - ... deep incisional surgical site
  • T81.42XA - ... deep incisional surgical site, initial encounter
  • T81.42XD - ... deep incisional surgical site, subsequent encounter
  • T81.42XS - ... deep incisional surgical site, sequela
  • T81.43 - ... organ and space surgical site
  • T81.43XA - ... organ and space surgical site, initial encounter
  • T81.43XD - ... organ and space surgical site, subsequent encounter
  • T81.43XS - ... organ and space surgical site, sequela
  • T81.44 - Sepsis following a procedure
  • T81.44XA - Sepsis following a procedure, initial encounter
  • T81.44XD - Sepsis following a procedure, subsequent encounter
  • T81.44XS - Sepsis following a procedure, sequela
  • T81.49 - ... other surgical site
  • T81.49XA - ... other surgical site, initial encounter
  • T81.49XD - ... other surgical site, subsequent encounter
  • T81.49XS - ... other surgical site, sequela

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 guidance for inclusions, exclusions, descriptions and more. The following references are applicable to the code T81.4:

Inclusion Terms

Inclusion 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 Code

Use 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 Excludes

Type 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

Code Classification

  • Injury, poisoning and certain other consequences of external causes (S00–T98)
    • Complications of surgical and medical care, not elsewhere classified (T80-T88)
      • Complications of procedures, not elsewhere classified (T81)

Code History

  • FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016
    (First year ICD-10-CM implemented into the HIPAA code set)
  • FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
  • FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
  • FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
  • FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020

Information for Patients

After Surgery

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
  • Bruises
  • Burns
  • Dislocations
  • Electrical injuries
  • Fractures
  • Sprains and strains

[Learn More]