2022 ICD-10-CM Code T81.4

Infection following a procedure

Version 2021

Not Valid for Submission

ICD-10:T81.4
Short Description:Infection following a procedure
Long Description:Infection following a procedure

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)

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.

Coding Guidelines

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:

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:

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

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.

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.

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

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


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Code History

  • FY 2021 - No Change, effective from 10/1/2020 through 9/30/2021
  • FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020
  • FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
  • FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
  • FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
  • FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016 (First year ICD-10-CM implemented into the HIPAA code set)