2024 ICD-10-CM Diagnosis Code T81.40XD

Approximate Synonyms

The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:

• Abscess of female pelvis
• Application site infection
• Infected seroma after surgical procedure
• Infected seroma due to and following procedure
• Infected seroma due to and following procedure
• Infection of tendon repair
• Infectious disorder of tendon
• Meningitis following procedure
• Organ surgical site infection
• Post cosmetic surgical skin infection
• Postoperative abscess of female pelvis
• Postoperative bacteremia
• Postoperative bacterial meningitis
• Postoperative infection
• Postoperative infection of thyroidectomy wound
• Postoperative intra-abdominal abscess
• Postoperative intra-abdominal abscess
• Postoperative meningitis
• Postoperative seroma
• Postoperative urinary tract infection
• Postoperative wound infection
• Postoperative wound infection
• Postoperative wound infection-deep
• Postprocedural abscess
• Postprocedural infection
• Postprocedural intraabdominal abscess
• Postprocedural intraabdominal abscess
• Seroma
• Seroma
• Seroma following procedure
• Seroma following procedure
• Urinary tract infection following procedure

Clinical Information

• Seroma

  tumor-like sterile accumulation of serum in a tissue, organ, or cavity. it results from a tissue insult and is the product of tissue inflammation. it most commonly occurs following mastectomy.

• Mastectomy

  surgical procedure to remove one or both breasts.

• Postoperative Infection

  any infection documented following a surgical procedure that was not evident or suspected prior to the procedure.

• Grade 1 Seroma, CTCAE|Grade 1 Seroma|Grade 1 Seroma

  asymptomatic; clinical or diagnostic observations only; intervention not indicated

• Grade 2 Seroma, CTCAE|Grade 2 Seroma|Grade 2 Seroma

  symptomatic; simple aspiration indicated

• Grade 3 Seroma, CTCAE|Grade 3 Seroma|Grade 3 Seroma

  symptomatic, elective invasive intervention indicated

• Seroma

  a collection of serum in the body.

• Seroma, CTCAE|Seroma|Seroma|Seroma

  a finding of tumor-like collection of serum in the tissues.

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:

• A - initial encounter
• D - subsequent encounter
• S - sequela

T81.40XD is grouped with Diagnostic Related Groups - MS-DRG Mapping

Diagnostic Related Groups (DRGs) are a classification system used to group together diagnosis codes for the purpose of reimbursement and healthcare management. DRGs are used to standardize the way hospitals and other providers are paid for inpatient services. In this system patients are grouped together based on their principal diagnosis in areas referred to as Major Diagnostic Categories (MDC). Once a patient is assigned a particular diagnostic category, providers receive a predetermined payment rate for the services rendered. This reimbursement rate is often fixed and is meant to cover the cost of care for that patient. Reimbursement is also affected by the relative weight of a diagnostic related group based on the severity of a patient's illness and the associated cost of care during hospitalization.

Diagnostic related groups encourage healthcare providers to focus on quality and efficiency in patient care while managing costs effectively. The diagnosis code is present in the following groups for version MS-DRG V41.0 applicable from 10/01/2023 through 09/30/2024.

MS-DRG	MS-DRG Title	MCD	Relative Weight
949	AFTERCARE WITH CC/MCC	23	1.0361
950	AFTERCARE WITHOUT CC/MCC	23	0.6282

The relative weight of a diagnostic related group determines the reimbursement rate based on the severity of a patient's illness and the associated cost of care during hospitalization.

Present on Admission (POA)

T81.40XD is exempt from POA reporting - The Present on Admission (POA) indicator is used for diagnosis codes included in claims involving inpatient admissions to general acute care hospitals. POA indicators must be reported to CMS on each claim to facilitate the grouping of diagnoses codes into the proper Diagnostic Related Groups (DRG). CMS publishes a listing of specific diagnosis codes that are exempt from the POA reporting requirement. Review other POA exempt codes here.

CMS POA Indicator Options and Definitions

POA Indicator	Reason for Code	CMS will pay the CC/MCC DRG?
Y	Diagnosis was present at time of inpatient admission.	YES
N	Diagnosis was not present at time of inpatient admission.	NO
U	Documentation insufficient to determine if the condition was present at the time of inpatient admission.	NO
W	Clinically undetermined - unable to clinically determine whether the condition was present at the time of inpatient admission.	YES
1	Unreported/Not used - Exempt from POA reporting.	NO

Replacement Code

T8140XD replaces the following previously assigned ICD-10-CM code(s):

• T81.4XXD - Infection following a procedure, subsequent encounter

Patient Education

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

[Learn More in MedlinePlus]

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 (broken bones)
• Sprains and strains

[Learn More in MedlinePlus]

Code History

• FY 2024 - No Change, effective from 10/1/2023 through 9/30/2024
• FY 2023 - No Change, effective from 10/1/2022 through 9/30/2023
• FY 2022 - No Change, effective from 10/1/2021 through 9/30/2022
• 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