ICD-10-CM Code T81.42XS

Infection following a procedure, deep incisional surgical site, sequela

Version 2020 Billable Code POA Exempt

Valid for Submission

T81.42XS is a billable code used to specify a medical diagnosis of infection following a procedure, deep incisional surgical site, sequela. The code is valid for the year 2020 for the submission of HIPAA-covered transactions. The ICD-10-CM code T81.42XS might also be used to specify conditions or terms like deep incisional surgical site infection or postoperative wound infection-deep. The code is exempt from present on admission (POA) reporting for inpatient admissions to general acute care hospitals.

ICD-10:T81.42XS
Short Description:Infct fol a proc, deep incisional surgical site, sequela
Long Description:Infection following a procedure, deep incisional surgical site, sequela

Synonyms

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

  • Deep incisional surgical site infection
  • Postoperative wound infection-deep

Diagnostic Related Groups

The ICD-10 code T81.42XS is grouped in the following groups for version MS-DRG V37.0 What are Diagnostic Related Groups?
The Diagnostic Related Groups (DRGs) are a patient classification scheme which provides a means of relating the type of patients a hospital treats. The DRGs divides all possible principal diagnoses into mutually exclusive principal diagnosis areas referred to as Major Diagnostic Categories (MDC).
applicable from 10/01/2019 through 09/30/2020.

  • 922 - OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC
  • 923 - OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC

Present on Admission (POA)

T81.42XS 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 CodePOA Reason for CodeCMS will pay the CC/MCC DRG?
YDiagnosis was present at time of inpatient admission.YES
NDiagnosis was not present at time of inpatient admission.NO
UDocumentation insufficient to determine if the condition was present at the time of inpatient admission.NO
WClinically undetermined - unable to clinically determine whether the condition was present at the time of inpatient admission.YES
1Unreported/Not used - Exempt from POA reporting. NO

Replacement Code

T8142XS replaces the following previously assigned ICD-10 code(s):

  • T81.4XXS - Infection following a procedure, sequela

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 2019 - Code Added, 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

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