2024 ICD-10-CM Diagnosis Code T81.44XS

Sepsis following a procedure, sequela

ICD-10-CM Code:
T81.44XS
ICD-10 Code for:
Sepsis following a procedure, sequela
Is Billable?
Yes - Valid for Submission
Chronic Condition Indicator: [1]
Not chronic
Code Navigator:

Code Classification

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

T81.44XS is a billable diagnosis code used to specify a medical diagnosis of sepsis following a procedure, sequela. The code is valid during the current fiscal year for the submission of HIPAA-covered transactions from October 01, 2023 through September 30, 2024. The code is exempt from present on admission (POA) reporting for inpatient admissions to general acute care hospitals.

T81.44XS is a sequela code, includes a 7th character and should be used for complications that arise as a direct result of a condition like sepsis following a procedure. According to ICD-10-CM Guidelines a "sequela" code should be used for chronic or residual conditions that are complications of an initial acute disease, illness or injury. The most common sequela is pain. Usually, two diagnosis codes are needed when reporting sequela. The first code describes the nature of the sequela while the second code describes the sequela or late effect.

Approximate Synonyms

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

  • Postoperative sepsis
  • Post-splenectomy sepsis
  • Sepsis in asplenic subject

Clinical Classification

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

Present on Admission (POA)

T81.44XS 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 IndicatorReason 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

T8144XS replaces the following previously assigned ICD-10-CM code(s):

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

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


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Sepsis

What is sepsis?

Sepsis is your body's overactive and extreme response to an infection. Sepsis is a life-threatening medical emergency. Without quick treatment, it can lead to tissue damage, organ failure, and even death.

What causes sepsis?

Sepsis happens when an infection you already have triggers a chain reaction throughout your body. Bacterial infections are the most common cause, but other types of infections can also cause it.

The infections are often in the lungs, stomach, kidneys, or bladder. It's possible for sepsis to begin with a small cut that gets infected or with an infection that develops after surgery. Sometimes, sepsis can occur in people who didn't even know that they had an infection.

Who is at risk for sepsis?

Anyone with an infection could get sepsis. But certain people are at higher risk:

  • Adults 65 or older
  • People with chronic conditions, such as diabetes, lung disease, cancer, and kidney disease
  • People with weakened immune systems
  • Pregnant women
  • Children younger than one

What are the symptoms of sepsis?

Sepsis can cause one or more of these symptoms:

  • Rapid breathing and heart rate
  • Shortness of breath
  • Confusion or disorientation
  • Extreme pain or discomfort
  • Fever, shivering, or feeling very cold
  • Clammy or sweaty skin

It's important to get medical care right away if you think you might have sepsis or if your infection is not getting better or is getting worse.

What other problems can sepsis cause?

Severe cases of sepsis can lead to septic shock, where your blood pressure drops to a dangerous level and multiple organs can fail.

How is sepsis diagnosed?

Your health care provider may use many tools to make a diagnosis:

  • A medical history, which includes asking about your symptoms
  • A physical exam, including checking vital signs (your temperature, blood pressure, heart rate, and breathing)
  • Lab tests that check for signs of infection or organ damage
  • Imaging tests such as an x-ray or a CT scan to find the location of the infection

Many of the signs and symptoms of sepsis can also be caused by other medical conditions. This may make sepsis hard to diagnose in its early stages.

What are the treatments for sepsis?

It is very important to get treatment right away. Treatment usually includes:

  • Antibiotics
  • Maintaining blood flow to organs. This may involve getting oxygen and intravenous (IV) fluids.
  • Treating the source of the infection
  • If needed, medicines to increase blood pressure

In serious cases, you might need kidney dialysis or a breathing tube. Some people need surgery to remove tissue damaged by the infection.

Can sepsis be prevented?

To prevent sepsis, you should try to prevent getting an infection:

  • Take good care of any chronic health conditions that you have
  • Get recommended vaccines
  • Practice good hygiene, such as handwashing
  • Keep cuts clean and covered until healed

NIH: National Institute of General Medical SciencesCenters for Disease Control and Prevention


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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

Footnotes

[1] Not chronic - A diagnosis code that does not fit the criteria for chronic condition (duration, ongoing medical treatment, and limitations) is considered not chronic. Some codes designated as not chronic are acute conditions. Other diagnosis codes that indicate a possible chronic condition, but for which the duration of the illness is not specified in the code description (i.e., we do not know the condition has lasted 12 months or longer) also are considered not chronic.