2026 ICD-10-CM Diagnosis Code T81.40XAInfection following a procedure, unspecified, initial encounter

ICD-10-CM Codes›S00–T88›T80-T88›T81

ICD-10-CM T81.40XA
CMSSource: CMS FY 2026 ICD-10-CM dataset · Effective Oct 1, 2025 – Sep 30, 2026

T81.40XA is a billable ICD-10-CM diagnosis code for infection following a procedure, unspecified, initial encounter. The 7th character A marks it as an initial encounter code, used while the patient is receiving active treatment. It is valid on HIPAA claims for fiscal year 2026 (October 1, 2025 through September 30, 2026) and groups to MS-DRG 856 through 858, 862 through 863. In AHRQ's Clinical Classifications Software (CCSR), this diagnosis falls under Complication of other surgical or medical care, injury, initial encounter.

Code Identity

ICD-10-CM Code
T81.40XA
Billable Status
Yes — Valid for Submission
Code Describes
Infection following a procedure, unspecified, initial encounter
Short Description
Infection following a procedure, unspecified, init
Parent Code
T81.40
Infection following a procedure, unspecified

Code Classification

ChapterS00–T88Injury, poisoning and certain other consequences of external causes
SectionT80-T88Complications of surgical and medical care, not elsewhere classified
CategoryT81Complications of procedures, not elsewhere classified
This CodeT81.40XAInfection following a procedure, unspecified, initial encounter

Approximate SynonymsGuidance

Alternate terms and clinical phrases that map to this code.

  • Abscess of female pelvis
  • Application site infection
  • Disorder of tendon repair
  • Infected seroma after surgical 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 meningitis
  • Postoperative seroma
  • Postoperative urinary tract infection
  • Postoperative wound infection
  • Postoperative wound infection-deep
  • Postprocedural abscess
  • Postprocedural infection
  • Postprocedural intraabdominal abscess
  • Seroma
  • Seroma following procedure
  • Urinary tract infection following procedure

Coding GuidelinesGuidance

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 applicable episode of care:

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

Source: ICD-10-CM Official Guidelines for Coding and Reporting, FY 2026, published by CMS and the National Center for Health Statistics.

Clinical ClassificationClinical

AHRQ’s CCSR groups this code into broader clinical categories.

CCSR INJ037
Complication of other surgical or medical care, injury, initial encounter
Default principal diagnosis: inpatient Yes · outpatient Yes

Clinical InformationClinical

  • 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.

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

    symptomatic; simple aspiration indicated

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

    symptomatic, elective invasive intervention indicated

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

    a finding of leakage due to breakdown of an anastomosis (surgical connection of two separate anatomic structures) in the small bowel.

  • Seroma, CTCAE|Seroma|Seroma|Seroma

    asymptomatic; clinical or diagnostic observations only; intervention not indicated

  • 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.

Patient EducationClinical

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.

Read the full article at MedlinePlus

Courtesy of MedlinePlus, a service of the U.S. National Library of Medicine.

Code History & ChangesHistory

Replacement T81.40XA replaces the following previously assigned code(s):

  • T81.4XXA - Infection following a procedure, initial encounter
FY 2019AddedAdded to the ICD-10-CM code setEffective October 1, 2018.
FY 2020–2025No changes
FY 2026CurrentCurrent code set, no changesEffective October 1, 2025 through September 30, 2026.

Questions About T81.40XAOverview

Is T81.40XA (Infection following a procedure, unspecified) a billable code?

Yes. This is a billable ICD-10-CM code, specific enough to report infection following a procedure, unspecified, initial encounter on HIPAA-covered claims from October 1, 2025 through September 30, 2026.

What does the 7th character A in T81.40XA mean?

The final character A marks the initial encounter: use it while the patient is receiving active treatment for infection following a procedure, unspecified, such as an emergency visit or first evaluation.

What MS-DRG does T81.40XA group to?

When infection following a procedure, unspecified, initial encounter is the principal diagnosis on an inpatient stay, it groups to MS-DRG 856, 857, 858, 862, 863, with relative weights from 0.9979 to 4.5487 depending on complications. Higher weights mean higher Medicare reimbursement.

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.