2026 ICD-10-CM Diagnosis Code T81.40XSInfection following a procedure, unspecified, sequela
T81.40XS is a billable ICD-10-CM diagnosis code for infection following a procedure, unspecified, sequela. The 7th character S marks it as a sequela code, which reports a problem that remains after the original condition has resolved. It is valid on HIPAA claims for fiscal year 2026 (October 1, 2025 through September 30, 2026) and groups to MS-DRG 922 through 923. The code is exempt from POA reporting. In AHRQ's Clinical Classifications Software (CCSR), this diagnosis falls under Complication, sequela.
Code Identity
Code Classification
Present on Admission (POA)Billing
T81.40XS is exempt from POA reporting on inpatient claims to general acute care hospitals. Review other POA exempt codes.
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.
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 indicatedGrade 2 Seroma, CTCAE|Grade 2 Seroma|Grade 2 Seroma
symptomatic, elective invasive intervention indicatedGrade 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 indicatedPostoperative 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 indicatedGrade 2 Seroma, CTCAE|Grade 2 Seroma|Grade 2 Seroma
symptomatic; simple aspiration indicatedGrade 3 Seroma, CTCAE|Grade 3 Seroma|Grade 3 Seroma
symptomatic, elective invasive intervention indicatedSeroma
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 T81.40XS replaces the following previously assigned code(s):
- T81.4XXS - Infection following a procedure, sequela
Questions About T81.40XSOverview
Is T81.40XS (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, sequela on HIPAA-covered claims from October 1, 2025 through September 30, 2026.
What does the 7th character S in T81.40XS mean?
The final character S makes this a sequela code: it reports a lingering problem that remains after the infection following a procedure, unspecified itself has resolved, not the original event.
What MS-DRG does T81.40XS group to?
When infection following a procedure, unspecified, sequela is the principal diagnosis on an inpatient stay, it groups to MS-DRG 922, 923, with relative weights from 1.0177 to 1.7494 depending on complications. Higher weights mean higher Medicare reimbursement.
Is T81.40XS exempt from POA reporting?
Yes. CMS lists this code among those exempt from present on admission reporting, so hospitals do not assign a POA indicator for infection following a procedure, unspecified, sequela on inpatient claims.
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.
