2026 ICD-10-CM Diagnosis Code T81.42XSInfection following a procedure, deep incisional surgical site, sequela
T81.42XS is a billable ICD-10-CM diagnosis code for infection following a procedure, deep incisional surgical site, 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. Coders also document this condition as deep incisional surgical site infection. In AHRQ's Clinical Classifications Software (CCSR), this diagnosis falls under Complication, sequela.
Code Identity
Code Classification
Present on Admission (POA)Billing
T81.42XS 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.
- Deep incisional surgical site infection
- Postoperative wound infection
- Postoperative wound infection-deep
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.
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 T81.42XS replaces the following previously assigned code(s):
- T81.4XXS - Infection following a procedure, sequela
Questions About T81.42XSOverview
Is T81.42XS a billable code?
Yes. This is a billable ICD-10-CM code, specific enough to report infection following a procedure, deep incisional surgical site, sequela on HIPAA-covered claims from October 1, 2025 through September 30, 2026.
What does the 7th character S in T81.42XS mean?
The final character S makes this a sequela code: it reports a lingering problem that remains after the infection following a procedure, deep incisional surgical site itself has resolved, not the original event.
What MS-DRG does T81.42XS group to?
When infection following a procedure, deep incisional surgical site, 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 T81.42XS 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, deep incisional surgical site, 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.
