T81.4 — Infection following a procedure
Is T81.4 billable?
No — T81.4 is a non-billable header code. T81.4 groups more specific codes and cannot be submitted on a claim. A valid ICD-10-CM code must be reported at the highest level of specificity available in its branch. Select one of the 18 billable codes beneath T81.4.
Billable codes under this header
- T81.40XAInfection following a procedure, unspecified, initial encounter
- T81.40XDInfection following a procedure, unspecified, subsequent encounter
- T81.40XSInfection following a procedure, unspecified, sequela
- T81.41XAInfection following a procedure, superficial incisional surgical site, initial encounter
- T81.41XDInfection following a procedure, superficial incisional surgical site, subsequent encounter
- T81.41XSInfection following a procedure, superficial incisional surgical site, sequela
- T81.42XAInfection following a procedure, deep incisional surgical site, initial encounter
- T81.42XDInfection following a procedure, deep incisional surgical site, subsequent encounter
- T81.42XSInfection following a procedure, deep incisional surgical site, sequela
- T81.43XAInfection following a procedure, organ and space surgical site, initial encounter
- T81.43XDInfection following a procedure, organ and space surgical site, subsequent encounter
- T81.43XSInfection following a procedure, organ and space surgical site, sequela
- T81.44XASepsis following a procedure, initial encounter
- T81.44XDSepsis following a procedure, subsequent encounter
- T81.44XSSepsis following a procedure, sequela
- T81.49XAInfection following a procedure, other surgical site, initial encounter
- T81.49XDInfection following a procedure, other surgical site, subsequent encounter
- T81.49XSInfection following a procedure, other surgical site, sequela
T81.4 at a glance
| Code | T81.4 |
|---|---|
| Description | Infection following a procedure |
| Billable | No — header code |
| Code set | ICD-10-CM FY2027 |
| Valid for encounters | October 1, 2026 – September 30, 2027 |
Use additional code
Report an additional code alongside T81.4 to fully describe the condition. T81.4 is sequenced first.
- code to identify infection
- code (R65.2-) to identify severe sepsis, if applicable
Excludes2 — not included here
The conditions below are not part of T81.4, but a patient may have both at the same time. When documentation supports it, T81.4 and the excluded code may both be reported.
- bleb associated endophthalmitis (H59.4-)
- infection due to infusion, transfusion and therapeutic injection (T80.2-)
- infection due to prosthetic devices, implants and grafts (T82.6-T82.7, T83.5-T83.6, T84.5-T84.7, T85.7)
- obstetric surgical wound infection (O86.0-)
- postprocedural fever NOS (R50.82)
- postprocedural retroperitoneal abscess (K68.11)
Code also
Two codes may be needed to describe the condition fully. Whether T81.4 is sequenced first depends on the reason for the encounter.
- , if applicable, disruption of internal operation (surgical) wound (T81.32-)
Inclusion terms
Alternative wording in documentation that is classified to T81.4.
- Wound abscess following a procedure
Use additional code — inherited from Chapter 19
Report an additional code alongside T81.4 to fully describe the condition. T81.4 is sequenced first.
- code to identify any retained foreign body, if applicable (Z18.-)
Use additional code — inherited from T80-T88
Report an additional code alongside T81.4 to fully describe the condition. T81.4 is sequenced first.
Use additional code — inherited from T81
Report an additional code alongside T81.4 to fully describe the condition. T81.4 is sequenced first.
- code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)
Excludes2 — not included here — inherited from Chapter 19
The conditions below are not part of T81.4, but a patient may have both at the same time. When documentation supports it, T81.4 and the excluded code may both be reported.
Excludes2 — not included here — inherited from T80-T88
The conditions below are not part of T81.4, but a patient may have both at the same time. When documentation supports it, T81.4 and the excluded code may both be reported.
- any encounters with medical care for postprocedural conditions in which no complications are present, such as:
- artificial opening status (Z93.-)
- closure of external stoma (Z43.-)
- fitting and adjustment of external prosthetic device (Z44.-)
- burns and corrosions from local applications and irradiation (T20-T32)
- complications of surgical procedures during pregnancy, childbirth and the puerperium (O00-O9A)
- mechanical complication of respirator [ventilator] (J95.850)
- poisoning and toxic effects of drugs and chemicals (T36-T65 with fifth or sixth character 1-4 or 6)
- postprocedural fever (R50.82)
- specified complications classified elsewhere, such as:
- cerebrospinal fluid leak from spinal puncture (G97.0)
- colostomy malfunction (K94.0-)
- disorders of fluid and electrolyte imbalance (E86-E87)
- functional disturbances following cardiac surgery (I97.0-I97.1)
- intraoperative and postprocedural complications of specified body systems (D78.-, E36.-, E89.-, G97.3-, G97.4, H59.3-, H59.-, H95.2-, H95.3, I97.4-, I97.5, J95.6-, J95.7, K91.6-, L76.-, M96.-, N99.-)
- ostomy complications (J95.0-, K94.-, N99.5-)
- postgastric surgery syndromes (K91.1)
- postlaminectomy syndrome NEC (M96.1)
- postmastectomy lymphedema syndrome (I97.2)
- postsurgical blind-loop syndrome (K91.2)
- ventilator associated pneumonia (J95.851)
Excludes2 — not included here — inherited from T81
The conditions below are not part of T81.4, but a patient may have both at the same time. When documentation supports it, T81.4 and the excluded code may both be reported.
- complications following immunization (T88.0-T88.1)
- complications following infusion, transfusion and therapeutic injection (T80.-)
- complications of transplanted organs and tissue (T86.-)
- specified complications classified elsewhere, such as:
- complication of prosthetic devices, implants and grafts (T82-T85)
- dermatitis due to drugs and medicaments (L23.3, L24.4, L25.1, L27.0-L27.1)
- endosseous dental implant failure (M27.6-)
- floppy iris syndrome (IFIS) (intraoperative) H21.81
- intraoperative and postprocedural complications of specific body system (D78.-, E36.-, E89.-, G97.3-, G97.4, H59.3-, H59.-, H95.2-, H95.3, I97.4-, I97.5, J95, K91.-, L76.-, M96.-, N99.-)
- ostomy complications (J95.0-, K94.-, N99.5-)
- plateau iris syndrome (post-iridectomy) (postprocedural) H21.82
- poisoning and toxic effects of drugs and chemicals (T36-T65 with fifth or sixth character 1-4)
What codes fall under T81.4? (6)
- T81.40Infection following a procedure, unspecifiednot billable
- T81.41Infection following a procedure, superficial incisional surgical sitenot billable
- T81.42Infection following a procedure, deep incisional surgical sitenot billable
- T81.43Infection following a procedure, organ and space surgical sitenot billable
- T81.44Sepsis following a procedurenot billable
- T81.49Infection following a procedure, other surgical sitenot billable
How long has T81.4 existed?
T81.4 has been in ICD-10-CM since at least FY2016, the earliest fiscal year on record here.
Derived from the official order files for FY2016–FY2026. FY2017 and FY2020 publish no order file, so those years are not covered.
What other codes are in the T81 family? (7)
- T81.1Postprocedural shocknot billable
- T81.3Disruption of wound, not elsewhere classifiednot billable
- T81.5Complications of foreign body accidentally left in body following procedurenot billable
- T81.6Acute reaction to foreign substance accidentally left during a procedurenot billable
- T81.7Vascular complications following a procedure, not elsewhere classifiednot billable
- T81.8Other complications of procedures, not elsewhere classifiednot billable
- T81.9Unspecified complication of procedurenot billable