ICD-10-CM › S00-T88 › T80-T88 › T81.4 Infection following a procedure › T81.41

T81.41

Infection following a procedure, superficial incisional surgical site

Not billableICD-10-CM diagnosis code.

This code exists but cannot be submitted on its own. It groups the more specific codes beneath it.

A category header for its whole life, FY2019 onwards. It has never been valid for submission on its own.

Submit one of these 3 more specific codes instead:

  • T81.41XA Infection following a procedure, superficial incisional surgical site, initial encounter
  • T81.41XD Infection following a procedure, superficial incisional surgical site, subsequent encounter
  • T81.41XS Infection following a procedure, superficial incisional surgical site, sequela

This code requires a seventh character. See the rule below.

What has happened to this code

Every change the publisher made, from 2019 to now.

  1. FY2019 Added to the code set Infection following a procedure, superficial incisional surgical site

Official coding rules

Published by CDC for FY2027. A rule attached to a category binds every code beneath it, so the rules inherited from this code's ancestors are shown with the code they come from.

Inherited from T81 Complications of procedures, not elsewhere classified

Seventh character required

  • The appropriate 7th character is to be added to each code from category T81

Excludes2 - not included here

  • 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)

Use additional code

  • code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)

Inherited from the T80-T88 section Complications of surgical and medical care, not elsewhere classified (T80-T88)

Excludes2 - not included here

  • 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)
  • 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.-)
  • 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)

Use additional code

  • code(s) to identify the specified condition resulting from the complication
  • code to identify devices involved and details of circumstances (Y62-Y82)

How CDC's index refers to this code

Wording from the official alphabetic index. Much of it appears nowhere in the code description, which is why a search for the everyday phrase so often finds nothing.

Codes in the same group

CodeDescriptionStatus
T81.40 Infection following a procedure, unspecified Not billable
T81.42 Infection following a procedure, deep incisional surgical site Not billable
T81.43 Infection following a procedure, organ and space surgical site Not billable
T81.44 Sepsis following a procedure Not billable
T81.49 Infection following a procedure, other surgical site Not billable
T81.4XXA Infection following a procedure, initial encounter Retired
T81.4XXD Infection following a procedure, subsequent encounter Retired
T81.4XXS Infection following a procedure, sequela Retired