Infection following a procedure, initial encounter

RetiredICD-10-CM diagnosis code.

No longer in the code set. Submitting it will not be accepted for a current date of service.

Billable FY2016 to FY2018. In the code set FY2016 to FY2018, and removed after that.

Use instead:

T81.40XA Infection following a procedure, unspecified, initial encounter stated for FY2018
T81.41XA Infection following a procedure, superficial incisional surgical site, initial encounter stated for FY2018
T81.42XA Infection following a procedure, deep incisional surgical site, initial encounter stated for FY2018
T81.43XA Infection following a procedure, organ and space surgical site, initial encounter stated for FY2018
T81.44XA Sepsis following a procedure, initial encounter stated for FY2018
T81.49XA Infection following a procedure, other surgical site, initial encounter stated for FY2018

What has happened to this code

Every change the publisher made, from 2007 to now. Entries marked draft are from the pre-implementation releases: ICD-10 took effect on 1 October 2015, so nothing before FY2016 was ever valid on a claim.

FY2007 Added to the draft code set draft Infection following a procedure, initial encounter
FY2019 Removed from the code set

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)

Codes in the same group

Code	Description	Status
T81.40	Infection following a procedure, unspecified	Not billable
T81.41	Infection following a procedure, superficial incisional surgical site	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
T81.4XXD	Infection following a procedure, subsequent encounter	Retired
T81.4XXS	Infection following a procedure, sequela	Retired