T81.4Infection following a procedure

T81.4 is the ICD-10-CM diagnosis code for infection following a procedure. It belongs to category T81 (complications of procedures, not elsewhere classified), block T80-T88 (complications of surgical and medical care, not elsewhere classified) and chapter 19 (injury, poisoning and certain other consequences of external causes). It is a header code, so it can't be reported by itself; one of its 9 subcodes must be used instead.

Within T81 (complications of procedures, not elsewhere classified), T81.4 is specifically for infection following a procedure. Related codes cover postprocedural shock (T81.1), disruption of wound, not elsewhere classified (T81.3), complications of foreign body accidentally left in body following procedure (T81.5), acute reaction to foreign substance accidentally left during a procedure (T81.6), vascular complications following a procedure, not elsewhere classified (T81.7), other complications of procedures, not elsewhere classified (T81.8) and unspecified complication of procedure (T81.9).

Codes in this range require a 7th character: A for initial encounter, D for subsequent encounter and S for sequela. Use placeholder "X" characters to fill any empty positions before the 7th character.

The conditions in its Excludes2 note aren't part of T81.4, but may be coded alongside it if the patient has both: 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-) and 2 more.

Use an additional code to identify infection: code (R65.2-) to identify severe sepsis, if applicable and code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5).

It has been part of ICD-10-CM since the code set took effect on October 1, 2015 and hasn't changed since.