Alphabetic Index FY2027

T81.40

Infection following a procedure, unspecified

FY2027Chapter 19: Injury, poisoning and certain other consequences of external causes/T80–T88 Complications of surgical and medical care, not elsewhere classified

Non-billable headerNot valid on its own. Use one of the more specific codes under it.

T81.40 is a non-billable ICD-10-CM code header for infection following a procedure, unspecified. Report a more specific code from it instead. It is part of the FY2027 code set, effective October 1, 2026. A 7th character is required to complete the code. Its coding notes include a Use additional code instruction, a Code also instruction and 41 Excludes2 entries.

7th character

Category T81 requires a 7th character. T81.40 has only 5 characters, so a placeholder X fills the 6th position.

Assembled code T81.40XA Open code

Guidelines tips

From the FY2027 Official Guidelines. ICD10Ref adds no rules of its own.

The 7th character depends on whether the patient is in active treatment, not on who sees the patient. An aftercare Z code is not used for injury aftercare.

Guidelines I.C.19.aInjuries: application of 7th charactersRead the official text

A complication code needs the provider's documented cause-and-effect link between the care and the condition. Some T codes already include the type of procedure, so no external cause code is needed.

Guidelines I.B.16; I.C.19.g.4Complications of careRead the official text

Code assignment depends on the provider's documentation linking the infection to the procedure. The site infection is sequenced first, with an additional code for sepsis following a procedure and one for the infectious agent.

Guidelines I.C.1.d.5Sepsis due to a postprocedural infectionRead the official text

Use additional code

Add the listed code as a secondary code, if known.

Inherited from T81.4 Infection following a procedure
  • code to identify infection
  • code (R65.2-) to identify severe sepsis, if applicable
Inherited from T81 Complications of procedures, not elsewhere classified
  • code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)
Also from chapter/block level (4 notes)
Inherited from T80–T88 Complications of surgical and medical care, not elsewhere classified
  • code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)
  • code(s) to identify the specified condition resulting from the complication
  • code to identify devices involved and details of circumstances (Y62-Y82)
Inherited from Chapter 19 Injury, poisoning and certain other consequences of external causes
  • code to identify any retained foreign body, if applicable (Z18.-)

Code also

Two codes may be needed to describe the condition. This note gives no sequencing order.

Inherited from T81.4 Infection following a procedure
  • , if applicable, disruption of internal operation (surgical) wound (T81.32-)

Excludes2

Not included here. Both codes may be reported if the patient has both conditions.

Inherited from T81.4 Infection following a procedure
Inherited from T81 Complications of procedures, not elsewhere classified
  • 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:
Also from chapter/block level (23 notes)
Inherited from T80–T88 Complications of surgical and medical care, not elsewhere classified
  • 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:
Inherited from Chapter 19 Injury, poisoning and certain other consequences of external causes
  • birth trauma (P10-P15)
  • obstetric trauma (O70-O71)

Notes

Also from chapter/block level (2 notes)
Inherited from Chapter 19 Injury, poisoning and certain other consequences of external causes
  • Use secondary code(s) from Chapter 20, External causes of morbidity, to indicate cause of injury. Codes within the T section that include the external cause do not require an additional external cause code
  • The chapter uses the S-section for coding different types of injuries related to single body regions and the T-section to cover injuries to unspecified body regions as well as poisoning and certain other consequences of external causes.

Alphabetic Index terms

Terms the official Alphabetic Index lists for this code. 4 entries

7th-character codes under T81.40 3