T81.40XA

Infection following a procedure, unspecified, initial encounter

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

BillableComplete code, valid to report

7th character: A
Use additional code
Code also
Excludes2

Care settingsHospital CC HAC

T81.40XA (also written T8140XA) is a billable ICD-10-CM diagnosis code for infection following a procedure, unspecified, initial encounter. It is part of the FY2027 code set, effective October 1, 2026. It is one of the 240 codes in category T81 (Complications of procedures, not elsewhere classified). The Alphabetic Index lists it under 4 entries. Its 7th character, A, means initial encounter. 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

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)

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:
- 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)

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:
- 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)

Inherited from Chapter 19 Injury, poisoning and certain other consequences of external causes

birth trauma (P10-P15)
obstetric trauma (O70-O71)

Care settings

How CMS programs treat this code. These are CMS claim edits and list entries, not coverage or eligibility rules.

Hospital CC

Counts as a complication or comorbidity (CC) when reported as a secondary diagnosis on an inpatient claim. It does not count when the principal diagnosis is one of the 55 codes in its exclusion list. Some MS-DRGs also ignore a CC or MCC that defines the DRG.

Source: CMS MS-DRG Definitions Manual v44, effective October 1, 2026, Appendix C

HAC

On the CMS list of hospital-acquired conditions (HAC 11: Surgical Site Infection - Bariatric Surgery; HAC 12: Surgical Site Infection - Certain Orthopedic Procedures of Spine, Shoulder and Elbow; HAC 13: Surgical Site Infection (SSI) Following Cardiac Implantable Electronic Device (CIED) Procedures). When the claim reports it with a present-on-admission (POA) indicator of N (not present) or U (documentation insufficient), CMS does not pay the CC or MCC DRG for it. A POA of Y (present) or W (clinically undetermined) is paid normally. Some HAC categories also require a listed procedure.

Source: CMS MS-DRG Definitions Manual v44, effective October 1, 2026, Appendix I; CMS Hospital-Acquired Conditions (HAC) Coding page, POA indicator payment table

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 T81.40. This code adds the 7th character. 4 entries