T81.4 – Infection following a procedure

ICD-10-CM 2027 diagnosis code · Complications of surgical and medical care, not elsewhere classified

Non-billable header

ICD-10-CM code T81.4

Code: T81.4 (claims format: T814)
Description: Infection following a procedure
Billable: No – use a more specific code below
Valid for: Dates of service October 1, 2026 – September 30, 2027 (FY2027)
Chapter: 19. Injury, poisoning and certain other consequences of external causes (S00-T88)
Block: T80-T88 Complications of surgical and medical care, not elsewhere classified
Parent codes: T81

Billable codes under T81.4

T81.4 is a header code and cannot be used on claims. Choose the most specific code:

T81.40 – Infection following a procedure, unspecifiedHeader (more codes below)
T81.41 – Infection following a procedure, superficial incisional surgical siteHeader (more codes below)
T81.42 – Infection following a procedure, deep incisional surgical siteHeader (more codes below)
T81.43 – Infection following a procedure, organ and space surgical siteHeader (more codes below)
T81.44 – Sepsis following a procedureHeader (more codes below)
T81.49 – Infection following a procedure, other surgical siteHeader (more codes below)

7th character values

Codes in this category need a 7th character to describe the encounter or episode of care (use placeholder X for empty positions).

Character	Meaning
`A`	initial encounter
`D`	subsequent encounter
`S`	sequela

Notes for T81.4

Applicable to:

Wound abscess following a procedure

Excludes2 (not included here):

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)

Use additional code:

code to identify infection
code (R65.2-) to identify severe sepsis, if applicable

Code also:

, if applicable, disruption of internal operation (surgical) wound (T81.32-)

Notes inherited from parent codes

Instructional notes at a category or block level apply to every code below it.

T81 – Complications of procedures, not elsewhere classified

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)

7th character note:

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

Block 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)
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)

Use additional code:

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)

Related codes in T81

Frequently asked questions

What is ICD-10 code T81.4?

T81.4 is the ICD-10-CM code for infection following a procedure, in the block T80-T88 (Complications of surgical and medical care, not elsewhere classified).

Is T81.4 a billable code?

No. T81.4 is a header code with more specific child codes; report one of the billable codes listed above.

What category does T81.4 belong to?

It belongs to category T81 – Complications of procedures, not elsewhere classified.

Source: CDC/NCHS ICD-10-CM FY2027 code files, tabular list and index. Reference only – code assignment must follow the official ICD-10-CM guidelines and documentation in the medical record.