ICD-10-CM diagnosis code
T81.40XS Infection following a procedure, unspecified, sequela
- Billable
- Yes, a complete code (FY2026)
Encounter (7th character)
This code is for a sequela: a complication or condition that arises as a direct result of the injury. The sequela itself is usually coded first, followed by this code.
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Other codes in T81
240 complete codes in this category.
- T81.329SDeep disruption or dehiscence of operation wound, unspecified, sequela
- T81.33XADisruption of traumatic injury wound repair, initial encounter
- T81.33XDDisruption of traumatic injury wound repair, subsequent encounter
- T81.33XSDisruption of traumatic injury wound repair, sequela
- T81.40XAInfection following a procedure, unspecified, initial encounter
- T81.40XDInfection following a procedure, unspecified, subsequent encounter
- T81.40XSInfection following a procedure, unspecified, sequela
- T81.41XAInfection following a procedure, superficial incisional surgical site, initial encounter
- T81.41XDInfection following a procedure, superficial incisional surgical site, subsequent encounter
- T81.41XSInfection following a procedure, superficial incisional surgical site, sequela
- T81.42XAInfection following a procedure, deep incisional surgical site, initial encounter
- T81.42XDInfection following a procedure, deep incisional surgical site, subsequent encounter
Documentation tips
- Make sure the note supports every element of the title, “Infection following a procedure, unspecified, sequela”: each detail in it should be traceable to the history, examination or assessment.
- Code to the highest specificity the documentation supports. If a detail is missing from the note, add it to the note rather than choosing a less specific code by default.
- Check the Tabular List and official guidelines for instructional notes (“code first”, “use additional code”, Excludes1/Excludes2) that apply to T81.
The international WHO ICD-10 also has T81, with its inclusion and exclusion notes; titles and detail can differ from ICD-10-CM.
ICD-10-CM is developed by the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, and is based on the WHO ICD-10. Codes and titles are reproduced unchanged from the FY2026 code list (effective 1 October 2025). Their use here does not imply endorsement by CDC, HHS or the U.S. Government. Changes effective on or after 1 October 2026 may not be reflected yet; check the current release at cdc.gov or cms.gov before submitting claims.
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