T81.4

Header — not billable

Infection following a procedure

The ICD-10 code for infection following a procedure is T81.4.

T81.4 is a non-billable header code. It groups related conditions but cannot be used on its own for reimbursement — select one of the 6 more specific codes below.

Clinical notes

Code also

Two codes may be needed to fully describe a condition, but unlike Code First/Use Additional Code, the sequencing order is not mandated by convention.

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

Excludes2 (not included here)

An Excludes2 note means the excluded condition is not part of this one, but a patient can have both at the same time — in that case both codes may be reported together.

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)

Also known as

Alternate wording, synonyms, or specific conditions that fall under this code, listed to help confirm you've picked the right one.

Wound abscess following a procedure

Use additional code

This code represents an underlying condition. When a related manifestation is also present, coding convention calls for an additional code to be listed after this one.

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Documentation support

General coding-documentation guidance — not a substitute for payer-specific requirements or professional coding judgment.

•This is a non-billable header code. Documentation must support a more specific child code before this diagnosis can be reported on a claim.
•Laterality-specific codes exist for this condition — confirm the affected side is documented.
•If the associated manifestation or related condition noted above is also documented, an additional code should be reported alongside this one.
•As a general rule, code to the highest level of specificity supported by the documentation in the medical record.