T81.41: Infection following a procedure, superficial incisional surgical site

Instructional note

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

Source: S00-T88 (chapter, inherited).

Instructional note

code to identify any retained foreign body, if applicable (Z18.-)

Source: S00-T88 (chapter, inherited).

Excludes2

birth trauma (P10-P15)

Source: S00-T88 (chapter, inherited).

Excludes2

obstetric trauma (O70-O71)

Source: S00-T88 (chapter, inherited).

Instructional note

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.

Source: S00-T88 (chapter, inherited).

Instructional note

code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)

Source: T80-T88 (section, inherited).

Instructional note

code(s) to identify the specified condition resulting from the complication

Source: T80-T88 (section, inherited).

Instructional note

code to identify devices involved and details of circumstances (Y62-Y82)

Source: T80-T88 (section, inherited).

Excludes2

any encounters with medical care for postprocedural conditions in which no complications are present, such as:

Source: T80-T88 (section, inherited).

Excludes2

artificial opening status (Z93.-)

Source: T80-T88 (section, inherited).

Excludes2

closure of external stoma (Z43.-)

Source: T80-T88 (section, inherited).

Excludes2

fitting and adjustment of external prosthetic device (Z44.-)

Source: T80-T88 (section, inherited).

Excludes2

burns and corrosions from local applications and irradiation (T20-T32)

Source: T80-T88 (section, inherited).

Excludes2

complications of surgical procedures during pregnancy, childbirth and the puerperium (O00-O9A)

Source: T80-T88 (section, inherited).

Excludes2

mechanical complication of respirator [ventilator] (J95.850)

Source: T80-T88 (section, inherited).

Excludes2

poisoning and toxic effects of drugs and chemicals (T36-T65 with fifth or sixth character 1-4 or 6)

Source: T80-T88 (section, inherited).

Excludes2

postprocedural fever (R50.82)

Source: T80-T88 (section, inherited).

Excludes2

specified complications classified elsewhere, such as:

Source: T80-T88 (section, inherited).

Excludes2

cerebrospinal fluid leak from spinal puncture (G97.0)

Source: T80-T88 (section, inherited).

Excludes2

colostomy malfunction (K94.0-)

Source: T80-T88 (section, inherited).

Excludes2

disorders of fluid and electrolyte imbalance (E86-E87)

Source: T80-T88 (section, inherited).

Excludes2

functional disturbances following cardiac surgery (I97.0-I97.1)

Source: T80-T88 (section, inherited).

Excludes2

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.-)

Source: T80-T88 (section, inherited).

Excludes2

ostomy complications (J95.0-, K94.-, N99.5-)

Source: T80-T88 (section, inherited).

Excludes2

postgastric surgery syndromes (K91.1)

Source: T80-T88 (section, inherited).

Excludes2

postlaminectomy syndrome NEC (M96.1)

Source: T80-T88 (section, inherited).

Excludes2

postmastectomy lymphedema syndrome (I97.2)

Source: T80-T88 (section, inherited).

Excludes2

postsurgical blind-loop syndrome (K91.2)

Source: T80-T88 (section, inherited).

Excludes2

ventilator associated pneumonia (J95.851)

Source: T80-T88 (section, inherited).

Instructional note

code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)

Source: T81 (category, inherited).

Excludes2

complications following immunization (T88.0-T88.1)

Source: T81 (category, inherited).

Excludes2

complications following infusion, transfusion and therapeutic injection (T80.-)

Source: T81 (category, inherited).

Excludes2

complications of transplanted organs and tissue (T86.-)

Source: T81 (category, inherited).

Excludes2

specified complications classified elsewhere, such as:

Source: T81 (category, inherited).

Excludes2

complication of prosthetic devices, implants and grafts (T82-T85)

Source: T81 (category, inherited).

Excludes2

dermatitis due to drugs and medicaments (L23.3, L24.4, L25.1, L27.0-L27.1)

Source: T81 (category, inherited).

Excludes2

endosseous dental implant failure (M27.6-)

Source: T81 (category, inherited).

Excludes2

floppy iris syndrome (IFIS) (intraoperative) H21.81

Source: T81 (category, inherited).

Excludes2

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.-)

Source: T81 (category, inherited).

Excludes2

ostomy complications (J95.0-, K94.-, N99.5-)

Source: T81 (category, inherited).

Excludes2

plateau iris syndrome (post-iridectomy) (postprocedural) H21.82

Source: T81 (category, inherited).

Excludes2

poisoning and toxic effects of drugs and chemicals (T36-T65 with fifth or sixth character 1-4)

Source: T81 (category, inherited).

Seventh-character instruction

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

Source: T81 (category, inherited).

Instructional note

initial encounter

Source: T81 (category, inherited).

Instructional note

subsequent encounter

Source: T81 (category, inherited).

Instructional note

sequela

Source: T81 (category, inherited).

Instructional note

Wound abscess following a procedure

Source: T81.4 (self, inherited).

Code also

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

Source: T81.4 (self, inherited).

Instructional note

code to identify infection

Source: T81.4 (self, inherited).

Instructional note

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

Source: T81.4 (self, inherited).

Excludes2

bleb associated endophthalmitis (H59.4-)

Source: T81.4 (self, inherited).

Excludes2

infection due to infusion, transfusion and therapeutic injection (T80.2-)

Source: T81.4 (self, inherited).

Excludes2

infection due to prosthetic devices, implants and grafts (T82.6-T82.7, T83.5-T83.6, T84.5-T84.7, T85.7)

Source: T81.4 (self, inherited).

Excludes2

obstetric surgical wound infection (O86.0-)

Source: T81.4 (self, inherited).

Excludes2

postprocedural fever NOS (R50.82)

Source: T81.4 (self, inherited).

Excludes2

postprocedural retroperitoneal abscess (K68.11)

Source: T81.4 (self, inherited).

Instructional note

Subcutaneous abscess following a procedure

Source: T81.41 (self, direct).

Instructional note

Stitch abscess following a procedure

Source: T81.41 (self, direct).

Seventh-character definitions

• A: initial encounter
• D: subsequent encounter
• S: sequela