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

Non-billable ICD-10-CM code.

Applicable to

• Subcutaneous abscess following a procedure
• Stitch abscess following a procedure

Applies from 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

7th character required

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

Applies from T81.4 Infection following a procedure

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-)

Code annotations containing back-references to T81.41

Back-references to T81.4

• Type 2 Excludes: K68.11 Postprocedural retroperitoneal abscess ("infection following procedure (T81.4-)")
• Type 1 Excludes: O86.0 Infection of obstetric surgical wound ("complications of procedures, not elsewhere classified (T81.4-)")
• Type 1 Excludes: R50.82 Postprocedural fever ("postprocedural infection (T81.4-)")
• Code First: R65.2 Severe sepsis ("infection following a procedure (T81.4-)")
• Type 2 Excludes: T80.2 Infections following infusion, transfusion and therapeutic injection ("postprocedural infections (T81.4-)")

Back-references to T81

• Code First: J98.51 Mediastinitis ("underlying condition, if applicable, such as postoperative mediastinitis (T81.-)")
• Type 2 Excludes: T78 Adverse effects, not elsewhere classified ("complications of surgical and medical care NEC (T80-T88)")
• Type 2 Excludes: T79 Certain early complications of trauma, not elsewhere classified ("complications occurring during or following medical procedures (T80-T88)")
• Type 2 Excludes: T79 Certain early complications of trauma, not elsewhere classified ("complications of surgical and medical care NEC (T80-T88)")
• Type 2 Excludes: T88 Other complications of surgical and medical care, not elsewhere classified ("complication following procedure NEC (T81.-)")

Diagnosis Index entries for T81.41

• Abscess (connective tissue) (embolic) (fistulous) (infective) (metastatic) (multiple) (pernicious) (pyogenic) (septic) › stitch
• Abscess (connective tissue) (embolic) (fistulous) (infective) (metastatic) (multiple) (pernicious) (pyogenic) (septic) › subcutaneous › following procedure
• Complication (s) (from) (of) › surgical procedure (on) › stitch abscess
• Infection, infected, infective (opportunistic) › postoperative wound › surgical site › superficial incisional
• Stitch › abscess

Nearby codes

• T81.4 Infection following a procedure
• T81.40 Infection following a procedure, unspecified
• T81.40XA Infection following a procedure, unspecified, initial encounter
• T81.40XD Infection following a procedure, unspecified, subsequent encounter
• T81.40XS Infection following a procedure, unspecified, sequela
• T81.41 Infection following a procedure, superficial incisional surgical site (this code)
• T81.41XA Infection following a procedure, superficial incisional surgical site, initial encounter
• T81.41XD Infection following a procedure, superficial incisional surgical site, subsequent encounter
• T81.41XS Infection following a procedure, superficial incisional surgical site, sequela
• T81.42 Infection following a procedure, deep incisional surgical site
• T81.42XA Infection following a procedure, deep incisional surgical site, initial encounter