Injury, Poisoning and Certain Other Consequences of External Causes
ICD-10 Code: T81.4XXA
Infection Following a Procedure, Initial Encounter
Post-operative or post-procedural infection, first treatment.
Clinical Information
Post-operative or post-procedural infection, first treatment. Common in US healthcare settings with specific coding requirements per ICD-10-CM guidelines.
Coding Guidelines
- 1Use T81.4XXA when clinical documentation supports this diagnosis
- 2Verify specificity requirements per ICD-10-CM Official Guidelines
- 3Code to highest level of specificity documented
- 4Consider associated conditions and combination coding rules
Common Uses
- Primary diagnosis in ambulatory settings
- Secondary diagnosis in inpatient settings
- ED/urgent care encounters
- Follow-up and monitoring visits
Related ICD-10 Codes
T81.XRelated code in same category
See ICD-10-CM manualFor complete related code list
Documentation Requirements
- Physician documentation must clearly state diagnosis
- Include severity, laterality, and specificity when applicable
- Document underlying cause if known
- Note acute vs. chronic where relevant
Real-World Coding Examples
Patient presents with infection following a procedure, initial encounter. Clinical findings support T81.4XXA diagnosis.
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