D78 vs T81.49XA

D78 (Intraoperative and postprocedural complications of the spleen) compared with T81.49XA (Infection following a procedure, other surgical site, initial encounter), from the official CMS tabular data. Both may be reported when both conditions are documented (Excludes2).

Relationship

Informational

Excludes2 relationship

T81.49XA

Infection following a procedure, other surgical site, initial encounter

↔

D78

Intraoperative and postprocedural complications of the spleen

Distinct conditions — both may be reported.

“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.-)”

An Excludes2 note means the excluded condition is not part of the code above it, but a patient can have both. Report both when both are documented.

Source: CMS ICD-10-CM tabular instructional notes

Can these codes be reported together?

Yes, when both are documented. T81.49XA carries an Excludes2 note covering D78: “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.-)”

Excludes2 marks distinct conditions — both may be reported when both are documented.

Side by side

	D78Intraoperative and postprocedural complications of the spleen	T81.49XAInfection following a procedure, other surgical site, initial encounter
Billing status	Non-billable header Report instead: D78.01, D78.02, D78.11, D78.12, D78.21	Billable
Classification	D50-D89 — Diseases of the Blood and Blood-forming Organs and Certain Disorders Involving the Immune Mechanism (D50-D89)	S00-T88 — Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88)
Definition	Intraoperative and postprocedural complications of the spleen is a non-billable ICD-10-CM category code (D78).	Infection following a procedure, other surgical site, initial encounter is a billable ICD-10-CM diagnosis code (T81.49A).
7th character	—	The appropriate 7th character is to be added to each code from category T81
Use additional code	—	code to identify infection code (R65.2-) to identify severe sepsis, if applicable code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)

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Derived from the official CMS ICD-10-CM tabular data (FY2026). Not billing advice; verify sequencing rules for the encounter. All data sources