T81.4 vs T81.40XD
T81.4 (Infection following a procedure) compared with T81.40XD (Infection following a procedure, unspecified, subsequent encounter), from the official CMS tabular data.
Summary
These codes represent different levels of the same hierarchy: T81.4 is the non-billable header that contains T81.40XD, so only T81.40XD (or a sibling) is reported.
Registry fact- What is different?
Title wording and billing status.T81.40XD’s title adds “unspecified, subsequent encounter” to the wording the two share (“Infection following a procedure”). T81.4 is a non-billable header; T81.40XD is billable.
Registry fact
- Can these codes be reported together?
Not as a pair.T81.4 is the non-billable header that contains T81.40XD. A header is not reported on a claim, so the choice is T81.40XD or a sibling that matches the documentation.
Registry fact
- Is there an Excludes1 relationship?
None.Neither entry carries an Excludes1 note that names the other code.
Official rule
- Is there an Excludes2 relationship?
None.Neither entry carries an Excludes2 note that names the other code. T81.4 carries 37 Excludes2 notes and T81.40XD carries 37 Excludes2 notes covering other codes; the side-by-side table quotes them.
Official rule
- Is one more specific?
Yes.T81.40XD is a subdivision of T81.4 in the tabular hierarchy, so it is the more specific of the two.
Registry fact
- Is one a parent or header code?
Yes.T81.4 is the non-billable header that contains T81.40XD. A header stands for the whole family beneath it and is not reported on a claim.
Registry fact
- Are there sequencing instructions?
None.Neither entry carries a Code First or Use Additional Code note that names the other.
Official rule
- Are there other coding relationships?
None found.No laterality, encounter-phase, Table of Neoplasms, Table of Drugs and Chemicals, or history-versus-active-disease relationship links these codes.
MedCoder-derived
Official rule: a tabular instructional note or a section of the ICD-10-CM Official Guidelines, quoted as published. Registry fact: the codes’ own published attributes (titles, billable status, position in the hierarchy, code set). MedCoder-derived: a reading MedCoder computes from those facts; it is not itself a rule. How to read the labels
Can these codes be reported together?
Not as a pair — T81.4 is not reportable. T81.4 is the non-billable category that contains T81.40XD.
A header stands for the whole family of codes beneath it and is not reported on a claim, so the choice is T81.40XD or a sibling that matches the documentation. No Excludes1/Excludes2 relationship exists between these codes in the official tabular list.
Official guidance behind these answers
Section I.B.2 — Level of Detail in Coding · applies to: T81.4 and T81.40XD
Diagnosis codes are to be used and reported at their highest number of characters available and to the highest level of specificity documented in the medical record. ICD-10-CM diagnosis codes are composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth and/or fifth characters and/or sixth characters, which provide greater detail. A three-character code is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable.
ICD-10-CM Official Guidelines FY2027
Quoted from the ICD-10-CM Official Guidelines for Coding and Reporting in effect for the release shown. The tabular notes above are the code-level instruction; these sections are the convention that says how such a note is applied. Source document (CMS PDF) · Release and checksum
Side by side
| T81.4Infection following a procedure | T81.40XDInfection following a procedure, unspecified, subsequent encounter | |
|---|---|---|
| Billing status | Non-billable header Report instead: T81.40XA, T81.40XD, T81.40XS, T81.41XA, T81.41XD | Billable |
| Classification | S00-T88 — Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88) | S00-T88 — Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88) |
| Definition | Infection following a procedure is a non-billable ICD-10-CM category code (T81.4). | Infection following a procedure, unspecified, subsequent encounter is a billable ICD-10-CM diagnosis code (T81.40XD). |
| 7th character | The appropriate 7th character is to be added to each code from category T81 | The appropriate 7th character is to be added to each code from category T81 |
| Includes | Wound abscess following a procedure | — |
| Excludes2 | 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) 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) any encounters with medical care for postprocedural conditions in which no complications are present, such as: artificial opening status (Z93.-) closure of external stoma (Z43.-) fitting and adjustment of external prosthetic device (Z44.-) burns and corrosions from local applications and irradiation (T20-T32) complications of surgical procedures during pregnancy, childbirth and the puerperium (O00-O9A) mechanical complication of respirator [ventilator] (J95.850) poisoning and toxic effects of drugs and chemicals (T36-T65 with fifth or sixth character 1-4 or 6) postprocedural fever (R50.82) cerebrospinal fluid leak from spinal puncture (G97.0) colostomy malfunction (K94.0-) disorders of fluid and electrolyte imbalance (E86-E87) functional disturbances following cardiac surgery (I97.0-I97.1) 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.-) postgastric surgery syndromes (K91.1) postlaminectomy syndrome NEC (M96.1) postmastectomy lymphedema syndrome (I97.2) postsurgical blind-loop syndrome (K91.2) ventilator associated pneumonia (J95.851) | 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) 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) any encounters with medical care for postprocedural conditions in which no complications are present, such as: artificial opening status (Z93.-) closure of external stoma (Z43.-) fitting and adjustment of external prosthetic device (Z44.-) burns and corrosions from local applications and irradiation (T20-T32) complications of surgical procedures during pregnancy, childbirth and the puerperium (O00-O9A) mechanical complication of respirator [ventilator] (J95.850) poisoning and toxic effects of drugs and chemicals (T36-T65 with fifth or sixth character 1-4 or 6) postprocedural fever (R50.82) cerebrospinal fluid leak from spinal puncture (G97.0) colostomy malfunction (K94.0-) disorders of fluid and electrolyte imbalance (E86-E87) functional disturbances following cardiac surgery (I97.0-I97.1) 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.-) postgastric surgery syndromes (K91.1) postlaminectomy syndrome NEC (M96.1) postmastectomy lymphedema syndrome (I97.2) postsurgical blind-loop syndrome (K91.2) ventilator associated pneumonia (J95.851) |
| 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) | 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) |
| Code also | , if applicable, disruption of internal operation (surgical) wound (T81.32-) | , if applicable, disruption of internal operation (surgical) wound (T81.32-) |
Notes are the code’s own tabular entry, quoted as published. A note that names the other code is the one the verdict above rests on.
Derived from the official CMS ICD-10-CM tabular data (FY2027). A coding-rule comparison, not billing advice: payer-specific edits and medical-necessity policy are outside its scope. All data sources