T81.41XA (Infection following a procedure, superficial incisional surgical site, initial encounter) compared with T81.41XS (Infection following a procedure, superficial incisional surgical site, sequela), from the official CMS tabular data. T81.41XA and T81.41XS code the same injury at a different phase of treatment.
Same underlying diagnosis, different encounter phase.
The 7th character records the phase of care for the encounter being coded, so a single encounter takes one of these characters, not several. Review whether both phases belong on the same episode of care.
Source: ICD-10-CM Official Guidelines, Section I.C.19.a
Same injury, other encounter phase. T81.41XA and T81.41XS code the same injury at a different phase of treatment, set by the 7th character.
The 7th character records the type of care given at the encounter being coded (ICD-10-CM Official Guidelines, Section I.C.19.a), so one encounter takes one of these, not both.
| T81.41XAInfection following a procedure, superficial incisional surgical site, initial encounter | T81.41XSInfection following a procedure, superficial incisional surgical site, sequela | |
|---|---|---|
| Billing status | Billable | 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, superficial incisional surgical site, initial encounter is a billable ICD-10-CM diagnosis code (T81.41A). | Infection following a procedure, superficial incisional surgical site, sequela is a billable ICD-10-CM diagnosis code (T81.41S). |
| 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 | Subcutaneous abscess following a procedure Stitch abscess following a procedure | Subcutaneous abscess following a procedure Stitch abscess following a procedure |
| 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) |
Derived from the official CMS ICD-10-CM tabular data (FY2026). Not billing advice; verify sequencing rules for the encounter. All data sources