T81.42XA vs T81.42XD

T81.42XA (Infection following a procedure, deep incisional surgical site, initial encounter) compared with T81.42XD (Infection following a procedure, deep incisional surgical site, subsequent encounter), from the official CMS tabular data. T81.42XA and T81.42XD code the same injury at a different phase of treatment.

Relationship

Review

Encounter relationship

T81.42XA

Initial encounter

Infection following a procedure, deep incisional surgical site, initial encounter

↔

T81.42XD

Subsequent encounter

Infection following a procedure, deep incisional surgical site, subsequent encounter

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

Can these codes be reported together?

Same injury, other encounter phase. T81.42XA and T81.42XD 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.

Side by side

	T81.42XAInfection following a procedure, deep incisional surgical site, initial encounter	T81.42XDInfection following a procedure, deep incisional surgical site, subsequent encounter
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, deep incisional surgical site, initial encounter is a billable ICD-10-CM diagnosis code (T81.42A).	Infection following a procedure, deep incisional surgical site, subsequent encounter is a billable ICD-10-CM diagnosis code (T81.42D).
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	Intra-muscular abscess following a procedure	Intra-muscular 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)

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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