T81.42XA is the authoritative medical code for Infection following a procedure, deep incisional surgical site, initial encounter. This classification is used in medical billing and clinical recording to specify the clinical criteria for infection following a procedure, deep incisional surgical site, initial encounter (ICD-10-CM T81.42XA), ensuring healthcare documentation aligns with 2026 federal coding standards.
Billing Status: YES. This is a valid, specific, and billable ICD-10-CM reference.
Official Registry Overview & Definition
Infection following a procedure, deep incisional surgical site, initial encounter is a billable ICD-10-CM diagnosis code T81.42A. Inclusion terms: Intra-muscular abscess following a procedure. Excludes2 (not included here): 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; 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 also: , if applicable, disruption of internal operation surgical wound T81.32-. 7th character: The appropriate 7th character is to be added to each code from category T81.
Official Tabular Instructional Notes
Sequencing, inclusion, and exclusion notes published for T81.42XA in the official ICD-10-CM tabular list.
Inclusion Terms
Alternative terms the tabular list files under this code.
- Intra-muscular abscess following a procedure
Excludes2 — Not Included Here
Conditions not covered by this code, but which may be reported alongside it when both are present.
- 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
- 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
Code Also
Additional codes that may be required to fully describe the encounter.
- , if applicable, disruption of internal operation surgical wound T81.32-
Use Additional Code
Supplementary codes the tabular list directs you to add.
- 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(s) to identify the specified condition resulting from the complication
- code to identify devices involved and details of circumstances Y62-Y82
Frequently Asked Questions (FAQ) & Clinical Guidance
Does T81.42XA require a 7th character?
Yes. The appropriate 7th character is to be added to each code from category T81.
Can T81.42XA be reported alongside related conditions?
Per official ICD-10-CM Excludes2 instructions, T81.42XA and the following are not considered part of each other and may both be reported when both conditions are present: 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-).
Is an additional code needed with T81.42XA?
Use additional code(s) to specify: 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(s) to identify the specified condition resulting from the complication.
What conditions are included under T81.42XA?
Infection following a procedure, deep incisional surgical site, initial encounter includes: Intra-muscular abscess following a procedure.
Nearest Codes in This Family
Official ICD-10-CM classifications closest to T81.42XA in its code family, with their registry titles.
- T81 — Complications of procedures, not elsewhere classified
- T81.1 — Postprocedural shock
- T81.10 — Postprocedural shock unspecified
- T81.10XA — Postprocedural shock unspecified, initial encounter
- T81.10XD — Postprocedural shock unspecified, subsequent encounter
- T81.10XS — Postprocedural shock unspecified, sequela
- T81.11 — Postprocedural cardiogenic shock
- T81.11XA — Postprocedural cardiogenic shock, initial encounter
- T81.11XD — Postprocedural cardiogenic shock, subsequent encounter
- T81.11XS — Postprocedural cardiogenic shock, sequela
View all 40 codes in the T81 family