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ICD-10/T81.42XS

T81.42XS ICD-10-CM Code: Infection following a procedure, deep incisional surgical site, sequela

T81.42XS is the authoritative medical code for Infection following a procedure, deep incisional surgical site, sequela. This classification is used in medical billing and clinical recording to specify the clinical criteria for infection following a procedure, deep incisional surgical site, sequela (ICD-10-CM T81.42XS), ensuring healthcare documentation aligns with current federal coding standards.

Billing Status: YES. This is a valid, specific, and billable ICD-10-CM reference.

Inpatient Payment Groups (MS-DRG)

MS-DRGs this diagnosis helps define, as principal or secondary, per the CMS ICD-10-CM/PCS MS-DRG Definitions Manual v43.0 (FY2026), Appendix B.

  • MS-DRG 922 — OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC (MDC 21)
  • MS-DRG 923 — OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC (MDC 21)

A diagnosis appearing in a group's logic does not by itself determine the DRG assigned to a stay; the grouper uses the full claim.

Code Set: Valid FY2026 and FY2027. FY2026 took effect October 1, 2025.

Official Registry Overview & Definition

Infection following a procedure, deep incisional surgical site, sequela is a billable ICD-10-CM diagnosis code (T81.42S). 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 T81.42XS 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.

  • Code also, if applicable, disruption of internal operation (surgical) wound (T81.32-)

Use Additional Code

Supplementary codes the tabular list directs you to add.

  • Use additional code to identify infection
  • Use additional code (R65.2-) to identify severe sepsis, if applicable
  • Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)
  • Use additional code(s) to identify the specified condition resulting from the complication
  • Use additional code to identify devices involved and details of circumstances (Y62-Y82)

Frequently Asked Questions (FAQ) & Clinical Guidance

Does T81.42XS require a 7th character?

Yes. The appropriate 7th character is to be added to each code from category T81.

Can T81.42XS be reported alongside related conditions?

Per official ICD-10-CM Excludes2 instructions, T81.42XS 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 T81.42XS?

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 T81.42XS?

Infection following a procedure, deep incisional surgical site, sequela includes: Intra-muscular abscess following a procedure.

Nearest Codes in This Family

Official ICD-10-CM classifications closest to T81.42XS in its code family, with their registry titles.

  • T81.41XD — Infection following a procedure, superficial incisional surgical site, subsequent encounter
  • T81.41XS — Infection following a procedure, superficial incisional surgical site, sequela
  • T81.42 — Infection following a procedure, deep incisional surgical site
  • T81.42XA — Infection following a procedure, deep incisional surgical site, initial encounter
  • T81.42XD — Infection following a procedure, deep incisional surgical site, subsequent encounter
  • T81.43 — Infection following a procedure, organ and space surgical site
  • T81.43XA — Infection following a procedure, organ and space surgical site, initial encounter
  • T81.43XD — Infection following a procedure, organ and space surgical site, subsequent encounter
  • T81.43XS — Infection following a procedure, organ and space surgical site, sequela
  • T81.44 — Sepsis following a procedure

View all codes in the T81 family