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T81.44XA ICD-10-CM Code: Sepsis following a procedure, initial encounter

Compare with another codeCheck this code on a claim

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

Coding at a Glance

7th character
Required — see the character table on this page
Tabular directives
37 Excludes2 · 6 use-additional codes · 1 code-also instruction
Risk adjustment
CMS-HCC V22 category 2

Billable · FY2027A valid, specific ICD-10-CM code, reportable for dates of service in FY2027.

What you need to know

Source: CMS/NCHS Official ICD-10-CM tabular notes, quoted. From the CMS/NCHS tabular list for the release in force. A note the category or block publishes applies to this code too; the Instructions section marks which is which.

Use additional codeReport with this code when documented
  • code to identify the sepsis
  • 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)

+2 more in Instructions

Code alsoMay be needed with this code
  • , if applicable, disruption of internal operation (surgical) wound (T81.32-)
Excludes2Not included here; may be reported together
  • 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-)

+33 more in Instructions

Most relevant related codes MedCoder-derived

Read off the official notes above and this code’s own position in the tabular list. Which to report is a documentation question; Compare shows the two side by side.

CompareCheck ClaimView Related Codes

Inpatient Payment Groups (MS-DRG)

Potential MS-DRG participation — not a DRG assignment.

MS-DRGs this diagnosis helps define, as principal or secondary, per the CMS ICD-10-CM/PCS MS-DRG Definitions Manual v44, Appendix B.

  • MS-DRG 791 — PREMATURITY WITH MAJOR PROBLEMS (MDC 15)
  • MS-DRG 793 — FULL TERM NEONATE WITH MAJOR PROBLEMS (MDC 15)
  • MS-DRG 856 — POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC (MDC 18)
  • MS-DRG 857 — POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC (MDC 18)
  • MS-DRG 858 — POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC (MDC 18)
  • MS-DRG 862 — POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC (MDC 18)
  • MS-DRG 863 — POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC (MDC 18)

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.

Coding instructions

Official Tabular Instructional Notes: the inclusion, exclusion and sequencing notes published for T81.44XA in the official ICD-10-CM tabular list, quoted as published.

Source: CMS/CDC — ICD-10-CM Tabular ListRelease: FY2027Effective: October 1, 2026

Trace:FY2027 changesChange historyRelease, file and checksum

Notes without a marker are published on T81.44XA itself; “inherited from” names the category or block whose note applies here.

Excludes2 — Not Included Here

Conditions not covered by this code, but which may be reported alongside it when both are present.

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-)

Source: inherited from T81.4

Use Additional Code

Supplementary codes the tabular list directs you to add.

  • Use additional code to identify the sepsis inherited from T81.44
  • Use additional code to identify infection inherited from T81.4
  • Use additional code (R65.2-) to identify severe sepsis, if applicable inherited from T81.4
  • Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5) inherited from T80-T88
  • Use additional code(s) to identify the specified condition resulting from the complication inherited from T80-T88
  • Use additional code to identify devices involved and details of circumstances (Y62-Y82) inherited from T80-T88

7th Character Guide

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

  • A — initial encounter (this page’s code)
  • D — subsequent encounter
  • S — sequela

How the encounter character is assigned. “Initial encounter” means the patient is receiving active treatment for the condition — it is not limited to the first visit, and a different or new provider giving active treatment still assigns it. “Subsequent encounter” covers care during the healing or recovery phase after active treatment. “Sequela” is for complications or conditions that arise as a direct result of the original condition.

ICD-10-CM Official Guidelines for Coding and Reporting, Section I.C.19.a (paraphrased by MedCoder).

Variant codes in this family

T81.44XA, T81.44XD, T81.44XS

Character meanings are CMS's official 7th-character extensions for this family, as carried in each variant code's official description; variant codes are registry rows. The explanation of how the encounter character is assigned is MedCoder editorial, distinct from the official content above it.

Coder workflow for T81.44XA

MedCoder structured workflow — derived from this code’s own official record

Before you code T81.44XA

  1. A 7th character is required in this family. Confirm the documented encounter: initial (active treatment), subsequent (healing or recovery phase), or sequela. This page’s code carries “A”. “Initial” means active treatment, not the first visit (Guidelines I.C.19.a).

    See the 7th Character Guide · Guide: 7th characters: initial, subsequent, sequela →

Choose the right path

  1. Is the encounter phase documented — active treatment, healing or recovery, or a sequela?
    Yes → Assign the matching 7th character; the variant codes are in the 7th Character Guide.
    No → The code is invalid without its 7th character — query for the missing element.

Consider T81.44XA. Then work the Use Additional Code note and review the Code Also note, and confirm the code is valid for the date of service in the Verify section.

Documentation check

The provider’s diagnostic statement
Codes are assigned from the provider’s documented diagnosis, not from clinical criteria, test values or a medication list (Guidelines I.A.19).
Encounter type
Active treatment, healing or recovery phase, or sequela — the basis of the 7th character (Guidelines I.C.19.a).
The conditions the Use Additional Code note names
Reported with this code when documented; a conditional instruction (“if applicable”, “if known”) applies only when the record supports it.

Official instructions as workflow

  • Excludes2 — not part of T81.44XA(37 notes)

    Coding workflow: The conditions named in this note are not included in T81.44XA. When the record documents both, both may be reported; the note is a boundary, not a prohibition.

    CompareH59.4, T80.2, T85.7, O86.0, R50.82, K68.11

    See the official tabular notes · Guidelines I.A.12.b

  • Use Additional Code — after identifying T81.44XA(6 notes)

    Coding workflow: Check whether the documentation supports the additional code(s) the note names, and report them with T81.44XA when it does. Where the instruction is conditional (“if applicable”, “if known”), it applies only when the record documents the condition.

    ReviewR65.2

    See the official tabular notes · Guidelines I.A.13

  • Code Also — related condition(1 note)

    Coding workflow: Review the related condition when both are documented and the instruction applies. A Code Also note does not fix sequencing; the order follows the circumstances of the encounter.

    ReviewT81.32

    See the official tabular notes · Guidelines I.A.17

Coding decision scenarios

Pattern scenarios for this code’s structure — decision rules, not clinical cases

Documentation: The patient returns during the healing or recovery phase after active treatment of the same condition.

Coding question: Which 7th character applies?

Path: Review the official 7th-character definitions for this family in the 7th Character Guide.

Reason: “Initial encounter” means active treatment, not the first visit; care during recovery takes “subsequent encounter”, and a complication arising from the original condition takes “sequela” (Guidelines I.C.19.a).

Documentation: A condition the Use Additional Code note names is documented.

Coding question: Is a second code reported with T81.44XA?

Path: Review the Use Additional Code note and the code it names.

Reason: The additional code is reported when the record documents the condition; a conditional instruction applies only when its condition is met (Guidelines I.A.13).

ReviewR65.2

Every row is derived from this code’s own record — its title, tabular notes, 7th-character family and same-category siblings — with fixed MedCoder wording; nothing is inferred about a patient. The official notes and guideline text are in the sections each row links to, and they control.

Don’t confuse T81.44XA with…

MedCoder analysis — pairs from this code’s official notes, distinctions written by MedCoder

The codes most likely to be picked instead of T81.44XA — named in its own official notes, or sharing its laterality or encounter family — with what separates them and which documentation moves the case. Each links to the full comparison.

  • T81.44XD— Encounter relationship (Review)

    Same underlying diagnosis, different encounter phase.

    The same diagnosis at a different phase of care; one encounter takes one 7th character.

    What moves you there: Documentation of a subsequent encounter moves the case to T81.44XD.

    Full comparison: T81.44XA vs T81.44XD →

  • T81.44XS— Encounter relationship (Review)

    Same underlying diagnosis, different encounter phase.

    The same diagnosis at a different phase of care; one encounter takes one 7th character.

    What moves you there: Documentation of a sequela moves the case to T81.44XS.

    Full comparison: T81.44XA vs T81.44XS →

  • H59.4— Excludes2 relationship (Informational)

    Distinct conditions — both may be reported.

    A distinct condition — both may be reported when both are documented.

    What moves you there: Documentation of bleb associated endophthalmitis adds H59.4; it is not part of this code and both may be reported when both are documented.

    Full comparison: T81.44XA vs H59.4 →

  • T80.2— Excludes2 relationship (Informational)

    Distinct conditions — both may be reported.

    A distinct condition — both may be reported when both are documented.

    What moves you there: Documentation of infection due to infusion, transfusion and therapeutic injection adds T80.2; it is not part of this code and both may be reported when both are documented.

    Full comparison: T81.44XA vs T80.2 →

  • T82.6— Excludes2 relationship (Informational)

    Distinct conditions — both may be reported.

    A distinct condition — both may be reported when both are documented.

    What moves you there: Documentation of infection due to prosthetic devices, implants and grafts adds T82.6; it is not part of this code and both may be reported when both are documented.

    Full comparison: T81.44XA vs T82.6 →

  • T82.7— Excludes2 relationship (Informational)

    Distinct conditions — both may be reported.

    A distinct condition — both may be reported when both are documented.

    What moves you there: Documentation of infection due to prosthetic devices, implants and grafts adds T82.7; it is not part of this code and both may be reported when both are documented.

    Full comparison: T81.44XA vs T82.7 →

Relationships are read from this code's own official notes, its laterality siblings and its encounter family; the wording of each distinction is MedCoder editorial, and the documentation named in each “what moves you there” line is the official note phrase or sibling title itself. Source: CMS ICD-10-CM tabular instructional notes; ICD-10-CM Official Guidelines, Section I.A.12.a.

Coding context

Guidelines, coding notes, decision aids, relationships (with MS-DRG and CCSR classification), hierarchy, HCC, coverage and the context map: what a coder reaches for after the core. Each section names whether it is official source data, a MedCoder-derived relationship or MedCoder editorial.

Code Overview

Sepsis following a procedure, initial encounter is a billable ICD-10-CM diagnosis code (T81.44XA).

MedCoder summary Summary composed by MedCoder from this code's official ICD-10-CM record. The tabular instructional notes themselves appear verbatim below.

Official Coding Guidelines

Official source data — quoted verbatim from the CMS/NCHS Official Guidelines

Verbatim excerpts from the ICD-10-CM Official Guidelines for Coding and Reporting (CMS/NCHS) that govern this code.

Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99), U07.1, U09.9 a. Human Immunodeficiency Virus (HIV) Infections 1) Code only confirmed cases

(b) Sepsis due to a postprocedural infection For sepsis following a postprocedural wound (surgical site) infection, a code from T81.41 to T81.43, Infection following a procedure, T81.49, Infection following a procedure, other surgical site, or a code from O86.00 to O86.03, Infection of obstetric surgical wound, or code O86.09, Infection of obstetric surgical wound, other surgical site, that identifies the site of the infection should be sequenced first, if known. Assign an additional code for sepsis following a procedure (T81.44) or sepsis following an obstetrical procedure (O86.04). Use an additional code to identify the infectious agent. If the patient has severe sepsis, the appropriate code from subcategory R65.2 should also be assigned with the additional code(s) for any acute organ dysfunction.

Decision Points

The directives on this code's own record, as a pre-claim checklist.

  1. A 7th character applies in this family. Confirm the documented encounter matches the character assigned. See the official 7th-character definitions and this code’s variants
  2. 6 Use Additional Code instructions — report the named additional code(s) when the documentation supports them. See the Use Additional Code notes
  3. 1 Code Also note — a second code may apply; the guidelines leave its sequencing to the circumstances of the encounter. See the Code Also notes
  4. 37 Excludes2 entries — those conditions are not part of this code and may be reported additionally when documented. See the Excludes2 notes

Checklist rows are derived from this code's own official directives; the wording of each check is MedCoder editorial. The official notes themselves are in the sections each row links to.

Verify Before Coding

  • CC as a secondary diagnosis (FY2027). Can raise the stay's MS-DRG severity tier.

From the code registry, the Medicare Code Editor, and the MS-DRG Definitions Manual. Check it against a full claim in Claim Check.

Relationships & Classification

MedCoder-derived relationships — computed from published CMS and AHRQ datasets

Other codes that name T81.44XA or its code family, from the CMS ICD-10-CM tabular instructional notes. Tabular-note edges are stored at the code family level that carries each note.

Referenced by 3 Excludes1 notes across 3 chapters: O86.0 — Infection of obstetric surgical wound (via T81.4.-), R50.82 — Postprocedural fever (via T81.4.-), T88.7 — Unspecified adverse effect of drug or medicament (via T81.-).

These codes’ tabular lists mark this diagnosis as mutually exclusive — not reported together unless the conditions are documented as unrelated.

Referenced by 5 Excludes2 notes across 2 chapters: K68.11 — Postprocedural retroperitoneal abscess (via T81.4.-), T78 — Adverse effects, not elsewhere classified (via T81.-), T79 — Certain early complications of trauma, not elsewhere classified (via T81.-), T80.2 — Infections following infusion, transfusion and therapeutic injection (via T81.4.-), T88 — Other complications of surgical and medical care, not elsewhere classified (via T81.-).

These codes’ tabular lists name this diagnosis as distinct — both may be reported when both are documented.

Referenced by 4 Code First instructions across 3 chapters: A40 — Streptococcal sepsis (via T81.44.-), A41 — Other sepsis (via T81.44.-), J98.51 — Mediastinitis (via T81.-), R65.2 — Severe sepsis (via T81.4.-).

Each of these codes carries a Code First note naming this condition — when that code is reported, THIS code is sequenced first, ahead of it.

MS-DRG Grouper Relationships (FY2027)

Potential MS-DRG participation — not a DRG assignment.

FY2027 MS-DRG: CC — Complication or Comorbidity. Reported as a secondary diagnosis, this code raises the stay's MS-DRG severity tier — except when the principal diagnosis is one of 55 clinically related codes on its CMS exclusion list.

Named in the grouper logic of 7 MS-DRGs: DRG 791 (MDC 15), DRG 793 (MDC 15), DRG 856 (MDC 18), DRG 857 (MDC 18), DRG 858 (MDC 18), DRG 862 (MDC 18), DRG 863 (MDC 18).

From the CMS MS-DRG Definitions Manual (Appendices B and C). Actual DRG assignment depends on the complete claim.

Clinical classification (AHRQ CCSR):INJ037 — Complication of other surgical or medical care, injury, initial encounter (default); INF002 — Septicemia.

Clinical Classifications Software Refined (CCSR) for ICD-10-CM Diagnoses. Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality.

Related Codes

Same clinical process (MS-DRG)

Acts as CC — raises the severity of other admissions. CMS groups these diagnoses into one MS-DRG principal-diagnosis exclusion process — a CC/MCC on this list never raises severity when the principal diagnosis is also on it.

H95.88 — Other intraoperative complications and disorders of the ear and mastoid process, not elsewhere classified, H95.89 — Other postprocedural complications and disorders of the ear and mastoid process, not elsewhere classified, I97.3 — Postprocedural hypertension, K68.11 — Postprocedural retroperitoneal abscess, L76.81 — Other intraoperative complications of skin and subcutaneous tissue, L76.82 — Other postprocedural complications of skin and subcutaneous tissue, M96.89 — Other intraoperative and postprocedural complications and disorders of the musculoskeletal system, N98.1 — Hyperstimulation of ovaries, N98.2 — Complications of attempted introduction of fertilized ovum following in vitro fertilization, N98.3 — Complications of attempted introduction of embryo in embryo transfer, N98.8 — Other complications associated with artificial fertilization, N98.9 — Complication associated with artificial fertilization, unspecified, T81.40XA — Infection following a procedure, unspecified, initial encounter, T81.41XA — Infection following a procedure, superficial incisional surgical site, initial encounter, T81.42XA — Infection following a procedure, deep incisional surgical site, initial encounter, T81.43XA — Infection following a procedure, organ and space surgical site, initial encounter, T81.49XA — Infection following a procedure, other surgical site, initial encounter, T81.82XA — Emphysema (subcutaneous) resulting from a procedure, initial encounter, T81.89XA — Other complications of procedures, not elsewhere classified, initial encounter, T81.9XXA — Unspecified complication of procedure, initial encounter, +34 more

Same injury, other encounter phase

Same injury, coded at a different phase of treatment via the 7th character.

T81.44XD — Sepsis following a procedure, subsequent encounterCompare T81.44XA vs T81.44XD →, T81.44XS — Sepsis following a procedure, sequelaCompare T81.44XA vs T81.44XS →

Same clinical category (CCSR)

AHRQ's Clinical Classifications Software groups these diagnoses under the same clinical categories (Complication of other surgical or medical care, injury, initial encounter, Septicemia).

T81.31XA — Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter, T81.320A — Disruption or dehiscence of gastrointestinal tract anastomosis, repair, or closure, initial encounter, T81.321A — Disruption or dehiscence of closure of internal operation (surgical) wound of abdominal wall muscle or fascia, initial encounter, T81.328A — Disruption or dehiscence of closure of other specified internal operation (surgical) wound, initial encounter, T81.329A — Deep disruption or dehiscence of operation wound, unspecified, initial encounter, T81.33XA — Disruption of traumatic injury wound repair, initial encounter, T81.40XA — Infection following a procedure, unspecified, initial encounter, T81.41XA — Infection following a procedure, superficial incisional surgical site, initial encounter, T81.42XA — Infection following a procedure, deep incisional surgical site, initial encounter, T81.43XA — Infection following a procedure, organ and space surgical site, initial encounter, T81.49XA — Infection following a procedure, other surgical site, initial encounter, T81.500A — Unspecified complication of foreign body accidentally left in body following surgical operation, initial encounter, T81.501A — Unspecified complication of foreign body accidentally left in body following infusion or transfusion, initial encounter, T81.502A — Unspecified complication of foreign body accidentally left in body following kidney dialysis, initial encounter, T81.503A — Unspecified complication of foreign body accidentally left in body following injection or immunization, initial encounter, T81.504A — Unspecified complication of foreign body accidentally left in body following endoscopic examination, initial encounter, T81.505A — Unspecified complication of foreign body accidentally left in body following heart catheterization, initial encounter, T81.506A — Unspecified complication of foreign body accidentally left in body following aspiration, puncture or other catheterization, initial encounter, T81.507A — Unspecified complication of foreign body accidentally left in body following removal of catheter or packing, initial encounter, T81.508A — Unspecified complication of foreign body accidentally left in body following other procedure, initial encounter, +279 more

Contextual Map

Every relationship of T81.44XA in one view: hierarchy, official tabular instructions in both directions, clinical classification, risk adjustment, MS-DRG participation, index terms and change history — each edge carrying the CMS source it derives from.

Run T81.44XA with these 12 related codes in Claim Check

Hierarchy

Referenced by Excludes1 notes

Referenced by Excludes2 notes

Referenced by Code First instructions

  • A40 — Streptococcal sepsis[Code First](via T81.44.-): “, if applicable, postprocedural sepsis (T81.44-)”— CMS ICD-10-CM tabular instructional notes · icd10cm-fy2027
  • A41 — Other sepsis[Code First](via T81.44.-): “, if applicable, postprocedural sepsis (T81.44-)”— CMS ICD-10-CM tabular instructional notes · icd10cm-fy2027
  • J98.51 — Mediastinitis[Code First](via T81.-): “underlying condition, if applicable, such as postoperative mediastinitis (T81.-)”— CMS ICD-10-CM tabular instructional notes · icd10cm-fy2027
  • R65.2 — Severe sepsis[Code First](via T81.4.-): “infection following a procedure (T81.4-)”— CMS ICD-10-CM tabular instructional notes · icd10cm-fy2027

Clinical classification (CCSR)

MS-DRG Grouper

MDC crossing

  • MDC 15 — Newborns and Other Neonates with Conditions Originating in Perinatal Period[MDC crossing]: “Newborns and Other Neonates with Conditions Originating in Perinatal Period — the grouper's crossing between diagnoses and procedures: a principal diagnosis sets the MDC, and same-MDC procedures move the stay to its surgical DRGs.”— CMS MS-DRG Definitions Manual · FY2027
  • MDC 18 — Infectious and Parasitic Diseases, Systemic or Unspecified Sites[MDC crossing]: “Infectious and Parasitic Diseases, Systemic or Unspecified Sites — the grouper's crossing between diagnoses and procedures: a principal diagnosis sets the MDC, and same-MDC procedures move the stay to its surgical DRGs. 1 same-MDC procedures group here; browse them on the MDC page.”— CMS MS-DRG Definitions Manual · FY2027

Nearest codes (40)

Change history

Relevant guides

Reference

Index terms and tables, published questions and FAQ, every source behind this page with its release and checksum, the date-of-service check and the complete change history.

Common coding questions

MedCoder editorial

Does T81.44XA require a 7th character?

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

Sources for this page

Codes, titles, notes, index terms and mappings on this page are transcribed from the datasets below. Relationships MedCoder computed and text MedCoder wrote are labelled where they appear.

Code, title, tabular notes and index terms Official source data
CMS/CDC ICD-10-CM FY2027 tabular list, index and tables, effective October 1, 2026 Release, file and checksum · Publisher’s page
Coding guidelines Official source data
ICD-10-CM Official Guidelines for Coding and Reporting (FY2027), quoted by section Release, file and checksum · Publisher’s page
Claim edits Official source data
CMS Definitions of Medicare Code Edits — v44.0 (October 2026) Release, file and checksum · Publisher’s page
Inpatient payment groups Official source data
CMS MS-DRG Definitions Manual (incl. Appendix B diagnosis index, Appendix C CC/MCC list, Appendix E procedure index) and IPPS Final Rule tables — v44 Release, file and checksum · Publisher’s page
Change history and date-of-service validity Official source data
CMS ICD-10-CM release addenda, ingested release by release into the change ledger Release, file and checksum · Publisher’s page
Comparisons, relationships and the contextual map MedCoder-derived relationship
Computed by MedCoder from the tabular notes and tables above; every derived relationship is marked as derived where it appears
Summary and FAQ answers MedCoder editorial explanation
Written by MedCoder to explain the sources above: drafted with AI assistance, checked by a person against the release files, and labelled as MedCoder text where it appears. Not official text.

Current data releases:ICD-10-CM FY2027 · ICD-10-PCS FY2027 · HCPCS October 2026 · MS-DRG v44 · Medicare Code Editor v44.0 · NCCI PTP Q4 2026 · MUE Q4 2026 · NCD code lists 2026-01 · LCD export September 20, 2026 · All releases and sources

Labels on this page: Official source data · MedCoder-derived relationship · MedCoder editorial explanation. How to read the labels · All data sources and release dates · CMS coding rules

Cite this page

Reference this page in a research guide, syllabus or article. The release is included because code content changes each year.

MedCoder.ai. "T81.44XA — Sepsis following a procedure, initial encounter." ICD-10-CM FY2027. https://medcoder.ai/icd10/code/t81.44xa-sepsis-following-a-procedure-initial-encounter

Change history

  • FY2019 — October 1, 2018
    Added to the code set
    Sepsis following a procedure, initial encounter
    FY2019 changes

Nearest Codes in This Family

Official ICD-10-CM classifications closest to T81.44XA in its code family, with their registry titles.

View all codes in the T81 family