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T81.49XA ICD-10-CM Code: Infection following a procedure, other surgical site, initial encounter

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, 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.

Official Registry Overview & Definition

Infection following a procedure, other surgical site, initial encounter is a billable ICD-10-CM diagnosis code (T81.49A).

Official Tabular Instructional Notes

Sequencing, inclusion, and exclusion notes published for T81.49XA in the official ICD-10-CM tabular list.

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-)

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 Compared Codes

The official Excludes notes on T81.49XA name these codes. Each comparison page covers when the two can — or must not — be reported together.

Change history

  • FY2019 — 2018-10-01
    Added to the code set
    Infection following a procedure, other surgical site, initial encounter
    FY2019 changes

Verify Before Coding

  • CC as a secondary diagnosis (FY2026). 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.

Relationships & Classification

Other codes that name T81.49XA 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.

2 Excludes1 notes across 2 chapters: O86.0 (via T81.4.-), R50.82 (via T81.4.-).

3 Excludes2 notes across 2 chapters: K68.11 (via T81.4.-), T80.2 (via T81.4.-), T88 (via T81.-).

2 Code First instructions across 2 chapters: J98.51 (via T81.-), R65.2 (via T81.4.-).

Potential MS-DRG Relationships (FY2026)

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 53 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).

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, T81.44XA — Sepsis following a procedure, 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, +32 more

Same injury, other encounter phase

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

T81.49XD — Infection following a procedure, other surgical site, subsequent encounter Compare T81.49XA vs T81.49XD →, T81.49XS — Infection following a procedure, other surgical site, sequela Compare T81.49XA vs T81.49XS →

Same clinical category (CCSR)

AHRQ's Clinical Classifications Software groups these diagnoses under the same clinical category (Complication of other surgical or medical care, injury, 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, T81.44XA — Sepsis following a procedure, 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, T81.509A — Unspecified complication of foreign body accidentally left in body following unspecified procedure, initial encounter, +230 more

Contextual Map

Every relationship of T81.49XA 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.

Hierarchy

  • S00-T88 — Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88) (S00-T88) [Hierarchy]
  • T80-T88 — Complications of surgical and medical care, not elsewhere classified [Hierarchy]

Referenced by Excludes1 notes

  • O86.0 — Infection of obstetric surgical wound [Excludes1](via T81.4.-): “complications of procedures, not elsewhere classified (T81.4-)” · check together
  • R50.82 — Postprocedural fever [Excludes1](via T81.4.-): “postprocedural infection (T81.4-)” · check together

Referenced by Excludes2 notes

  • K68.11 — Postprocedural retroperitoneal abscess [Excludes2](via T81.4.-): “infection following procedure (T81.4-)” · check together
  • T80.2 — Infections following infusion, transfusion and therapeutic injection [Excludes2](via T81.4.-): “postprocedural infections (T81.4-)” · check together
  • T88 — Other complications of surgical and medical care, not elsewhere classified [Excludes2](via T81.-): “complication following procedure NEC (T81.-)” · check together

Referenced by Code First instructions

  • J98.51 — Mediastinitis [Code First](via T81.-): “underlying condition, if applicable, such as postoperative mediastinitis (T81.-)” · check together
  • R65.2 — Severe sepsis [Code First](via T81.4.-): “infection following a procedure (T81.4-)” · check together

Clinical classification (CCSR)

  • INJ037 — Complication of other surgical or medical care, injury, initial encounter [CCSR]

Potential MS-DRG

  • CC — Complication or Comorbidity [MS-DRG severity]: “As a secondary diagnosis this code can raise the stay's MS-DRG severity tier (CC).”
  • DRG 791 — PREMATURITY WITH MAJOR PROBLEMS [MS-DRG]: “PREMATURITY WITH MAJOR PROBLEMS (MDC 15)”
  • DRG 793 — FULL TERM NEONATE WITH MAJOR PROBLEMS [MS-DRG]: “FULL TERM NEONATE WITH MAJOR PROBLEMS (MDC 15)”
  • DRG 856 — POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC [MS-DRG]: “POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC (MDC 18)”
  • DRG 857 — POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC [MS-DRG]: “POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC (MDC 18)”
  • DRG 858 — POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC [MS-DRG]: “POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC (MDC 18)”
  • DRG 862 — POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC [MS-DRG]: “POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC (MDC 18)”
  • DRG 863 — POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC [MS-DRG]: “POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC (MDC 18)”

MDC crossing · procedures

  • 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.”
  • 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.”
  • and 1 more

Nearest codes (40)

  • T81 — Complications of procedures, not elsewhere classified [Sibling]
  • T81.40XA — Infection following a procedure, unspecified, initial encounter [Sibling]
  • T81.40XD — Infection following a procedure, unspecified, subsequent encounter [Sibling]
  • T81.40XS — Infection following a procedure, unspecified, sequela [Sibling]
  • T81.41 — Infection following a procedure, superficial incisional surgical site [Sibling]
  • T81.41XA — Infection following a procedure, superficial incisional surgical site, initial encounter [Sibling]
  • T81.41XD — Infection following a procedure, superficial incisional surgical site, subsequent encounter [Sibling]
  • T81.41XS — Infection following a procedure, superficial incisional surgical site, sequela [Sibling]
  • and 32 more

Change history

  • FY2019 — Added to the code set [Change history]

Frequently Asked Questions (FAQ) & Clinical Guidance

Does T81.49XA require a 7th character?

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

Nearest Codes in This Family

Official ICD-10-CM classifications closest to T81.49XA in its code family, with their registry titles.

  • T81.44 — Sepsis following a procedure
  • T81.44XA — Sepsis following a procedure, initial encounter
  • T81.44XD — Sepsis following a procedure, subsequent encounter
  • T81.44XS — Sepsis following a procedure, sequela
  • T81.49 — Infection following a procedure, other surgical site
  • T81.49XD — Infection following a procedure, other surgical site, subsequent encounter
  • T81.49XS — Infection following a procedure, other surgical site, sequela
  • T81.5 — Complications of foreign body accidentally left in body following procedure
  • T81.50 — Unspecified complication of foreign body accidentally left in body following procedure
  • T81.500 — Unspecified complication of foreign body accidentally left in body following surgical operation

View all codes in the T81 family