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T81.530A ICD-10-CM Code: Perforation due to foreign body accidentally left in body following surgical operation, initial encounter

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

Coding at a Glance

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 v43, Appendix B.

  • MS-DRG 791 — PREMATURITY WITH MAJOR PROBLEMS (MDC 15)
  • MS-DRG 793 — FULL TERM NEONATE WITH MAJOR PROBLEMS (MDC 15)
  • MS-DRG 919 — COMPLICATIONS OF TREATMENT WITH MCC (MDC 21)
  • MS-DRG 920 — COMPLICATIONS OF TREATMENT WITH CC (MDC 21)
  • MS-DRG 921 — COMPLICATIONS OF TREATMENT WITHOUT CC/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.

Coding instructions

Official Tabular Instructional Notes: the inclusion, exclusion and sequencing notes published for T81.530A in the official ICD-10-CM tabular list, quoted as published.

Notes without a marker are published on T81.530A 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.

Use Additional Code

Supplementary codes the tabular list directs you to add.

  • 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)

Source: 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

T81.530A, T81.530D, T81.530S

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 T81.530A

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

Before you code T81.530A

  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 →

  2. Laterality is coded in this family. Confirm the side documented — right, left, or bilateral — and select the matching code (this page’s code: left). The unspecified-side code applies only when the record states no side. Laterality is assigned from the documented side; where a bilateral code exists and both sides are documented, it is used instead of two unilateral codes (Guidelines I.B.13).

    See the relationships section · Guide: Laterality coding →

  3. T81.530A’s title joins a condition with an associated condition or complication. Confirm each component is documented. Where the classification presumes the link through the “with” convention, only a provider statement that the conditions are unrelated defeats it. A combination code is assigned only when it fully identifies the documented conditions; a required second code for the stage, type or manifestation is still reported when the notes ask for it (Guidelines I.B.9, I.A.15).

    Guide: Combination codes →

Choose the right path

  1. Is the side documented?
    Yes → Select the code for the documented side (or the bilateral code when both sides are documented and one exists).
    No → Use the unspecified-side code only when the record states no side; a query is the alternative.
  2. 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 T81.530A. Then work the Use Additional Code 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).
Laterality
Right, left or bilateral as documented; unspecified only when the record states no side (Guidelines I.B.13).
Encounter type
Active treatment, healing or recovery phase, or sequela — the basis of the 7th character (Guidelines I.C.19.a).
The associated condition or complication
Whether the associated condition the title names is documented; the “with” convention presumes some links, and a provider statement that the conditions are unrelated defeats it (Guidelines I.A.15).
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 T81.530A(31 notes)

    Coding workflow: The conditions named in this note are not included in T81.530A. When the record documents both, both may be reported; the note is a boundary, not a prohibition.

    CompareT80, T86, L23.3, L24.4, L25.1, M27.6

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

  • Use Additional Code — after identifying T81.530A(3 notes)

    Coding workflow: Check whether the documentation supports the additional code(s) the note names, and report them with T81.530A when it does. Where the instruction is conditional (“if applicable”, “if known”), it applies only when the record documents the condition.

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

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: The record documents the condition on one side only.

Coding question: Which code in this family applies?

Path: Select the sibling code for the documented side.

Reason: Laterality is assigned from the documented side; the unspecified-side code is for records that state no side (Guidelines I.B.13).

Documentation: Only one of the components this code’s title joins is documented.

Coding question: Is T81.530A supported?

Path: Review the code for the documented component on its own.

Reason: A combination code is assigned only when it fully identifies the documented conditions; otherwise the documented component takes its own code (Guidelines I.B.9).

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.

Code Overview

Perforation due to foreign body accidentally left in body following surgical operation, initial encounter is a billable ICD-10-CM diagnosis code (T81.530A).

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

Indexed Clinical Terms (1)

Official source data — entries quoted as published, in the Index’s own lookup phrasing

Clinical term phrases from the official ICD-10-CM Index to Diseases and Injuries that map to this code. These are alphabetic-index entries shown as the Index writes them — lookup phrasing, not necessarily the wording of a final diagnosis.

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. Laterality is coded in this family. Confirm the documented side matches the code — the opposite-side siblings are in the relationships section. See the opposite-side sibling codes
  3. 3 Use Additional Code instructions — report the named additional code(s) when the documentation supports them. See the Use Additional Code notes
  4. 31 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 (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 in Claim Check.

Relationships & Classification

MedCoder structured relationships — computed from published CMS and AHRQ datasets

Other codes that name T81.530A 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 2 Excludes1 notes across 2 chapters: T88.7 — Unspecified adverse effect of drug or medicament (via T81.-), Z18 — Retained foreign body fragments (via T81.5.-).

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

Referenced by 10 Excludes2 notes: T15 — Foreign body on external eye (via T81.5.-), T15-T19 — Effects of foreign body entering through natural orifice (T15-T19) (via T81.5.-), T16 — Foreign body in ear (via T81.5.-), T17 — Foreign body in respiratory tract (via T81.5.-), T18 — Foreign body in alimentary tract (via T81.5.-), T19 — Foreign body in genitourinary tract (via T81.5.-), T78 — Adverse effects, not elsewhere classified (via T81.-), T79 — Certain early complications of trauma, not elsewhere classified (via T81.-), T81.6 — Acute reaction to foreign substance accidentally left during a procedure (via T81.5.-), 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 1 Code First instruction: J98.51 — Mediastinitis (via T81.-).

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 (FY2026)

Potential MS-DRG participation — not a DRG assignment.

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 96 clinically related codes on its CMS exclusion list.

Named in the grouper logic of 5 MS-DRGs: DRG 791 (MDC 15), DRG 793 (MDC 15), DRG 919 (MDC 21), DRG 920 (MDC 21), DRG 921 (MDC 21).

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.

T81.520A — Obstruction due to foreign body accidentally left in body following surgical operation, initial encounter, T81.521A — Obstruction due to foreign body accidentally left in body following infusion or transfusion, initial encounter, T81.522A — Obstruction due to foreign body accidentally left in body following kidney dialysis, initial encounter, T81.523A — Obstruction due to foreign body accidentally left in body following injection or immunization, initial encounter, T81.524A — Obstruction due to foreign body accidentally left in body following endoscopic examination, initial encounter, T81.525A — Obstruction due to foreign body accidentally left in body following heart catheterization, initial encounter, T81.526A — Obstruction due to foreign body accidentally left in body following aspiration, puncture or other catheterization, initial encounter, T81.527A — Obstruction due to foreign body accidentally left in body following removal of catheter or packing, initial encounter, T81.528A — Obstruction due to foreign body accidentally left in body following other procedure, initial encounter, T81.529A — Obstruction due to foreign body accidentally left in body following unspecified procedure, initial encounter, T81.531A — Perforation due to foreign body accidentally left in body following infusion or transfusion, initial encounter, T81.532A — Perforation due to foreign body accidentally left in body following kidney dialysis, initial encounter, T81.533A — Perforation due to foreign body accidentally left in body following injection or immunization, initial encounter, T81.534A — Perforation due to foreign body accidentally left in body following endoscopic examination, initial encounter, T81.535A — Perforation due to foreign body accidentally left in body following heart catheterization, initial encounter, T81.536A — Perforation due to foreign body accidentally left in body following aspiration, puncture or other catheterization, initial encounter, T81.537A — Perforation due to foreign body accidentally left in body following removal of catheter or packing, initial encounter, T81.538A — Perforation due to foreign body accidentally left in body following other procedure, initial encounter, T81.539A — Perforation due to foreign body accidentally left in body following unspecified procedure, initial encounter, T81.590A — Other complications of foreign body accidentally left in body following surgical operation, initial encounter, +75 more

Same injury, other encounter phase

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

T81.530D — Perforation due to foreign body accidentally left in body following surgical operation, subsequent encounterCompare T81.530A vs T81.530D →, T81.530S — Perforation due to foreign body accidentally left in body following surgical operation, sequelaCompare T81.530A vs T81.530S →

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).

T81.520A — Obstruction due to foreign body accidentally left in body following surgical operation, initial encounter, T81.521A — Obstruction due to foreign body accidentally left in body following infusion or transfusion, initial encounter, T81.522A — Obstruction due to foreign body accidentally left in body following kidney dialysis, initial encounter, T81.523A — Obstruction due to foreign body accidentally left in body following injection or immunization, initial encounter, T81.524A — Obstruction due to foreign body accidentally left in body following endoscopic examination, initial encounter, T81.525A — Obstruction due to foreign body accidentally left in body following heart catheterization, initial encounter, T81.526A — Obstruction due to foreign body accidentally left in body following aspiration, puncture or other catheterization, initial encounter, T81.527A — Obstruction due to foreign body accidentally left in body following removal of catheter or packing, initial encounter, T81.528A — Obstruction due to foreign body accidentally left in body following other procedure, initial encounter, T81.529A — Obstruction due to foreign body accidentally left in body following unspecified procedure, initial encounter, T81.531A — Perforation due to foreign body accidentally left in body following infusion or transfusion, initial encounter, T81.532A — Perforation due to foreign body accidentally left in body following kidney dialysis, initial encounter, T81.533A — Perforation due to foreign body accidentally left in body following injection or immunization, initial encounter, T81.534A — Perforation due to foreign body accidentally left in body following endoscopic examination, initial encounter, T81.535A — Perforation due to foreign body accidentally left in body following heart catheterization, initial encounter, T81.536A — Perforation due to foreign body accidentally left in body following aspiration, puncture or other catheterization, initial encounter, T81.537A — Perforation due to foreign body accidentally left in body following removal of catheter or packing, initial encounter, T81.538A — Perforation due to foreign body accidentally left in body following other procedure, initial encounter, T81.539A — Perforation due to foreign body accidentally left in body following unspecified procedure, initial encounter, T81.590A — Other complications of foreign body accidentally left in body following surgical operation, initial encounter, +230 more

Contextual Map

Every relationship of T81.530A 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 T81.530A with these 11 related codes in Claim Check

Hierarchy

Referenced by Excludes1 notes

Referenced by Excludes2 notes (10)

Referenced by Code First instructions

  • J98.51 — Mediastinitis[Code First](via T81.-): “underlying condition, if applicable, such as postoperative mediastinitis (T81.-)”— CMS ICD-10-CM tabular instructional notes · icd10cm-fy2026

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 · FY2026
  • MDC 21 — Injuries, Poisonings and Toxic Effects of Drugs[MDC crossing]: “Injuries, Poisonings and Toxic Effects of Drugs — 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. 32,029 same-MDC procedures group here; browse them on the MDC page.”— CMS MS-DRG Definitions Manual · FY2026

Index entries

  • Foreign body, accidentally left following a procedure, surgical operation, resulting in, perforation[Index term]— CMS ICD-10-CM Index to Diseases and Injuries · icd10cm-fy2026

Nearest codes (40)

Change history

  • FY2016 — In the code set at ICD-10-CM adoption [Change history]— CMS release files (code change ledger) · icd10cm-fy2016

Common coding questions

Does T81.530A 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 FY2026 tabular list, index and tables, effective October 1, 2025 Release, file and checksum · Publisher’s page
Claim edits Official source data
CMS Definitions of Medicare Code Edits — v43.1 (April 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 — v43 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 structured 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 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.

Labels on this page: Official source data · MedCoder structured relationship · MedCoder explanation. How to read the labels · All data sources and release dates

Change history

  • FY2016 — October 1, 2015
    In the code set at ICD-10-CM adoption
    Perforation due to foreign body accidentally left in body following surgical operation, initial encounter

No changes since FY2016 — additions, deletions, description changes and billable-status changes are tracked through FY2027 (effective October 1, 2026), and none are recorded for this code. Note changes are tracked from FY2027 only.

Nearest Codes in This Family

Official ICD-10-CM classifications closest to T81.530A in its code family, with their registry titles.

View all codes in the T81 family