Complications of Surgical and Medical Care ICD-10-CM codes

ICD-10-CM codes for complications of procedures not elsewhere classified (T81), including surgical site infection, wound dehiscence, postprocedural shock, and retained foreign bodies, with the related T80 to T88 categories.

348 codes, 253 billable. FY2027, valid from October 1, 2026. In chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes.

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How to code Complications of Surgical and Medical Care

Complication codes require the provider to document a cause-and-effect relationship between the care and the condition; a condition that occurs after surgery is not a complication just because of the timing. T80 covers complications of infusion, transfusion, and injection (T80.211A bloodstream infection from a central venous catheter, T80.1XXA vascular complications). T81 is complications of procedures not elsewhere classified. T82 through T85 are complications of devices, implants, and grafts by body system (T82.7XXA infection of a cardiac or vascular device, T84.50XA infection of an unspecified internal joint prosthesis, T85.71XA infection of a peritoneal dialysis catheter). T88 covers other complications such as those following immunization (T88.1XXA) and anaphylaxis from a correctly administered drug (T88.6XXA). All take a seventh character A, D, or S.

Surgical site infection is T81.4-: T81.40XA unspecified, T81.41XA superficial incisional, T81.42XA deep incisional, T81.43XA organ and space, T81.44XA sepsis following a procedure, and T81.49XA other surgical site. Add a code for the infection itself when it is documented, for example cellulitis or abscess, and for sepsis following a procedure code T81.44XA with the sepsis code and any organ dysfunction. Wound dehiscence is T81.3- (T81.31XA external surgical wound, T81.32- internal). Postprocedural shock is T81.1- (T81.10XA unspecified, T81.11XA cardiogenic, T81.12XA septic). T81.5- and T81.6- report foreign bodies and substances accidentally left during a procedure. T81.9XXA is an unspecified complication of a procedure.

Body-system chapters contain their own postprocedural complication codes, and those take precedence over T81 when they describe the condition: K91.89 for digestive, I97.89 for circulatory, N99.89 for genitourinary. Obstetric procedure complications are coded in chapter 15. The external cause codes Y83 and Y84 (Y83.1 surgical operation with implant, Y83.8 other surgical procedures, Y84.8 other medical procedures) may be added to identify the procedure as the cause.

All Complications of Surgical and Medical Care codes

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