Crystal's MCW Coder HubICD-10-CM T85.79XA - Infection and Inflammatory Reaction Due to Other Internal Prosthetic Devices, Implants and Grafts, Initial Encounter
⚠️ Note: T85.79XA is an ICD-10-CM diagnosis code, not a CPT procedure code. Fields such as wRVU, global period, and assistant payable do not apply directly to diagnosis codes. This note includes associated CPT procedure codes and their billing information in the Associated CPT Procedures section below.
Short Definition
Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts — initial encounter. This code describes a local or systemic infectious or inflammatory complication arising from an implanted internal prosthetic device, implant, or graft that does not have a more specific ICD-10-CM code within the T85 category. The “initial encounter” (7th character A) indicates the patient is receiving active treatment for the condition.
Long / Clinical Definition
T85.79XA represents an infection and/or inflammatory reaction that has developed at the site of, or in direct response to, an internally placed prosthetic device, implant, or graft — one that is not captured by a more specific T85.7x subcode. This category functions as the “other” catch-all for device-related infections within the T85 family.
The infection may manifest across a wide clinical spectrum:
- Localized wound infection at the surgical implantation site
- Peri-device abscess or cellulitis overlying the implant
- Biofilm formation on the device surface with chronic low-grade infection
- Inflammatory reaction (sterile or infectious) to the implanted material itself
- Systemic infection/sepsis arising from hematogenous seeding of the device
The word “inflammatory reaction” is intentionally broad — it encompasses both confirmed infectious etiologies (bacterial, fungal, mycobacterial) and sterile inflammatory reactions triggered by the device material (e.g., silicone-associated inflammatory response, foreign body reaction escalating to clinical infection).
7th Character Definitions
| 7th Character | Code | Definition | Clinical Application |
|---|---|---|---|
| A | T85.79XA | Initial encounter | Patient is receiving active treatment (including new providers, hospitalization, surgery) — use this throughout the entire active treatment phase, even across multiple providers and visits |
| D | T85.79XD | Subsequent encounter | Routine follow-up care after active treatment is complete (wound healing, routine monitoring, outpatient checks post-discharge) |
| S | T85.79XS | Sequela | Late effects/residual conditions caused by the device infection (e.g., chronic sinus tract, scarring, implant failure, chronic osteomyelitis adjacent to implant) |
⚠️ 7th Character A does NOT mean “first visit.” Per ICD-10-CM Official Coding Guidelines (Chapter 19), the 7th character A should be used for all encounters where the patient is still receiving active treatment for the device infection — regardless of how many times the patient has been seen, by how many different providers, or whether this is a new provider. Switch to D only when active treatment has concluded. Switch to S for residual/late effects.
6th Character “X” — Placeholder
T85.79 requires a placeholder X in the 6th position to allow for the required 7th character extension. This is purely a structural requirement of ICD-10-CM and carries no clinical meaning. The code structure is:
- T = Injury/complication chapter
- 85 = Complications of other internal prosthetic devices
- .7 = Infection/inflammatory reaction type
- 9 = “Other” (not peritoneal catheter, insulin pump, or nervous system device)
- X = Mandatory placeholder
- A/D/S = Episode of care
Area of the Body / Applicable Devices
T85.79XA applies to infections involving any internal prosthetic device, implant, or graft within the T85 category that is not specifically enumerated by a more precise T85.7x subcode.
Devices and Implants Covered by T85.79XA
| Device / Implant Type | Clinical Setting | Notes |
|---|---|---|
| Breast implants (saline, silicone, tissue expanders) | Plastic/Reconstructive Surgery | Breast implant-associated infection; capsular contracture with secondary infection |
| Intraocular lens (IOL) | Ophthalmology | Post-cataract extraction IOL infection; endophthalmitis secondary to IOL |
| Cochlear implants | Otolaryngology / ENT | Device-associated wound infection; deep infection; explantation required |
| Bile duct stent / biliary prosthesis | Gastroenterology / GI Surgery | Cholangitis, biliary stent infection, bile duct prosthesis-related sepsis |
| Esophageal antireflux device (LINX, Nissen-related hardware) | General Surgery | Infection/inflammatory reaction involving esophageal prosthetic |
| Gastrointestinal prosthetic devices | General Surgery / GI | Prosthetic pyloric/sphincter devices, esophageal stents |
| Prosthetic intervertebral disc (artificial disc replacement) | Spine Surgery | Deep infection of cervical or lumbar artificial disc — distinct from hardware infection |
| Intrathecal drug delivery pump (not nervous system electrode) | Pain Management / Neurosurgery | Pump pocket infection; intrathecal catheter tip inflammation — when not covered by T85.73x |
| Penile implant / prosthesis | Urology | ⚠️ Verify: T83.61XA (infection of implanted penile prosthesis) may be more specific — use T85.79XA only if T83.6x does not capture the device |
| Orbital implant (prosthetic eye/globe) | Ophthalmology | Infection of orbital prosthetic device |
| Temporomandibular joint (TMJ) prosthesis | Oral/Maxillofacial Surgery | Device infection in TMJ replacement |
| Laryngeal prosthesis / tracheal implant | ENT / Thoracic Surgery | Infection of implanted laryngeal or tracheal prosthetic |
| Other implanted devices not specified in T82-T84 or T85.71-T85.73 | Various | Any internal device/implant/graft not covered by a more specific T-code |
Devices NOT Covered by T85.79XA (Use More Specific Codes)
| Device | Correct Code Family | Notes |
|---|---|---|
| Cardiac pacemaker, AICD, cardiac lead | T82.7XXA | Complications of cardiac/vascular devices |
| Vascular graft (aortic, peripheral) | T82.7XXA | Vascular prosthetic infection |
| Orthopedic joint replacement (hip, knee) | T84.50XA-T84.59XA | Internal joint prosthesis infection |
| Orthopedic bone fixation device (pins, screws, rods) | T84.7XXA | Other internal orthopedic device infection |
| Urinary catheter / ureteral stent / urethral prosthetic | T83.51XA-T83.59XA | Urinary prosthetic device infection |
| Penile prosthesis | T83.61XA | Infection of implanted penile prosthesis (more specific) |
| Testicular prosthesis | T83.62XA | Infection of implanted testicular prosthesis |
| VP shunt / ventricular shunt | T85.730A | Specific nervous system code — more specific than T85.79XA |
| Implanted neurostimulator (brain/spinal/peripheral) | T85.731A-T85.738A | Specific nervous system device codes |
| Peritoneal dialysis catheter | T85.71XA | More specific — do not use T85.79XA |
| Insulin pump | T85.72XA | More specific — do not use T85.79XA |
| Cranial or spinal infusion catheter | T85.735A | More specific — do not use T85.79XA |
| Transplanted organs/tissue | T86.x | Transplant complications — separate category entirely |
Code Tree / Hierarchy
ICD-10-CM (FY2026)
└── Chapter XIX - Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88)
└── T80-T88 - Complications of Surgical and Medical Care, NEC
└── T85 - Complications of Other Internal Prosthetic Devices, Implants and Grafts
├── T85.0 - Mechanical complication of ventricular intracranial (communicating) shunt
├── T85.1 - Mechanical complication of implanted electronic stimulator of nervous system
├── T85.2 - Mechanical complication of intraocular lens
├── T85.3 - Mechanical complication of other ocular prosthetic devices, implants and grafts
├── T85.4 - Mechanical complication of breast prosthesis and implant
├── T85.5 - Mechanical complication of gastrointestinal prosthetic devices, implants and grafts
├── T85.6 - Mechanical complication of other specified internal prosthetic devices, implants and grafts
├── T85.7 - INFECTION AND INFLAMMATORY REACTION due to internal prosthetic devices
│ ├── T85.71xA/D/S - due to peritoneal dialysis catheter
│ ├── T85.72xA/D/S - due to insulin pump
│ ├── T85.73 - due to nervous system devices
│ │ ├── T85.730A/D/S - ventricular intracranial (communicating) shunt
│ │ ├── T85.731A/D/S - implanted electronic neurostimulator, brain electrode lead
│ │ ├── T85.732A/D/S - implanted electronic neurostimulator, peripheral nerve electrode lead
│ │ ├── T85.733A/D/S - implanted electronic neurostimulator, spinal cord electrode lead
│ │ ├── T85.734A/D/S - implanted electronic neurostimulator, generator pocket
│ │ ├── T85.735A/D/S - cranial or spinal infusion catheter
│ │ ├── T85.738A/D/S - other nervous system device, implant or graft
│ │ └── T85.739A/D/S - unspecified nervous system device
│ └── T85.79 - due to OTHER internal prosthetic devices, implants and grafts
│ ├── T85.79XA - initial encounter ✅ ← THIS CODE
│ ├── T85.79XD - subsequent encounter
│ └── T85.79XS - sequela
├── T85.8 - Other specified complications of internal prosthetic devices (embolism, fibrosis, hemorrhage, pain, stenosis, thrombosis)
│ ├── T85.81 - Embolism due to internal prosthetic devices, implants and grafts
│ ├── T85.82 - Fibrosis due to internal prosthetic devices, implants and grafts
│ ├── T85.83 - Hemorrhage due to internal prosthetic devices, implants and grafts
│ ├── T85.84 - Pain due to internal prosthetic devices, implants and grafts
│ ├── T85.85 - Stenosis due to internal prosthetic devices, implants and grafts
│ ├── T85.86 - Thrombosis due to internal prosthetic devices, implants and grafts
│ └── T85.89 - Other specified complications, NEC
└── T85.9 - Unspecified complication of internal prosthetic device, implant and graft
├── T85.9XXA - initial encounter
├── T85.9XXD - subsequent encounter
└── T85.9XXS - sequela
Related T-Code Families (for comparison/cross-reference):
├── T82.7XXA - Infection and inflammatory reaction due to cardiac/vascular prosthetic devices
├── T83.5x-T83.6x - Infection due to urinary/genital prosthetic devices
└── T84.5x-T84.7x - Infection due to orthopedic prosthetic devices and implants
ICD-10-CM Tabular Includes & Excludes
Includes (at T85.7 subcategory level)
The T85.7 subcategory Includes notation covers:
- Infection caused by the presence of an internal prosthetic device, implant, or graft
- Inflammatory reaction caused by the presence of an internal prosthetic device, implant, or graft
- Foreign body reaction with secondary infection
- Biofilm-associated infection of an implanted device
- Peri-device abscess or wound infection attributable to the presence of the device
Use Additional Code (Mandatory Sequencing Instructions)
Per ICD-10-CM Chapter 19 tabular conventions for T85.79XA, the following additional codes are required or strongly directed:
| Instruction | Code(s) to Add | Clinical Context |
|---|---|---|
| Use additional code to identify infection | B95.x - Streptococcus or Staphylococcus as cause of disease; B96.x - Other bacterial agents; B37.x - Candidiasis | Identify the specific infectious organism when documented (e.g., B95.61 = MSSA, B95.62 = MRSA, B96.20 = Unspecified E. coli) |
| Use additional code for sepsis | A40.x / A41.x | When systemic infection/sepsis is documented — sepsis should be sequenced before T85.79XA if it is the reason for admission |
| Use additional code for associated fever | R50.81 (Fever due to other known physiological condition) or R50.9 | If fever is present and clinically attributed to the device infection |
Excludes 1 (Cannot Code Together — Mutually Exclusive)
| Excluded Code | Description | Reason |
|---|---|---|
| T82.7XXA | Infection/inflammatory reaction due to cardiac and vascular prosthetic devices | These devices have a dedicated category — do not use T85.79XA for pacemakers, cardiovascular stents, vascular grafts |
| T83.5x, T83.6x | Infection due to urinary/genital prosthetic devices | Urinary prosthetics (catheters, penile prosthesis, testicular implants) have specific T83 codes — they are excluded from T85.79XA |
| T84.5x, T84.7x | Infection due to orthopedic prosthetic devices | Joint replacements, bone fixation devices → use T84.x family exclusively |
| T85.71x | Peritoneal dialysis catheter infection | More specific code — never use T85.79XA when T85.71x applies |
| T85.72x | Insulin pump infection | More specific code — do not use T85.79XA |
| T85.730-T85.739 | Nervous system device infections (shunts, neurostimulators) | More specific codes — never use T85.79XA when these apply |
Excludes 2 (Not Included Here — May Be Coded Together)
| Excluded Code | Description | Coding Guidance |
|---|---|---|
| T81.40x-T81.49x | Infection following a procedure (surgical site infection) | ✅ May code together: SSI is a different construct than device infection; T81.4x covers the SSI, T85.79XA covers the device-related infection — these can coexist and both be reported |
| Z87.39 | Personal history of other musculoskeletal disorders | ✅ May code together for history of prior device complications |
| L97.x, L98.x | Non-pressure ulcer/open wound | ✅ May code together when wound breakdown is present concurrent with device infection |
| A40.x / A41.x | Streptococcal/Staphylococcal/Other sepsis | ✅ Code together: when sepsis develops from the device infection, report BOTH the sepsis code AND T85.79XA |
| B95.x, B96.x | Infectious agents (organism codes) | ✅ Add to identify the infecting organism |
Code First — Principal Diagnosis Sequencing Rules
Per ICD-10-CM guidelines, when sepsis is present and attributable to the device infection:
- Sequence the sepsis code (A41.x or A40.x) FIRST as the principal diagnosis
- Followed by T85.79XA as the underlying cause
- Followed by the organism code (B95.x/B96.x)
Note
This is a critical sequencing rule that affects MS-DRG assignment and can shift the case from MDC 18 (DRG 856-858) to MDC 18 sepsis DRGs (DRG 871-872-873) with significantly different reimbursement weights.
HCC Status & Risk Adjustment
Direct HCC Status of T85.79XA
| Item | Value |
|---|---|
| CMS-HCC V28 Direct Mapping | ❌ Not directly HCC-mapped |
| HHS-HCC (ACA Exchange Plans) | ❌ Not mapped |
| RAF Score Contribution (standalone) | $0 additional RAF from T85.79XA alone |
HCC-Mapped Conditions Commonly Coded WITH T85.79XA
| ICD-10-CM | Description | HCC Status | HCC # | Coding Relationship |
|---|---|---|---|---|
| A41.01 | Sepsis due to MRSA | ✅ HCC-2 | Septicemia, Sepsis, Systemic Inflammatory Response Syndrome (SIRS) | When device infection causes MRSA sepsis — sequence sepsis first |
| A41.02 | Sepsis due to MSSA | ✅ HCC-2 | Same | MSSA bacteremia/sepsis from device |
| A41.9 | Sepsis, unspecified organism | ✅ HCC-2 | Same | Avoid — specify organism when documented |
| A49.01 | MRSA infection, unspecified site | ✅ HCC-2 | Same | When sepsis criteria not met but MRSA documented |
| B95.61 | MRSA as cause of disease classified elsewhere | ✅ May trigger HCC-2 in context | Organism code — add as additional | |
| R65.20 | Severe sepsis without septic shock | ✅ HCC-2 | SIRS with organ dysfunction | Add when severe sepsis criteria met |
| R65.21 | Severe sepsis with septic shock | ✅ HCC-2 | Most severe tier | MCC level — significantly impacts DRG |
| E11.51 | Type 2 DM with diabetic peripheral angiopathy without gangrene | ✅ HCC-107 | Diabetes with vascular complications | Diabetes greatly increases device infection risk and severity |
| E11.621 | Type 2 DM with foot ulcer | ✅ HCC-18 | Diabetic foot | Concurrent wound complication |
| N18.4 | CKD Stage 4 | ✅ HCC-328 | CKD | Immunocompromised state increases infection risk |
| D84.9 | Immunodeficiency, unspecified | ✅ HCC-47 | Immune disorders | Immunosuppression (transplant, HIV, chemotherapy) |
| B20 | HIV disease | ✅ HCC-1 | HIV/AIDS | Severely immunocompromised |
| Z79.899 | Long-term use of other medication | ❌ Not HCC | — | Immunosuppressants, biologic agents — important context code |
| Z79.52 | Long-term use of systemic steroids | ❌ Not HCC | — | Steroid-induced immunosuppression |
Note
💡 RAF Optimization Note for Medicare Advantage: While T85.79XA itself carries no RAF weight, the clinical complications it causes and its underlying risk factors often do. A device-infected patient with sepsis (HCC-2), CKD (HCC-328), and diabetes with complications (HCC-37) can carry substantial RAF weight. Every documented and managed condition should be captured. Ensure the infectious disease consultant’s documentation (organism, severity) is coded in addition to the underlying device complication.
MS-DRG Assignment (Inpatient Facility)
The MS-DRG assignment for T85.79XA as principal diagnosis varies significantly based on:
- Whether an operating room (O.R.) procedure is performed during the same admission
- The presence or absence of MCCs and CCs
- Whether sepsis is coded (shifts to sepsis DRGs)
Primary MS-DRG Pathway (T85.79XA as Principal + O.R. Procedure Performed)
| MS-DRG | Description | CC/MCC Tier | MDC |
|---|---|---|---|
| 856 | Postoperative or Post-Traumatic Infections with O.R. Procedure with MCC | MCC present | MDC 18 |
| 857 | Postoperative or Post-Traumatic Infections with O.R. Procedure with CC | CC present, no MCC | MDC 18 |
| 858 | Postoperative or Post-Traumatic Infections with O.R. Procedure without CC/MCC | No CC/MCC | MDC 18 |
Note
O.R. procedures that commonly trigger this DRG pathway: device removal (CPT equivalent), debridement, irrigation and drainage, wound exploration, explantation with or without replacement, etc.
Secondary MS-DRG Pathway (T85.79XA as Principal + NO O.R. Procedure)
| MS-DRG | Description | CC/MCC Tier | MDC |
|---|---|---|---|
| 862 | Postoperative and Post-Traumatic Infections without O.R. Procedure with MCC or CC | CC or MCC present | MDC 18 |
| 863 | Postoperative and Post-Traumatic Infections without O.R. Procedure without CC/MCC | No CC/MCC | MDC 18 |
Sepsis DRG Pathway (When Sepsis is Coded — T85.79XA Sequenced After Sepsis Code)
| MS-DRG | Description | Tier | Notes |
|---|---|---|---|
| 871 | Septicemia or Severe Sepsis with O.R. Procedure with MCC | MCC | Highest-weighted sepsis DRG |
| 872 | Septicemia or Severe Sepsis with O.R. Procedure without MCC | No MCC | |
| 870 | Septicemia or Severe Sepsis without O.R. Procedure with MCC | MCC | |
| 871 / 872 | Septicemia/Severe Sepsis with/without OR | — | Depends on concurrent procedure |
Note
💡 Facility Coder Alert: This is one of the highest DRG assignment complexity scenarios in the entire ICD-10-CM system. The difference between DRG 856 (device infection with MCC + OR procedure) and DRG 870/871 (sepsis with OR procedure + MCC) can be dramatic in reimbursement weight. The key decision point is whether sepsis is the principal diagnosis or the device infection is. Apply UHDDS principal diagnosis guidelines strictly: the condition established after study to be chiefly responsible for the admission. When both sepsis AND device infection are present, query the attending to clarify which drove the admission decision.
Common CC/MCC Codes That Shift DRG Tier for T85.79XA Cases
| Code | Description | CC/MCC Status |
|---|---|---|
| A41.x | Sepsis (various organisms) | MCC |
| R65.20 | Severe sepsis without shock | MCC |
| R65.21 | Severe sepsis with septic shock | MCC |
| J96.00 | Acute respiratory failure, unspecified | MCC |
| N17.9 | Acute kidney injury (AKI) | CC |
| D62 | Acute posthemorrhagic anemia | CC |
| E87.1 | Hypo-osmolality and hyponatremia | CC |
| K72.00 | Acute and subacute hepatic failure without coma | MCC |
| I50.9 | Heart failure, unspecified | CC |
| N18.4 | CKD Stage 4 | CC |
| B95.61 | MRSA as causative organism | CC (in most grouper versions) |
| E11.65 | Type 2 DM with hyperglycemia | CC |
| Z87.39 | Personal history of musculoskeletal conditions | Non-CC (contextual) |
Associated CPT Procedure Codes & wRVU Values
Since T85.79XA is a diagnosis code, the following represents CPT procedures most commonly performed in the management of infected internal prosthetic devices, implants, and grafts. wRVU values are 2026 estimates.
Device Removal / Explantation (Device-Specific)
| CPT | Description | 2026 wRVU (est.) | Assistant Payable | Global Period |
|---|---|---|---|---|
| 19328 | Removal of intact mammary implant | 5.48 | Yes - Ind. 1 | 090 |
| 19330 | Removal of ruptured mammary implant; including implant contents | 8.20 | Yes - Ind. 1 | 090 |
| 66985 | Insertion of intraocular lens prosthesis (secondary implant) | 10.32 | Yes - Ind. 1 | 090 |
| 69930 | Cochlear device implantation with mastoidectomy | 15.49 | Yes - Ind. 1 | 090 |
| 43289 | Unlisted laparoscopy procedure, esophagus (for esophageal device removal — unlisted) | Variable | Verify | 090 |
| 22870 | Removal of total disc arthroplasty (artificial disc), anterior approach, each level; cervical | 14.00 (est.) | Yes - Ind. 1 | 090 |
| 22872 | Removal of total disc arthroplasty, anterior approach; lumbar | 16.00 (est.) | Yes - Ind. 1 | 090 |
| 62365 | Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion | 5.93 | Yes - Ind. 1 | 090 |
Incision and Drainage / Wound Management
| CPT | Description | 2026 wRVU (est.) | Assistant Payable | Global Period |
|---|---|---|---|---|
| 10180 | Incision and drainage, complex, postoperative wound infection | 2.22 | Yes - Ind. 1 | 010 |
| 10060 | Incision and drainage of abscess; simple or single | 0.70 | No | 010 |
| 10061 | Incision and drainage of abscess; complicated or multiple | 1.05 | No | 010 |
| 11010 | Debridement including removal of foreign material at site of complicated open fracture and/or dislocation; skin and subcutaneous tissues | 2.07 | Yes - Ind. 1 | 010 |
| 11043 | Debridement, muscle and/or fascia; first 20 sq cm or less | 3.19 | Yes - Ind. 1 | 010 |
| 97597 | Debridement, open wound; first 20 sq cm | 0.90 | No | 000 |
Breast Implant-Specific (Most Common T85.79XA Application)
| CPT | Description | 2026 wRVU (est.) | Assistant Payable | Global Period |
|---|---|---|---|---|
| 19328 | Removal of intact mammary implant | 5.48 | Yes - Ind. 1 | 090 |
| 19330 | Removal of ruptured mammary implant | 8.20 | Yes - Ind. 1 | 090 |
| 11008 | Removal of prosthetic material or mesh, abdominal wall for infection | 15.33 | Yes - Ind. 1 | 090 |
| 19316 | Mastopexy (may be performed at implant removal-revision) | 9.51 | Yes - Ind. 1 | 090 |
| 19340 | Insertion of breast implant (at time of mastopexy or reconstruction) | 5.17 | Yes - Ind. 1 | 090 |
Biliary Stent / GI Device Management
| CPT | Description | 2026 wRVU (est.) | Assistant Payable | Global Period |
|---|---|---|---|---|
| 43274 | ERCP with removal and exchange of transpapillary stent | 5.32 | No | 000 |
| 43276 | ERCP with removal and exchange of biliary stent(s) requiring balloon dilation | 6.52 | No | 000 |
| 47480 | Cholecystotomy or cholecystostomy with removal of calculi (separate procedure) | 9.42 | Yes - Ind. 1 | 090 |
| 47562 | Laparoscopic cholecystectomy | 7.79 | Yes - Ind. 1 | 090 |
Infectious Disease Management (Office/Inpatient)
| CPT | Description | 2026 wRVU (est.) | Global Period |
|---|---|---|---|
| 99223 | Initial hospital care, high complexity | 3.86 | 000 |
| 99233 | Subsequent inpatient E/M, high complexity | 2.00 | 000 |
| 99215 | Office/outpatient E/M, established patient, high complexity | 2.85 | 000 |
| 99291 | Critical care, first 30-74 minutes | 4.50 | 000 |
Common Modifiers for Associated CPT Codes
| Modifier | Description | Application with T85.79XA Context |
|---|---|---|
| -78 | Unplanned return to OR related to prior procedure | When device removal/debridement is necessitated by an infected implant during the global period of the original implant placement surgery |
| -58 | Staged or related procedure within global period | When planned device removal or revision is performed as a staged step within the global period of the original implant |
| -79 | Unrelated procedure during global period | For completely unrelated surgical procedures performed during the global period |
| -22 | Increased Procedural Services | When device removal is significantly more complex than typical due to extensive infection, biofilm, tissue necrosis, or prior failed attempts |
| -59 | Distinct Procedural Service | When debridement and device removal are separately reportable as distinct procedures at the same session |
| -LT / -RT | Laterality | For bilateral devices (e.g., bilateral breast implants) when only one side is infected |
| -50 | Bilateral | When both sides of a bilateral implant are simultaneously infected and managed |
| -80 | Assistant Surgeon | For major explantation procedures where an assistant is needed |
| -AS | APP as Assistant at Surgery | For Medicare/Medicaid APP assistant billing |
| -GY | Not a Medicare Benefit | Certain cosmetic-related device procedures are not Medicare-covered — use when applicable with cosmetic breast implant cases |
Coding Examples / Scenarios
Scenario 1 - Infected Breast Implant, Initial Presentation (Outpatient)
Clinical Situation: A 44-year-old female with silicone breast implants placed 3 years ago presents to her plastic surgeon with a 5-day history of right breast swelling, erythema, warmth, and purulent drainage from the right incision site. Cultures grow MSSA. She is treated with antibiotics and wound care. The decision is made to remove the right implant.
ICD-10-CM:
T85.79XA- Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter (the infected breast implant — active treatment phase)B95.61- Methicillin-susceptible Staphylococcus aureus (MSSA) infection as cause of diseases classified elsewhere (organism code — always add when documented)Z98.89- Other specified postprocedural states (history of prior implant placement — optional context)
CPT (Office Visit + Decision for Surgery):
99215-57- Office visit, established patient, high complexity; modifier -57 indicates the decision for major surgery (implant removal) was made at this visit
Scenario 2 - Infected Breast Implant: Inpatient Explantation (Return to OR within Global Period)
Clinical Situation: The same patient returns to the OR 8 days after the original implant placement (still within the 90-day global period of the original augmentation mammoplasty, CPT 19325). She is admitted for explantation of the infected right breast implant.
CPT (Explantation):
19328-78-RT- Removal of intact mammary implant, right side; modifier -78 (unplanned return to OR for complication within global period of original implant surgery); modifier -RT for right side
ICD-10-CM:
T85.79XA- Infection/inflammatory reaction due to other internal prosthetic device, implants and grafts, initial encounterB95.61- MSSA as causative organismN99.820- (if applicable — check if any procedural complication code is relevant)
⚠️ Modifier -78 signals to the payer that this is a complication-driven return to OR within the original procedure’s global period. Reimbursement is typically paid at the facility component only (intraoperative). A new global period does NOT begin with modifier -78.
Scenario 3 - MRSA Infected Cochlear Implant with Hospital Admission
Clinical Situation: A 7-year-old child with a previously placed cochlear implant presents with persistent pain and swelling over the right temporal/mastoid region and fever for 4 days. CT scan shows peri-device fluid collection and early mastoiditis. Blood cultures grow MRSA. The child is admitted for IV vancomycin and device evaluation.
ICD-10-CM (Inpatient Sequencing):
A41.02- Sepsis due to MRSA (principal diagnosis — the MRSA sepsis is the primary driver of admission)T85.79XA- Infection/inflammatory reaction, other internal prosthetic device, initial encounter (the cochlear implant is the source)B95.62- MRSA as cause of diseases classified elsewhere (organism code)R65.20- Severe sepsis without septic shock (add if severe sepsis criteria met — MCC)
Expected MS-DRG (if MRSA sepsis sequenced first):
- DRG 870 - Septicemia or Severe Sepsis without O.R. Procedure with MCC (or DRG 871/872 if OR procedure performed)
⚠️ Sequencing Critical: If T85.79XA is sequenced first here (instead of A41.02), the case groups to MDC 18 DRG 856/862 (device infection DRGs), which carries a substantially lower relative weight than the sepsis DRGs (870/871). The sepsis drove the admission — sequence it first per UHDDS guidelines.
Scenario 4 - Infected Biliary Stent (Biliary Prosthesis), Initial Encounter
Clinical Situation: A 72-year-old male with a previously placed plastic biliary stent for common bile duct stricture presents to the emergency department with fever (39.4°C), right upper quadrant pain, and jaundice. ERCP performed urgently; the biliary stent is found to be occluded and infected (cholangitis). The stent is removed and replaced.
CPT:
43276- ERCP with removal and exchange of biliary stent(s) with balloon dilation
ICD-10-CM:
K83.09- Other cholangitis (the acute cholangitis — may be the principal diagnosis if it drove the admission)T85.79XA- Infection/inflammatory reaction, other internal prosthetic device, initial encounter (the infected biliary stent)B96.89- Other specified bacterial agents as cause (if organism documented)K83.1- Obstruction of bile duct (if documented)
✅ Both K83.09 (cholangitis) and T85.79XA (infected biliary prosthesis) are reportable together — they represent different aspects of the same clinical event (the acute cholangitis is the clinical syndrome; T85.79XA specifies the stent as the cause).
Scenario 5 - Infected Prosthetic Intervertebral Disc (Lumbar Artificial Disc)
Clinical Situation: A 48-year-old male with a lumbar artificial disc replacement (L4-L5, placed 18 months ago) presents with worsening back pain, elevated CRP, and WBC. MRI confirms peri-disc fluid collection consistent with deep infection. He is admitted for surgical debridement and IV antibiotics.
CPT (Surgery):
22872- Removal of total disc arthroplasty, anterior approach; lumbar
ICD-10-CM:
T85.79XA- Infection/inflammatory reaction, other internal prosthetic device, initial encounter (infected lumbar artificial disc — prosthetic disc is covered by T85.79XA, not T84.7XXA which is for orthopedic hardware/bone fixation devices)M46.36- Infection of intervertebral disc (pyogenic), lumbar region (add to capture the disc space infection as a concurrent condition — verify with attending documentation)B95.61orB96.x- Organism code (add when documented)
💡 Coding Note: The prosthetic intervertebral disc (artificial disc replacement) is a T85 device (other internal prosthetic device), NOT a T84 orthopedic device. Orthopedic hardware (screws, rods, plates for spine fusion) would be T84.7XXA. An artificial disc replacement = T85.79XA. This is a commonly misapplied distinction.
Scenario 6 - Infected Insulin Pump ⚠️ (Wrong Code Example — Use T85.72XA Instead)
Clinical Situation: A 36-year-old female with Type 1 diabetes presents with an infected insulin pump pocket site.
INCORRECT Coding:
- ❌
T85.79XA- Do NOT use — insulin pump has its own specific code
CORRECT Coding:
- ✅
T85.72XA- Infection and inflammatory reaction due to insulin pump, initial encounter E10.649- Type 1 DM with hypoglycemia without coma (if applicable)B95.x/B96.x- Organism code (add when documented)
⚠️ This scenario is included as a negative example to reinforce the specificity hierarchy. Always exhaust more specific T85.7x codes before defaulting to T85.79XA. T85.79XA is only appropriate when no more specific T85.7x code exists for the device in question.
Scenario 7 - Sequential 7th Characters: Active Treatment → Subsequent → Sequela
Clinical Situation: A patient has an infected right breast implant managed over 6 months.
| Phase | Date Range | Code | Rationale |
|---|---|---|---|
| Initial/Active treatment | Weeks 1-8 (hospitalization, explantation, IV antibiotics, wound care) | T85.79X**A** | Patient is undergoing active treatment — all providers, all settings |
| Subsequent encounter | Weeks 9-20 (routine wound checks, oral antibiotics, healing monitoring) | T85.79X**D** | Active treatment concluded; routine follow-up only |
| Sequela | Week 24+ (breast deformity, chronic sinus tract, capsular fibrosis from prior infection requiring revision) | T85.79X**S** | Late effect — the implant infection has resolved but its residual damage now requires treatment |
💡 The transition from A → D → S must reflect the actual clinical phase. The most common coding error is continuing to use 7th character A long after active treatment has concluded, or prematurely switching to D while the patient is still on IV antibiotics or in active wound care.
Scenario 8 - Multiple Device Infections in Same Patient
Clinical Situation: A 68-year-old immunocompromised male (on chronic immunosuppression post-kidney transplant) presents with concurrent infection of a cochlear implant (right) AND a gastrointestinal prosthesis (biliary stent). Both are being actively treated simultaneously.
ICD-10-CM:
T85.79XA- Infection/inflammatory reaction, other internal prosthetic device, initial encounter (covers both the cochlear implant infection AND the biliary stent infection — T85.79XA can be reported once to cover multiple “other” device infections when the category code is the same)A41.9- Sepsis, unspecified (if systemic infection present)Z94.0- Kidney transplant status (immunosuppressed context)D84.9- Immunodeficiency, unspecified (immunosuppressed state — adds CC/HCC weight)Z79.899- Long-term use of other medication (immunosuppressants)
💡 When T85.79XA covers multiple “other” devices in the same patient, the code is typically reported once. If the infections involve distinct device categories (e.g., one in T84 orthopedic AND one in T85 other internal), each category’s infection code would be reported separately.
Scenario 9 - Outpatient Wound Care During Active Treatment (7th Character Guidance)
Clinical Situation: A patient was discharged from the hospital after explantation of an infected breast implant. She is now coming to the wound care clinic weekly for dressing changes, irrigation, and monitoring of the healing pocket. The surgeon has not yet declared the infection “resolved” — she remains on oral antibiotics.
ICD-10-CM (Wound Care Visits):
T85.79X**A**- (NOT T85.79XD) — The patient is still actively being treated (ongoing antibiotics, active wound management by the surgeon). Use 7th character A until the treating provider documents the infection has resolved and the patient is in routine follow-up.
CPT:
97602- Non-selective debridement, non-autolytic (wound care)- OR
97597- Selective debridement, first 20 sq cm
Documentation Requirements
For T85.79XA to support accurate coding, audit defense, and appropriate MS-DRG assignment, clinical documentation should include:
- Device identification: Clearly document the type of internal prosthetic device, implant, or graft that is infected (e.g., “left silicone breast implant,” “biliary stent,” “cochlear implant,” “lumbar artificial disc”)
- Confirmation of infection vs. inflammatory reaction: Document whether the process is confirmed infectious (culture data, clinical signs) or an inflammatory reaction (sterile capsular contracture with superimposed infection)
- Infecting organism: Document the specific pathogen when identified (MRSA, MSSA, Pseudomonas, Candida, coagulase-negative Staph, etc.) — required for organism code
- Clinical severity: Document whether criteria for sepsis are met (SIRS criteria, organ dysfunction) — critical for MCC-level coding and DRG tier
- Timing relationship to original implant: Document whether the infection is acute postoperative (within 30-90 days) or late/chronic (months to years post-implant) — affects coding context and POA status
- Treatment provided: Antibiotics (IV vs. oral), surgical management, device removal, washout, staged reconstruction
- Present on Admission (POA) indicator: Document whether the infection was present at the time of admission or developed during the hospitalization — required for inpatient claims; affects HAC (Hospital-Acquired Condition) determination
- Comorbidities affecting management: Immunosuppression, diabetes, CKD, malnutrition — all should be documented as managed during the encounter
- Disposition of the device: Was it removed, retained with treatment, or replaced? Document explicitly
- Laterality when applicable: Right vs. left when device is unilateral (e.g., cochlear implant, breast implant)
Coding Tips & Pitfalls
💡 Always exhaust more specific T85.7x codes first. T85.79XA is the “other” code and should only be used when no more specific T85.7x subcode applies. Before coding T85.79XA, verify: Is this a peritoneal dialysis catheter (T85.71x)? Insulin pump (T85.72x)? Nervous system device/shunt/neurostimulator (T85.730-T85.739)? If yes, use the specific code instead.
💡 Do NOT confuse T85.79XA with T84.7XXA. T84.7XXA covers infection of orthopedic internal devices (joint prostheses covered under T84.5x, bone fixation hardware — screws, rods, plates — covered under T84.7XXA). T85.79XA covers infection of other internal prosthetic devices (breast implants, cochlear implants, IOLs, biliary stents, artificial discs, intrathecal pumps). The distinction matters for DRG accuracy and specificity.
💡 Sepsis sequencing is the highest-stakes decision. When a device infection causes sepsis, whether to sequence sepsis (A41.x) first or the device infection (T85.79XA) first dramatically affects MS-DRG assignment and facility reimbursement. Per UHDDS guidelines, the principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission. When both are present, document which drove the admission decision and sequence accordingly. When in doubt, query the physician.
💡 7th character A ≠ first visit only. This is the most widespread coding error with T-code complications. Continue using 7th character A throughout the entire active treatment phase — regardless of the number of visits, providers, or settings. Switch to D only when active treatment is genuinely complete.
💡 POA = N opens the door to HAC designation. A Hospital-Acquired Condition (HAC) payment penalty may apply if T85.79XA is coded as not present on admission (POA = N). This means the device infection developed after the patient was admitted. Facilities must ensure the POA indicator is correctly assigned. An infected implant present on admission (patient comes in already infected) = POA Yes. An infection that develops in a previously non-infected implant during the hospitalization = POA No — HAC risk. Documentation of the POA status must be explicit.
💡 Organism codes are not optional. The ICD-10-CM tabular directs you to “use additional code to identify the infection” (B95.x, B96.x, B97.x). These organism codes are not merely supplementary — they are required by coding guidelines and directly impact CC/MCC status, MRSA-specific reporting, and infection surveillance. Always add B95.62 (MRSA) or B95.61 (MSSA) when documented, as these carry CC weight in some grouper versions.
💡 Prosthetic disc = T85, not T84. Artificial disc replacement (cervical or lumbar) is classified in the T85 category as “other internal prosthetic device” — NOT in T84 (orthopedic devices). The T84 category covers joint replacements (hips, knees) and bone fixation hardware (screws, rods, plates), but the artificial disc/total disc replacement falls under T85 since it is replacing the disc (a non-bone structure) with a prosthetic device. This is frequently miscoded.