ICD-10 Coding for Dehiscence of Surgical Wound(T81.31XA, T85.73XA, O90.0)
Complete ICD-10-CM coding and documentation guide for Dehiscence of Surgical Wound. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Dehiscence of Surgical Wound
T81.3Primary Range
Disruption of wound, not elsewhere classified
Primary range for coding dehiscence of surgical wounds not related to prosthetic devices.
Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts
Used when dehiscence is directly related to a prosthetic device.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| T81.31XA | Disruption of external operation wound, not elsewhere classified, initial encounter | Use for initial encounter of external wound dehiscence not related to a device. |
|
| T85.73XA | Infection and inflammatory reaction due to internal prosthetic device, implant and graft, initial encounter | Use when dehiscence is directly caused by a prosthetic device. |
|
| O90.0 | Disruption of cesarean delivery wound | Use specifically for dehiscence of cesarean delivery wounds. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for dehiscence of surgical wound
Essential facts and insights about Dehiscence of Surgical Wound
Primary ICD-10-CM Codes for dehiscence of surgical wound
Decision Criteria
documentation Criteria
- Document the location and depth of the wound.
Applicable To
- External surgical wound dehiscence
Excludes
- Infection of surgical wound (T81.4-)
Clinical Validation Requirements
- Clinical notes specifying external wound disruption
- Imaging confirming external wound separation
Code-Specific Risks
- Ensure documentation specifies 'external' to avoid misclassification.
Coding Notes
- Ensure to document the cause and depth of the wound.
T85.73XA - Infection and inflammatory reaction due to internal prosthetic device, implant and graft, initial encounter
Use when dehiscence is directly caused by a prosthetic device.
Applicable To
- Dehiscence related to prosthetic device
Excludes
- Mechanical complication of prosthetic device (T82.8-)
Clinical Validation Requirements
- Documentation linking dehiscence to a prosthetic device
- Imaging or surgical notes confirming device involvement
Coding Notes
Linkage to device must be explicit in documentation.
O90.0 - Disruption of cesarean delivery wound
Use specifically for dehiscence of cesarean delivery wounds.
Applicable To
- Post-cesarean wound dehiscence
Excludes
- Infection of obstetric surgical wound (O86.0)
Clinical Validation Requirements
- Clinical notes confirming cesarean wound disruption
- Post-operative notes indicating wound separation
Coding Notes
Specific to obstetric cases; ensure correct context.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Dehiscence of Surgical Wound to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code T81.31XA.
Impact
Clinical: Inaccurate clinical picture of the patient's condition., Regulatory: Non-compliance with coding standards., Financial: Potential loss of reimbursement for device-related complications.
Mitigation Strategy
Always document device involvement if applicable., Review surgical notes for device details.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Poor data quality affecting clinical records.
Mitigation Strategy
Ensure documentation specifies whether the wound is external or internal.
Impact
Reimbursement: Potential underpayment if device-related codes are not used., Compliance: Non-compliance with coding standards., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Document explicit linkage to the device if involved.
Impact
Risk of audits if device involvement is not documented.
Mitigation Strategy
Ensure thorough documentation of any prosthetic devices involved.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Dehiscence of Surgical Wound, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Dehiscence of Surgical Wound
Use these documentation templates to ensure complete and accurate documentation for Dehiscence of Surgical Wound. These templates include all required elements for proper coding and billing.
Post-surgical wound dehiscence
Specialty: General SurgeryRequired Elements
- Wound location
- Wound depth
- Presence of infection
- Cause of dehiscence
- Device involvement
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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