ICD-10 Coding for Infection of Surgical Wound(T81.41XA, T81.42XA, T81.43XA)
Complete ICD-10-CM coding and documentation guide for Infection 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 Infection of Surgical Wound
T81.4Primary Range
Infection following a procedure
This range covers infections that occur as a result of surgical procedures, including superficial, deep, and organ/space infections.
Infections of obstetric surgical wounds
This range is specific to infections following obstetric procedures, such as cesarean sections.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| T81.41XA | Infection following a procedure, superficial incisional site | Use when the infection is limited to the skin and subcutaneous tissue of the incision. |
|
| T81.42XA | Infection following a procedure, deep incisional site | Use when the infection extends into the fascial and muscle layers. |
|
| T81.43XA | Infection following a procedure, organ and space site | Use when the infection involves organs or spaces manipulated during the procedure. |
|
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 surgical wound infection
Essential facts and insights about Infection of Surgical Wound
Primary ICD-10-CM Codes for infection of surgical wound
Decision Criteria
clinical Criteria
- Presence of purulent drainage and superficial tissue involvement
Applicable To
- Superficial incisional surgical site infection
Clinical Validation Requirements
- Documentation of erythema, warmth, and purulent drainage from the incision site
- Positive culture from superficial swab
Code-Specific Risks
- Misclassification as cellulitis without purulent drainage
Coding Notes
- Ensure documentation specifies 'superficial' to avoid misclassification.
T81.42XA - Infection following a procedure, deep incisional site
Use when the infection extends into the fascial and muscle layers.
Applicable To
- Deep incisional surgical site infection
Excludes
- Organ/space infection (T81.43-)
Clinical Validation Requirements
- Documentation of infection involving fascial and muscle layers
- Operative notes confirming deep tissue involvement
Coding Notes
Ensure documentation specifies 'deep' involvement to avoid misclassification.
T81.43XA - Infection following a procedure, organ and space site
Use when the infection involves organs or spaces manipulated during the procedure.
Applicable To
- Organ/space surgical site infection
Excludes
- Deep incisional infection (T81.42-)
Clinical Validation Requirements
- Imaging or operative findings confirming organ/space involvement
- Positive culture from a sterile site
Coding Notes
Ensure documentation specifies organ/space involvement to avoid misclassification.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
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 Infection of Surgical Wound to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code T81.41XA.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims or reduced reimbursement.
Mitigation Strategy
Use specific terminology for infection depth and type, Ensure linkage to surgical procedure is documented
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data on surgical site infections.
Mitigation Strategy
Use L02.91 for abscess without deeper tissue involvement.
Impact
Inaccurate documentation of infection depth can lead to incorrect coding.
Mitigation Strategy
Ensure detailed documentation of anatomical layers involved in the infection.
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 Infection of Surgical Wound, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Infection of Surgical Wound
Use these documentation templates to ensure complete and accurate documentation for Infection of Surgical Wound. These templates include all required elements for proper coding and billing.
Postoperative infection documentation
Specialty: General SurgeryRequired Elements
- Location and depth of infection
- Type of drainage
- Systemic signs
- Causative organism
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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