ICD-10 Coding for Sternal Wound Infection(T81.4xx, T81.3xx)
Complete ICD-10-CM coding and documentation guide for Sternal Wound Infection. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Sternal Wound Infection
T81.3-T81.4Primary Range
Complications of procedures, not elsewhere classified
This range includes codes for postprocedural infections and dehiscence, which are relevant to sternal wound infections following surgery.
Bacterial and viral infectious agents
These codes are used to specify the infectious organism involved in the sternal wound infection.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| T81.4xx | Infection following a procedure, not elsewhere classified | Use for infections following procedures such as CABG involving the sternum. |
|
| T81.3xx | Disruption of operation wound, not elsewhere classified | Use if there is a mechanical complication or dehiscence preceding infection. |
|
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 sternal wound infection
Essential facts and insights about Sternal Wound Infection
Primary ICD-10-CM Codes for sternal wound infection
Decision Criteria
clinical Criteria
- Presence of purulent drainage and positive culture
coding Criteria
- Post-surgical infection involving the sternum
Applicable To
- Postprocedural infection involving sternum
Excludes
- Infections not related to a procedure
Clinical Validation Requirements
- Positive wound culture
- Imaging showing mediastinitis or sternal osteomyelitis
Code-Specific Risks
- Omitting the 7th character for encounter type
Coding Notes
- Ensure to document the specific organism and use the appropriate 7th character for encounter type.
T81.3xx - Disruption of operation wound, not elsewhere classified
Use if there is a mechanical complication or dehiscence preceding infection.
Applicable To
- Sternal dehiscence with infection
Excludes
- Infections without mechanical complication
Clinical Validation Requirements
- Surgical note confirming hardware failure
- Intraoperative visualization of infection
Coding Notes
Ensure to document the mechanical complication and infection details.
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 Sternal Wound Infection to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code T81.4xx.
Impact
Clinical: May affect treatment decisions., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Always document culture results., Use organism-specific codes.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Impacts accuracy of clinical data.
Mitigation Strategy
Always use T81.4 for post-surgical sternal infections.
Impact
Using non-specific codes can trigger audits.
Mitigation Strategy
Ensure detailed documentation and correct code selection.
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 Sternal Wound Infection, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Sternal Wound Infection
Use these documentation templates to ensure complete and accurate documentation for Sternal Wound Infection. These templates include all required elements for proper coding and billing.
Post-CABG Sternal Infection
Specialty: Cardiothoracic SurgeryRequired Elements
- Wound size and characteristics
- Culture results
- Imaging findings
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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