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Home/Diagnosis/ICD-10 Coding for Infected Surgical Wound

ICD-10 Coding for Infected Surgical Wound

T81.41
T81.42

Complete ICD-10-CM coding and documentation guide for icd-10 coding for infected surgical wound includes clinical validation requirements, medical necessity guidelines, and coding policies.

Also Known as:
Surgical Site Infection
Postoperative Wound Infection
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Key Information: ICD-10 Coding for Infected Surgical Wound

Essential facts and insights about ICD-10 Coding for Infected Surgical Wound

Use ICD-10 code T81.41 for infection following a procedure, superficial incisional site, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Infection following a procedure, superficial incisional site

Non-Billable
T81.41
Non-Billable

Diagnostic Criteria

  • • Infection limited to skin or subcutaneous tissue

Applicable To

  • • Superficial incisional surgical site infection

Important Notes

  • • Ensure documentation specifies the infection is postprocedural and superficial.

Infection following a procedure, deep incisional site

Non-Billable
T81.42
Non-Billable

Diagnostic Criteria

  • • Infection involving muscle or fascia
  • • Imaging or surgical exploration confirming depth

Applicable To

  • • Deep incisional surgical site infection

Important Notes

  • • Document the specific depth and involvement of deeper tissues.
Ancillary Codes

Additional codes that may be used with this diagnosis

B95.62

Methicillin-resistant Staphylococcus aureus (MRSA) as the cause of diseases classified elsewhere

Use to specify MRSA as the causative organism.

B96.20

Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere

Use to specify E. coli as the causative organism.

Frequently Asked Questions

What is the ICD-10 code for an infected surgical wound?

The ICD-10 code for an infected surgical wound depends on the depth: T81.41 for superficial, T81.42 for deep incisional, and T81.43 for organ/space infections.

How do you code a postprocedural infection?

Postprocedural infections are coded using the T81.4- series, specifying the depth and location of the infection, such as T81.41 for superficial infections.

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