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Home/Diagnosis/ICD-10 Coding for Postoperative Infection

ICD-10 Coding for Postoperative Infection

T81.41XA
T81.44XA

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

Also Known as:
Surgical Site Infection
Post-op Infection
postsurgical infection
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Key Information: ICD-10 Coding for Postoperative Infection

Essential facts and insights about ICD-10 Coding for Postoperative Infection

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

Primary ICD-10-CM Codes

Infection following a procedure, superficial incisional surgical site

Billable Code
T81.41XA
Billable

Diagnostic Criteria

  • • Presence of purulent drainage from the incision site
  • • Positive culture for pathogenic organisms

Applicable To

  • • Superficial incisional SSI

Important Notes

  • • Ensure documentation specifies the depth of infection.

Sepsis following a procedure

Billable Code
T81.44XA
Billable

Diagnostic Criteria

  • • Blood cultures positive for pathogenic organisms
  • • Clinical signs of systemic infection

Applicable To

  • • Postoperative sepsis

Important Notes

  • • Ensure sepsis is documented as related to the procedure.
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.

R65.21

Severe sepsis with septic shock

Use if septic shock is present.

Frequently Asked Questions

What is the ICD-10 code for a postoperative infection?

The ICD-10 code for a postoperative infection is T81.4-, which covers various types of surgical site infections.

How do you code sepsis following a procedure?

For sepsis following a procedure, use T81.44XA, ensuring it is sequenced after the infection code.

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