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Home/Diagnosis/ICD-10 Coding for Postoperative Wound Infection

ICD-10 Coding for Postoperative Wound Infection

T81.41XA
T81.44XA

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

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

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

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

Primary ICD-10-CM Codes

Infection following a procedure, superficial incisional site, initial encounter

Billable Code
T81.41XA
Billable

Diagnostic Criteria

  • • Presence of purulent drainage and localized erythema

Applicable To

  • • Superficial incisional surgical site infection

Important Notes

  • • Ensure documentation specifies the infection site and organism if known.

Sepsis following a procedure, initial encounter

Billable Code
T81.44XA
Billable

Diagnostic Criteria

  • • Positive blood cultures
  • • Fever greater than 38.5°C post-surgery

Applicable To

  • • Sepsis due to surgical site infection

Important Notes

  • • Ensure sepsis is clearly linked to the surgical 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 when MRSA is confirmed by culture.

R65.21

Severe sepsis with acute organ dysfunction

Use when severe sepsis with organ dysfunction is documented.

Frequently Asked Questions

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

The ICD-10 code for a postoperative wound infection depends on the type and depth of the infection, such as T81.41XA for superficial incisional infections.

How do you code a postoperative infection with MRSA?

For a postoperative infection with MRSA, use T81.41XA for the infection and B95.62 to specify MRSA as the organism.

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