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

ICD-10 Coding for Sternal Wound Infection

T81.4xx
T81.3xx

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

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

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

Use ICD-10 code T81.4xx for infection following a procedure, not elsewhere classified, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Infection following a procedure, not elsewhere classified

Non-Billable
T81.4xx
Non-Billable

Diagnostic Criteria

clinical:
  • • Presence of purulent drainage and positive culture
coding:
  • • Post-surgical infection involving the sternum

Applicable To

  • • Postprocedural infection involving sternum

Important Notes

  • • Ensure to document the specific organism and use the appropriate 7th character for encounter type.

Disruption of operation wound, not elsewhere classified

Non-Billable
T81.3xx
Non-Billable

Diagnostic Criteria

clinical:
  • • Surgical note confirming hardware failure
  • • Intraoperative visualization of infection

Applicable To

  • • Sternal dehiscence with infection

Important Notes

  • • Ensure to document the mechanical complication and infection details.
Ancillary Codes

Additional codes that may be used with this diagnosis

R65.2-

Severe sepsis

Use if severe sepsis or septic shock is present.

E11.9

Type 2 diabetes mellitus without complications

Use if diabetes is a contributing factor.

B37.89

Other forms of candidiasis

Use if Candida infection is present.

Frequently Asked Questions

What is the ICD-10 code for sternal wound infection?

The ICD-10 code for sternal wound infection is T81.4xx, used for postprocedural infections involving the sternum.

How do you document a sternal wound infection?

Document the wound size, depth, exudate, culture results, and imaging findings to ensure accurate coding and management.

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