Complete ICD-10-CM coding and documentation guide for icd-10 coding for surgical site infection includes clinical validation requirements, medical necessity guidelines, and coding policies.
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Essential facts and insights about ICD-10 Coding for Surgical Site Infection
Use ICD-10 code T81.41XA for infection following a procedure, superficial incisional, initial encounter, ensuring proper documentation in clinical notes.
Additional codes that may be used with this diagnosis
Methicillin-resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere
Use when MRSA is confirmed as the infectious agent.
Severe sepsis with septic shock
Use when severe sepsis is present with organ dysfunction.
The ICD-10 code for a superficial surgical site infection is T81.41XA, used when the infection is limited to the skin or subcutaneous tissue.
For a post-C-section infection with sepsis, use O86.03 for the organ/space infection and O86.04 for sepsis, adding R65.21 if severe sepsis is present.