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

ICD-10 Coding for Surgical Wound Infection

T81.41X-
T81.42X-

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

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

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

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

Primary ICD-10-CM Codes

Infection following a procedure, superficial incisional

Non-Billable
T81.41X-
Non-Billable

Diagnostic Criteria

  • • Presence of purulent drainage and erythema limited to the skin and subcutaneous tissue.

Applicable To

  • • Superficial incisional surgical site infection

Important Notes

  • • Ensure the depth of infection is clearly documented to select the appropriate code.

Infection following a procedure, deep incisional

Non-Billable
T81.42X-
Non-Billable

Diagnostic Criteria

  • • Abscess extending to fascia/muscle confirmed by imaging

Applicable To

  • • Deep incisional surgical site infection

Important Notes

  • • Document the specific depth of infection to ensure accurate coding.
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 identify the organism causing the infection.

B95.61

Methicillin-susceptible Staphylococcus aureus (MSSA) as the cause of diseases classified elsewhere

Use to identify the organism causing the infection.

Frequently Asked Questions

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

The ICD-10 code for a surgical wound infection is T81.4-, with specific codes for superficial, deep, and organ/space infections.

How do you code a deep surgical wound infection?

For a deep surgical wound infection, use ICD-10 code T81.42X-, which covers infections involving fascia or muscle.

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