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T81.49
ICD-10-CM
Infection of Surgical Wound

Find information on surgical site infection diagnosis, including clinical documentation requirements, ICD-10 codes (like T81.4), postoperative wound infection treatment, and prevention strategies. Learn about superficial incisional SSI, deep incisional SSI, and organ/space SSI. This resource provides guidance for healthcare professionals on accurate diagnosis coding and best practices for managing surgical wound infections. Explore resources related to wound care, antimicrobial therapy, and infection control protocols for optimal patient outcomes.

Also known as

Surgical Site Infection
Postoperative Wound Infection

Diagnosis Snapshot

Key Facts
  • Definition : Microbial invasion of tissues involved in a surgical procedure, causing inflammation.
  • Clinical Signs : Redness, swelling, pain, warmth, pus, fever, delayed healing.
  • Common Settings : Hospitals, surgical centers, outpatient clinics, home healthcare.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC T81.49 Coding
T81.4-

Infection following a procedure

Infections after surgery, classified by site.

T81.8-

Other complications of procedures

Unspecified post-procedural complications.

L00-L99

Diseases of the skin and subcu

Skin infections, some related to surgical wounds.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the surgical wound superficial?

  • Yes

    Site specified?

  • No

    Is it a deep incisional SSI?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Surgical Wound Infection
Superficial Surgical Site Infection
Deep Surgical Site Infection

Documentation Best Practices

Documentation Checklist
  • Surgical wound infection diagnosis code
  • Document purulence, erythema, or warmth
  • Note wound location and depth
  • Specify organism if identified by culture
  • Post-op day of infection onset required

Coding and Audit Risks

Common Risks
  • Unspecified Organ/Site

    Coding lacks specificity regarding the infected surgical site, leading to inaccurate data and potential claims issues. CDI can query for anatomical location.

  • Superficial vs. Deep

    Incorrectly coding superficial incisional SSI as deep when documentation supports only superficial involvement. Impacts quality reporting and reimbursement.

  • Post-op Complication Timing

    Failure to accurately document the timeframe of the infection relative to the surgical procedure. Crucial for distinguishing SSI from other infections.

Mitigation Tips

Best Practices
  • Accurate ICD-10-CM coding for surgical site infections (SSI)
  • Timely wound assessment and CDI for prompt SSI diagnosis
  • Follow evidence-based guidelines for SSI prevention and treatment
  • Thorough documentation of wound care and antibiotic prophylaxis
  • Regular compliance audits for SSI prevention protocols

Clinical Decision Support

Checklist
  • Purulent drainage or erythema noted?
  • Post-op fever or localized pain present?
  • Positive wound culture obtained?
  • WBC count elevated? Consider SIRS criteria.
  • Surgical site consistent with ICD-10 T81.4?

Reimbursement and Quality Metrics

Impact Summary
  • Infection of Surgical Wound: Reimbursement and Quality Metrics Impact Summary
  • Keywords: surgical site infection SSI coding ICD-10 postoperative complications reimbursement claims denial hospital-acquired infection HAC quality reporting value-based purchasing
  • Impact 1: Reduced reimbursement due to HAC penalties.
  • Impact 2: Increased costs associated with extended care.
  • Impact 3: Negative impact on hospital quality scores and public reporting.
  • Impact 4: Potential for increased claim denials due to coding errors.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Document surgical site, depth, laterality
  • Query physician if organism identified
  • Code wound infection, post-op complication
  • Check ICD-10-CM guidelines for specificity
  • Consider T81.4 for superficial infection

Documentation Templates

Patient presents with signs and symptoms consistent with surgical wound infection.  The patient reports increased pain at the surgical site, described as throbbing or aching, along with erythema, edema, and warmth surrounding the incision.  Purulent drainage, potentially with a foul odor, may be observed.  The patient may also exhibit systemic symptoms such as fever, chills, or malaise.  Onset of these symptoms occurred [Number] days post-operatively following a [Type of surgery] procedure performed on [Date of surgery].  Differential diagnosis includes cellulitis, hematoma, seroma, and dehiscence.  The diagnosis of surgical site infection is made based on clinical presentation, including local signs of inflammation and potential purulent drainage.  Laboratory tests such as a complete blood count with differential and wound cultures may be obtained to further evaluate the infection and guide antibiotic therapy.  Treatment plan includes wound care management with [Describe wound care regimen, e.g., debridement, irrigation, packing], and initiation of [Antibiotic name and dosage].  Patient education provided regarding signs of worsening infection and the importance of adherence to the prescribed treatment plan.  Follow-up appointment scheduled in [Number] days to assess response to treatment and monitor for complications such as abscess formation or sepsis.  ICD-10 code T81.4XXA, Postprocedural wound infection, assigned.  CPT codes for wound care and debridement will be determined based on the specific procedures performed.
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