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
Infection following a procedure
Infections after surgery, classified by site.
Other complications of procedures
Unspecified post-procedural complications.
Diseases of the skin and subcu
Skin infections, some related to surgical wounds.
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?
When to use each related code
Description |
---|
Surgical Wound Infection |
Superficial Surgical Site Infection |
Deep Surgical Site Infection |
Coding lacks specificity regarding the infected surgical site, leading to inaccurate data and potential claims issues. CDI can query for anatomical location.
Incorrectly coding superficial incisional SSI as deep when documentation supports only superficial involvement. Impacts quality reporting and reimbursement.
Failure to accurately document the timeframe of the infection relative to the surgical procedure. Crucial for distinguishing SSI from other infections.
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.