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T89.03XA
ICD-10-CM
Infection of Wound

Find comprehensive information on Infection of Wound diagnosis, including clinical documentation tips, ICD-10 codes (L08.8, L08.9), medical coding guidelines, and healthcare best practices for wound infection treatment. Learn about signs and symptoms, diagnosis criteria, and appropriate terminology for accurate and efficient medical record keeping related to infected wounds, surgical site infections, and other wound complications. This resource supports healthcare professionals in proper documentation and coding for optimal patient care and reimbursement.

Also known as

Wound Infection
Surgical Site Infection

Diagnosis Snapshot

Key Facts
  • Definition : Invasion of wound tissues by pathogenic microorganisms, causing inflammation and delayed healing.
  • Clinical Signs : Redness, swelling, pain, warmth, pus, fever, delayed healing, foul odor.
  • Common Settings : Surgical sites, traumatic injuries, burns, chronic ulcers, diabetic foot ulcers.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC T89.03XA Coding
T81.4XXA-T81.4XXS

Infection following infusion

Infection complicating a vascular access device insertion.

T81.8XXA-T81.8XXS

Other complications of procedures

Infections following other unspecified procedures, including wound infection.

L08.8X-L08.9

Local infections of skin and subcutaneous tissue

Covers various localized skin infections, some potentially related to wounds.

Code-Specific Guidance

Decision Tree for

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

Is the wound surgical?

  • Yes

    Is it superficial?

  • No

    Is the site specified?

Documentation Best Practices

Documentation Checklist
  • Wound infection signs/symptoms documented (e.g., erythema, purulence)
  • Location and size of infected wound clearly specified
  • Microbiology culture results if obtained
  • Treatment plan for wound infection documented
  • ICD-10-CM diagnosis code T79.3 or other appropriate code

Coding and Audit Risks

Common Risks
  • Unspecified Site

    Coding Infection of Wound without specifying the anatomical location leads to inaccurate coding and claims rejection.

  • Missing Causative Organism

    Lack of documentation of the causative organism for wound infections impacts coding specificity and appropriate treatment.

  • Superficial vs. Deep

    Failure to distinguish between superficial and deep wound infections can lead to incorrect code assignment and reimbursement issues.

Mitigation Tips

Best Practices
  • Document wound size, depth, location precisely for accurate ICD-10 coding.
  • Specify infection type (e.g., cellulitis, abscess) for proper CDI and billing.
  • Note signs/symptoms (e.g., purulence, erythema) to support infection diagnosis.
  • Record organism if known via culture to improve coding specificity and care.
  • Follow established guidelines for wound care documentation to ensure compliance.

Clinical Decision Support

Checklist
  • Verify purulent drainage or exudate presence
  • Document wound site, size, depth, and characteristics
  • Check patient temperature, WBC, and other inflammatory markers
  • Rule out other possible etiologies (e.g., dermatitis, ulcer)

Reimbursement and Quality Metrics

Impact Summary
  • Infection of Wound reimbursement hinges on accurate ICD-10 coding (e.g., T81.4XXA) and appropriate documentation of depth, site, and cause to justify treatment intensity and avoid claim denials.
  • Quality metrics impacted: Surgical Site Infection (SSI), Hospital-Acquired Infection (HAI), Readmission rates. Accurate coding and timely intervention crucial for optimal reimbursement and performance.
  • Coding specificity for infection type, organism, and anatomical site is vital for accurate MS-DRG assignment and appropriate reimbursement levels, affecting hospital case mix index.
  • Delayed or inadequate wound infection treatment negatively impacts patient outcomes, increases length of stay, and elevates healthcare costs, affecting value-based care metrics.

Streamline Your Medical Coding

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

Quick Tips

Practical Coding Tips
  • Document wound infection specifics
  • Code infection site and organism
  • Query physician for clarity if needed

Documentation Templates

Patient presents with signs and symptoms consistent with wound infection.  Clinical findings include erythema, edema, warmth, and tenderness surrounding the wound site.  Purulent drainage or a foul odor may be present.  Patient may report increased pain at the wound site.  Differential diagnosis includes cellulitis, abscess, and delayed wound healing.  Wound culture obtained to identify the causative organism and guide antibiotic therapy.  Current wound care regimen reviewed and adjusted as needed, potentially incorporating debridement, irrigation, and advanced wound dressings.  Patient education provided on wound care and signs of worsening infection.  Diagnosis: Infection of wound.  Plan:  Monitor wound for improvement.  Adjust treatment plan based on culture results and clinical response.  Follow-up scheduled to assess healing progress and address any complications such as systemic infection or sepsis.  Relevant keywords:  wound infection, infected wound, wound care, wound healing, purulent drainage, erythema, edema, cellulitis, abscess, debridement, irrigation, antibiotic treatment, wound culture, microbial infection, signs of infection, infection symptoms, wound management, healthcare, clinical documentation, medical coding, ICD-10, medical billing.