Facebook tracking pixel
K65.9
ICD-10-CM
Intra-abdominal Infection

Find comprehensive information on Intra-abdominal Infection diagnosis, including clinical documentation tips, ICD-10 codes (K65), medical coding guidelines, and healthcare best practices. Learn about symptoms, treatment options, and differential diagnosis for peritonitis, abscess, and other intra-abdominal infections. This resource supports accurate clinical documentation and coding for optimal patient care and reimbursement. Explore relevant information for physicians, nurses, coders, and other healthcare professionals.

Also known as

Abdominal Abscess
Peritoneal Abscess
Intestinal Abscess

Diagnosis Snapshot

Key Facts
  • Definition : Infection within the abdominal cavity, often involving organs like the appendix or intestines.
  • Clinical Signs : Abdominal pain, fever, nausea, vomiting, tenderness, guarding, rigidity.
  • Common Settings : Appendicitis, diverticulitis, perforated bowel, postoperative complications.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC K65.9 Coding
K65-K67

Peritonitis and other intra-abdominal infections

Covers various infections within the abdominal cavity.

A00-B99

Certain infectious and parasitic diseases

Includes some intra-abdominal infections if not specified elsewhere.

J00-J99

Diseases of the respiratory system

May be relevant for infections affecting the diaphragm related to the abdomen.

Code-Specific Guidance

Decision Tree for

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

Is the infection localized?

  • Yes

    Specific organ/site involved?

  • No (Generalized peritonitis)

    Code K65.9 for peritonitis, unspecified

Code Comparison

Related Codes Comparison

When to use each related code

Description
Intra-abdominal Infection
Peritonitis
Abdominal Abscess

Documentation Best Practices

Documentation Checklist
  • Document infection location (e.g., peritoneum, liver)
  • Specify infection source if known (e.g., appendicitis)
  • Describe signs/symptoms (e.g., fever, pain, tenderness)
  • Lab results supporting diagnosis (e.g., WBC, cultures)
  • Imaging findings confirming infection (e.g., CT, ultrasound)

Coding and Audit Risks

Common Risks
  • Unspecified Site

    Coding intra-abdominal infection without specifying the anatomical site leads to inaccurate DRG assignment and lost revenue.

  • Sepsis Miscoding

    Incorrectly coding sepsis with or without intra-abdominal infection can impact severity and reimbursement. Proper documentation is crucial.

  • Post-op Infection

    Distinguishing between post-operative and community-acquired intra-abdominal infection is critical for accurate coding and quality reporting.

Mitigation Tips

Best Practices
  • Document source of infection for ICD-10 specificity (K65.x)
  • Thorough exam with imaging for precise IAI localization (Z10.89)
  • Culture infected fluid for antibiotic guidance and CDI
  • Clearly document antibiotic selection rationale for compliance
  • Query physician for clarification if documentation is vague

Clinical Decision Support

Checklist
  • Verify abdominal pain, tenderness, or guarding documented
  • Confirm imaging (CT, ultrasound) findings support infection
  • Check labs: WBC, CRP, lactate for inflammatory markers
  • Document source of infection (e.g., appendicitis, diverticulitis)
  • Ensure antibiotic selection aligns with suspected pathogen

Reimbursement and Quality Metrics

Impact Summary
  • Intra-abdominal Infection reimbursement hinges on accurate ICD-10 K65 coding and appropriate POA indicator reporting, impacting MS-DRG assignment and case mix index.
  • Coding quality directly affects sepsis severity metrics and hospital-acquired infection reporting, impacting public quality scores and potential penalties.
  • Timely and specific documentation of infection source and management is crucial for proper coding and optimal reimbursement.
  • Accurate coding and documentation of intra-abdominal infections influence hospital value-based purchasing programs and pay-for-performance incentives.

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 source, type, location
  • Specify abscess, peritonitis details
  • Code underlying cause, if known
  • Query physician if documentation unclear
  • Consider sepsis codes if applicable

Documentation Templates

Patient presents with signs and symptoms suggestive of intra-abdominal infection (IAI).  Presenting complaints include abdominal pain, localized or diffuse, with varying intensity.  Fever, chills, nausea, vomiting, and anorexia may also be present.  Physical examination reveals tenderness to palpation, guarding, rebound tenderness, and potentially abdominal distension.  Depending on the source and severity of the infection, the patient may exhibit signs of sepsis, such as tachycardia, hypotension, and altered mental status.  Laboratory findings may reveal leukocytosis, elevated inflammatory markers (CRP, ESR), and positive blood cultures if bacteremia is present.  Imaging studies, such as CT abdomen and pelvis with IV contrast, ultrasound, or diagnostic laparoscopy, are crucial for identifying the source of infection (e.g., appendicitis, diverticulitis, perforated viscus, abscess) and guiding treatment.  Differential diagnoses include gastroenteritis, inflammatory bowel disease, and other abdominal pathologies.  Treatment for intra-abdominal infection typically involves intravenous antibiotics targeting suspected pathogens, fluid resuscitation, and pain management.  Surgical intervention, such as drainage of abscesses or resection of the infected source, may be necessary depending on the specific etiology and severity of the IAI.  The patient's clinical status will be closely monitored for response to therapy and potential complications, such as septic shock, multi-organ dysfunction, and abdominal compartment syndrome.  Patient education regarding medication adherence, wound care (if applicable), and follow-up appointments is essential.
Intra-abdominal Infection - AI-Powered ICD-10 Documentation