ICD-10 Coding for Infection of Wound(T81.41X, O86.01)
Complete ICD-10-CM coding and documentation guide for Infection of Wound. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Infection of Wound
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| T81.41X | Infection following a procedure, superficial incisional | Use for superficial incisional infections post-surgery. |
|
| O86.01 | Infection of obstetric surgical wound, superficial incisional | Use for superficial infections post-obstetric surgery. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for postoperative wound infection
Essential facts and insights about Infection of Wound
Primary ICD-10-CM Codes for infection of wound
Decision Criteria
clinical Criteria
- Presence of superficial erythema without deep tissue involvement.
Applicable To
- Superficial incisional infection
Excludes
- Deep incisional infection
- Organ/space infection
Clinical Validation Requirements
- Superficial erythema
- No fascial involvement
Code-Specific Risks
- Incorrect use for deep infections
Coding Notes
- Ensure documentation specifies the depth of infection.
O86.01 - Infection of obstetric surgical wound, superficial incisional
Use for superficial infections post-obstetric surgery.
Applicable To
- Superficial obstetric wound infection
Excludes
- Deep obstetric wound infection
Clinical Validation Requirements
- Erythema and discharge at incision site
Coding Notes
Ensure obstetric context is clearly documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Infection of Wound to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code T81.41X.
Impact
Clinical: Inaccurate treatment decisions., Regulatory: Non-compliance with coding standards., Financial: Potential for denied claims.
Mitigation Strategy
Always include culture results in documentation.
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Use T81.4- series for procedure-related infections.
Impact
Using unspecified codes or incorrect sequencing.
Mitigation Strategy
Regular training on coding updates and documentation standards.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Infection of Wound, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Infection of Wound
Use these documentation templates to ensure complete and accurate documentation for Infection of Wound. These templates include all required elements for proper coding and billing.
Postoperative wound infection
Specialty: SurgeryRequired Elements
- Wound size and depth
- Exudate description
- Culture results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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