ICD-10 Coding for Surgical Site Infection(T81.41XA, O86.03)
Complete ICD-10-CM coding and documentation guide for Surgical Site Infection. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Surgical Site Infection
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| T81.41XA | Infection following a procedure, superficial incisional, initial encounter | Use when the infection is limited to the skin or subcutaneous tissue. |
|
| O86.03 | Infection of obstetric surgical wound, organ and space | Use for organ/space infections following obstetric procedures. |
|
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 superficial surgical site infection
Essential facts and insights about Surgical Site Infection
Primary ICD-10-CM Codes for surgical site infection
Decision Criteria
clinical Criteria
- Presence of purulent drainage and positive culture from superficial tissue
Applicable To
- Superficial incisional SSI
Excludes
- Infection of obstetric surgical wound (O86.0-)
Clinical Validation Requirements
- Purulent drainage from skin or subcutaneous tissue
- Surgeon diagnosis of superficial SSI
Code-Specific Risks
- Risk of using unspecified codes when depth is documented
Coding Notes
- Ensure documentation specifies the depth of infection to avoid unspecified codes.
O86.03 - Infection of obstetric surgical wound, organ and space
Use for organ/space infections following obstetric procedures.
Applicable To
- Organ/space SSI post-C-section
Clinical Validation Requirements
- Intra-abdominal abscess confirmed by imaging or surgery
Coding Notes
Ensure the documentation specifies the organ/space involvement.
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.
Cutaneous abscess, unspecified
L02.91Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Surgical Site Infection to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code T81.41XA.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Increases risk of non-compliance with coding standards., Financial: Potential for denied claims due to lack of specificity.
Mitigation Strategy
Educate clinicians on the importance of detailed documentation, Implement standardized templates for surgical notes
Impact
Reimbursement: May lead to reduced reimbursement due to lack of specificity., Compliance: Increases risk of audit due to non-compliance with coding guidelines., Data Quality: Reduces the accuracy of clinical data and reporting.
Mitigation Strategy
Always use the most specific code available based on documentation.
Impact
High frequency of unspecified codes can trigger audits.
Mitigation Strategy
Ensure documentation supports the most specific code available.
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 Surgical Site Infection, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Surgical Site Infection
Use these documentation templates to ensure complete and accurate documentation for Surgical Site Infection. These templates include all required elements for proper coding and billing.
Orthopedic Postoperative Infection
Specialty: OrthopedicsRequired Elements
- Procedure date
- Wound class
- Signs of infection
- Culture results
- Depth of infection
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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