AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2018 Issue 4; New/Revised ICD-10-CM Codes

Surgical Site Infection Following a Procedure

Subcategory T81.4, Infection following a procedure, has been expanded and new codes created to identify surgical site infections according to depth. Six codes were created to describe infection following a procedure: unspecified (T81.40); infection following a procedure, superficial incisional surgical site (T81.41); infection following a procedure, deep incisional surgical site (T81.42); infection following a procedure, organ and space surgical site (T81.43); sepsis following a procedure (T81.44); and infection following a procedure, other surgical site (T81.49). These codes are assigned based on the provider’s documentation of a postsurgical wound infection (surgical site...

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