Subcategory O86.0, Infection of obstetric surgical wound, was expanded and new codes created to describe obstetric surgical wounds according to the depth:
- Infection of obstetrical surgical wound, unspecified (O86.00);
- Infection of obstetric surgical wound, superficial incisional site (O86.01);
- Infection of obstetric surgical wound, deep incisional site (O86.02);
- Infection of obstetric surgical wound, organ and space site (O86.03);
- Sepsis following an obstetrical procedure (O86.04); and
- Infection of obstetric surgical wound, other surgical site (O86.09).
These codes are assigned based on the provider’s documentation of a postoperative obstetrical wound infection (surgical site infection).
This code expansion aligns with the new codes at category T81.4, Infection following procedure, and is consistent with the Centers for Disease Control and Prevention criteria for defining a Surgical Site Infection (SSI). The Patient Assessment and Outcome Committee of the American Association for the Surgery of Trauma requested these code revisions in order to distinguish the severity of an infection following a procedure.
In addition, revisions were made to the ICD-10-CM Official Guidelines for Coding and Reporting to clarify usage of the new codes.
A 25-year-old female was readmitted to the hospital with fever, tachycardia, tachypnea, erythema, discharge, and induration of the cesarean incision site. She had delivered an infant via low transverse cesarean section approximately one week ago. The provider ordered blood, urine, and wound cultures. The blood and wound cultures were positive for beta-hemolytic Streptococcus group B. The provider’s documentation reflected beta-hemolytic Streptococcal group B sepsis due to deep incisional infection of cesarean wound. How should this case be coded?