2025 ICD-10-CM code T81.4
(Active) Effective Date: N/A Injury, poisoning and certain other consequences of external causes - Surgical wound infection 19 Feed
Infection following a procedure, such as a wound abscess.
The medical necessity for using this code is determined by the presence of an infection directly related to a prior medical or surgical procedure.
The clinician is responsible for identifying and documenting the specific infection, the procedure that preceded it, and any related complications like severe sepsis. They should also ensure appropriate treatment and follow-up care.
In simple words: This code indicates an infection that develops after a medical procedure, like surgery or other invasive treatment. It could be a wound infection or a more general infection related to the procedure.
Infection following a procedure. This includes wound abscesses that occur after a procedure. Use additional code to identify the specific infection. Use additional code (R65.2-) to identify severe sepsis, if applicable. Excludes2: bleb associated endophthalmitis (H59.4-), infection due to infusion, transfusion and therapeutic injection (T80.2-), infection due to prosthetic devices, implants and grafts (T82.6-T82.7, T83.5-T83.6, T84.5-T84.7, T85.7), obstetric surgical wound infection (O86.0-), postprocedural fever NOS (R50.82), postprocedural retroperitoneal abscess (K68.11).
Example 1: A patient develops a surgical site infection after an appendectomy. The infection is identified as Staphylococcus aureus., A patient undergoes a colonoscopy and subsequently develops an abscess at the biopsy site. , After a central venous catheter placement, a patient develops a bloodstream infection. The infection is identified as methicillin-resistant Staphylococcus aureus (MRSA).
Documentation should include the type of infection, the location of the infection, the date of the procedure, and any signs or symptoms of the infection. If sepsis is suspected, it should also be documented and coded accordingly.
** It is crucial to differentiate between infections directly related to a procedure and infections occurring coincidentally after a procedure. This code should only be used when a clear causal link can be established.
- Payment Status: Active
- Specialties:Infectious Disease, General Surgery, Internal Medicine
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital,Ambulatory Surgical Center