Coding for Postoperative Wound Infection

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Coding for Postoperative Wound Infection
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Postoperative Wound Care

• A postoperative wound infection arises in the
  tissues of an surgical cut or operative area at
  any point, from one day to many years after a
  surgical procedure. However, it most commonly
  occurs between five and ten days post surgery.
• From an ICD-9-CM coding viewpoint, there is no
  time limitation regarding the assignment of a
  complication code.
• Postoperative wound infection is classified to
  ICD-9-CM code 998.59
• A coding directive under code 998.59 indicates
  the need to use an additional code to identify
  the infection

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2016 ICD-10 Code for Infection following a
procedure

• Code T81.4 is listed in section T81 
• ("Complications of procedures)
• Inclusion Terms
• Intra-abdominal abscess following a procedure
• Post procedural infection, not elsewhere
  classified
• Sepsis following a procedure
• Stitch abscess following a procedure
• Sub phrenic abscess following a procedure
• Wound following a procedure

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Five tips for coding postoperative or
post-traumatic infections

• Know which conditions drive these MS-DRGs
• Understand how surgical and medical procedures
  differ. 
• Identify documentation and other challenges. 
• Be on the lookout for infections due to devices. 
• Perform proactive audits

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Find your companion in MBCs Wound Care billing
services

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