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v1.0.0
ICD-10 Guide
DiagnosesSurgical Site Infection

Surgical Site Infection

ICD-10 Coding for Surgical Site Infection(T81.41XA, O86.03)

PRIMARY SPECIALTYOrthopedics
COMPLEXITYHigh
LAST UPDATED09/15/2025
Sam Tuffun, PT, DPT
Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Surgical Site Infection?
Essential facts and insights about Surgical Site Infection

Key Clinical Considerations:

  • Redness, swelling, warmth, and pain at the surgical site
  • Positive culture from the surgical site or purulent drainage
  • Fever and systemic signs of infection

Clinical Information

Clinical Criteria & Documentation Requirements

  • Date and time of surgery, type of procedure, and postoperative care details
  • ICD-10 terminology such as 'Surgical Site Infection' or 'SSI'
  • Examples include detailed descriptions of symptoms, cultures taken, and treatment provided

Coding Guidelines

Usage Guidelines & Examples

  • Usage guidelines include coding based on the specific site and type of surgery.
  • Common errors include misclassifying the infection type or failing to document the surgical procedure.

Code Exclusions

Important Exclusions

  • Wound infections unrelated to surgical procedures.
  • Alternative codes for other types of infections such as cellulitis or abscess.

Related ICD-10 Codes

Primary Codes
T81.4
Infection following a procedure, not elsewhere classified
S72.001A
Unspecified fracture of the neck of femur, initial encounter for closed fracture
Ancillary Codes
B95.62
R65.21
Differential Codes
L02.91

Related CPT Codes

CPT codes will be available in a future update.

Specialty Focus

Primary Specialty

Orthopedics

Specialty Applications

  • Postoperative patients in orthopedic settings, particularly those undergoing joint replacement or fracture repair.
  • Inpatient and outpatient surgical facilities.

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

  • Comprehensive clinical documentation
  • Accurate code selection based on clinical criteria
  • Proper exclusion considerations
  • Specialty-specific coding guidelines

Documentation

Documentation Templates

Billing Information

Billing Considerations

  • Ensure proper documentation for billing
  • Verify code specificity requirements
  • Check for any additional codes needed
  • Review payer-specific guidelines

Common Issues

  • Insufficient clinical documentation
  • Incorrect code selection
  • Missing supporting diagnoses
  • Timing and frequency documentation

Frequently Asked Questions

Documentation requirements?

Document all signs, symptoms, and treatment interventions related to the infection.

Billing considerations?

Ensure accurate coding to reflect the severity and complexity of the infection for appropriate reimbursement.