Surgical Site Infection ICD-10-CM Codes

What ICD-10 Codes are Used for Surgical Site Infection 

• T81.42: This surgical site infection ICD 10 points to a deeper incisional surgical site infection. Infections at this level affect the skin and subcutaneous tissue and extend to the muscle layers. These infections are more serious, potentially causing fever and requiring more intensive treatment.
• T81.43: This ICD 10 code for surgical site infection comes into play for infections involving organs or spaces opened during surgery. Such infections are particularly concerning due to the potential impact on vital internal areas. They often necessitate specialized care, as they can lead to complications affecting organ function.
• T81.44: The ICD 10 surgical site infection code T81.44 is crucial as it represents sepsis after a procedure. Sepsis is a critical medical condition where the body’s response to infection becomes systemic, affecting multiple organs. It requires immediate attention to prevent severe complications and even death.
• T81.49: For cases where the site of infection isn’t specified, T81.49- is used. As one of the common Surgical Site Infection ICD Codes, it accounts for instances when an infection occurs post-procedure, but the exact location isn’t detailed in the medical records.
• T81.50: Accidentally leaving a foreign body inside the body following a procedure is represented by T81.50. This code highlights a potential complication that can lead to infections, pain, and other issues, warranting further medical assessment.
• T81.51: Finally, T81.51 is a infection of surgical site ICD 10 code for infections after procedures caused by unspecified organisms. This suggests that the precise organism responsible for the infection couldn’t be identified despite testing and clinical examination.

Which Surgical Site Infection ICD codes are Billable: 

Yes, the ICD-10 codes you listed are billable for surgical site infection (SSI). These codes are used to indicate the type of infection, the depth of the infection, and the site of the infection. The specific code that is used will depend on the payer and the specific circumstances of the case.

Clinical Information

• A surgical site infection (SSI) is an infection that develops in the skin or tissues near the location of a surgical incision.
• SSIs can be categorized into three primary types. First is the superficial incisional SSIs that occur within the skin’s outer layers and subcutaneous tissue. Next, the deep incisional SSIs extend to the deeper layers, involving skin, subcutaneous tissue, and muscle. Lastly, is the organ/space SSIs emerge within organs or spaces that were opened during surgery.
• SSIs are primarily caused by bacteria entering the surgical wound during the surgery or during the healing process. Notably, Staphylococcus aureus, coagulase-negative staphylococci, and Enterococcus spp. are common culprits behind SSIs.
• Several risk factors contribute to the likelihood of SSI development. First, the duration and complexity of the surgical procedure. Second is the patient’s age, underlying medical conditions, and immune system status. Third, symptoms of SSIs can vary depending on the infection type. However, prevalent indicators include redness, pain, swelling, warmth, and discharge from the wound.
• Treating SSIs hinges on infection type and severity. Antibiotics are typically used to manage most cases. In severe instances, surgical wounds may require reopening and drainage.
• Preventive measures to minimize SSIs include implementing sound surgical techniques, administering antibiotics before surgery, cleaning the surgical area with antiseptic solutions, adhering to sterile practices, such as wearing gloves and gowns and avoiding smoking, and maintaining stable blood sugar levels.

Synonyms Include:

• Wound infection
• Postoperative infection
• Incisional infection
• Iatrogenic infection
• Hospital-acquired infection
• Healthcare-associated infection
• Nosocomial infection