Coding for Obstetric Surgical Site Infections
ICD-10-CM added several new codes for fiscal year 2019 to chapter 15: Pregnancy, Childbirth and the Puerperium (O00-09A) under subcategory O86 Other puerperal infections. To use these codes, you now need to know the depth of the post-procedural surgical site infection (SSI) and whether there is sepsis.
The new SSI codes are:
O86.00 Infection of obstetric surgical wound, unspecified
O86.01 Infection of obstetric surgical wound, superficial incisional site
O86.02 Infection of obstetric surgical wound, deep incisional site
O86.03 Infection of obstetric surgical wound, organ and space site
O86.04 Sepsis following an obstetrical procedure
O86.09 Infection of obstetric wound, other surgical site
In other words, report O86.01 if the SSI is just below the skin (subcutaneous); O86.02 if the infection is intramuscular; or O86.3 if the infection is intra-abdominal or subphrenic (beneath the diaphragm).
According to the 2019 ICD-10-CM Official Guidelines for Coding and Reporting (1.C.1.d.(5)(b)), for sepsis due to an obstetric postprocedural infection, code first the infection that identifies the site (O86.01-O86.03), followed by O86.4 for the sepsis. Use an additional code (B95-B97) to identify the infectious agent.