Wiki "Infected laceration repair"

Community Wiki

This is a community-maintained wiki post containing the most important information from this thread. You may edit the Wiki once you have been on AAPC for 30 days and have made 5 posts. Learn More
G
Code: T81.4XXA

Code Name: ICD-10 Code for Infection following a procedure, initial encounter

Block: Complications of surgical and medical care, not elsewhere classified (T80-T88)
Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)
code(s) to identify the specified condition resulting from the complication
code to identify devices involved and details of circumstances (Y62-Y82)

Excludes 2: any encounters with medical care for postprocedural conditions in which no complications are present, such as:artificial opening status (Z93.-)
closure of external stoma (Z43.-)
fitting and adjustment of external prosthetic device (Z44.-)
burns and corrosions from local applications and irradiation (T20-T32)
complications of surgical procedures during pregnancy, childbirth and the puerperium (O00-O9A)
mechanical complication of respirator [ventilator] (J95.850)
poisoning and toxic effects of drugs and chemicals (T36-T65 with fifth or sixth character 1-4 or 6)
postprocedural fever (R50.82)
specified complications classified elsewhere, such as:cerebrospinal fluid leak from spinal puncture (G97.0)
colostomy malfunction (K94.0-)
disorders of fluid and electrolyte imbalance (E86-E87)
functional disturbances following cardiac surgery (I97.0-I97.1)
intraoperative and postprocedural complications of specified body systems (D78.-, E36.-, E89.-, G97.3-, G97.4, H59.3-, H59.-, H95.2-, H95.3, I97.4-, I97.5, J95.6-, J95.7, K91.6-, L76.-, M96.-, N99.-)
ostomy complications (J95.0-, K94.-, N99.5-)
postgastric surgery syndromes (K91.1)
postlaminectomy syndrome NEC (M96.1)
postmastectomy lymphedema syndrome (I97.2)
postsurgical blind-loop syndrome (K91.2)
ventilator associated pneumonia (J95.851)

Details: Infection following a procedure, initial encounter
T81.4

Use additional code (R65.2-) to identify severe sepsis, if applicable

Excludes1: obstetric surgical wound infection (O86.0)
postprocedural fever NOS (R50.82)
postprocedural retroperitoneal abscess (K68.11)

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)
T81

Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)

Excludes2: complications following immunization (T88.0-T88.1)
complications following infusion, transfusion and therapeutic injection (T80.-)
complications of transplanted organs and tissue (T86.-)
specified complications classified elsewhere, such as:complication of prosthetic devices, implants and grafts (T82-T85)
dermatitis due to drugs and medicaments (L23.3, L24.4, L25.1, L27.0-L27.1)
endosseous dental implant failure (M27.6-)
floppy iris syndrome (IFIS) (intraoperative) H21.81
intraoperative and postprocedural complications of specific body system (D78.-, E36.-, E89.-, G97.3-, G97.4, H59.3-, H59.-, H95.2-, H95.3, I97.4-, I97.5, J95, K91.-, L76.-, M96.-, N99.-)
ostomy complications (J95.0-, K94.-, N99.5-)
plateau iris syndrome (post-iridectomy) (postprocedural) H21.82
poisoning and toxic effects of drugs and chemicals (T36-T65 with fifth or sixth character 1-4 or 6)

Guidelines: Injury, poisoning and certain other consequences of external causes (S00-T88)

Note: Use secondary code(s) from Chapter 20 , External causes of morbidity, to indicate cause of injury. Codes within the T section that include the external cause do not require an additional external cause code

Note: The chapter uses the S-section for coding different types of injuries related to single body regions and the T-section to cover injuries to unspecified body regions as well as poisoning and certain other consequences of external causes.

Use additional code to identify any retained foreign body, if applicable (Z18.-)

Excludes 1:birth trauma (P10-P15)
obstetric trauma (O70-O71)

For more details on T81.4XXA, ICD-10 Code for Infection following a procedure, initial encounter , visit: https://coder.aapc.com/icd-10-codes/
Messages
142
Best answers
0
Patient presents to ED with knee pain and swelling, S/P laceration repair 3 days ago.

Clinical Impression is "infected laceration repair, right knee."

From what I'm reading (granted, it is an ICD-9 Coding Clinic), the coder "should assume that the wound is the problem and the source of the infection rather than the surgical technique" IN THE ABSENCE OF ANY DOCUMENTATION TO THE CONTRARY.

Because he clearly says "infected laceration REPAIR," am I okay to code to "Infection following a procedure, initial encounter" (T81.4xxA) with secondary of "local infection of the skin and subcutaneous tissue, unspecified" (L08.9) to identify infection?

Am I interpreting and applying this correctly?

Do I require a code for the active treatment (subsequent encounter?) of the original open wound? Otherwise, you really have no idea WHERE the original wound was. However, definition of "subsequent encounter" states "receiving ROUTINE CARE" during the healing phase. Since it's infected, it would no longer be "routine care," I wouldn't think.

Subsequent encounter (7th character 'D'): Used for encounters after active treatment for the injury has been provided and is receiving routine care during the healing or recovery phase. Examples of subsequent care: ...wound check...and follow up visits following injury treatment.

Thank you!
 
Last edited:
Top