Long-Term Care Survey Alert

Tip: You must describe the infection to list an additional code.

Last month, we brought you instruction on how to code for surgical wounds under ICD-9. Read on for details on how these codes crosswalk in ICD-10.

Good news: The logic you use to find them remains unchanged.

For example: When providing care for a patient’s infected surgical wound, you currently report 998.59 (Other postoperative infection).

ICD-10: When you make the switch to ICD-10, you’ll report infected surgical wounds with T81.4xxD (Infection following a procedure; subsequent encounter). The seventh character "D" indicates that this is a subsequent encounter following the active phase of treatment and the patient is receiving routine care.

List additional code: In both systems, you should also list a code to identify the infection, such as 041.12 (Methicillin resistant Staphylococcus aureus) in ICD-9 or B95.62 (Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere) in ICD-10.

And, just as in ICD-9, you’ll list a more specific code when you have more detailed information about the infected wound.

For example: ICD-9 code 996.66 (Infection and inflammatory reaction due to internal prosthetic device, implant and graft; due to internal joint prosthesis) will be replaced with ICD-10 code T84.5-xD (Infection and inflammatory reaction due to internal joint prosthesis, subsequent encounter) with the fifth character to describe the specific joint affected and a D to indicate subsequent encounter as the seventh character.