Orthopedic Coding Alert

Question: Our surgeon treated a soft-tissue infection on a patient's finger. Which diagnosis code should we report for this?


South Carolina Subscriber


Answer: The answer depends on the type of infection. If the physician describes cellulitis to the skin on the finger, you should report one of the following codes: 681.00 (Cellulitis and abscess of finger and toe; finger;  unspecified), 681.01 (- felon), 681.02 (- Onychia and paronychia of finger), 727.05 (Other tenosynovitis of hand and wrist), or 041.x (Bacterial infection in conditions classified elsewhere and of unspecified site).

If the surgeon is treating an infection to a soft tissue other than the skin, you could report 728.89 (Other disorders of muscle, ligament, and fascia; other).

And, if the infection is of unknown origin or cannot be classified into these categories, you might consider 686.9 (Unspecified local infection of skin and subcutaneous tissue).

If the documentation does not reveal the type of infection or how deep it was, you should ask the surgeon for more details.