Part B Insider (Multispecialty) Coding Alert

Hint: Identify the infection and document an infected device, if any.

When selecting the diagnosis codes for infected surgical wounds in ICD-10, you will follow the same logic as you do in ICD-9 but the 7th character in the codes make them distinct. Knowing the right approach can help you to easily submit your claims under ICD-10.

ICD-9: When reporting the diagnosis of an infection in the surgical wounds, you report ICD-9 code 998.59 (Other postoperative infection).

ICD-10: When ICD-10 is implemented next year, you will switch to code T81.4xxD (Infection following a procedure; subsequent encounter) to report infected surgical wounds. You need to be attentive to the seventh character. Here the seventh character "D" indicates that you are reporting ‘subsequent encounter’ following the active phase of the treatment. You may report character "A" for ‘initial encounter’ and "S" for ‘sequela.’

Do Not Forget To Identify the Infection

When reporting postoperative wound infections, you may report additional codes to identify the type of the organism causing the infection. Example, 041.12 (Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site) is the ICD-9 code for methicillin resistant Staphylococcus aureus (MRSA). The corresponding ICD-10 code is B95.62 (Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere). Another example is code 041.9 (Bacterial infection unspecified in conditions classified elsewhere and of unspecified site). The corresponding ICD-10 code is B96.89 (Other specified bacterial agents as the cause of diseases classified elsewhere). You may however, list more specific codes when you have more information for the infected wound.

Confirm If Device Is the Cause

You report 996.66 (Infection and inflammatory reaction due to internal joint prosthesis) if the cause of the infection is documented to be the implanted device. In ICD-10, the corresponding code is T84.50XA (Infection and inflammatory reaction due to unspecified internal joint prosthesis, initial encounter). Here, the 5th character describes the specific joint affected and the 7th character indicates subsequent encounter.