ICD-10-CM 2019: Add These Surgical Wound Infection Codes to Your Toolkit

surgical wound infection ICD-10 coding

If you read our ICD-10-CM 2019 overview, you know to expect new surgical wound infection codes effective Oct. 1, 2018. Get to know the notes with the codes to be sure you can match your documentation to these more specific 2019 diagnosis codes when the time comes.

Ob-Gyn Coders, Don’t Miss These Changes

The first set of new codes are under O86.0- (Infection of obstetric surgical wound). In the 2018 code set, O86.0 is a complete, reportable code. In 2019, you’ll need an additional character that provides more detail about the wound site.

Important: If you forget the additional character for O86.0- after the 2019 changes are implemented, the payer won’t accept the code.

Notes: Before we get to the new codes, though, let’s look at the 2019 Excludes1 notes that go with the codes.

  • Excludes1
    • complications of procedures, not elsewhere classified (T81.4-)
    • postprocedural fever NOS (R50.82)
    • postprocedural retroperitoneal abscess (K68.11).

Codes: Now that you know what you will NOT be coding under O86.0-, let’s look at what surgical wound infections you will code under this subcategory. The bullets under certain codes show you the inclusion notes. If the documentation you code from matches the descriptor or the inclusion notes, you’ll know you’ve got the information you need to choose the most specific code. Be sure to note the “use additional code” instruction for the last code, too. (Bold added for emphasis.)

  • O86.00 (Infection of obstetric surgical wound, unspecified)
  • O86.01 (Infection of obstetric surgical wound, superficial incisional site)
    • Subcutaneous abscess following an obstetrical procedure
    • Stitch abscess following an obstetrical procedure
  • O86.02 (Infection of obstetric surgical wound, deep incisional site)
    • Intramuscular abscess following an obstetrical procedure
    • Sub-fascial abscess following a procedure
  • O86.03 (Infection of obstetric surgical wound, organ and space site)
    • Intraabdominal abscess following an obstetrical procedure
    • Subphrenic abscess following an obstetrical procedure
  • O86.04 (Sepsis following an obstetrical procedure)
    • Use additional code to identify the sepsis

All Surgical Coders, Get Familiar With These Updates

The changes to O86.0- are very similar to those for another group of codes, T81.4- (Infection following a procedure).

Notes: If you use these T81.4- codes, be sure to keep in mind that some notes that were Excludes1 in 2018 will change to Excludes2 for 2019:

  • Excludes2
    • obstetric surgical wound infection (O86.0-)
    • postprocedural fever NOS (R50.82)
    • postprocedural retroperitoneal abscess (K68.11).

Codes: In ICD-10-CM 2018, T81.4- codes already require a seventh character, but you fill in the fifth and sixth character places with place-filler X. The 2019 code set changes will require you to use an actual digit for the fifth character. Your new options are below, again with bold added for emphasis.

  • T81.40- (Infection following a procedure, unspecified)
  • T81.41- (Infection following a procedure, superficial incisional surgical site)
    • Subcutaneous abscess following a procedure
    • Stitch abscess following a procedure
  • T81.42- (Infection following a procedure, deep incisional surgical site)
    • Intra-muscular abscess following a procedure
  • T81.43- (Infection following a procedure, organ and space surgical site)
    • Intra-abdominal abscess following a procedure
    • Subphrenic abscess following a procedure
  • T81.44 (Sepsis following a procedure)
    • Use additional code to identify the sepsis
  • T81.49 (Infection following a procedure, other surgical site)

What About You?

Is this level of specificity already in your documentation for infections following a procedure, or will these ICD-10-CM 2019 code changes require documentation training to ensure you can select the most specific code?



Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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