Surgical Site Infections
The October 2018 updates included expansion of Subcategory T81.4, Infection following a procedure, and new codes were created to identify surgical site infections according to depth. Six codes were created to describe infections following a procedure:
|T81.40||Infection following a procedure, unspecified|
|T81.41||Infection following a procedure, superficial incisional surgical site
|T81.42||Infection following a procedure, deep incisional surgical site
|T81.43||Infection following a procedure, organ and space surgical site
|T81.44||Sepsis following a procedure
|T81.49||Infection following a procedure, other surgical site|
The Patient Assessment and Outcome Committee of the American Association for the Surgery of Trauma requested these code revisions in order to distinguish the severity of an infection following a procedure. These categories are consistent with the Centers for Disease Control and Prevention criteria for defining a Surgical Site Infection (SSI).
SSIs remain a substantial cause of morbidity, prolonged hospitalization, and death and are the most costly hospital acquired infection. Sound infection definitions are necessary for appropriate surveillance and feedback of data to reduce and prevent occurrences. The table below provides a summary of specific criteria identified by the CDC for SSIs. Familiarity with these definitions will allow for accurate reporting of these diagnoses and provide clinical findings to support compliant query opportunities when appropriate.
|T81.41 – Infection following a procedure, superficial incisional surgical site||
|T81.42 – Infection following a procedure, deep incisional surgical site||
|T81.43 Infection following a procedure, organ and space surgical site||