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:

Code	Description
T81.40	Infection following a procedure, unspecified
T81.41	Infection following a procedure, superficial incisional surgical site Subcutaneous abscess following a procedure Stitch abscess beyond the point of suture penetration 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

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.

Code	CDC Criteria
T81.41 – Infection following a procedure, superficial incisional surgical site	Involves only skin and subcutaneous tissue of the incision Purulent drainage from the superficial incision Organism(s) identified from an aseptically-obtained specimen from the superficial incision or subcutaneous tissue by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment
T81.42 – Infection following a procedure, deep incisional surgical site	Involves deep soft tissues of the incision (for example, fascial and muscle layers) Purulent drainage from the deep incision A deep incision that spontaneously dehisces, or is deliberately opened or aspirated by a surgeon, attending physician* or other designee AND organism(s) identified from the deep soft tissues of the incision. Patient has at least one of the following signs or symptoms: fever, localized pain or tenderness An abscess or other evidence of infection involving the deep incision that is detected on gross anatomical or histopathologic exam, or imaging test
T81.43 Infection following a procedure, organ and space surgical site	Involves any part of the body deeper than the fascial/muscle layers that is opened or manipulated during the operative procedure Purulent drainage from a drain that is placed into the organ/space (for example, closed suction drainage system, open drain, T-tubedrain, CT-guided drainage) An abscess or other evidence of infection involving the organ/space that is detected on gross anatomical or histopathologic exam, or imaging test evidence suggestive of infection.