Surgical Wound ICD-10-CM Codes

Explore the ICD-10-CM codes linked to surgical wounds, essential for precise medical documentation, appropriate billing, and strategic treatment decisions for 2023.

By Joshua Napilay on Jun 16, 2024.

Fact Checked by Ericka Pingol.

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Surgical Wound ICD-10-CM Codes

What ICD-10 Codes are Used for Surgical Wounds?

A surgical wound refers to an incision or cut made into the body by a surgeon during a procedure. Surgical wounds need accurate coding for postoperative care, complications, and billing purposes. The ICD-10-CM provides standardized codes for these surgical-associated conditions.

Commonly Used ICD-10-CM Codes for Surgical Wounds:

T81.30XA - Disruption of wound, unspecified, initial encounter

A generic code used for cases where a surgical wound has come apart, but there's no information on how it occurred.

T81.31XA - Disruption of internal operation (surgical) wound, not elsewhere classified, initial encounter

The wound from an internal surgery has opened up or disrupted, not due to any reasons listed elsewhere.

T81.32XA - Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter

An external surgical wound has come apart, but not for any reasons listed explicitly in other categories.

T81.4XXA - Infection following a procedure, initial encounter

This code indicates a patient has developed an infection due to a surgical procedure.

T81.83XA - Pain during or following a procedure, initial encounter

The patient is experiencing pain either during or after a surgical procedure.

(Note: The term 'initial encounter' typically implies the wound or condition is being treated immediately after the surgery or after discovering the issue, and it may have subsequent codes for follow-ups or complications.)

Which Surgical Wound ICD codes are Billable?

  • T81.30XA - Yes
  • T81.31XA - Yes
  • T81.32XA - Yes
  • T81.4XXA - Yes
  • T81.83XA - Yes

Clinical Information

  • Surgical wounds are intentional incisions made by healthcare providers during procedures.
  • They are classified by their cleanliness, depth, and complexity.
  • Proper care is crucial to prevent complications such as infections, wound disruptions, or hematomas.
  • Signs of complications can include pain beyond expected levels, redness, swelling, pus, or the wound opening up.
  • Treatment may involve antibiotics, wound care, or in some cases, further surgical interventions.

Synonyms Include:

  • Post-operative wound
  • Surgery incision site
  • Operative cut
  • Surgical site
  • Procedure wound
Medical Billing and Coding Software

Commonly asked questions

When should a Surgical Wound ICD code be used?

A Surgical Wound ICD code should be utilized when documenting care related to a patient's surgical incision, especially when addressing complications or specific post-operative care needs.

What are the common treatments for conditions coded with Surgical Wound Diagnosis Codes?

Treatments include wound care (cleaning and dressing), antibiotics for infections, pain management, or possible corrective surgeries for disruptions.

What does a diagnosis code for a Surgical Wound indicate?

A diagnosis code for a Surgical Wound signifies issues or care related to an incision made during a surgical procedure, including standard healing or complications that arise.

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