ICD Code T81.49XA

ICD code T81.49XA is an infection that occurs at a surgical site other than the primary incision after a procedure, and this code is used for the initial encounter or first time the patient is being treated for this infection.

1. Patient presents with signs of infection (e.g., redness, swelling, warmth, pain, or discharge) at a surgical site that is not the primary incision or operative field.

2. Infection occurs after a surgical or medical procedure.

3. The affected site is classified as an "other" surgical site, not the main operative area.

4. Clinical documentation confirms the infection is directly related to the recent procedure.

5. This is the initial encounter for the infection (first time being evaluated or treated for this specific infection).

6. Laboratory or imaging findings may support the diagnosis of infection at the surgical site.

7. No evidence that the infection is due to a device, implant, or graft (use different codes if these are involved).

Relevant CPT codes that may be used to treat ICD code T81.49XA include:

- 10180 (Incision and drainage, complex, postoperative wound infection)

- 11042 (Debridement, subcutaneous tissue)

- 11043 (Debridement, muscle and/or fascia)

- 12020 (Treatment of superficial wound dehiscence; simple closure)

- 12021 (Treatment of superficial wound dehiscence; with packing)

- 97597 (Removal of devitalized tissue, first 20 sq cm or less)

- 97598 (Removal of devitalized tissue, each additional 20 sq cm)

- 99211–99215 (Evaluation and management, established patient, office or other outpatient visit)

- 99221–99223 (Initial hospital care, per day, for the evaluation and management of a patient)

CPT code selection should be based on the specific clinical scenario and provider documentation.

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