post op wound infection, cellulitis , abscess

pt had a mastectomy to left breast approx. 30 days ago. Presented to ER with according to H&P was a post op wound infection ( this was documented by one MD) and another documented cellulitis with abscess to incision site. I&D was performed, pt has MRSA in wound. so , do I code post wound infection or cellulitis and abscess followed by code for MRSA or both? Home health ordered for wound care .

Comments

  • Hi,
    You have in your message that one MD stated post-op wound infection and the other stated cellulitis and abscess to incision site. These dx are on in the same, the second MD just stated it differently. You would code the post op wound infection (the T81.4 code encompasses abscesses and cellulitis) with the MRSA infection following after. Hope this helps.

    Jennifer Smith, RHIT, CCA, BCHH-C ICD-10, HCS-O
    Quality Assurance Coding Reviewer
    13801 Reese Blvd W | Suite 160 | Huntersville, NC 28078
    OFFICE: (361) 500-2348
    jennifer.smith@transpirus.com
    Transpirus.com
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