Posttraumatic wound infection not elsewhere classified

This code identifies an infection that develops in a wound following a traumatic injury, such as a laceration, abrasion, or puncture wound. The infection is a direct consequence of the trauma and is not specified as a surgical site infection or other specific type of infection elsewhere in the classification.

Apply this code when documentation clearly indicates a bacterial or other microbial infection arising in a wound caused by an external force or injury. This is appropriate for infections of accidental wounds, not those resulting from surgical procedures. Documentation should specify the traumatic nature of the initial wound and the subsequent infection.

• Ensure the infection is directly related to a traumatic wound, not a surgical wound (which would typically use a T81.4- code in ICD-10-CM).
• Always sequence this code after the primary traumatic injury code.
• Look for documentation of pus, erythema, warmth, pain, or positive cultures from the wound site following trauma.