Coding an infection in skin flap

We are looking for a code to describe an infection with drainage of skin flap over an eye that was removed. Problem is the surgery was 7 years ago and this suddenly began draining last week. Now we are doing daily wound care. Any suggestions? The eye was removed due to melanoma.



Kathy Hamilton RN

395 Tillman Road, Lufkin, TX 75901
Phone (936) 632-9400
Fax (936) 632-9425
Cell (936) 635-6465


  • Is the patient on antibiotics for the infection? Remember that skin flaps
    aren't considered surgical wounds, they remain the type of wound that was
    originally present (in this case, a malignant lesion)​. Have you considered
    T86.822A? (Skin graft infection, 7th character dependent on whether the
    patient is on antibiotics). Use additional code to identify the infection.
    Look also at T86.820- (skin graft rejection) and T86.821- (skin graft
    failure), dependent on documentation from the provider.

    Was this an artificial skin graft? In that case there may be mechanical
    breakdown or displacement of artificial skin graft and decellularized
    allodermis (T85.613- or T85.623-)

    This seems very unlikely given the scenario you presented, but if the
    original procedure was more extensive and there is a prosthetic orbit, use
    T85.32-- (displacement of prosthetic orbit).

    Hope these get you started in the right direction. Good luck! Thanks for
    sharing this interesting, although unfortunate, scenario.

    Beth Johnson, MBA, BSN, RN, CRRN, HCS-O, HCS-D / ICD-10
    Johnson, Richards, & Associates, LLC
    Brighton, MI
    office 248-289-0331

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