A patient develops a surgical-site infection after abdominal surgery and is admitted with sepsis. The surgeon clearly documents “sepsis due to postoperative wound infection.” Which diagnosis category is generally sequenced first?
A.
The systemic sepsis code
B.
The postprocedural infection code identifying the surgical-site infection
Sepsis resulting from a postprocedural infection follows specialized sequencing rules. The code identifying the postprocedural infection or surgical-site infection is sequenced first when applicable, followed by the code for sepsis following a procedure and any additional codes required for the infectious organism or severe sepsis.
The FY 2026 Official Guidelines specifically state that for sepsis following a postprocedural wound or surgical-site infection, the appropriate postprocedural infection code is sequenced first. An additional code for sepsis following a procedure is then assigned. If severe sepsis exists, the appropriate R65.2- code and codes for acute organ dysfunction are additionally reported.
This differs from ordinary sepsis due to a localized infection, where the systemic infection is typically sequenced before the localized infection when sepsis is the reason for admission.
The cause-and-effect relationship is also essential. A wound infection merely occurring after surgery does not automatically establish a postprocedural complication. Here, the surgeon has explicitly documented that relationship, so the necessary clinical linkage is present.
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