HCPCS G9311: No Surgical Site Infection - OpenPayer

Summary & Overview

HCPCS G9311: No Surgical Site Infection

HCPCS Level II code G9311 denotes documentation of no surgical site infection after a surgical procedure. Nationally, precise coding for postoperative infection status is important for performance measurement, quality reporting, and accurate clinical records. Clear use of G9311 helps distinguish uncomplicated recoveries from cases requiring further intervention, influencing quality metrics and post-acute care pathways.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of how G9311 is used in clinical documentation and billing contexts, typical sites of service, common modifiers associated with postoperative assessment encounters, and guidance on where data is not available. The publication also outlines implications for quality reporting and administrative coding processes, and highlights areas where policy updates or payer-specific billing rules may affect claim adjudication.

This summary addresses clinical context, documentation expectations, and the administrative role of G9311 in postoperative reporting. Data not available in the input is noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG9311HCPCS Level IIpostoperative assessmentsurgical follow-upinfection surveillancequality reportingbillingclinical documentation

Billing Code Overview

HCPCS Level II code G9311 indicates No surgical site infection. This code documents the clinical assessment that a patient has not developed a surgical site infection following a procedure.

Service type: Postoperative assessment / surgical follow-up
Typical site of service: Outpatient surgical follow-up visit or postoperative clinic evaluation

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A typical patient scenario involves a postoperative evaluation following a clean surgical procedure (for example, elective laparoscopic cholecystectomy or hernia repair) in which the surgeon documents the absence of a surgical site infection. The patient presents for a routine wound check at the surgical clinic 7–14 days after the operation, reporting normal healing, minimal pain controlled with oral analgesics, no purulent drainage, no increasing erythema, and no systemic signs of infection (fever, tachycardia). The clinician performs a focused wound inspection, documents intact incisions without drainage, palpates for fluctuance or induration, confirms absence of erythema spreading beyond the immediate incision, and records the finding as “no surgical site infection.” The workflow includes review of the operative note, assessment of wound appearance, reconciliation of postoperative antibiotics (if any), and documentation of wound status in the medical record. If the visit is for routine postoperative care without complications, the encounter may be billed with the appropriate postoperative follow-up or evaluation code and the G9311 HCPCS Level II code is used to indicate a documented absence of surgical site infection for quality reporting or tracking purposes.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when work required is substantially greater than usually required (rare for a simple wound check).

HCPCS G8752: Most Recent Systolic Blood Pressure < 140 mmHg

HCPCS-G9535-NORMAL-NEUROLOGICAL-EXAMINATION-OUTPATIENT-ASSESSMENT

HCPCS G9535: Normal Neurological Examination

HCPCS-G8749-ABSENCE-SYSTEMIC-SIGNS-SYMPTOMS-MELANOMA-ASSESSMENT

HCPCS G8749: Absence of Signs or Symptoms of Systemic Spread of Melanoma

HCPCS-G0563-SBRT-POSETRON-EMISSION-GUIDED-DELIVERY-UP-TO-5-FRACTIONS

HCPCS G0563: SBRT Delivery with PET-Guided Real-Time Adjustments, Up to 5 Fractions

HCPCS-G0122-BARIUM-ENEMA-COLORECTAL-CANCER-SCREENING

HCPCS G0122: Colorectal Cancer Screening, Barium Enema

HCPCS-G0445-HIGH-INTENSITY-STI-COUNSELING-30MIN

HCPCS G0445: High-Intensity STI Prevention Counseling, 30 Minutes

HCPCS-G9315-AMOXICILLIN-FIRST-LINE-ANTIBIOTIC-AT-DIAGNOSIS

HCPCS G9315: Amoxicillin First-Line Antibiotic at Diagnosis

HCPCS-G9765-SYSTEMIC-THERAPY-DECLINE-OR-CONTRAINDICATIONS-DERM

HCPCS G9765: Documentation of Systemic Therapy Decline or Contraindication

HCPCS-G8569-PROLONGED-POSTOPERATIVE-INTUBATION-OVER-24-HOURS

HCPCS G8569: Prolonged Postoperative Intubation (>24 hours)

HCPCS-G9983-REMOTE-IN-HOME-EVALUATION-MANAGEMENT

HCPCS G9983: Remote In-Home Evaluation and Management Visit

Showing 1–10 of 1996

Taxonomy Code	Specialty	Notes
`207P00000X`	General Surgery	Most common specialty performing the index operations and postoperative wound checks.
`208D00000X`	Dermatology	Performs excisions and postoperative wound evaluations for cutaneous surgeries.
`262LM0800X`	Physician Assistant	Frequently documents wound checks and postoperative assessments under supervising surgeons.
`207L00000X`	Colon and Rectal Surgery	Performs anorectal and colorectal procedures with subsequent wound surveillance.
`207K00000X`	Obstetrics & Gynecology	Performs gynecologic surgeries with routine postoperative incision assessments.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z48.02`	Encounter for removal of sutures and drains	Reflects routine postoperative wound care visits where absence of infection is assessed.
`Z48.89`	Encounter for other specified postoperative care and examination	General postoperative follow-up code for wound evaluations and documentation of no infection.
`Z09`	Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm	Used for scheduled postoperative assessments when treatment course is complete and monitoring is needed.
`L08.9`	Local infection of the skin and subcutaneous tissue, unspecified	Represents wound infection when present; contrast to documentation of `G9311` indicating absence.
`T81.4XXA`	Infection following a procedure, initial encounter	Used when a post-procedural infection occurs; relevant as the inverse finding to `G9311`.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, low to moderate complexity	Common code for a routine postoperative wound check visit where absence of infection is documented.
`99214`	Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity	Used when the postoperative visit requires moderate complexity decision-making or management.
`49505`	Repair initial inguinal hernia, age 5 years or older; reducible	Example index procedure that would have postoperative wound assessments where `G9311` may be reported for no SSI.
`47562`	Laparoscopy, surgical; cholecystectomy	Common inpatient/outpatient surgery with subsequent wound checks documenting absence of infection.
`11042`	Debridement, subcutaneous tissue (includes epidermis and dermis when performed); first 20 sq cm or less	May be performed if wound infection or necrotic tissue is present—contrast to `G9311` which documents no infection.

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