Transition to ICD 10 CM/PCS –
Injuries – Health Status
Part I
May 21, 2015
Irene Mueller, EdD, RHIA
AHIMA Approved
ICD-10-CM/PCS Trainer
© 2015 by Irene L. E. Mueller
Objectives
• After attending this workshop, participants
will be able to
• Describe general/specific ICD-10-CM Chapter
coding guidelines and coding conventions
guidelines for Chapters 19-21 by reviewing
examples and case studies and completing
assigned exercises
• Explain related ICD-10-CM documentation
requirements
2
Agenda
• 10 am – 10:05 am
Introduction
• 10:05 am – 10:50 am Injuries,
External Causes
• 10:50 am – 11:00 am Break
• 11:00 am – 11:50 am Health Status,
Complications
• 11:50 am – 12:00 pm Assignments and
Questions
3
Readings
• Chapter 22A&B, pp. 371• Basic 1CD-10392, 397-411
CM/PCS Coding,
2013 Ed.
• Chapter 23, pp. 417-435
• Chapter 24, pp. 439-483
Coding Resources
• Previous Coding Webinars
• 2014 Other Consequences of External Causes;
Preparing for ICD-10-CM/PCS Parts I & II
• 2014 Physical Injuries and External Causes;
Preparing for ICD-10-CM/PCS Parts I & II
• 2012 MS A&P, MS Diagnoses, Skeletal Dx
Coding, etc.
5
Chapter 19
Injury, poisoning and certain other
consequences of external causes (S00-T88)
Chapter 19 Blocks
7
Injury and Poisoning Chapter
• ICD-10-CM Chapter 19 – 2 sections
•S=
• Various types of injuries related to single body
regions
•T=
• Injuries to unspecified body regions
• Poisonings & certain other consequences of
external causes
• 7th Character Extension required for many
chapter codes
8
ICD-10-CM Chapter 19
• More details
• Laterality & type of encounter (initial,
subsequent, sequela)
• Significant component of code expansion
• 7th character = type of encounter
9
ICD-10-CM Coding of Injuries
• Significant changes
• General sites, then
types of injury
• Top of body down
• Axial, then
Appendicular
skeleton
• Types of injury,
superficial to deeper
•
•
•
•
•
•
•
Superficial Injury
Open Wound
Fractures
Dislocations/sprains
Nerve Injuries
Blood vessel Injuries
Muscle, fascia, tendon
Injuries
• Crush injuries
• Traumatic amputations
• Other injuries
Injury Coding Guidelines
•
•
•
•
I.C.19.a.
I.C.19.b.
I.C.19.c.
I.C.19.d.
7th characters
Coding of Injuries
Traumatic fractures
Burns and Corrosions
11
Injury Coding Guidelines
• I.C.19.b.1. Superficial Injuries
• I.C.19.b.2. Injury w/nerve/blood vessels
• I.C.19.c.1.
Fx Initial vs Subsequent visit
• I.C.19.c.2.
Multiple fx sequencing
• I.C.19.d.1 – 9. Burn Coding
12
AI and Injuries
• Main Terms
• General types of Injury
• Burn, Dislocation, Fracture, Wound, etc.
• Subterms id site of injury
13
Seventh
th
(7 )
characters
• A, D, S required for most Injury codes
• Z aftercare codes NOT used for injuries
• Traumatic Fx codes have other 7th
characters
• NO 7th character extension for open physeal
fracture
14
Initial Encounters (A)
• Initial encounter 7th character used
while patient receiving active treatment
for condition
• Surgical treatment
• Emergency department encounter
• Evaluation and treatment by new physician
• Can be used each time pt actively
treated for same condition
15
Subsequent Encounter (D)
• Subsequent encounter 7th Character used for
encounters after patient’s active treatment
completed
• Now receiving routine care for condition
during healing or recovery phase
•
•
•
•
Cast change or removal
Removal of external or internal fixation device
Medication adjustment
Other aftercare & follow-up visits following
treatment of injury or condition
16
Sequela (S)
• Complications or
conditions directly caused
by injury
• Must use 2 codes
• Code for current condition
(NO S)
• Code for original injury
WITH S
• In this order, usually
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r/File:Cicatrices_de_flagellation_sur_un_escl
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17
7th Character –
2015 Guidelines
• In past, ICD-10-CM Official Guidelines included evaluation and
management by new physician as example of initial treatment
(7th character A). For 2015, Cooperating Parties modified
guidelines
• While the patient may be seen by new or different provider
over course of treatment for an injury, assignment of 7th
character based on whether patient undergoing active
treatment & NOT whether provider seeing patient for first time.
• What matters = What is done for patient during encounter
• Examples of active treatment are
• Surgical treatment
• ED encounter
• Evaluation and continuing treatment by same or different physician
18
Injury Coding
• Use combination codes, when available
• OR Separate codes for EACH injury
• DO NOT assign T07 in Inpt, unless no
other info available
• S00-T14.9 are NOT used for
• Surgical wounds/complications thereof
• Sequence most serious injury first
• Indicated by Physician or tx focus
19
Aftercare Codes
• Aftercare Z codes NOT used for
aftercare for conditions when 7th
characters available to ID subsequent
episodes of care
• For aftercare of injury, assign acute
injury code with 7th character for
“subsequent encounter”
20
Blood vessel/Nerve Injury
• Injury resulting in minor damage to peripheral
nerves/blood vessels
• Primary injury sequenced first
• Then blood vessel/nerve injuries
• When primary injury is to blood vessels/nerves,
Sequence 1st
21
Burns
Thermal, except from
sun
Electric
Radiation
Corrosions
Chemical burns
Chapter 19
Burns
22
Burns and Corrosions
• Burn = Thermal burn (NOT sunburn)
• Corrosion = Chemical burn
• Same Guidelines for both types of burns
• Current burn = T20-T25
• Depth, Extent, Agent (X code)
• Burns of Eye/Internal Organs = T26-T28
• Site only
23
Burn Coding
• Burns of same local site (3-character code)
• Code to highest degree (code only once)
• Non-healing burn = acute burn
• Necrosis of burned skin = non-healed
• Infected burn = acute burn
• Use add’l code for infection
• Multiple burn sites
• Assign separate codes for each site
• Avoid T30
24
External Cause Coding for
Burns
• External cause of injury code used
• To ID source and intent of burn
• Place occurred
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25
Internal and External Burns
• When patient has BOTH internal and
external burns
• PDx determined by circumstances of
admission
• May be instances where other conditions
also present at time of admission
• Ex: smoke inhalation, corrosive vapors
26
Burn Extent
• T31 = extent of burned body surface
• T32 = extent of corrosion of body surface
• Use as add’l codes
• Data for evaluating burn mortality
• When 3rd-degree burn over 20% + of body
• Rule of Nines
27
Guideline for Extent of Burn
I.C.19.d.6.
28
Rule of Nines
• ADULT:
Head and Neck
=
Posterior Trunk
=
Anterior Trunk
=
Each Upper Extremity =
Each Lower Extremity =
Perineum
=
9%
18%
18%
9%
9%
1%
29
Rule of Nines
• BABY:
Head and Neck
=
Posterior Trunk
=
Anterior Trunk
=
Each Upper Extremity =
Each Lower Extremity =
18%
18%
18%
9%
14%
30
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31
Non-Healing or Infected Burns
• Non-healing burns
• Coded as acute burns
• Necrosis of burned skin = non-healed burn
• Any documented infected burn site
• Add’l code for infection
32
Burn Sequelae
• Use burn/corrosions code with S Extension
• When appropriate, can code both current
burn and sequelae codes
• Burns do not heal at same rate
• Can have both healed and healing at same
time
33
Burn Coding Sequencing
• Highest degree of burn sequenced first
• External AND internal burns
• Sequence according to admission
circumstances
• Burn + Other related issues
• Sequence according to admission
circumstances
• External cause code should be used
34
Multiple Burns Sequencing
• PDX = burn site of greatest severity
• Then use following order
• A. Deep necrosis of underlying tissues w/
loss of body part (deep 3rd/4th degree)
• B. Deep necrosis of underlying tissues without loss
of body part (deep 3rd/4th degree)
• C. Full-thickness skin loss (3rd degree)
• D. Blisters, epidermal loss (2nd degree)
• E. Eythema (1st degree)
• F. Unspecified
35
Traumatic Fx Coding
• Apply multiple injury coding guidelines
• Multiple fxs sequenced in order of severity
• Documentation must support order
36
Traumatic Fractures
• Classified as
• 1 Displaced or non-displaced
• 2 Open or closed
• 3 Specific type
• Which bone
• Exact part of bone
• Fx not indicated as displaced/nondisplaced - code
to displaced
• Fx not indicated as open/closed - code to closed
37
Traumatic Fx
th
7
Characters
Used as long as pt receiving active tx
38
Traumatic Fx 7th Characters
2012 Webinar
39
Fx Complications
• Complications of surgical care for fxs
during healing/recovery phase
• Complication codes
• Complications of Fxs
• Use appropriate 7th character
• Non union
• Mal union
40
Glasgow Coma Scale
• Score from 3 – 15
• 3 categories; points added together for score
• Eye opening
• Verbal response
• Motor response
• Score of 3 = NO response in all categories
• R40.24- used when no individual scores
• ICD-10-CM specific for each category
41
Coma in ICD-10-CM
• “Coma” expanded to include coding for
somnolence, stupor, and coma
• Somnolence (R40.0) = Drowsiness
• Stupor (R40.1) = Catatonic stupor or semicoma
• Coma (R40.2-) = Unconsciousness
• Any associated skull fracture or intracranial
injury would be coded 1st
• 7th character required
• Glasgow (coma scale) score available
42
Patients w/Coma Scale
• Patients with traumatic brain injuries,
cerebrovascular disease or sequelae of
cerebrovascular disease
• Diagnosis code reported 1st
• R40.2- should be added to report score
• Determines level of central nervous system
damage or injury
• Also indicates whether patient conscious or
comatose
43
GCS Scoring
• Glasgow (coma scale) score available
• Typically reported as a total score 0-15
• Higher score = higher functioning
• ICD-10-CM coding will need score from
each of assessment areas
• Eye opening
• Verbal response
• Motor response
44
GCS Ranges
• Mild: GCS 13-15. = Mild brain injury
• Moderate: GCS 9-12. Patient often experiences
LOC greater than 30 minutes. Pt’s physical or
cognitive impairments may/may not resolve and
patient may benefit from therapy
• Severe: GCS 3-8. = Coma. Patient exhibits no
meaningful response; performs no voluntary
activities
45
GCS Subcategories
• 1 = Greatest impairment (never or none)
• Assigned sequentially, with highest
number assigned for best performance
• Best score in each subcategory reported
• ICD-10-CM code for each score in scale
46
GCS 7th Character
• Added to each code (R40.21-, R40.22- and R40.23-)
• IDs WHEN scale process carried out/recorded
• 7th character should be same for each of 3 codes
• When GCS scored multiple times during admission, codes
can be reported more than once
• 7th characters are
• Unspecified time
• In the field (EMT or ambulance)
• At arrival to ED
• At hospital admission
• 24 hours or more after hospital admission
47
GCS Total Score ONLY
• When individual scores not documented, only total
score documented
• Assign R40.24 for Glasgow Coma Scale, total score.
• Total score of 3-8 = in coma
• Total score of 9+ = NOT in coma
• R40.241 Glasgow Coma Scale score 13-15
• R40.242 Glasgow Coma Scale score 9-12
• R40.243 Glasgow Coma Scale score 3-8
• When GCS NOT documented, OR only partial score
reported, assign code R40.244, other coma
48
GCS Documentation
• GCS does NOT have to be reported
by physician to code
• EMT or paramedic may document
patient’s initial GCS score in field
• Coder can use pre-hospital
report that contains EMT’s
documentation
• Coders can also pick up this
information from other nonphysician practitioners
49
Glasgow Coma Scale
Example
• Pt admitted to IRF following 2-week stay at acute-care
hospital for treatment of TBI after fall from ladder. On 5th day
after admission to IRF, Glasgow Coma Scale test scored.
• Eyes open: 2 = R40.2124
• Verbal response: 3 = R40.2234
• Motor response: 2 = R40.2324
• Eyes-open response score 2 = Eyes opened to pain
• Verbal response score 3 = Inappropriate words
• Motor response score of 2 = Extension
• 7th character assigned = 4 = score obtained 24+ hours after
admission
50
Multiple Injuries
• Code for most severe injury = PrDx
• Determined by physician
• Treatment provided
51
Superficial Injuries in
ICD-10-CM
• Abrasion
• Excoriation
• Avulsion
• Wound, Open
• Bite (nonvenomous)
• Superficial
• Open
• Blister (nonthermal)
• Burn
• Contusion
• Corrosion
• Exfoliation
• Desquamation
•
•
•
•
•
•
External Constriction
Foreign Body
Frostbite
Incision
Laceration
52
Wound
Superficial Injuries
• NOT coded when part of more severe
injury
• Example:
• Road rash in same area of body as
open fx due to motorcycle accident
53
Wounds ICD-10-CM
• Classified by Body SITE, then type
• Open wounds consistent across body sites
• Open wound Types classified in ICD-10-CM
•
•
•
•
•
•
Laceration w/o foreign body
Laceration w/ foreign body
Puncture wound w/o foreign body
Puncture wound w/ foreign body
Open bite
Unspecified open wound
54
Wounds in ICD-10-CM
• Note: Code also any associated wound
infection
• NO concept of delayed healing/treatment
• Some types may have add’l and/or unique
code specificity
• w/ or w/o penetration into body cavity or organ
• Add’l specificity of laceration as minor, moderate,
or major
• Add’l anatomic specification
• left/right, front/back, flexor/extensor
55
Cellulitis Vs Open Wound
Sequencing depends on circumstances of admission/encounter
• Pt suffered laceration of
lower leg while hiking 2
days ago; came to hospital
on his return.
• Cellulitis beginning to
develop. Wound
cleansed, nonexcisional
debridement, &
antibiotics started for
cellulitis.
• Wound and Cellulitis
coded
• Pt suffered minor puncture
injury to finger removing
staple at office. 5 days later,
admitted to hospital because
of cellulitis of finger, tx with
IV.
• Wound didn’t require tx,
therefore NOT coded
Chapter 19
Poisoning, Adverse Effect, Underdosing, Toxic effects (T36-T65)
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T36-T50
• Includes:
• Adverse effect of correct substance properly
administered (hypersensitivity, reaction, etc.)
• Poisoning by
• Overdose of substance
• Wrong substance given or taken in error
• Underdosing by (NOT in ICD-9-CM)
• (inadvertently) (deliberately) taking less substance than
prescribed or instructed
• Use add’l code for INTENT OF underdosing
• Failure to dose during medical/surgical care
• Pt’s underdosing
58
Adverse Effects and
Poisonings (T36-T50)
• Adverse Effects
• Nature of adverse effect 1st
• Add’l code for drug
• Poisonings
• Poisoning Code
• Code(s) for all manifestations
• Then code for drug
• Same sequencing as ICD-9-CM
59
Adverse Effect
• Correct substance administered as prescribed
• Adverse effect (manifestation) sequenced 1st
• T code from Therapeutic use column 2nd
• CANNOT use T code from any other column
• Adverse Effect T codes MUST BE REPORTED
60
Adverse Effect
Documentation
• Dx statements of
• Toxic effect,
toxicity, intoxication
due to prescription
drug (digitalis,
lithium)
• w/o any further info
• Indicates Adverse
Effect
• Other terms for AE
• Allergic reaction
• Cumulative effect
(toxicity)
• Hypersensitivity
• Idiosyncratic reaction
• Paradoxical reaction
• Synergistic reaction
• Toxicity
Adverse Effects
• Pt differences
• Age, sex, disease, Genetic factors
• Drug-related
•
•
•
•
•
Type
Administration route
Duration of tx
Dosage
Bioavailability
62
AE Drug T codes
• When agent causes multiple adverse
reactions, assign T code ONCE
• When 2+ drugs are responsible, code
individually unless combo T code
63
Unspecified AE
• T88.7 AE effect of drugs & medicaments
• CAN be used in OUTpatient setting
• Inappropriate for Inpatient setting
• Code S&S with this T code
64
Sequela of AE of Drugs
• Code residual condition
• Add’l code
• T Code for drug that caused AE with S 7th
character
• Chronic effects of drug taken for long
time and still being taken = Current AE
• When delayed effects AFTER stopping
= Sequela
65
AE Sequela Examples
• Brain damage caused by penicillin
allergy (while taking med)
• G93.9, T36.0x5A
• Brain damage caused by penicillin
allergy (stopped using 6 months ago)
• G93.9, T36.0x5S
66
Poisoning
• Substance used incorrectly
• Error in prescription
• Drug overdose (Intentional/Accidental)
• Non-prescribed drug taken with correctly
prescribed/taken drug
• Wrong administration method
• Wrong dosage given/taken
• Wrong medication given/taken
67
Poisonings in ICD-10-CM
• Combination codes for poisonings &
associated external cause (accidental,
intentional self-harm, assault, undetermined)
• Rearranged Table of Drugs & Chemicals
• All poisoning columns together, then adverse
Improvement!
effect and underdosing
• When intent NOT documented, code
Accidental
• Undetermined intent = Specific documentation
in record; intent can’t be determined
68
Poisoning Guidelines
• Use as many codes as necessary to describe
completely all drugs, medicinal or biological
substances
• If same code would describe causative
agent – assign code only once
• If two or more drugs, medicinal or
biological substances – code each
individually unless a combination code
listed
69
Coding a Poisoning
• Code from Poisoning column 1st
• 2ndary code = Manifestation
• T code = How substance used
• Accident, Assault, Suicide, etc.
• CANNOT use T code from AE column
• One code indicates poisoning,
substance, intent and encounter
70
Poisoning by Interaction
• Tx drug and nonprescription drug or
alcohol
• Poisoning code for
EACH substance
• Manifestation, if
documented
• Ex: Coma due to
Adverse reaction to
Valium taken
correctly, but with 2
martinis
• T42.4x1A
• T51.0x1A
• R40.20
Poisoning External Causes
codes
• Cause NOT stated = Undetermined T code
72
Sequela of Poisoning
• Same Sequela rules
• Residual condition (Manifestation) coded 1st
• Code for drug = Add’l code
• Add S 7th character
73
Substance
Abuse/Dependence
• When documentation of
abuse/dependence in Poisoning situation
• Assign as add’l code
74
Underdosing
• Taking
• Less medication than prescribed by provider, or
• Less than manufacturer’s instructions
• Underdosing codes require 7th character
• ALWAYS 2ndary code
• When Underdosing causes relapse or
exacerbation of medical condition being
treated by medication
• Medical condition coded
75
Underdosing due to
Noncompliance
• Z91.12- Patient’s intentional underdosing of
medication regimen
• or Z91.13- Patient’s unintentional
underdosing of medication regimen
• When complication of care (NOT patient)
• Appropriate code from Y63.6-Y63.9
(Failure in dosing) should be added
76
Using Table of Drugs
• Coder must determine
• Adverse Effect vs Poisoning
• Decision Tables - Fig. 22B-1, 2
• Taking less/stopping drug
• NOT poisoning OR adverse effect
• Underdosing in ICD-10-CM
• Toxic effects of NON-medicinal substances
= follow Poisoning steps
77
Adverse Effects vs Poisoning
Condition due to Drug, Med. Bio?
NO
Code Condition
Yes
Med used exactly as prescribed? NO Code as Poisoning
Add code for condition
Add T code
Yes
Alcohol/non-prescr. drug also
NO Code condition
taken?
Add AE T code
Yes
Code as Poisoning
Add code for condition
Add T code
78
Table of Drugs
• Rows = Drugs, medicinal substances
• Columns = Poisoning code, T codes
• ALWAYS VERIFY in TL
• Instructional Notes
• Ex: T36.-- Poisoning by antibiotics
• Note to use appropriate 7th character
79
Specific Drug NOT in Table
• American Hospital Formulary Service
(AHFS)
• Index from brand names, etc to #
• Hospital Pharmacist is valuable resource
• May have to research drug name to find
type and then find type in Table
80
Complications (T80-T88)
Many complications coded in
Body System Chapters
81
Complications
• T80 Complications following infusion, transfusion and
therapeutic injection
• T81 Complications of procedures, NEC
• T82 Complications of cardiac/vascular prosthetic devices,
implants and grafts
• T83 Complications of GU prosthetic devices, implants & grafts
• T84 Complications of internal orthopedic prosthetic devices,
implants and grafts
• T85 Complications of other internal prosthetic devices,
implants and grafts
• T86 Complications of transplanted organs and tissue
• T87 Complications peculiar to reattachment and amputation
• T88 Other complications of surgical and medical care, NEC
82
PostOp Complication vs
PostOp condition
• PostOp Complication = Unexpected
problems due to prior surgery
• Most frequent complications = Bleeding,
infection and protracted pain
• PostOp Condition =Expected after certain
surgeries
• Intraoperative/postprocedural complication
• Codes in body system chapter with codes
specific to organs and structures of that body
83
system
Documentation of
Complications of Care I.B.16
• Code assignment based on provider’s
documentation of relationship bet.
Condition/care or procedure
• Guideline extends to any complications
of care, regardless of chapter where
code located
• NOT all conditions occurring
during/following medical care/surgery
classified as complications
84
Documentation of
Complications of Care I.B.16
• Must be cause-&-effect
relationship bet. care provided
& condition, and indication in
documentation that it is
complication
• Query provider for clarification,
if complication NOT clearly
documented
85
Complication codes with
external cause included
• Some T80-T88 codes have external cause
included in code
• Nature of complication
• Type of procedure that caused complication
• Ex: T81.512 Adhesions due to FB
accidently left in body following kidney
dialysis
• NO external cause code to ID type of
procedure necessary with these codes
86
Pain due to medical devices
• Pain associated w/devices, implants or
grafts left in surgical site (Ex: Painful hip
prosthesis)
• Chapter 19 code(s) (T codes)
• Add’l code(s) from G89 to ID acute or
chronic pain due to presence of device,
implant or graft
87
Complication Coding
Example 1
Bloodstream infection due to central venous catheter
T80.211A
88
Complication Coding
Example 2
• Dehiscence of closure rib cage, Right
ribs 5-7
T81.32xA
89
Break Time
• Fluid Exchanges
90