By Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer
When a patient suffers a traumatic injury or poisoning, we need to report how they became injured and where they were when it happened. You already know this from ICD-9-CM. Similarly, in ICD-10-CM, to tell the whole story, you need to report codes that explain:
- Cause of the injury, such as a car accident or a fall off a ladder
- Place of the occurrence, such as the park or the kitchen
- Activity during the occurrence, such as playing basketball or gardening
- Patient’s status, such as paid employment, on-duty military, or leisure activity
That’s a lot of information.
However, think how important these details are to the reimbursement process, as well as to research studies. Connecting traumatic brain injuries to those riding a bicycle or motorcycle provided the statistics that legislators needed to mandate riders wear helmets. Including a code to report a fall into a swimming pool may help with getting improved fencing and save others.
Sharing the knowledge that the injury occurred while the patient was hiking in the woods can support the administration of an anti-toxin that saves the patient’s life.
To begin the process of determining the appropriate external cause codes for a specific encounter, start in the Alphabetic Index.
However, these codes have a separate index. You will not use the Alphabetic Index to Diseases, in which you usually find a suggestion for an ICD-10-CM code. Instead, you will use the Alphabetic Index to External Causes, located after the Alphabetic Index to Diseases, after the Table of Drugs and Chemicals, and before the Tabular List.
Cause of the injury code
When a body part meets with an external object and the result is an injury, you must explain what that external object or force was. Sequence this external cause code after the code or codes for the injury itself.
The cause may be anything from being stepped on by a cow (W55.29X-) to falling from scaffolding (W12.XXX-) to the forced landing of a hot air balloon injuring the occupant (V96.02X-).
Domestic violence, child abuse, and elder abuse are considered assault and may be the cause of a physical injury (code category Y07).
You need to determine from the documentation what caused the fracture, dislocation, sprain, or strain and report it with the appropriate code or codes.
With ICD-10-CM, the external cause codes will continue to be reported throughout treatment, not solely with the first encounter.
Clinicians in the ED and those who see the patient during the new admission or evaluation once the patient arrives on the floor will need some additional training to ask the necessary questions to the patient so these codes can be reported accurately.
This information is important to the reimbursement process. Consider a patient who was driving a pickup truck and injured in a collision with a heavy transport vehicle in a non-traffic accident (code V54.0-). By having this information, billing may direct the claim to the auto insurance company (not the health insurance carrier). In addition, the information may support any legal action.
Place of occurrence codes
You may be familiar with ICD-9-CM code category E849 (place of occurrence), used to report where the patient was when he or she was injured.
In ICD-10-CM, code category Y92 (place of occurrence of the external cause) provides you with many more options. For example, you can report that the patient slipped and tore his deltoid muscle while he was at a:
- Apartment (category Y92.03-)
- Boarding house (Y92.04-)
- Institutional location (Y92.1-)
- Mobile home (Y92.02-)
- Non-institutional location
- Single-family (private) house (Y92.01-)
You can also state specifically where precisely the patient suffered the injury:
- Bathroom
- Bedroom
- Driveway
- Garage
- Garden
- Kitchen
- Yard
The codes are quite specific, so you need to ensure that your physicians are equally specific in their documentation.
In ICD-9-CM, you had one code (E849.4) to report a place for recreation and sport. ICD-10-CM includes different codes to identify if that sports location was, among others:
- Basketball court (ICD-10-CM code Y92.310)
- Golf course (Y92.39)
- Soccer field (Y92.322)
- Squash court (Y92.311)
- Skating rink (Y92.330for ice skating, Y92.331 for roller skating)
Activity codes
Code category Y93 in ICD-10-CM provides you with many activities to identify what exactly the patient was doing when he or she became injured.
This is very similar to ICD-9-CM codes E001-E030.
Dancing, yoga, gymnastics, jumping on a trampoline, and cheerleading all have their own codes, and this is just one subcategory!
Y93.C1 (activity, computer keyboarding) could support a workers’ compensation claim for carpal tunnel syndrome. Code Y93.82 (activity, spectator at an event) could explain how the patient went to a baseball game and ended up with electrical injuries if it follows code T75.01xA (shock due to being struck by lightning). And fair warning to those who insist on texting while driving; we will report Y93.C2 (activity, hand-held interactive electronic device).
Patient’s status
This sounds a bit obscure, certainly. What was the patient’s status at the time the injury occurred? Just as with ICD-9-CM code category E000, ICD-10-CM code category Y99 (external cause status) includes four options:
- Y99.0, civilian activity done for income or pay—in other words, on the job for pay or other compensation, excluding on-duty military or volunteers
- Y99.1, military activity, excluding off-duty status at the time
- Y99.2, Volunteer activity
- Y99.8, other external cause status, which includes leisure activities, student activities, and working on a hobby
This detail is important to the entire process, including reimbursement and continuity of care. For example, when you report that the patient’s status was “civilian activity done for income or pay,” it will be clear that this is a workers’ compensation case and not a claim to be sent to the patient’s health insurance carrier.
Remember, an external cause code can never be a first-listed code, and it can never be the only code reported. External cause codes are reported secondary to the codes that report the injury itself.
And as the ICD-10-CM Official Guidelines for Coding and Reporting remind us, we don’t have a national requirement for mandatory ICD-10-CM external cause code reporting. Be sure you know which payers require external cause codes. Even if these codes are not required, they provide a wealth of additional detail that can better tell the patient’s story.
Editor’s note: Safian, of Safian Communications Services in Orlando, Florida, is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee. Email her at ssafian@embarqmail.com.