Basic ICD10 CM and ICD10 PCS Coding 2016
Basic ICD-10 -CM and ICD-10 -PCS Coding 2016 Edition Chapter 22 A: Injury (S 00 -T 34) © 2016
Learning Objectives • Review the chapter’s learning objectives • Review the chapter’s key terms • Many different injuries are described in this chapter with individual definitions and rules for coding • At the conclusion of this chapter, what must you know about the coding of traumatic injuries and related procedures? © 2016
ICD-9 -CM Chapter 19 Injury, Poisoning and Certain Other Consequences of External Cause, S 00 -T 88, Describe Injuries • This lesson focuses on traumatic injuries • Arranged by body region beginning with the head and concluding with the ankle and foot • Grouping of injury types together under the anatomic site where it occurred • Other conditions include burns and frostbite © 2016
ICD-9 -CM Chapter 19 Injury, Poisoning and Certain Other Consequences of External Cause, S 00 -T 88, Describe Injuries • The listing of conditions that follow the anatomic site are – Superficial injury; open wound; fracture – Dislocation and sprain; injury of nerves – Injury of blood vessels; Injury of muscle and tendon – Crushing injury – Traumatic amputation – Other and unspecified injuries © 2016
ICD-9 -CM Chapter 19 Injury, Poisoning and Certain Other Consequences of External Cause, S 00 -T 88, Describe Injuries • Blocks T 20 -T 22 classify burns and corrosions • Burn codes identify thermal burns, except sunburns, that come from a heat source, from electricity and radiation • Corrosion are burns due to chemicals © 2016
Coding Guidelines and Instructional Notes for Chapter 19 • At beginning of chapter 19 is note – Use secondary code(s) from chapter 20, External causes of morbidity, to indicate cause of injury • Codes within the T section that include the external cause do not require an additional external cause code © 2016
Coding Guidelines and Instructional Notes for Chapter 19 • ICD-10 -CM contains a note under the different categories of open wounds to direct the coder to code also any associated wound infection © 2016
Coding Guidelines and Instructional Notes for Chapter 19 • Most categories in chapter 19 have 7 th character extensions that identify the encounter – A = Initial Encounter – D = Subsequent Encounter – S = Sequela © 2016
Coding Guidelines and Instructional Notes for Chapter 19 • Fracture extensions are unique to the type of bone and the type of fracture as well as the episode of care, such as – Initial encounters – Subsequent encounters – Sequela © 2016
Coding Guidelines and Instructional Notes for Chapter 19 • Chapter-specific guidelines of ICD-10 -CM address – Application of 7 th characters in chapter 19 – Coding of injuries • Superficial injuries; primary injury with damage to nerves and blood vessels – Coding of traumatic fractures • Initial vs. subsequent encounter for fractures • Multiple fractures sequencing © 2016
Coding Guidelines and Instructional Notes for Chapter 19 • Chapter-specific guidelines of ICD-10 -CM address – Coding of burns and corrosions • Sequencing of burn and related condition • Burns of the same local site • Non-healing burns • Infected burn • Assign separate codes for each burn site • Extent of body surface involve • Treatment of sequela of burns • Sequelae with late effect and current burn © 2016
Coding Overview for ICD-10 -CM Chapter 19 • Classifies injuries according to the general type • Chapter 19 use two alphabetic letters as the first character of the code: “S” and “T” – The “S” section provides codes for various types of injuries related to single body system – The “T” section covers injuries to unspecified body regions as well as poisonings and certain other consequences of external causes © 2016
Seventh Characters in ICD-10 -CM Chapter 19 • Some injury codes have less than seven characters in length • A placeholder character X is used to fill a position to allow the addition of the seventh character to complete the code – For example, S 01. 01 XA, initial encounter for care of a laceration without foreign body of scalp – Sixth character is the placeholder value of X so the seventh character for initial encounter can be used © 2016
Seventh Characters in ICD-10 -CM Chapter 19 • The seventh character A for initial encounter is used while the patient is receiving active treatment for the injury, for example, surgical treatment, emergency department (ED) encounter, and evaluation and continuing treatment by the same or a different physician • The seventh character D for subsequent encounter is used for encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase • The seventh character S for sequela is used for complications or conditions that arise as a direct result of an injury – the S is added to the injury code, not the sequela or current condition © 2016
Fracture Codes in ICD-10 -CM Chapter 19 • Fracture codes include – Type of fracture – Specific anatomical site – Whether the fracture is displaced or not – Laterality – Routine vs delayed healing – Nonunions – Malunions © 2016
Fracture Codes in ICD-10 -CM Chapter 19 • Types of fractures are: – Closed fracture occurs when the bone breaks, but there is no puncture or open wound in the skin – Open fracture occurs when the bone breaks through the skin and may or may not be visible through the wound – Displaced fracture has a break into two or more parts and the ends of the bone needs to be realigned – Nondisplaced fracture is a crack in a bone, but the bone remains in alignment • Figure 22 A. 1, figure 22 A. 2, and figure 22 A. 3 are illustrations of various types of fractures © 2016
Fracture Codes in ICD-10 -CM Chapter 19 • Other types of fractures include – Comminuted fracture – Greenstick fracture – Impacted fracture – Oblique fracture – Pathological fracture – Stress fractures – Transverse fracture – Malunion fracture – Nonunion fracture • Review the definitions of all fractures in the textbook © 2016
Fracture Codes in ICD-10 -CM Chapter 19 • Fracture codes include 7 th characters ‒ A-Initial encounter for closed fracture ‒ B-Initial encounter for open fracture ‒ D-Subsequent encounter for fracture with routine healing ‒ G-Subsequent encounter for fracture with delayed healing ‒ K-Subsequent encounter for fracture with nonunion ‒ P-Subsequent encounter for fracture with malunion ‒ S-Sequelae © 2016
Fracture Codes in ICD-10 -CM Chapter 19 • Open fracture codes include 7 th characters such as ‒ B-Initial encounter for open fracture type I or II ‒ C-Initial encounter for open fracture type IIIA, IIIB, or IIIC ‒ E-Subsequent encounter for open fracture type I or II ‒ F-Subsequent encounter for open fracture type IIIA, IIIB, IIIC with routine healing ‒ H-Subsequent encounter for open fracture type I or II with delayed healing © 2016
Fracture Codes in ICD-10 -CM Chapter 19 • Open fracture codes include 7 th characters such as ‒ J-Subsequent encounter for open fracture type IIIA, IIIB, IIIC with delayed healing ‒ M-Subsequent encounter for open fracture type I or II with nonunion ‒ N-Subsequent encounter for open fracture type IIIA, IIIB, IIIC with nonunion ‒ Q-Subsequent encounter for open fracture type I or II with malunion ‒ R-Subsequent encounter for open fracture type IIIA, IIIB, IIIC with malunion © 2016
Fracture Guidelines in ICD-10 -CM Chapter 19 • According to ICD-10 -CM Coding Guidelines for fracture coding – When a fracture is not indicated as displaced or nondisplaced, it should be coded as displaced – When a fracture not indicated as open or closed, it should be coded as closed © 2016
Initial and Subsequent Encounters • Initial encounter in ICD-10 -CM means the patient is receiving active treatment for the injury, for example, surgical treatment, emergency department encounter, and evaluation and treatment by a new physician • Subsequent encounter in ICD-10 -CM means the patient has received active treatment; it means the patient is receiving routine care for the injury during the healing or recovery phrase; for example to change or remove a cast, remove fixation device, other aftercare, medication adjustments, and follow up visits following injury treatment © 2016
Sequela Situations • Seventh character S for sequela is used for complications and conditions that arise as a direct result of an injury, such as a scar formation after a burn • When coding for a sequela, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself • The 7 th character of S is added only to the injury code • This identifies the injury responsible for the sequela • The specific type of sequela is sequenced first • The injury code is sequenced second with the 7 th character of S © 2016
Dislocation and Subluxation • Dislocation is the displacement of a bone from its joint, specifically a disarrangement of the normal relation of the bones that form the joint • Joints most commonly affect are fingers, thumbs, and shoulders • A dislocation can occur with a fracture and the two conditions would be coded as a fracture • Figure 22 A. 4 is an illustration of the shoulder anatomy • A subluxation is an incomplete dislocation with the contact between the joint surfaces remaining in place • Main terms for the Alphabetic Index are “dislocation” by site and “subluxation” by site © 2016
Sprains and Strains • A sprain is a traumatic injury of the tendons, muscles, or supporting ligaments around a joint that may be the result of a turning or twisting of a body part • Treatment includes support, rest, and alternating heat and cold packs for the injury to heal • Figure 22 A. 5 illustrated the ligaments involved in an ankle sprain • Strain is an overstretching or overexertion of some part of the musculature; a strain can be a partial tear in the muscle attached to a bone • Treatment usually responds to rest, application of ice, and compression of the area with a wrap or supportive device © 2016
Intracranial Injury, Excluding Those with Skull Fracture • Category S 06, Intracranial injury, is used for various forms of traumatic brain injury excluding these injuries that occur with a skull fracture • Fourth character identify the specific intracranial injuries • Sixth character identify whether the patient did or did not have a loss of consciousness • Diagnosis of “head injury” is less specific and coded to S 09 category © 2016
Injury to Internal Organs • Injury to Internal Organs are coded to the organ site or region where the injury is present • Main terms are “injury, internal” with subterms for the anatomic sites, such as, aorta, bladder, bronchus, cecum, intestine as well as other internal sites • Other entries in the Index are “injury, internal, intraabdominal” for example for injuries to internal organs within a cavity • Seventh characters of “A”, “D”, and “S” are applied to identify the encounter of care © 2016
Open Wound and Crush Injury • A traumatic open wound is an injury of the soft tissue parts associated with a break or a rupture of the skin • May be animal bites, avulsions, cuts, lacerations, puncture wounds, and traumatic amputation • An open wound may be a penetrating wound, which involves the passage of an object through tissue that leaves an entrance and exit, as in the case of a knife or gunshot wound • Open wounds are classified by site, for example, head, neck, thorax, abdomen, lower back, pelvis and external genitalia, shoulder and upper arm, elbow and forearm, wrist, hand fingers, hip, thigh, knee, lower leg, ankle, feet and toes © 2016
Open Wound and Crush Injury • A crush injury or crushing wound occurs when a body part is caught or squeezed between two heavy objects usually by a high degree of pressure or force • Causes bruising, bleeding, compartment syndrome, fractures, lacerations, nerve injuries, and wound infections • Crushing syndrome is caused by trauma and characterized by destruction of muscle and bone with hemorrhage and fluid loss resulting in hypovolemic shock, hematuria, renal failure, and coma • Classified by site, such as head, neck, thorax, abdomen, lower back, pelvis, external genitalia, shoulder, upper arm, elbow, forearm, wrist, hand, fingers, hip, thigh, lower leg, ankle, and foot © 2016
Burns and Corrosions • Burns are caused by a heat source, such as fire or electricity • Corrosions are burns due to a chemical • Both are coded by site, depth, extent, and by agent or external cause • Burns of the eye and internal organs are coded by site • Burns are identified by the degree of the burn © 2016
Burns and Corrosions • • • © 2016 First-degree burn is least severe and includes damage to the epidermis or outer layer of skin alone Second-degree burn involves the epidermis and dermis – Mild to moderate edema with blisters – Known as superficial partial thickness or deep partial thickness • Superficial extends into the upper dermal layer and skin is pink or red • Deep extends into the deeper layers of derma leaving the skin red to pale with moderate edema Third-degree burn is most severe and includes all three layers of skin: epidermis, dermis and subcutaneous – Known as full-thickness burn – Skin may appear black, brown, yellow, white, or red; edema is severe – Burn penetrates the derma and may reach the subcutaneous fat
Burns and Corrosions • If multiple external burns exist, the site of the burn with the highest degree is coded and sequenced first – Additional codes are used for additional sites with lesser degree burns • External and internal burns may be sequenced according to the circumstances, that is, what is the main reason for the encounter • When burns exist with other injuries, such as smoke inhalation or organ failure, either condition could be listed first depending on the circumstances of the admission • When there is a burn of varying degrees on one site, one code is assigned for the highest degree for that site • A non-healing burn is coded as an acute burn • If a burn site is infected, an additional code for the infection is also assigned © 2016
Superficial Injury • Contusion are injuries of the soft tissue, the skin is not broken, small vessels or capillaries are ruptured and bleeding occurs in the tissue – May be referred to as a bruise – When blood becomes trapped in the interstitial spaces, the result is a hematoma • Contusions are classified according to the body site with laterality for the right, left, and unspecified site © 2016
Superficial Injury • Superficial injuries are conditions such as abrasion, blister, external constriction, superficial foreign body, insect bite, and other superficial bite of a specific location – Main term is “injury, superficial” followed by the body part with laterality for right, left, and unspecified side or by the word for the injury – Appropriate seventh character is used to identify the episode of care (A, D, or S) © 2016
Injury to Blood Vessels, Nerves, and Spinal Cord • When a primary injury results in minor damage to peripheral nerves or blood vessels, the code for the primary injury is sequenced first with additional codes for injuries to nerves, spinal cord, or blood vessels • When the primary or major injury is to the blood vessel or nerve, the code for that injury is sequenced first • Injuries to blood vessels may be a minor laceration or a major laceration that could be a complete transection or traumatic rupture of the blood vessel © 2016
Injury to Blood Vessels, Nerves, and Spinal Cord • Injuries to regions of the spinal cord as classified by – Type of injury such as complete lesion, central cord syndrome, anterior cord syndrome, Brown-Sequard syndrome, or other incomplete lesions – Injury to a spinal cord are classified by spinal region and then by level, for example, cervical or lumbar • Injuries to nerves are coded by the specific nerve involved • Each injuries requires a seventh character (A, D, and S) © 2016
Injury to Blood Vessels, Nerves, and Spinal Cord • Instructional notes appear for coding injuries to blood vessels, nerves, and spinal cord • Examples of notes include the following: – – Code first any associated intracranial injury Code any associated open wound Code any associated fracture Code any associated transient paralysis • The injuries require a seventh character to identify the episode of care (A, D, or S) © 2016
Traumatic Amputation • A traumatic amputation is the loss of a body part as the result of an accident or trauma • Amputations can be partial or complete • Categories for amputations of upper and lower extremities such as – Shoulder and upper arm – Elbow and forearm – Wrist, hand, and fingers – Hip and thigh – Lower leg – Ankle and foot © 2016
Traumatic Amputation • Each category requires the use of the appropriate seventh character to identify whether the treatment is initial (A), subsequent (D), or sequela of the amputation (S) • Laterality and the level of the amputation are included in the code © 2016
Effects of Foreign Body Entering Through Natural Orifice • Condition is the result of a foreign body entering through a natural orifice • These codes do not include a foreign body accidentally left in an open wound, a foreign body in penetrating wound, residual foreign body in soft tissue, or splinter without an open found • Categories are body systems with the 4 th, 5 th, and 6 th characters to identify the specific body part where the foreign body is located • Sixth character identifies a complication if present © 2016
Effects of Foreign Body Entering Through Natural Orifice • The main terms in the Alphabetic Index is “foreign body” and various subterms such as the site or “entering through orifice” • Other foreign bodies may be present with a laceration or a foreign body accidentally left following a procedure – Foreign body, in, laceration • Seventh character is used to indicate whether the episode of care is initial, subsequent, or sequela © 2016
Frostbite • Frostbite damages skin and subcutaneous tissue when the skin is exposed to low environmental temperatures • Patients with peripheral vascular disease and diabetes are more likely to develop frostbite when exposed to the cold • Injury is classified as to whether it is superficial or frostbite with tissue necrosis and to the site – More common sites are head and face, ear, nose, thorax, abdominal wall, arm, wrist, hand, finger, hip, thigh, knee, ankle, foot, and toe – Seventh character (A, D) indicate episode of care © 2016
ICD-10 -PCS Coding for Procedures Related to the Treatment of Injuries • Coding Fracture Treatment • Reposition is the root operation to move a body part to its normal location or other suitable location, that is all or a portion of a body part • Objective of the procedure is to restore the normal function and move the bone or bone fragments back into their proper position • Physician may use the term of “reduction” instead of reposition © 2016
ICD-10 -PCS Coding for Procedures Related to the Treatment of Injuries • Coding Fracture Treatment • The insertion of a device such as a pin to hold a nondisplaced fracture in position allows it to heal properly • Another insertion procedure to treat a fracture is putting in a bone growth stimulator to promote healing • Root operation is “insertion” © 2016
ICD-10 -PCS Coding for Procedures Related to the Treatment of Injuries • Coding Fracture Treatment • Immobilization is limiting or preventing motion of a body part • Immobilization is the placement of a cast or splint to promote healing of a fracture or dislocation • Codes identify the site/region with the device specifying if it is a splint, cast, or brace and the approach is always external © 2016
ICD-10 -PCS Coding for Procedures Related to the Treatment of Injuries • Coding Repair of Lacerations • Repair as the root operation is to restore, to the extent possible, a body part to its normal anatomical structure and function • Repair procedures include a variety of procedures such as suturing lacerations of the skin • If the repair is performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded • Repair are coded according to the body part of skin and its specific location • Approach is always external © 2016
- Slides: 46
