Colorado Trauma Network Colorado Trauma Registry Coding Injuries

Colorado Trauma Network/ Colorado Trauma Registry Coding Injuries in ICD 10 CM 10/1/2014 Health and Safety Data Services

Know someone who drowned from jumping off burning water skis? ICD 9 CM code 820 Description Fracture of neck of femur Roughed up by an Orca whale? Been injured in a spacecraft? ICD 10 CM main code S 72. 0 S 72. 1 S 72. 2 S 79. 0 Description Fracture of head and neck of femur Pertrochanteric fracture Subtrochanteric fracture of femur Physeal fracture of upper end of femur Don’t worry! There’s a code for that! Health and Safety Data Services

ICD 10 CM Conventions ICD 10 CM code structure – Specific injury site (e. g. , head, S 00 -S 09; neck, S 10 -S 19) are grouped rather than grouping by injury type as in ICD 9 CM (e. g. , fractures, 800 -829; dislocations, 830 -839) – More details for specific body regions (e. g. , right/left, bilateral, open/closed, rupture, severity of open fractures) – Codes with no predecessor in ICD 9 CM • Under dosing Blood type Glasgow Coma Scale Health and Safety Data Services

ICD 10 CM Conventions One ICD 9 CM code can be represented by multiple ICD 10 CM codes ICD 9 CM 807. 03 Description ICD 10 CM Description S 22. 4 Closed fracture of three ribs S 22. 41 Multiple fractures of ribs, right side S 22. 42 Multiple fractures of ribs, left side S 22. 43 Multiple fractures of ribs, unilateral S 22. 49 Multiple fractures of ribs, unspecified side Red = General Equivalence Mappings (GEMS) GEMS are not a substitute for learning how to use ICD 10 CM! Health and Safety Data Services

ICD 10 CM Conventions Level of Detail in Coding Composed of codes with 3, 4, 5, 6 or 7 digits • Three digits as the heading of a category • Can be followed by fourth and/or five digits which provide greater detail Seventh position and placeholders • “X” is used as a placeholder at certain codes to ensure the seventh value is always in the seventh position (also allows for future expansion) • The seventh position is the episode of care (initial, subsequent, sequela) e. g. , “A” (for initial encounter) is in the seventh position in “S 03. 4 xx. A Sprain of jaw, initial encounter” Health and Safety Data Services

ICD 10 CM Coding Manual • The latest version of the ICD 10 CM coding manual is available at: http: //www. cdc. gov/nchs/icd 10 cm. htm – Scroll down to “FY 2015 release of ICD-10 -CM” and click on “ICD-10 -CM PDF Format” and then “ICD 10 CM_FY 2015_Full_PDF. zip” file, and then the “FY 15_Tabular” file and go to Chapter 19 • This website posts a new coding manual each year, which includes any new codes that have been added • The new version goes into effect on October 1 each year Health and Safety Data Services

Don’t worry! There’s a code for that! ICD 9 CM code Description 820 Fracture of neck of femur es – there’s a different code for that! ICD 10 CM main code S 72. 0 S 72. 1 S 72. 2 S 79. 0 Description Fracture of head and neck of femur Pertrochanteric fracture Subtrochanteric fracture of femur Physeal fracture of upper end of femur Health and Safety Data Services

Chapter 19 – Injury Diagnosis Codes The basic structure in ICD 10 CM (3 -7 positions) S 52. 131 A Displaced fracture of neck of right radius, initial encounter for closed fracture #1 -Chapter (alpha –all letters except U) #2 -Major body region (always numeric) #3 -Major nature of injury #4 -6 -specific body region and nature of injury (placeholder when necessary) #7 - type of encounter A = Initial, D = Subsequent S = Sequela ICD 9 CM code 820 Description Fracture of neck of femur ICD 10 CM main code S 72. 0 S 72. 1 S 72. 2 S 79. 0 #1 #2 #3 • #4 #5 #6 #7 Injury chapter Elbow and forearm Fracture. Decimal upper end of radius neck of radius displaced, right radius Initial encounter Description Fracture of head and neck of femur Pertrochanteric fracture Subtrochanteric fracture of femur Physeal fracture of upper end of femur (with the exception of fractures) Health and Safety Data Services

Code Positions 1 -2 1: chapter 2: major body region 2: Major Body Region of Injury Site ICD 10 CM positions 1 -2 head S 0 neck S 1 thorax S 2 ICD 9 CM code Description ICD 10 CM main code abdomen, lower back, lumbar spine, pelvis and external genitals 820 Fracture of neck of femur shoulder and upper arm elbow and forearm S 72. 0 S 72. 1 S 72. 2 S 79. 0 Description S 3 Fracture of head and neck of femur Pertrochanteric fracture Subtrochanteric fracture of femur Physeal fracture of upper end of femur S 4 S 5 wrist, hand fingers S 6 hip and thigh S 7 knee and lower leg S 8 ankle and foot S 9 Health and Safety Data Services

Position 3 Major Nature of Injury Within each major body region, injuries are organized from superficial to deeper body structures 3: Major nature of injury 2: Major body region head Blood Muscle and Crush Amp. Other vessels tendons S 05 S 06 S 03 S 04 S 07 S 08 S 09 eye/orbit intracranial S 13 S 14 S 15 S 16 S 17 x S 19 S 23 S 24 S 25 heart S 26 S 27 S 28 S 29 S 36 abd ICD 10 CM main. S 34 Description S 33 S 35 S 37 S 38 S 39 -organs code Fracture of head and neck of femur S 43 S 72. 0 S 46 S 47 S 48 S 49 S 72. 1 S 44 Pertrochanteric S 45 fracture Subtrochanteric fracture of femur S 53 S 72. 2 S 55 S 56 S 79. 0 S 54 Physeal fracture of upper end of femur S 57 S 58 S 59 elbow forearm Superficial Open Fracture D/S/S Nerves S 00 S 01 S 02 neck S 10 S 11 thorax S 20 S 21 abdomen, lower back, lumbar ICD 9 CM code Description S 30 S 31 spine and pelvis shoulder and upper 820 arm Fracture of neck of femur S 40 S 41 S 12 S 22 elbow and forearm S 50 S 51 S 52 wrist and hand S 60 S 61 S 62 hip and thigh S 70 S 71 S 72 knee and lower leg S 80 S 81 S 82 ankle and foot S 90 *D/S/S = joint dislocation/sprain/strain S 91 S 92 S 32 S 42 S 63 S 64 S 73 S 74 hip S 83 S 84 low knee -leg S 93 S 94 S 65 S 66 S 67 S 68 S 69 S 75 S 76 S 77 S 78 S 79 S 85 S 86 low-leg low -leg S 87 S 88 S 89 S 95 S 96 S 97 S 98 S 99 Health and Safety Data Services

Position 4 4: Often a specific body region (subsection of 2 (e. g. , from head to nose)). Also see “other parts” or “unspecified” – similar to what would be derived from a ICD 9 CM GEM 3: Major nature of injury 2: Major body region Superficial Open Fracture D/S/S head S 00 ICD 9 CM code neck thorax abdomen, lower back, lumbar spine, pelvis 820 Description Fracture of neck of femur S 11 S 22 Common 4 th position terms Scalp, nose, Description ear, lips and oral cavity ICD 10 CMeyelid, main code S 72. 0 and Fracture of head and neck of femur Larynx trachea, thyroid, pharynx and S 72. 1 Pertrochanteric fracture S 72. 2 esophagus Subtrochanteric fracture of femur cervical S 79. 0 Physeal fracture of upper end of femur Thoracic vertebra, sternum, one rib, multiple ribs, flail chest Lumbar intervertebral disc, lumbar vertebra, sacroiliac and sacrococcygeal joint, unspecified S 33 parts of lumbar spine and pelvis, rupture of symphysis pubis, ligaments of lumbar spine Health and Safety Data Services

Fracture of Femoral Neck 1: chapter 2: major body region 3: major nature of injury 4: specific body region (often a subsection of 2; e. g. , hip to femur) ICD 9 CM code 820 Description Fracture of neck of femur Description 820 Fracture of neck of femur ICD 10 CM main code S 72. 0 S 72. 1 S 72. 2 S 79. 0 Description of head and neck of femur ICD 10 CM main code Fracture Description Pertrochanteric fracture Subtrochanteric fracture of femur S 72. 0 Fracture of head Physeal fracture of upper end of femurand neck of femur S 72. 1 Pertrochanteric fracture S 72. 2 Subtrochanteric fracture of femur S 79. 0 Physeal fracture of upper end of femur Health and Safety Data Services

Fracture of Rib(s), Sternum, Larynx and Trachea 1: chapter 2: major body region 3: major nature of injury 4: specific body region (e. g. , from neck to trachea) ICD 9 CM code 807 820 Description Fracture of neck of femur Description Fracture of rib(s), sternum, larynx and trachea ICD 10 CM main code S 72. 0 S 72. 1 S 72. 2 S 79. 0 Description Fracture of head and neck of femur Pertrochanteric fracture ICD 10 CM main code Description Subtrochanteric fracture of femur Physeal fracture of upper end of femur S 12. 8 Fracture of other parts of neck S 22. 2 Fracture of sternum S 22. 3 Fracture of one rib S 22. 4 Fracture of multiple ribs S 22. 5 Flail chest Health and Safety Data Services

Position 5 4: specific body region 5: often a specific nature of injury (often associated with 3; e. g. , from open to puncture); sometimes a cause code (e. g. , bite) 3: major nature of 4 th position Common 5 th position terms injury Superficial injury abrasion, blister (nonthermal), contusion, Superficial injury of of ear (S 00. 4) external constriction, foreign body, insect bite head (S 00) (nonvenomous), other bite Open. Description wound of ICD 9 CM ICD 10 CM main Description Open wound ofcode neck code thyroid gland laceration or puncture w/ w/o foreign body, bite 820 Fracture of neck of femur S 72. 0 Fracture of head and neck of femur (S 11) S 72. 1 Pertrochanteric fracture (S 11. 1) S 72. 2 Subtrochanteric fracture of femur S 79. 0 Physeal fracture of upper end of femur Fracture of rib(s), Multiple fracture sternum and thoracic Right/left side, bilateral of ribs (S 22. 4) spine (S 22) Dislocation and sprain Subluxation and of joints and dislocation of L 1/L 2…L 4/L 5 lumbar vertebra ligaments of lumbar vertebra spine and pelvis (S 33) (S 33. 1) Health and Safety Data Services

Position 6 5: often a specific nature of injury (often associated with 3; e. g. , from open to puncture); sometimes a cause code (e. g. , bite) 6: often a more specific region or nature of injury, placeholder or LOC 4 th position 5 th position code Superficial injury of ear (S 00. 4) ICD 9 CM code 820 External constriction of ear (S 00. 43) Description Fracture of neck of femur Open wound of thyroid gland (S 11. 1) Multiple fracture of ribs (S 22. 4) Common 6 th position terms ICD 10 CM main code S 72. 0 S 72. 1 S 72. 2 S 79. 0 Right, left, unspecified Description Fracture of head and neck of femur Pertrochanteric Laceration with foreign body of fracture X – placeholder Subtrochanteric fracture of femur Physeal fracture of upper end of femur thyroid gland (S 11. 12) Multiple fracture of ribs, right X – placeholder side (S 22. 41) Subluxation and dislocation of of lumbar vertebra (S 33. 1) L 4/L 5 lumbar vertebra (S 33. 14) Select subluxation or dislocation Health and Safety Data Services

Measure twice, cut once! ICD 9 CM code 820 Description Fracture of neck of femur Y 93. D 1 Actively knitting and crocheting Cookie fatigue, Santa? ICD 10 CM main code S 72. 0 S 72. 1 S 72. 2 S 79. 0 Description Fracture of head and neck of femur Pertrochanteric fracture Subtrochanteric fracture of femur Physeal fracture of upper end of femur T 73. 3 xx. S Exhaustion due to excessive exertion Health and Safety Data Services

Epidural Hematoma with LOC 1: S 2: Head 3: Muscle and tendons + some organs 4: From head to epidural (often a subsection of 2) 5: Placeholder (often a subsection of 3) 6: LOC duration ICD 9 CM Description main code 852 Subarachnoid, subdural and extradural hemorrhage ICD 10 CM main code S 06. 4 Description 5: 6: Epidural hemorrhage x 0 -9 Possible ICD 10 CM code S 06. 4 x 3 A Epidural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes Health and Safety Data Services

Contusion in Head or Neck Region ICD 9 CM Description ICD 10 CM Description code 920 Contusion of face, scalp, S 00. 93 X Contusion of unspecified part of head and neck except eye(s) S 00. 03 Contusion of scalp Contusion of nose S 00. 33 1: chapter Contusion of ear S 00. 43 2: major body region S 00. 431 Contusion of right ear 3: major nature of injury S 00. 432 Contusion of left ear 4: specific body ICD 9 CM region code Description ICD 10 CM main Description S 00. 439 Contusion of unspecified ear code (often a subsection 2 of; femur 820 Fractureof of neck S 72. 0 Fracture of head and neck of femur S 00. 53 Contusion of lip and S 72. 1 Pertrochanteric fracture oral cavity S 72. 2 Subtrochanteric fracture of femur e. g. , from head to scalp) S 79. 0 Physeal S 00. 531 Contusion offracture lip of upper end of femur 5: specific nature of injury S 00. 532 Contusion of oral cavity (often a subsection of 3; S 00. 83 Contusion of other part of head e. g. , superficial to contusion) Contusion of throat S 10. 0 6: often a placeholder, location, Contusion of other specified part of neck S 10. 83 or more injury specificity S 10. 93 X Contusion of unspecified part of neck Red = GEMS equivalent Health and Safety Data Services

Episode of Care - Position 7 Type of encounter* A: Initial encounter Active treatment, ER encounter, evaluation and treatment by a new physician D: Subsequent encounter Routine care during healing/recovery phase (e. g. , cast change/removal, removal of external fixation device, planned follow-up visits) ICD 9 CM code 820 S: Sequela Description Fracture of neck of femur ICD 10 CM main code S 72. 0 S 72. 1 S 72. 2 S 79. 0 Description Fracture of head and neck of femur Pertrochanteric fracture Subtrochanteric fracture of femur Physeal fracture of upper end of femur Complications or conditions that arise as a direct result of the injury (e. g. , scar from burn) – Sequela replaced the late effects categories (905 -909) in ICD 9 CM – Only used with the injury code where the sequela exists *with the exception of fractures Health and Safety Data Services

Position 7 - Fractures Type of encounter** A Initial encounter for closed fracture B Initial encounter for open fracture D Subsequent encounter for fracture with routine healing G K Subsequent encounter for fracture with delayed healing ICD 9 CM code Description ICD 10 CM main code S 72. 0 S 72. 1 S 72. 2 S 79. 0 Description Subsequent encounter for fracture with nonunion 820 Fracture of neck of femur Fracture of head and neck of femur Pertrochanteric fracture Subtrochanteric fracture of femur Physeal fracture of upper end of femur P Subsequent encounter for fracture with malunion S Sequela **for use with fractures only Note: In ICD-10 -CM, a fracture not indicated as displaced or nondisplaced should be coded to displaced, and a fracture not designated as open or closed should be coded as closed. Health and Safety Data Services

Position 7 – OPEN Fractures Type of encounter*** Apply to categories: S 52 – Fracture of forearm S 72 – Fracture of femur Gustilo open fracture classification B Initial encounter for open fracture type I or II S 82 – Fracture of lower leg C Initial encounter for open fracture type IIIA, IIIB, IIIC E Subsequent encounter for open fracture type I or II with routine healing F Subsequent for open fracture. ICD 10 CM typemain. IIIA, IIIB, IIIC with routine healing ICD 9 CM code encounter Description H Fracture of head and neck of femur Subsequent encounter for open fracture type I or II withfracture delayed healing Pertrochanteric 820 Fracture of neck of femur code S 72. 0 S 72. 1 S 72. 2 S 79. 0 Subtrochanteric fracture of femur Physeal fracture of upper end of femur 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 ***for with open fractures only Health and Safety Data Services

ICD 9 CM code 820 Description Fracture of neck of femur ICD 10 CM main code S 72. 0 S 72. 1 S 72. 2 S 79. 0 Description Fracture of head and neck of femur Pertrochanteric fracture Subtrochanteric fracture of femur Physeal fracture of upper end of femur Health and Safety Data Services

For More Information Scott Beckley, Ph. D Health Facilities and EMS Division Colorado Department of Public Health & Environment 4300 Cherry Creek Drive South Denver, CO 80246 -1530 scott. beckley@state. co. us P: (303) 692 -2851 F: (303) 691 -7720 www. coems. info ICD 9 CM code 820 Description Fracture of neck of femur ICD 10 CM main code S 72. 0 S 72. 1 S 72. 2 S 79. 0 Description Fracture of head and neck of femur Pertrochanteric fracture Subtrochanteric fracture of femur Physeal fracture of upper end of femur Health and Safety Data Services