Note: Nancy Maguire has written a number of articles for our “Getting Paid” blog providing an overview of ICD-10 and the coding changes required. You can read these articles now. In this series of articles, she will look specifically at changes in specific chapters from ICD-9 to ICD-10.
An injury is a general term that refers to bodily harm caused by accidents, falls, blows, burns or corrosions, sprains, strains and more. The term “injury” may be synonymous with a wound or with trauma. ICD-10 classifies injuries to the anatomic site of the injury whereas ICD-9 classifies injuries to the type of injury (ex, fractures).
If the patient suffers multiple injuries, separate codes would be assigned for each injury unless a combination code is provided, in which case the combination code would be assigned. Chapter 19 covers the S-section for coding different types of injuries related to a single body region (ex, code S00.01xA, “Abrasion of scalp, initial encounter”), and the T-section covering injuries to unspecified body regions (ex, T17.890A, “Other foreign object in other parts of respiratory tract, part unspecified causing asphyxiation, initial encounter”). The T-section also describes poisoning and certain other consequences of external causes (ex, T42.3x1D, “Poisoning by barbiturates, accidental (unintentional), subsequent encounter”). The 7th character of “A” indicates an initial encounter and the 7th character of “D” is for a subsequent encounter. The majority of code assignments in chapter 19 require a 7th character assignment and most frequently it will be an A, D, or S (sequel or late effect):
- Extension “A” for initial encounters is used while the patient is receiving active treatment for the injury (e.g., surgical treatment, emergency department encounter, and evaluation and treatment by a new physician).
- The extension “D” for subsequent encounters 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 (e.g., cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow-up visits following injury treatment).
- Extension “S”, sequel (late effect), is used for complications or conditions that arise as a direct result of an injury, such as contracture after an injury. The contracture is the sequela of the injury. When using extension S, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The S is added only to the injury code, not the sequela code. The S extension identifies the injury responsible for the sequela. The specific type of sequela (e.g., contracture) is sequenced first, followed by the injury code. Sequela is a new term in ICD-10-CM and using the sequela extension replaces the late effects categories (905–909) in ICD-9-CM.
Code blocks begin each chapter in ICD-10-CM and there are 20 category blocks in chapter 19. Each block has a series of related conditions; for example, blocks S00-S09 describe injuries to the head. Blocks S60-S69 relate to injuries of the wrist and hand. Chapter 19 Injury codes have a fifth character to define the type of injury, a sixth character may describe laterality and a seventh character requirement for the encounter, (ex, S42.221G, “2-part displaced fracture of surgical neck of right humerus, subsequent encounter for fracture with delayed healing”). The 7th character will differ based on the injuries sustained.
Clinical terms and code descriptors are very specific in ICD-10
The clinical terms and code descriptors are very specific in ICD-10 and even the experienced coder may require additional anatomy and physiology training in preparation for this change. The S codes describing injuries have over 38,000 codes and a fracture of the femur could have over 600 code choices. The physician documentation must support the site of the injury, laterality, and the healing process, especially in coding fractures.
There are specific rules to follow in assigning ICD-10 diagnosis codes as there are in ICD-9 code selection. A fracture not indicated as displaced or nondisplaced should be coded to displaced. A fracture not indicated as open or closed should be coded to closed. Multiple fractures are sequenced in accordance with the severity of the fracture. Documentation must support the order of severity.
Care for complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7th character extensions for subsequent care with nonunion (K, M, N), or subsequent care with malunion (P, Q, R). For example, code S52.111P describes a Torus fracture of upper end of right radius, subsequent encounter for closed fracture with malunion. That is a lot of information bundled into one code and is an example of the detail required for ICD-10 codes in many cases.
Categories T36-T50 include codes for poisoning by, adverse effects of, and underdosing of drugs, medicaments, and biological substances. Underdosing is a new term in this section and describes taking less of a medication than is prescribed or instructed by the manufacturer, whether inadvertently or deliberately. The individual subcategories include poisoning by, adverse effect of, and underdosing choices. For example, subcategory T38.4x (Poisoning by, adverse effect of and underdosing of oral contraceptives):
- T38.4×1 Poisoning by oral contraceptives, accidental (unintentional);
- T38.4×2 Poisoning by oral contraceptives, intentional self-harm;
- T38.4×3 Poisoning by oral contraceptives, assault;
- T38.4×4 Poisoning by oral contraceptives, undetermined;
- T38.4×5 Adverse effect of oral contraceptives;
- T38.4×6 Underdosing of oral contraceptives (codes for underdosing will never be the primary or first-listed code).
The appropriate 7th character is to be added to each code from category T38 (A- initial encounter, D-subsequent encounter, or S-sequel encounter).
Complications of surgical and medical care
Chapter 19 also includes codes for complications of surgical and medical care, not classified elsewhere (T80-T88):
- T80 category describes Complications following infusion, transfusion and therapeutic injection;
- T81 Complications of procedures, not elsewhere classified;
- T82 Complications of cardiac and vascular prosthetic devices, implants and grafts;
- T83 Complications of genitourinary prosthetic devices, implants and 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, not elsewhere classified.
Categories T80-T88 must have a 7th character extension (A, D, S) to complete the full code. Additional code(s) would be assigned to identify the specified condition resulting from the complication. For example, T80.21 describes an infection due to central venous catheter and requires a 7th character. Code T80.21xA is a full code for the initial encounter. The placeholder X is required for the missing digit in the 6th place. If the physician documented the infection as sepsis, code A41.9 would be an additional code.
Chapter 19 can be complex and confusing at times, but the instructional notes and guidelines will make it less of a challenge. There are some codes in this chapter that describe the injury and the cause; in this case an external cause code will not be assigned (chapter 20). This chapter will require patience and persistence but with time and practice it can be managed.
Nancy Maguire, ACS, PCS, FCS, HCS-D, CRT, author of The Nancy Maguire GPS to ICD-10-CM Planning and Implementation Guide, is a nationally-renowned procedural and diagnostic coding instructor, bootcamp trainer, and workshop leader. She has spent more than 30 years as a hands-on coder and has authored countless coding articles and presentations. In her expansive career, she has transitioned from nursing, to coding, to practice management, auditing and consulting. Nancy served as Director of Coding and Reimbursement at UTMB in Galveston Texas for four years. She served the first two terms as president of AAPC in the early 1990s.
Hear Nancy speak in two complimentary archived webinars on ICD-10 presented by Kareo medical billing software: How to Prepare for ICD-10/5010 to Reduce F41.1 (Anxiety Reaction) or Preparing for ICD-10-CM: The Nitty-Gritty of Diagnosis Coding.