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Procedure
Practice 01/15/00 - Coding
Recommendations
Injuries
and Poisoning - Part 2
Injuries and Poisoning
- Part 1
Coders in all healthcare facilities review and assign codes
for accidental injury cases. This month we begin a two-part
review of pertinent coding guidelines with examples from selected
sections of ICD-9-CM, Chapter 17, Injury and Poisoning.
Chapter 17 classifies the following injuries:
- Fractures, dislocations, sprains and strains
- Intracranial injuries with and without loss of consciousness
- Internal injuries
- Open wounds, burns, and contusions
- Superficial, vascular, and nervous system (spinal cord)
injuries
- Crush and foreign body injuries
- Late effects of injuries, poisoning, and other external
causes
- Poisoning and toxic effects of both medicinal and nonmedicinal
substances
- Certain traumatic complications and unspecified injuries
- Other and unspecified effects of external causes
- Complications of surgical and medical procedures
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Code each separate injury
in order to capture the most accurate data regarding the
type and extent of trauma.
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The combination codes for
multiple injuries should be used only if documentation
is insufficient to detail each component injury.
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If the patient with a current
fracture is admitted as an inpatient for an unrelated
diagnosis, the fracture may be coded as an additional
diagnosis if it has a bearing on the hospital stay. According
to Coding Clinic, a V-code should be used to
code the presence of the fracture. |
Example: A 12-year-old
boy was admitted for status asthmaticus, but also had
a right arm cast for a radial shaft fracture. The child
required nursing care for dressing, bathing, and eating
because of his cast. In this case, the coder assigns 493.91,
Asthma, unspecified, with status asthmaticus, as
the principal diagnosis. In addition, it is appropriate
to assign code V54.9, Unspecified orthopedic aftercare,
because the fracture required increased nursing care during
the patient's hospital stay.
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In multiple injury cases,
the code for the most severe injury as documented by the
attending physician is sequenced first.
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Do not code superficial injuries
associated with more severe injuries of the same site.
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Example: A patient suffered
an abrasion of the nose and a nasal bone fracture. Assign
802.0, Fracture of face bones, nasal bones, closed,
to correctly code this case.
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If an injury such as an open
wound caused minor damage to vascular structures or peripheral
nerves, code the primary injury first and assign secondary
codes for the injured blood vessels or nerves. If the
primary injury was to the blood vessels or nerves, that
injury is coded first. If documentation of the injuries
is unclear, ask the physician to document the severity
of the injury in question. |
Example: The patient
cut her hand on a piece of broken glass and suffered an
open wound of the palm with tendon involvement and damage
to the digital nerve. The correct sequence of codes for
this case is 882.2, Open wound of hand with tendon
involvement, and 955.6, Injury to digital nerve.
Also assign E920.8, Accident caused by other specified
cutting and piercing instruments or objects, to identify
the external cause of the injury.
Example: The diagnostic
statement reads: "Laceration of peroneal nerve and
puncture wound of lower leg with foreign body due to BB
gun blast." In this case, the peroneal nerve laceration
was the primary injury. Sequence the codes as follows:
956.3, Injury to peripheral nerve of pelvic girdle
and lower limb, peroneal nerve; 891.1, Open wound
of knee, leg and ankle, with foreign body;
and E922.4, Accident caused by firearm and air gun
missile, air gun.
Skull Fractures
The skull is composed of two portions, the viscerocranium
(facial bones) and the neurocranium (braincase). Fractures
of the neurocranium (categories 800-801 and 803-804) must
be coded to the fifth digit level, the fifth digit being the
indicator of loss of consciousness. Since skull fractures
result from trauma, many patients are treated within the emergency
setting, and the level of consciousness may change prior to
admission. Review all documentation, including the emergency
room and ambulance records, to determine the level of consciousness
and duration of loss of consciousness. Also look for evidence
of concussion. If documented, use the fifth digit 9 to indicate
a concussion.
Example: A man fell from
a ladder and suffered a closed occipital fracture. The ambulance
run sheet documents a 10-minute loss of consciousness at
the scene of the accident; however, the patient was awake
and alert upon arrival at the emergency room. The correct
codes for this case are 801.02, Closed fracture of base
of skull without mention of intracranial injury, with brief
(less than one hour) loss of consciousness; and E881.0,
Fall from ladder.
Vertebral Column Fractures
Fractures of the vertebrae are coded to categories 805 and
806. Codes 805.0 and 805.1 require a fifth digit (0-8) to
identify the site of cervical vertebral injury. In all cases
of vertebral fractures, be certain to review documentation
for associated spinal cord injury. Look for signs and symptoms
such as spinal concussion, paralysis, hematomyelia, paraplegia,
or quadriplegia. In cases of documented spinal cord damage,
choose a combination code from category 806, Fracture of
vertebral column with spinal cord injury. It is incorrect
to assign a separate code for spinal cord damage associated
with a vertebral fracture.
Example: The record documents
a closed sacral fracture with associated cauda equina injury.
Assign 806.62, Fracture of vertebral column with other
cauda equina injury, sacrum and coccyx, closed.
Multiple Fractures and Fractures with
Dislocations
Multiple fractures of specified sites are generally coded
individually by site based upon the level of detail provided
in the medical record. Combination categories for multiple
fractures may be used if the record does not provide sufficient
detail to code with more specificity. Specific principles
govern the application of multiple fracture codes.
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Multiple fractures of the
same limb, classified to the same three or four digit
category, are coded to that category. |
Example: A patient was struck by a falling
object and suffered closed fractures of the metacarpals
and phalanges of the right hand. This case is coded 817.0,
Multiple fractures of hand bones, closed.
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Multiple unilateral or bilateral
fractures of the same bone classified to different 4th
digit subcategories of the same three-digit code are coded
individually by site. |
Example: The diagnostic statement reads:
"Open fracture of distal radius with closed radial
shaft fracture." Because the 4th digit subcategories
for a radial shaft and a distal radius fracture are not
the same, two codes are needed for this case. Assign 813.52,
Other fractures of distal end of radius, alone, open,
and 813.21, Fracture, radial shaft, closed.
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The Index to Diseases contains
specific coding instructions for multiple fractures of
sites classifiable to different 3-digit categories. Remember
that if sufficient detail is provided in the record, each
component fracture should be coded separately. The combination
categories for multiple fractures are used only if the
chart does not provide enough information to code with
more specificity. |
Example: The diagnostic statement reads:
"Open facial fractures with multiple fractures of
thoracic and lumbar vertebrae." Because the patient
was transferred emergently to a trauma center, no further
detail is provided in the record. The correct code assignment
for this case is 804.50, Multiple fractures of skull
or face with other bones, open without mention of intracranial
injury, unspecified state of consciousness.
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Multiple fractures are sequenced
according to the severity of the fracture. The coder should
consult the physician if a sequencing question exists.
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Example: A child sustained closed fractures
of the orbital floor, 3rd and 4th ribs, after falling
off a horse. The physician determined that the orbital
floor fracture was the most severe injury. Correct coding
and sequencing for this case is as follows: 802.6, Orbital
floor (blow-out) fracture, closed; 807.02, Closed
fracture of two ribs; and E828.2, Accident involving
animal being ridden, injuring rider of animal.
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Cases of combined fracture
and dislocation of the same anatomic site are assigned
only the fracture code. Instructions in the Alphabetic
Index state: "dislocation, with fracture: see fracture,
by site." |
Example: A patient is treated for a
closed fracture of the medial malleolus with dislocation
of the ankle joint. Assign 824.0, Fracture of medial
malleolus, closed.
Other and Unspecified Fractures
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Fractures not specified as
either open or closed are coded as closed unless associated
conditions or complications indicate the fracture was
open. For example, if the clinical record implies a wound
is "compound," "infected," "missile,"
"puncture," or "with foreign body,"
the fracture may be open, but the coder should always
seek physician verification before assigning the code.
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Remember that an open wound
associated with a fracture does not always indicate an
open fracture. If the wound is superficial and does not
expose the fracture site, then the fracture is coded as
closed.
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Two types of fractures are
not the result of injury and are assigned codes from other
ICD-9-CM chapters. Fractures due to birth injuries are
assigned codes from Chapter 15, which deals with conditions
arising in the perinatal period. Pathological fractures
are coded to Chapter 13, the musculoskeletal and connective
tissue chapter. |
A dislocation is the traumatic displacement of the bones
in an articulating joint such that they lose their normal
anatomic position. The bones may completely lose contact with
their articulating surfaces, or the loss of contact may be
partial with only mild displacement.
The first step in coding dislocations is to determine if
the dislocation is open or closed. Make sure to select the
appropriate 4th digit subclassification to correctly identify
the open/closed status. Then follow these basic guidelines:
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If a bone has both a fracture
and dislocation, code to the fracture.
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In cases of multiple dislocations,
apply as many codes as needed to accurately describe the
sites.
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The initial dislocation of
a joint is coded to the acute injury code. Subsequent
dislocations of the same site are coded to the musculoskeletal
system chapter as recurrent dislocations.
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Code chronic dislocations
due to injury as recurrent.
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Depending upon the specifics
of the case, recurrent dislocations may be coded to the
musculoskeletal system or to the congenital anomaly chapter. |
Example: If the record states only "dislocation
of hip," the following coding possibilities exist:
- 835.00, Dislocation of hip, closed dislocation,
dislocation of hip, unspecified;
- 754.30, Congenital dislocation of the hip, unilateral;
- 718.35, Recurrent dislocation of joint, pelvic
region and thigh.
In this example, the documentation does not specify whether
the dislocation is an acute initial event (835.00), a chronic
condition (718.35), or a congenital joint abnormality (754.30).
Always review the entire record and then ask the physician
if the nature of the diagnosis remains vague.
A sprain is a complete or partial tear in one or more of
the ligaments that surround and support a joint. A strain
is an injury to tendons and/or muscles caused by overuse or
overextension. This code range also applies to ruptures of
joint capsules, ligaments, muscles, and tendons.
Example: A soccer player hyperextended
her knee during a kick and ruptured the posterior cruciate
ligament. The correct codes for this case are 844.2, Sprains
or strains of knee and leg, cruciate ligament of knee;
and E927, Overexertion and strenuous movements.
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Per the "Excludes"
note at the beginning of this code series, tendon laceration
due to an open wound is not coded to this category. Open
wounds with tendon involvement are coded to 880-884 and
890-894 with the 4th digit of 2.
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Be sure to read the "Excludes"
note under 848.5, Pelvic sprains and strains, which
directs the coder to 665.6 (with the appropriate 5th digit
of 0, 1, or 4) to code damage to pelvic joints and ligaments
sustained during childbirth. |
Codes 850.0 through 850.9 are used specifically to code concussion
without other mention of intracranial injury. Concussion is
a condition that occurs when the brain strikes the skull as
the result of a blow or whiplash injury to the head. Though
the injury is not severe enough to cause a cerebral contusion
(coded to category 851), concussion can cause confusion, disorientation,
nausea and vomiting, or impairment of vision or balance. Most
concussion patients recover completely within 48 hours of
injury.
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When coding concussion, be
sure to select the appropriate 4th digit to indicate any
loss of consciousness. |
Example: A 6-year-old child fell from
his bike and struck his head. He is unconscious for approximately
3 minutes. He presented to the emergency department with
headache, dizziness, nausea and vomiting. The physician's
discharge diagnosis was head injury with concussion and
brief loss of consciousness. The correct codes for this
case are 850.1, Concussion with brief loss of consciousness;
and E826.1, Pedal cycle accident, pedal cyclist.
Note that code 959.01, Head injury, unspecified,
is not correct in this case, as it specifically excludes
head injury with concussion.
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As with the series of codes
for neurocranial fracture, codes 851-854 require a 5th
digit to describe any loss of consciousness.
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Cuts and bruises to the brain
are coded to category 851, Cerebral lacerations and
contusions. Review documentation for evidence of head
trauma with severe head bruising or open head wound, neurologic
deficits such as abnormal respirations, unequal pupil
size and response, varying degrees of paralysis, and seizure
activity.
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Categories 852 and 853 describe
subdural, subarachnoid, extradural, and other intracranial
bleeding caused by injury. The 4th digit subclassifications
denote the presence or absence of an open intracranial
wound.
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Category 854 is used for other
and unspecified brain injuries that cannot be coded to
850-853 or 959.01 (head injury NOS). |
Internal
Injury of Thorax, Abdomen, and Pelvis (860-869)
This code range covers internal injury to the organs of the
major body cavities. Many types of injuries and injury mechanisms
are addressed: blunt trauma, blast injury, laceration, hematoma,
crushing injury, puncture, tear, bruising, concussion (of
organs other than the brain), and traumatic rupture.
Codes within this range are categorized by body region:
- Traumatic pneumothorax and hemothorax (860)
- Injuries to heart and lungs (861)
- Injuries to other intra-thoracic organs (862)
- Injuries to gastrointestinal tract (863)
- Injury to liver (864)
- Injury to spleen (865)
- Injury to kidney (866)
- Injury to pelvic organs (867)
- Injury to other intra-abdominal organs (868)
- Injury to unspecified or ill-defined organs (869)
The 4th digit subcategories within each 3-digit code series
denote the presence or absence of an open wound. The description
"with open wound" includes open wounds that may
be infected as well as open wounds with foreign bodies.
The following 3-digit categories require a 5th digit:
- 861
- 862.2-862.3
- 863.2-863.9
- 864
- 865
- 866
- 868
Example: The diagnostic statement reads:
"Ruptured spleen due to fall from tree." A review
of category 865, Injury to spleen, reveals that we
will need a 4th digit to indicate the absence of an open
wound and a 5th digit to describe the extent of the trauma.
Assign 865.04, Injury to spleen without mention of open
wound into cavity, massive parenchymal disruption, and
E884.9, Other fall from one level to another, to
describe the external injury cause.
Open wounds are bites, cuts, avulsion injuries, lacerations,
puncture wounds, and traumatic amputations.
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The term "complicated"
used in the 4th digit subdivisions of categories 873-897
denotes open wounds with major infection, foreign body,
delayed healing, or delayed treatment.
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Per the "Excludes"
note at the beginning of this code range the following
types of injuries are coded to other categories within
Chapter 17: burns, crush injuries, puncture of internal
organs, superficial injuries, and open wounds that are
incidental to fractures, dislocations, internal injuries,
or intracranial injuries.
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Do not code late effects of
open wounds to this code range. Refer to the Index of
Diseases entry "Late, effect, wound, open, by site"
to determine the correct code. (Late effects will be discussed
in February's Coding Edge). |
Codes are categorized by general body region and then further
subdivided. The three broad subheadings are:
- Head, neck, and trunk (870-879)
- Upper limbs (880-887)
- Lower limbs (888-897)
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Read wound descriptions carefully
to determine the site of injury, tendon involvement, the
presence of infection, the presence of foreign body (frequently
documented as dirt, wood chips, debris, gravel, shrapnel,
etc.), and elapsed time between injury and treatment.
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Example: A motorcyclist lost control
of his bike on a wet highway and sustained an open wound
of the forearm. The emergency room nurse documented the
presence of gravel and dirt embedded in the wound. The
diagnostic statement reads, "Contaminated 7 cm open
wound of forearm." Assign 881.10, Open wound of
elbow, forearm and wrist, complicated, forearm; and
E816.2, Motor vehicle traffic accident due to loss
of control, without collision on the highway, motorcyclist.
This series of codes includes arterial hematomas, avulsions,
cuts, lacerations, ruptures, traumatic aneurysms, and traumatic
fistulas of blood vessels secondary to other injuries.
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If the major injury was to
a blood vessel, code and sequence that injury first. |
Example: The diagnostic statement reads:
"Penetrating wound of thigh with rupture of common
femoral artery." Code 904.0, Injury to blood vessels
of lower extremity and unspecified sites; common femoral
artery, is sequenced first as the major injury. Assign
890.0, Open wound of hip and thigh without mention
of complication, as a secondary diagnosis.
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Minor damage to a blood vessel
is sequenced as an additional diagnosis after coding the
primary injury. |
Example: The patient sustained an open
wound of the ring finger with damage to tendons and vascular
structures. The primary code is 883.2, Open wound of
finger with tendon involvement. Assign 903.5, Injury
to blood vessels of upper extremity, digital blood vessels,
as a secondary code.
Practice
Makes Perfect
Are you ready for some hands-on
practice?
Read the patient report(s) on
our procedure
practice page.
Assign the appropriate codes and then compare your answers
with our coding
recommendations.
Good luck!
Back to:
Top
- Overview
and General Guidelines
- Fractures
- Dislocations
- Sprains
and Strains
- Intracranial Injury
Internal Injury - Open
Wounds - Injury
to Blood Vessels
Injuries
and Poisoning - Part 2
If you have comments or suggestions about our code selections
or about any topic on our Coding Edge® pages, please e-mail
us at codingedge@lagunamedsys.com.
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