Procedure Practice 02/15/00 - Coding Recommendations

Injuries and Poisoning - Part 1

Feature Article 02/15/00

Injuries and Poisoning - Part 2

Late Effects - Superficial Injury - Burns - Traumatic Compliacations - Poisoning
Child Maltreatment Syndrome - Compliacations of Surgical and Medical Care
     

This month, we conclude our review of ICD-9-CM Chapter 17 with guidelines and selected examples from the following subsections:

• Late Effects of Injuries, Poisoning, Toxic Effects, and Other External Causes
• Superficial Injury
• Burns
• Certain Traumatic Complications and Unspecified Injuries
• Poisoning by Drugs, Medicinal, and Biological Substances
• Child Maltreatment Syndrome
• Complications of Surgical and Medical Care, Not Elsewhere Classified

In a departure from our usual format, we have not included a final case study for you to code. Instead, flex your coding muscle by assigning the ICD-9-CM diagnosis codes for the examples found throughout our review (they are listed again on our Coding Practice page), then compare your answers to the suggested codes on the Coding Recommendations page. Because the examples are taken from real medical records, some of them include more detail than others. Code each example to the extent possible given the documentation provided, including the appropriate E-code(s).

Late Effects of Injuries, Poisoning, Toxic Effects,
and Other External Causes (905-909)

If the words "late effects" make you cringe, you are not alone. These codes are confusing for many coders. To dispel their mystery, we offer the following guidelines and examples:

	This series of codes describes residual conditions that are due to injuries classified elsewhere within Chapter 17 (800-999).
	Each type of injury described within Chapter 17 has its own "Late Effects" category.
	A late effect is any condition specified by the attending physician as due to a prior acute injury.

	Late effects may occur at any time after the acute injury.
	When coding late effects of injury, first sequence the nature of the late effect, then list the late effect code.

Example 1: The physician diagnosed a chronic knee effusion due to a previously treated acute tear of the posterior horn of the medial meniscus.

Example 2: A patient was seen for left leg paralysis due to a spinal cord injury suffered in a motor vehicle accident three years ago.

 

Superficial Injury (910-919)

Superficial injuries include abrasions, friction burns, blisters (not due to burns), nonvenomous insect bites, superficial foreign bodies such as splinters that are not associated with major open wounds, and minor lacerations.

	Be sure to read the "Excludes" note at the beginning of this code series for those specific injuries that must be coded elsewhere.
	Subcategories in this series are arranged by body site or region.
	Within each subcategory, 4th digits denote the type of superficial injury and the presence or absence of associated infection.
	Superficial injuries of the eye and adnexa are coded to their own special subcategory (918).

Example 3: The physician diagnoses infected blisters of the 4th and 5th toes due to a pinching injury sustained when the patient's foot had gotten caught in a rusty metal door.

 

Burns (940-949)

This series of codes includes current injuries due to electricity, flames, hot objects, lightning, radiation, chemicals, and scalds. As always, selection of the correct code(s) depends upon physician documentation. Review the medical record carefully for information about site and degree of burn, whether the burn is current or healed, and the presence of complications or late effects.

	Codes 940.0 through 940.9 categorize site and severity of burns of the eye and ocular adnexa.
	The code range of 941-946 is arranged by body site. Select the appropriate 4th digit 0 through 5 within this range to identify the depth of burn by degree.

First degree burns damage only the outer layer of the epidermis and result in erythema of the skin.

Second degree burns cause blistering and damage to the epidermis as well as part of the underlying dermis.

Third degree burns result in full thickness skin loss.

Deep third degree burns are burns with necrotic tissue. These burns are further specified as with or without loss of a body part. NOTE: Some physicians may use the term "4th degree" for this type of injury. Always query the physician if a question exists as to the extent of burn.

Example 4: A child was treated in the emergency room for 2nd degree burns of the palms of both hands after touching a hot kitchen stovetop.

Category 947 is used to code burns of internal organs. This category includes burns due to ingestion of chemicals.

Example 5: A student was treated for burns of the gums, tongue, and esophagus after an accidental ingestion of hydrochloric acid during a high school chemistry class.

In multiple burn cases, sequence the code for the highest degree of burn first.

Example 6: The physician documented second degree burns of the left forearm and third degree burns of the hand due to accidental explosion of fireworks.

Burns of different degrees coded to the same 3-digit category are coded to the highest degree documented in the medical record.

Example 7: A woman suffered first and second degree burns of her chest and abdomen after accidentally spilling a pot of boiling water.

	Per the "Excludes" note at the beginning of this code range, sunburns and friction burns are not coded here. Assign 692.71 from the Skin and Subcutaneous Tissue chapter for sunburn; select a code from 910-919 with the appropriate 4th digit of 0 or 1 for friction burns.
	Assign two codes for cases of infected burns after initial treatment. First select a code from the 940-949 range; then assign 958.3, Posttraumatic wound infection.
	Code nonhealing burns as acute burns. Necrosis of burned skin is also coded as a nonhealed burn.

Example 8: A patient was treated for an infected, nonhealing, third-degree burn of the left thigh.

Codes 906.5 through 906.9 are the secondary codes used for late effects of burns. Remember, a late effect is any condition that the physician stated to be due to a previous acute injury. Contractures and scars are examples of common late effects of burns. Be sure to first code the specific residual condition followed by the appropriate late effect code.

In cases of patients admitted for plastic surgery to repair residual damage from old burns, code the specific residual condition (e.g., joint contracture, scar tissue) first, followed by a late effect code. The code selection and sequencing of late effects remain the same regardless of whether or not the patient was admitted for surgery. Do not use V51, Aftercare involving the use of plastic surgery, for these cases.

Example 9: A patient was admitted for the release of a knee joint contracture due to previous burns sustained when his clothing ignited from a campfire.

Because burns heal at different rates, it is possible that a patient may have had both healed and nonhealed burns concurrently. It is correct to assign a code for the current burn as well as a late effect code (if appropriate) for the same case. The sequencing of the codes will depend upon the reason for admission.

Example 10: The patient was admitted for skin grafting to repair scar tissue on the neck due to an old burn. During hospitalization, this patient also received regular dressing changes and debridement of an unhealed 3rd degree burn on the dorsum of the foot.

Category 948 classifies burns according to the extent of body surface involved. This category may be used alone if the site of burn is unspecified. It may also be used as a supplemental code if both the burn site and extent of body surface are documented.   The "Rule of Nines" is the method used to estimate the percent of total body surface burned. This method is accurate for adults only and is not used for infants or children.   Body Area % of Total Body Surface Head and neck 9% Each arm 9% Anterior leg 9% Posterior leg 9% Anterior trunk 18% Posterior trunk 18% Genitalia 1%

	The 4th digits 0-9 in category 948 denote the total percent of body surface burned regardless of the degree of burn.
	The 5th digits 0-9 in category 948 identify the percent of body surface with third degree burn.

Example 11: A patient presented to the emergency department with burns to 30% of the body: 20% of the body surface suffered 2nd degree burns, and 10% of the body suffered 3rd degree burns.

 

Certain Traumatic Complications
and Unspecified Injuries (958-959)

Codes 958.0-958.8 describe specific complications of trauma. The complications may be concurrent with the acute injury or occur while the injury is healing. Do not confuse these codes with the late effects codes.

Complications addressed in this category are air embolism, fat embolism, secondary and recurrent hemorrhage, traumatic shock, posttraumatic wound infection, traumatic anuria, posttraumatic muscle contracture, traumatic subcutaneous emphysema, and other early complications of trauma.

Air embolism is a rare but serious complication in which air is drawn into an open vein.

Assign 958.0 only in cases of air embolism complicating a traumatic injury. Air embolism due to implanted devices is coded to 996.7 with the appropriate 5th digit. Air embolism due to infusion, perfusion, or transfusion is coded 999.1. Air embolism complicating pregnancy, abortion, and ectopic or molar pregnancies are also coded elsewhere.

Fat embolism is a fairly common complication of fractures in which fat is drawn into the damaged blood vessels at the injury site.

	Assign 958.1 only if fat embolism was a complication of trauma. Fat embolism complicating pregnancy or abortion is coded elsewhere per the "Excludes" note.
	Examples of secondary and recurrent hemorrhage include spontaneous bleeding of healing granulation tissue or renewed bleeding following thrombolysis.

Example 12: A patient was treated in the emergency department for a nasal fracture. Bleeding was controlled, a splint applied and the patient sent home. He returned to the ED several hours later with new bleeding from both nares. Code the diagnosis for the second ED visit.

Assign 958.3, Posttraumatic wound infection not elsewhere classified, if the infection is not specifically identified as cellulitis or abscess.

Codes 959.0-959.9 are vague and should only be used if the documentation of injury does not allow more detailed coding. The codes in this range are subdivided by general body site.

The "Excludes" note directs the coder to other sections within Chapter 17 to code unspecified injury of blood vessels, eye, internal organs, intracranial sites, nerves, and spinal cord.

Example 13: The patient sustained a closed head injury and blunt trauma to the chest wall after striking a tree while sledding.

Poisoning by Drugs, Medicinal,
and Biological Substances (960-979)

These codes cover cases of patients who suffered an adverse reaction or poisoning from a drug, medicine, or biological substance taken by mistake or a correct substance given incorrectly, including administration of an overdose.

Such medication errors may be documented as a wrong medication given or taken; an incorrect dosage given or taken; an accidental or deliberate overdose; an adverse interaction between a prescribed medication and an over-the-counter drug; or an interaction between therapeutic substance(s) and alcohol.

Specifically excluded from this code range are adverse effects of substances that were correctly administered. These cases are coded according to the nature of the adverse effect. Always read the medical record carefully to determine if the condition was a poisoning or an adverse effect. Read and be guided by the "Excludes" note at the beginning of this code range.

	If a nonprescribed drug was taken in combination with a correctly prescribed and administered drug, any drug toxicity or reaction is coded as a poisoning.
	Code selection is not affected by the type of provider who administered the drug. The drug may have been given by a nurse, physician, or any other qualified clinician.
	Use a code from this range for each drug, medicinal, or biological substance taken or given in error.
	The code selected from range 960-979 is sequenced first.
	Use an additional code to specify the effects of the poisoning.
	Acute conditions due to the combination of a drug with alcohol or other drug abuse are classified to this code range.
	Use the appropriate E code from the Table of Drugs and Chemicals to identify the circumstances of the poisoning: accident, suicide attempt, assault, or undetermined.
	Because codes 960-979 are used only in cases of improper drug administration, it is incorrect to pair them with an E code from the "therapeutic use" column.

Example 14: The diagnostic statement indicates respiratory failure due to accidental overdose of Valium and pseudoephedrine.

Example 15: A patient was admitted in a comatose state after having ingested an unknown amount of vodka and antidepressants in a suicide attempt.

Use 977.8, Other specified drugs and medicinal substances, for specified drugs that cannot be classified elsewhere. Examples of these kinds of substances are radiological contrast agents and diagnostic agents and kits.

	If a drug is not specified, assign 977.9, Unspecified drug or medicinal substance.
	Refer to Appendix C of the Disease Tabular Section for drugs not listed in the Table of Drugs and Chemicals. The appendix contains the American Hospital Formulary Service (AHFS) drug list (by AHFS number and drug type or family) and also provides the correct ICD-9-CM diagnosis code.
	Once you know the AHFS number, locate it in the Table of Drugs and Chemicals under the main heading "Drug." The table will provide the correct diagnosis code and a selection of E codes.
	Do not code directly from the Table of Drugs and Chemicals. Refer back to the Tabular List to verify your code selection.

Example 16: An oncology nurse erroneously administered too much of a new antineoplastic medication. The patient suffered facial edema and persistent vomiting.
 

An unexpected reaction in a patient to a drug correctly prescribed and administered or taken by the patient is considered an adverse effect.

In adverse effect cases, code the nature of the adverse effect followed by the E code for "therapeutic use" of the specific drug or medicinal agent. If the nature of the adverse effect is not specified, assign code 995.2, Unspecified adverse effect of drug, medicinal and biological substance. Do not use a code from the 960-979 series.

Example 17: A child presented to the physician's office with hives due to Amoxicillin therapy for otitis media. The mother verified that the medication had been correctly administered for three days.

Child Maltreatment Syndrome (995.50-995.59)

Always code the appropriate abuse code from this code range first with additional code(s) to describe injuries. Also use an E code to identify the nature of the abuse and the perpetrator.

Example 18: A child was struck by his stepfather and sustained an orbital floor fracture.

Complications of Surgical and Medical Care,
Not Elsewhere Classified (996-999)

This category includes conditions that occur if the patient sustained additional injury, illness, or other complication as the result of medical or surgical care. Complications due to other comorbid conditions or due to conditions that were unrelated to the patient's surgery or medical care are not coded to this category.

The medical record must document that the condition was due to a surgical procedure or other medical care. If in doubt about the cause-effect relationship of a complication and care, ask the physician for clarification. For example, the phrase "postoperative urinary retention" indicates that the condition occurred some time after an operative episode; whether or not it resulted from the surgery requires further clarification.

Some postoperative conditions are normal sequelae to surgery. Examples of conditions that may be normal postoperative states include atelectasis, urinary retention, fever, blood loss anemia, and gastrointestinal ileus. If these conditions required clinical evaluation, increased nursing care, diagnostic testing, monitoring, treatment or other medical management, or required additional time in the hospital, then the coder should query the physician to determine whether or not the condition was a true postoperative complication.

	Always cross-reference the Index to Diseases under both the main term for the type of complication and the heading "Complications" to ensure accurate code assignment. The complicating condition may be listed under one or both of these headings.
	Always read the "Includes" and "Excludes" notes that pertain to each category and subcategory within this range of codes. The directions provided in these notes are crucial to correct code selection.
	It is appropriate to assign a single code from 996-999 provided the complication is not listed in the numerous "Excludes" notes in this code range.
	Assign a second code if the nature of the complication is not specified within the 996-999 code description.

Example 19: The physician documented a streptocococcal infection due to the presence of an indwelling urinary catheter.

	Codes 996.00-996.99, Complications Peculiar to Certain Specified Procedures, include complications due to the use of artificial or natural substitutions or devices, internal anastomoses (excluding the gastrointestinal or urinary tract), grafts, implants, internal devices, or transplants. Reattachment of extremities is included in this category.
	Mechanical complications of artificial skin and decellularized allodermis are coded to 996.55, Mechanical complications of other specified prosthetic device, implant and graft; due to artificial skin graft and decellularized allodermis; dislodgement, displacement, failure, nonadherence, poor incorporation, shearing.

Example 20: A patient was treated for poor incorporation of a decellularized allodermis graft of the right lower leg.

	Mechanical complications of arteriovenous dialysis catheters are coded 996.1. Mechanical complications of peritoneal dialysis (e.g., Tenckhoff catheter leakage through exit site) are coded 996.56.
	Codes from subcategory 996.8, Complications of transplanted organ, are assigned to cases of transplant rejection or cases with other existing complications or diseases of the transplanted organ. Post-transplant illnesses that affected the function of the transplanted organ require two codes to describe the disease and its impact on the organ.
	Assign 996.8 with the appropriate 5th digit for any complication or disease of a transplanted organ. Use an additional code to identify the nature of the complication. All medical conditions that affected the function of the transplanted organ may be coded as complications of the transplanted organ, regardless of whether the condition existed prior to transplantation or began after transplantation.

Example 21: A kidney transplant patient was seen for a perirenal abscess of the transplanted kidney.

Example 22: A patient who was status post lung transplant was treated for chronic interstitial lung disease. The medical record indicates that the patient had suffered from this condition prior to transplantation.

Post-transplant surgical complications that did not affect the organ’s function are coded to the code category for that complication.

Example 23: A kidney transplant patient suffered a postoperative wound infection.
 

Codes 997.00-997.99, Complications Affecting Specified Body Systems, Not Elsewhere Classified, includes the nervous, cardiac, peripheral vascular, respiratory, gastrointestinal, and urinary systems. Complications of amputation stumps are also coded to this code range.

Assign 997.1 for cardiac complications that occurred as the direct result of a procedure. An additional code may be used to identify the complication. Per the "Excludes" note, this code does not include conditions listed as long-term effects of cardiac surgery or conditions due to the presence of a cardiac prosthetic device. These later conditions are coded 429.4, Functional disturbances following cardiac surgery.

Example 24: A patient suffered postoperative left heart failure due to repair of an abdominal aortic aneurysm.
 

Per the "Excludes" note under code 997.4, complications of gastrostomy, enterostomy, and colostomy procedures are not coded here, but are coded to the Digestive System chapter.

Example 25: A patient presented to the emergency department with malfunction of his colostomy appliance.
 

Code range 998.0-998.9, Other Complications of Procedures, NEC, includes postoperative shock, hemorrhage, hematoma and seroma, accidental puncture or laceration, operative wound dehiscence, foreign body accidentally left in wound during a procedure, postoperative infection, postoperative fistula, acute reaction to foreign substance accidentally left in wound during a procedure, and emphysema resulting from a procedure.
  

Practice Makes Perfect!

Are you ready for some hands-on practice? The above examples are repeated on our Procedure Practice page. Assign the appropriate codes and then compare your answers with our coding recommendations. Good luck!

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Top - Late Effects - Superficial Injury - Burns - Traumatic Compliacations - Poisoning
Child Maltreatment Syndrome - Compliacations of Surgical and Medical Care
 
Injuries and Poisoning - Part 1

If you have comments or suggestions about our code selections or about any topic on our Coding Edge® pages, please send an e-mail us at codingedge@lagunamedsys.com.