Vol. 14 •Issue 23 • Page 8
Don’t Get Hit by Inappropriate Injury Codes
There were 24.6 million medically attended injury and poisoning episodes in the United States in 2001 (according to the Summary Health Statistics for the U.S. Population, National Health Interview Survey, 2001), which makes injuries one of the most common reasons for seeking health care. This also means that proper classification of the types and combinations of injuries is so important.
Coders should ensure that they understand all coding guidelines related to injuries before taking the certified coding specialist (CCS) or certified coding associate (CCA) exams.
Chapter 17 of ICD-9-CM classifies in-juries, poisoning, other effects of external causes and complications of surgical and medical care. Because the chapter involves such a diverse array of topics, the focus of this article will be injuries only. Injuries may be further subdivided into the following sections:
• Fractures (800-829)
• Dislocations (830-839)
• Sprains and Strains of Joints and Adjacent Muscles (840-848)
• Intracranial Injury, Excluding those with Skull Fracture (850-854)
• Internal Injury of Thorax, Abdomen and Pelvis (860-869)
• Open Wounds (870-897)
• Injury to Blood Vessels (900-904)
• Late Effects of Injuries, Poisonings, Toxic Effects and Other External Causes (905-909)
• Superficial Injuries (910-919)
• Contusion with Intact Skin Surface (920-924)
• Crushing Injuries (925-929)
• Effects of Foreign Body Entering Through Orifice (930-939)
• Burns (940-949)
• Injury to Nerves and Spinal Cord (950-957)
• Certain Traumatic Complications and Unspecified Injuries (958-959)
The first step in assigning codes for injuries is to determine the extent of the injuries, particularly if multiple injuries are present. In most cases, separate codes are assigned for each injury unless a combination code is provided, in which case only the combination code is assigned. Multiple injury codes are available for use but shouldn’t be assigned unless the in- formation required for a more specific code isn’t provided.
In most cases the level of detail should be present in the documentation to assign the specific injury codes. But in some cases this may not be feasible, such as when a patient with multiple injuries is only stabilized and then immediately transferred to a trauma center. When coding multiple injuries, the coder should be aware that the term “with” indicates involvement of both sites, whereas “and” denotes involvement of either or both sites.
The diagnosis code reflecting the most serious injury (as determined by the physician) should be sequenced first when assigning more than one injury code. Coders should also keep in mind that codes for superficial injuries, such as abrasions or contusions, should not be assigned when the injury is associated with more severe injuries of the same site.
For instance, if a physician documents “contusion of the forearm with resulting distal radius fracture,” only the fracture would be coded. The contusion is considered a symptom or component of the fracture. Likewise, if documentation indicates “fracture dislocation,” only a code for the fracture is assigned. According to Coding Clinic, 3rd Quarter 1990, p. 13: “For purposes of classification, ICD-9-CM assigns only the fracture code to fracture-dislocations of the same site. It is incorrect to also code the dislocation.”
Guidelines for Fracture Coding
The fracture diagnosis codes are constructed in such a way that each digit or group of digits implies a different concept. The first three digits denote the major body site involved, including:
• Fractures of the skull (800-804)
• Fractures of the neck and trunk (805-809)
• Fractures of the upper limb (810-819)
• Fractures of the lower limb (820-829)
The fourth digits of fracture codes usually indicate whether a fracture is open or closed and the fifth digits typically indicate more specific bones within the general site. Open fractures are those in which an open wound communicates with the fracture site and in many cases the bone is visible. Open fracture documentation terminology may include: compound, infected, missile, puncture or with foreign body. Closed fractures may be described as: comminuted, depressed, elevated, fissured, greenstick, impacted, linear, simple, slipped epiphysis or spiral.
A closed fracture does not involve a situation in which the skin is perforated with an open wound down to the site of the fracture.
Whenever the documentation is ambiguous or conflicting the physician should be queried for clarification, but if in doubt, a fracture not indicated as open or closed should be classified as closed. Coders should also be familiar with bone anatomy and be aware that documentation of “condyle,” “coronoid process,” “ramus” and “symphysis” refer to a portion of a bone fractured, not to the name of the bone itself.
A few other general guidelines for fracture coding include:
• Multiple fractures of same limb classifiable to the same three-digit or four-digit category are coded to that category.
• Multiple unilateral or bilateral fractures of same bone(s) but classified to different fourth-digit subdivisions (bone part) within the same three-digit category are coded individually by site.
• Multiple fracture categories 819 and 828 classify bilateral fractures of both upper limbs (819) and both lower limbs (828), but without any detail at the fourth-digit level other than open and closed type of fractures.
• Multiple fractures are sequenced in accordance with the severity of the fracture and the physician should be asked to list the fracture diagnoses in the order of severity.
There are several specific guidelines that involve skull fractures and intracranial injuries. These diagnoses are classified to categories 800, 801, 803 and 804 and differentiate the skull fractures by site. Fourth digits indicate whether the fracture is open or closed and whether or not an intracranial injury was present. Codes for skull fractures and intracranial injuries without skull fractures use fifth digits to describe whether or not there was a loss of consciousness, how long it lasted and whether there was a return to the pre-existing level of consciousness. Intracranial injuries that are not associated with skull fractures are assigned to the 850 through 854 categories and should not be confused with those injuries classified in the 80X categories. Coders should also keep in mind that if medical record documentation indicates “closed head injury” only, and there is no other indication of a serious injury, that code 959.01 (Head injury, unspecified) should be assigned. Coding Clinic, 4th Quarter 1997, p. 46 describes this guideline:
“Prior to Oct. 1, 1997, head injury not otherwise specified, was assigned to category 854, Intracranial injury of other and unspecified cause. There was misuse of this code for minor head injuries or when a more specific cerebral injury code should be used. To address this issue, code 959.01, Head injury, unspecified, has been created.”
Although the conditions discussed above are not all-inclusive, they contain many of the most commonly-assigned conditions in the United States today. Coding staff should review the ICD-9-CM Official Guidelines for Coding and Reporting, Section C.17. Injury and Poisoning. An upcoming article will cover burn, laceration and crush injuries in another issue. The following quiz will test your knowledge.
1. A 10-year-old girl was thrown from her bike after being struck by a car while crossing a busy street. The ED physician’s diagnosis was “significant head trauma with concussion.” The nurse’s note states that the EMT reported the patient was unconscious for about 10 minutes prior to transport. A skull series was obtained, and the radiologist’s impression was “hairline fracture of frontal bone, without evidence of intracranial injury or hemorrhage.” Which injury diagnosis code(s) would be assigned?
d. 803.02, 850.1
2. A 14-year-old male patient was injured while skateboarding. The injuries included a fracture of the femur shaft with multiple significant abrasions of the thigh. Which injury diagnosis code(s) would be assigned?
c. 821.00, 919.0
d. 821.01, 916.0
3. A 27-year-old male collided with another player while playing basketball and suffered a fracture dislocation of his left second finger metacarpal base. Which injury diagnosis code(s) would be assigned?
c. 815.02, 834.01
4. After suffering a fracture of the ankle three months ago, a 69-year-old patient presented with what was found to be a fracture non-union. She was treated with additional surgery and discharged. Which injury diagnosis code(s) would be assigned?
b. 824.8, 905.4
d. 733.82, 905.4
This month’s column has been prepared by Melinda Stegman, MBA, CCS, manager of clinical HIM services, HSS Inc. (www.hssweb.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.
Answers to CCS PREP!
1. b Code 803.02 is correct because when a fracture is evident, the code for concussion (850.1) is not assigned. Code 800.02 is also incorrect because it reflects a fracture of the vault of the skull, which is not documented in this case. Code 850.00 is incorrect because it does not include the information related to the loss of consciousness at the scene mentioned by the EMT in the nurse’s notes.
2. a The appropriate diagnosis code is 821.01 because the fracture of the femur is specified as involving the shaft and was closed. Fracture coding guidelines also instruct that separate codes for more superficial injuries of the same site (such as abrasions) should not be assigned.
3. b Because the patient fractured the MC base, code 815.02 is most appropriate. Coding guidelines also specify that if a dislocation is associated with a fracture at the same site, only the fracture code is assigned.
4. d The condition treated on this visit was the fracture non-union, which is coded to 733.82. The fact that the fracture non-union was a late effect of the initial fracture should be indicated with code 905.4 as an additional code. A fracture late effect should not be coded with the acute fracture code.