1. Injury Data Introduction Intermediate Injury Prevention August 23-26, 2011 – Billings, MT
Utilize the “Participants Summary Presentation” (see template) to illustrate value of data.
Inform students that next 2 days will focus on Injury Data, with three major blocks of instruction:
Review and morbidity/mortality coding (“Injury Data Introduction”)
Data Collection (“Data Collection”; “Data Collection Planning”; “Data Collection Lab”)
Basic Injury Epidemiology & Statistics (“Data Analysis”; “WISQARS”)

2. Injury Data Introduction
Session Goal:
Review injury data concepts fr: Intro to IP Course
Understand classification system for injury morbidity & mortality
Session Objectives:
Describe the uses of data
Define types of data
Identify common sources of injury data
Describe classification system for injury coding
Interpret listings of injury morbidity/mortality codes
Session goal & Objectives: (“By the end of the session, participants will be able to…)
Describe the uses of data including understanding an injury problem, guiding injury prevention programming, and uses in evaluation
Define the term “injury” as used in data collection—we will introduce a systematic method of classifying injury, the ICD
Define the types of data. We’ll include a review of some data terms we used in Introduction to IP, as well as a few new terms
List general sources of data

3. In Review… What are the two types of data? (hint: words v. numbers)
How are data used in IP?
What are the sources of injury data?
Open Floor Discussion (ask the questions to the students; engage them to provide personal experiences; consider using flip chart to facilitate discussion)
Two Types of Data:
Qualitative data: used to understand people’s opinions/attitudes/beliefs; collected through interviews, surveys, focus groups; gives insight on development of your program/messages/materials.
Quantitative data: raw numbers/counts; used indentify injury patterns. Collected through surveillance, observations, risk assessments; gives insight on setting program priorities and evaluating impact of your program.
Use of Data in IP:
Understand trends/patterns/risk factors/causes of injury in a population
Set priorities for prevention
Guide/persuade decision makers re: public health policy (i.e., community survey data re: passing a seat belt law)
Develop program messages & materials (design of float coats in AK; safety message for a targeted group)
Justify needs/build your case for funding (i.e., grants)
Evaluate your program
What are some common sources of injury data?
Local IHS Severe Injury Surveillance System (SISS)
Resource and Patient Management System (RPMS)
Medical Records & Death Certificates
EMS & Police
Observations (i.e., seat belt surveys, home safety assessments)
Questionnaires/Surveys/Focus Groups/Key Informant Interviews

4. Two Types of Data Qualitative Data Interviews Surveys Focus groups
Gives insight on development of your program/messages/materials
Quantitative Data
Raw numbers
Counts
Identify injury patterns
Surveillance
Observations
Risk assessments
Two Types of Data:
Qualitative data: used to understand people’s opinions/attitudes/beliefs; collected through interviews, surveys, focus groups; gives insight on development of your program/messages/materials.
Quantitative data: raw numbers/counts; used indentify injury patterns. Collected through surveillance, observations, risk assessments; gives insight on setting program priorities and evaluating impact of your program.
Use of Data in IP:
Understand trends/patterns/risk factors/causes of injury in a population
Set priorities for prevention
Guide/persuade decision makers re: public health policy (i.e., community survey data re: passing a seat belt law)
Develop program messages & materials (design of float coats in AK; safety message for a targeted group)
Justify needs/build your case for funding (i.e., grants)
Evaluate your program
What are some common sources of injury data?
Local IHS Severe Injury Surveillance System (SISS)
Resource and Patient Management System (RPMS)
Medical Records & Death Certificates
EMS & Police
Observations (i.e., seat belt surveys, home safety assessments)
Questionnaires/Surveys/Focus Groups/Key Informant Interviews

5. Use of Data in Injury Prevention
Understand trends patterns
Risk factors
Causes of injury in a population
Set priorities for prevention
Guide/persuade decision makers
Develop a program messaging & materials (design of float coats in AK; safety message for a targeted group)
Justify needs/build your case for funding (i.e., grants)
Evaluate your program

6. Common sources of injury data?
Local IHS severe injury surveillance system
Resources and patient management system
Medical records & death certificates
EMS & police
Questionnaires
Surveys
Focus groups
Key information interviews
Observations (seat belt surveys, home safety assessments)

7. In Review… What are the agents of injury?
(hint: Injury results from the transfer of energy)
What are the two main categories of injury?
(hint: MVC and Domestic Violence are examples)
Agents of Injury: (Remember from Level 1, the epi triangle, with host, agent, and environment?)
Injuries, for the most part, result from short-term exposure to large concentrations of energy:
Mechanical: crushing injury in wringer washer, energy transferred during M/V crash
Thermal: heat injuries—fire, hot water scalding
Chemical: battery acid spill, poisoning
Electrical: lightening
Radiation: sunburn, overexposure to x-ray
Absence of oxygen: drowning, suffocation, smoke inhalation, carbon monoxide
Absence of heat: hypothermia, frostbite
Excess heat: heat stroke (hyperthermia)
Two Main Injury Categories: (An “agents of injury” isn’t a very specific way to categorize injuries for data collection and analysis)
Unintentional: Drowning, Fall, Fire/Burn, MVC, Poisoning, Other
Intentional: Suicide, Self-Harm, Assault (child abuse, elder abuse, domestic violence, etc)
Note to Instructor:
Transition from two main categories of injury to ICD-9
Consider statement similar to: “…In the medical field, injuries are classified with a standardized coding system call the International Classification of Disease…”

8. Agents of Injury
Mechanical: crushing injury in wringer washer, energy transferred during MV crash
Thermal: heat injuries –fire, hot water scalding
Chemical: battery acid spills, poisoning
Electrical: lightening
Radiation: sunburn, overexposure to x-ray
Absence of oxygen: drowning, suffocation, smoke inhalation, Carbon monoxide
Absence of heat: hypothermia, frostbite
Excess heat: heat stroke (hyperthermia)
Agents of Injury: (Remember from Level 1, the epi triangle, with host, agent, and environment?)
Injuries, for the most part, result from short-term exposure to large concentrations of energy:
Mechanical: crushing injury in wringer washer, energy transferred during M/V crash
Thermal: heat injuries—fire, hot water scalding
Chemical: battery acid spill, poisoning
Electrical: lightening
Radiation: sunburn, overexposure to x-ray
Absence of oxygen: drowning, suffocation, smoke inhalation, carbon monoxide
Absence of heat: hypothermia, frostbite
Excess heat: heat stroke (hyperthermia

9. Two Main Categories of Injury
Unintentional
Drowning
Fall
Fire
Burn
MVC
Poisoning
Intentional
Suicide
Self-Harm
Assault
Child Abuse
Elder Abuse
Domestic Violence
Two Main Injury Categories: (An “agents of injury” isn’t a very specific way to categorize injuries for data collection and analysis)
Unintentional: Drowning, Fall, Fire/Burn, MVC, Poisoning, Other
Intentional: Suicide, Self-Harm, Assault (child abuse, elder abuse, domestic violence, etc)

10. International Classification of Disease
Diagnosis Codes
Cause of Injury Codes
ICD-9 (Non-fatal)
ICD-10 (Deaths)
Note to Instructor:
There are several very good online resources for ICD-9 (some are include on a PPT slide at the end of this presentation)
The World Health Organization (WHO) is a very good resource: and includes a good “history lesson” at
The American Academy of Professional Coders (AAPC) is another good resource: Go to the “resources” tab for ICD-10 and ICD-9 info. Of particular interest is the “code translator.”
The purpose of this presentation is not to make students expert, certified coders; instead we’re providing a general overview for students to have a good understanding of how injury is classified, how to query an existing database with ICD codes, and how to conduct a simple analysis of such a database.
International Classification of Disease (general history & description):
History of ICD dates back to the 1850s (again, see WHO website for more on history)
Since 1948, World Health Organization (oversees the ICD
ICD is the international standard diagnostic classification system for all general epidemiological, many health management purposes and clinical use (including billing).
ICD includes codes for diagnosis of disease and injury; and cause of injury codes
Codes are updated annually; so it’s important to understand that new codes will influence multi-year analysis (example: Fall from skateboard introduced in year 3 of a 5 year dataset…if you didn’t know that was a new code, you would misinterpret that skateboard fall injuries didn’t start until yr3).
Since 1999 the United States has utilized two ICD versions:
ICD-9: Used to code non-fatal (i.e., doctor’s office visits and hospitalizations)
ICD-10: Used to code deaths
The two versions don’t directly correlate. One reason is that ICD-10 expands to 141,000 codes compared to ICD-9’s 17,000

11. Diagnosis Codes ICD-9 ICD-10 Morbidity Required for Billing Numeric
Updated > annually
Phase out: 2013
Mortality
Alphanumeric
S00-T98
Updated every Oct.
Oct. 1, 2013 Morbidity
ICD diagnosis codes for illness and nature of injury (some “old timers” might refer to them as “N-Codes)
Note to Instructor:
Describe differences between ICD-9 and ICD-10 diagnosis codes (as they related to injury prevention)
A good resource on ICD-10 overview is provided by the AAPC at
ICD-9 (Diagnosis Codes)
Used exclusively in the US for coding diagnosis of non-fatal illness & injury (most other countries use ICD-10 for both morbidity & mortality coding)
Diagnosis codes are required for medical billing.
Medical personnel may generically refer to diagnosis codes as ICD9 codes; although you will learn that ICD9 includes more than just diagnosis codes.
Injuries are numeric codes in the range of the ICD-9
Updated at least annually
The Dept of Health & Human Services has indicated on Oct. 1, 2013 the ICD-9 will be phased out for coding of medical bills (Medicare reimbursement) and replaced with ICD-10.
ICD-10 (Diagnosis Codes)
Used exclusively in the US for coding diagnosis of fatal illness & injury (most other countries use ICD-10 for both morbidity & mortality coding)
Basically, this is the “cause of death” on a death certificate
Injuries are alphanumeric codes in the range S00-T98 of the ICD-10
“S” are codes to a specific body part
“T” are codes to multiple body parts; burns; poisoning

12. Diagnosis Codes - Examples
ICD-9
ICD-10
Fractures
Open Wound
Crushing
Burns
Poisoning
Injury to…
Head
Neck
Knee/Lower Leg
Mult. Body Parts
Burns & Corrosn
Frostbite
Poisoning
S00-S09
S10-S19
S80-S89
T00-T07
T20-T32
T33-T35
T36-T50
Note to Instructor:
Slide is intended to illustrate coding differences between ICD-9 and ICD-10
A big difference is ICD-9 code categories focus on the nature of injury (i.e., fracture or burn); while ICD-10 categories focus more on the injured body part
The example ICD-9 code illustrates the specificity of the coding where 800 refers to fx vault of skull; the 4th digit (.0) refers to no intercranial injury; and the 5th digit (.x5) refers to mild loss of consciousness (LOC) defined by ICD-9 as less than 1 hr.
After brief overview, refer to ICD-9 and ICD-10 handouts for full listing of injury diagnosis groups.
fx vault of skull; closed; no intercranial injury
less than 1 hr LOC
800.02
See Reference Handout

13. External Cause of Injury Codes
ICD-9
ICD-10
Morbidity
Not required for billing
Numeric preceded by “E”
E800-E999
Allows for code for Place
Updated > annually
Phase out: 2013
State laws/coding rates vary
IHS hospital d/c rates: high
IHS ED & CHS rates: low
Mortality
Required for death certif
Alphanumeric
V01-Y98
Allows for code for Place
Allows for code for Activity
Updated every Oct.
Oct. 1, 2013 Morbidity
Note to Instructor:
Describe differences between ICD-9 and ICD-10 external cause of injury codes (as they related to injury prevention)
A good resource on ICD-10 overview is provided by the AAPC at
ICD-9 (External Cause of Injury Codes)
Used exclusively in the US for coding external cause of injury (most other countries use ICD-10 for both morbidity & mortality coding)
Unlike diagnosis codes; are not required for medical billing.
Referred to as “E-Codes” due to naming format (numeric preceded by “E”)
Same numeric range as diagnosis codes
There are separate, supplemental E-codes to identify the place of injury (home, school, etc)…although under-utilized
Also, updated at least annually
Also planned to be phased out on Oct. 1, 2013 the ICD-9 and replaced with ICD-10.
Per 2004 study ( only 26 states require E-coding for hospital discharges; enforcement varies, resulting in only about 40% of those states having hospital discharge E-code rates at above 90%.
IHS does a great job E-coding for hospital discharges when the d/c is from one of our facilities.
E-code rates are low for ambulatory (incl. emerg. Dept.) and for cases involving CHS. For example, a 2005 study in the Reno District (PHX Area) looked at E-code rates in 7 IHS & tribal clinics over a 4 year period ( ) and found 0-97% (51% average) of injury cases had E-codes. What can be done to improve E-code rates? Reno District staff shared results with clinic administrators and discussed the important public health application of E-codes. A few clinics decided to implement policies to require E-coding.
ICD-10 (External Cause of Injury Codes)…for the most part, same discussion/explanation as ICD-10 Diagnosis Codes
Used exclusively in the US for coding external cause of death on death certificates (most other countries use ICD-10 for both morbidity & mortality coding)
Injuries are alphanumeric codes in the range V01-Y98
Like ICD-9, allows for coding for place; but also allows for code for activity (what person was doing prior to death; i.e, physical activity, working)

14. Diagnosis Codes - Examples
ICD-9
ICD-10
MV Traffic Accidents
Falls
Suicide/Self-Inflicted
Homicide (Assault)
E810-E819
E880-E888
E950-E959
E960-E969
Transport Accidents
Falls
Intentional Self-Harm
Assault
V01-V99
W00-W19
X60-X84
X85-Y09
Note to Instructor:
Slide is intended to illustrate coding differences between ICD-9 and ICD-10
A big is that ICD-10 provides many more coding options, thus allowing for the ability to be much more descriptive and specific for “research” purposes. For example, ICD-10 provides 20 codes for Falls; while ICD-9 provides only 9 codes for Falls (see Reference Handouts)
Again, emphasize ICD-9 and ICD-10 datasets shouldn’t be merged for analysis due to the significant differences in coding and additional codes in ICD-10.
See Reference Handout

15. X X X . Y E Anatomy of an E-Code Injury Category Specificity
Note to Instructor:
Because we’ll later be querying an ICD-10 dataset (WISQARS), the following slides and exercise are intended to provide students a better understanding of ICD-9s E-codes.
An E-code is a 4 (sometimes just 3) digit number preceded by the letter E.
The first 3 digits indicate the type of injury group.
The fourth digit, which follows the decimal point, provides additional descriptive information or specificity of the injury event.
Injury Category
Specificity

16. 8 1 3 . 2 E Anatomy of an E-Code MVC; collision w/other vehicle
Example E-code 813.2
The number 813 indicated the injury involved a motor vehicle traffic accident involving collision with another vehicle.
The “.2” indicates the injured person was a motorcyclist.
MVC; collision w/other vehicle
Injured person was a motorcyclist

17. Analysis of E-Codes MVC E800-E825 MVC invol. pedestrian
Fall; playground equip.
Fall E880-E888
E-Codes allow ability to identify injury trends
This slide illustrates a listing of E-codes you might receive from query of a hospital discharge database
One easy, low tech method of trying using E-codes to determine injury trends and identify potential intervention strategies is to print the E-code listing from the database.
Draw lines to separate the groupings.
It is apparent that the 2 leading injury types for this community are MVCs and Falls.
But can we identify any further patterns or trends in injury with E-codes. Yes, when you look up each code within the groupings you will note that there appears to be: (a) a possible MVC-pedestrian problem per the frequency of E814.7; and (b) a possible playground-equipment related fall problem per E884.0.
In summary, when injuries are E-coded you can determine trends in the general type of injury (E-code range, E880-E888), as well as trends of specific types of injury (E-code, 884.0).
Fire E890-E899
Suicide E950-E959
Assault E960-E969

18. E-Code Example: Falls (E880-E888) Fall from: …escalator …ladder
…sidewalk curb …scaffolding
…building/structure …diving
…well …storm drain/manhole
…playground …cliff
…chair …wheelchair
…bed …other furniture
…commode …roller skates
…skateboard …skis
…snowboard …other/unspecified
E-coding allows the ability to describe specific causes and contributing factors associated with an injury event.
For example, there are individual codes that allow for the coding of fall injuries associated with…review slide.

19. Analysis of E-Codes Falls E800-E888 Fall from sidewalk curb
Fall from stairs
Fall from chair
Fall from commode
You might query a dataset and find the following listing of fall E-codes
A simple analysis method is to list them in order, draw a line to separate same codes
And you might be able to identify some trends
Beware…Unfortunately, we often find that vague or unspecific E-codes are used…resulting in “Other/Unspecified” as the leading type of fall.
Unspecified Fall

20. E-Codes Limitations Records Not Always E-coded
Miscoding & Inconsistent Coding
Poor Chart Info = Nonspecific E-Code
Don’t Always Provide Desired Specificity
Must Stay Apprised of Updates
While ICD-9 codes are very important and useful, there are some limitations associated with E-codes that you should be aware of:
Not always E-coded…especially contract care facilities.
Miscoding/Inconsistent coding…human error and interpretation problems. For example, fall from vehicle might be coded as: E818 “Other noncollision motor vehicle traffic accident; fall from MV while in motion” or E884.9 “Other fall from one level to another; from stationary vehicle, tree, embankment, haystack”.
Insufficient info…fell and fractured hip.
Not always desired specificity…E918…caught accidentally in or between objects. Must look at narrative…in SC found these were wringer washer related.
Stay appraised of updates…pre-1997 no domestic violence code, reflected only weapon (E966; knife). In 1997 new E-code E967.3…adult abuse by spouse or partner. If unaware of update might be misled of DV epidemic beginning in 1997.

21. Injury Fatality Hospitalization
E Coded on Death Certificate by Coroner
E Coded at Hospital
Diagram illustrates how injuries are typically assigned ICD-9 or ICD-10 External Cause of Injury codes
Important Note: Coding requires Certification!
State Government
County Health Department
WISQARS Data System
(Web- Based)
National Center for Health Statistics

22. External Cause of Injury Coding References
American Academy of Professional Coders
World Health Organization
CDC National Center for Health Statistics
CDC article on improving E-coding
A few ICD-9, ICD-10, and E-coding references
Note: A quick internet search will also result in several vendors for code books, as well as, several online listings of codes.

23. E-Code Exercise
Online ICD-9 code lookup tool is at:
But have students use hardcopy to get a feel for the codes and how they are structured.
E-code Exercise: (allow approx 30 minutes)
Use hardcopy of ICD-9 and the ICD-9 E-code listing (pg 2 of handout: “ICD 9 Summary of Codes”)
Students learn how to E-code a typical injury description that might be found in a medical record.
Students also learn potential for miscoding and importance of complete injury descriptions.
Students may work individually or in pairs.
Have half the class start with case description #1 and the other half start with #10 (to ensure all are coded if time starts running out).
Using answer key, review answers and comments (provide copy of answer key to students after discussion).
Extra Credit E-Code Analysis Exercise: (for those that finish the E-code Exercise early)
Continue use of hardcopy of ICD-9 and the ICD-9 E-code listing (pg 2 of handout: “ICD 9 Summary of Codes”)
Students identify main injury categories and conduct simple counts to answer the exercise questions.
Provide answer sheet for anyone that wants one.
Searchable ICD-9 code: