1. Training for Trauma Registrars 7/18/14 Holly Hedegaard, MD, MSPH INJURY CODES IN ICD-10-CM 1

2. General description of ICD-10-CM Chapter 19, Injury Diagnosis Codes Break for Lunch Chapter 20, External Cause of Injury Codes Related codes to consider TRAINING OVERVIEW 2

3. Clinical modification of ICD-10 First draft for public comment in 1997 Field tested by the AHA and AHIMA in 2003 New concepts/codes added annually through the ICD Coordination and Maintenance Committee at NCHS ICD-10-CM 3

4. Relevant codes for ambulatory and managed care encounters Greater specificity in code assignment Addition of sixth and seventh characters Combination diagnosis/symptom codes Expanded injury codes Of the approx 70,000 codes in ICD-10-CM, 43,000 are in the injury chapters! WHAT’S NEW IN ICD-10-CM? 4

5. http://www.cdc.gov/nchs/icd/icd10cm.htm#icd2015 1. Scroll down to “FY 2015 release of ICD-10-CM” 2. Select “ICD-10-CM PDF Format” 3. Select “ICD10CM_FY2015_Full_PDF.zip” 4. Select “FY15_Tabular.PDF” 5. Select Chapter 19 (injury diagnosis codes) or Chapter 20 (external cause codes) ICD-10-CM ON-LINE 5

6. A code to code reference dictionary for ICD-9- CM and ICD-10-CM Offers possible acceptable translation alternatives One ICD-9-CM code can be represented by multiple ICD-10-CM codes and vice versa New concepts in ICD-10-CM that have no predecessor in ICD-9-CM (e.g., underdosing, blood type, Glasgow Coma Scale) GENERAL EQUIVALENCE MAPS (GEMS) 6

7. http://www.cdc.gov/nchs/icd/icd10cm.htm#icd2015 1. Scroll down to “FY 2015 release of ICD-10-CM” 2. Select “General Equivalence Mapping Files” ICD-10-CM GEMS 7

8. CHAPTER 19 INJURY DIAGNOSIS CODES 8

9. General differences between ICD-9-CM and ICD-10-CM ICD-10-CM code structure Details for specific body regions SECTION OVERVIEW 9

10. ICD-9-CM VS ICD-10-CM FOR INJURY DIAGNOSES 10

11. ICD-9-CM: 813.22 Fracture of shaft of ulna, closed ICD-10-CM: S52.244A Nondisplaced spiral fracture of shaft of ulna, right arm, initial encounter for closed fracture ICD-9-CM VS ICD-10-CM FOR INJURY DIAGNOSES 11

12. S52.244A Nondisplaced spiral fracture of shaft of ulna, right arm, initial encounter for closed fracture Injury Chapter 12

13. S52.244A Nondisplaced spiral fracture of shaft of ulna, right arm, initial encounter for closed fracture Major Body Region 13

14. S52.244A Nondisplaced spiral fracture of shaft of ulna, right arm, initial encounter for closed fracture Major nature of injury 14

15. S52.244A Nondisplaced spiral fracture of shaft of ulna, right arm, initial encounter for closed fracture Specific details on body region and nature of injury 15

16. S52.244A Nondisplaced spiral fracture of shaft of ulna, right arm, initial encounter for closed fracture Type of Encounter 16

17. CHANGE IN PRIMARY AXIS OF INJURY DIAGNOSIS CODES 17

18. STRUCTURE OF INJURY DIAGNOSIS CODES IN ICD-10-CM 18

19. STRUCTURE OF INJURY DIAGNOSIS CODES IN ICD-10-CM 19

20. STRUCTURE OF INJURY DIAGNOSIS CODES IN ICD-10-CM 20

21. S52.244A Nondisplaced spiral fracture of shaft of ulna, right arm, initial encounter for closed fracture Specific details on body region and nature of injury 21

22. SUPERFICIAL INJURY (3 RD CHARACTER = 0) Specific type of superficial injury provided in 5th character Abrasion Blister Contusion External constriction Superficial foreign body Insect bite (nonvenomous) 22

23. SUPERFICIAL INJURY (3 RD CHARACTER = 0) S = Injury Chapter 0 = Head 0 = Superficial injury. 2 = Eyelid and periocular area 1 = Abrasion 1 = Laterality (right) A = Initial encounter 23

24. OPEN WOUND (3 RD CHARACTER = 1) Specific type of open wound provided in 5th character Laceration w/foreign body Laceration w/o foreign body Puncture wound w/foreign body Puncture wound w/o foreign body Bite 24

25. OPEN WOUND (3 RD CHARACTER = 1) S = Injury Chapter 4 = Shoulder and upper arm 1 = Open wound. 0 = Shoulder 3 = Puncture wound w/o foreign body 1 = Laterality (right) A = Initial encounter 25

26. OPEN WOUND (3 RD CHARACTER = 1) Specific type of open wound provided in 5th character S41.01 Laceration of shoulder without foreign body S41.02 Laceration of shoulder with foreign body S41.03 Puncture wound of shoulder without foreign body body 26

27. FRACTURE (3 RD CHARACTER = 2) Specific type of fracture provided in 5th character Comminuted Greenstick Oblique Spiral Segmental Torus Transverse Displaced vs non-displaced 27

28. FRACTURE (3 RD CHARACTER = 2) S42.312 Greenstick fx, shaft of left humerus S42.342 Spiral fx, shaft of left humerus S42.352 Comminuted fx, shaft of left humerus S42.362 Segmental fx, shaft of left humeruss 28

29. LATERALITY (“6 TH CHARACTER”) S00.411 Abrasion of right ear S81.012 Laceration without foreign body, left knee S22.43Multiple fractures of ribs, bilateral S72.336Nondisplaced oblique fracture of shaft of unspecified femur 29

30. TYPE OF ENCOUNTER 7 TH CHARACTER A: Initial encounter Active treatment, ER encounter, evaluation and treatment by new physician D:Subsequent encounter Routine care during healing phase (e.g., cast change/removal, removal of external fixation device) S:Sequela Complications or conditions that arise as a direct result of the injury of an injury 30

31. TYPE OF ENCOUNTER 7 TH CHARACTER – FRACTURES 31

32. TYPE OF ENCOUNTER S52 FRACTURE OF FOREARM 32

33. DETAILS FOR SPECIFIC BODY REGIONS 33

34. Unique codes for skull fx and intracranial injury No combo codes as in ICD-9-CM Skull fx codes do not include modifier for loss of consciousness (LOC) No distinction for closed vs open Include 7 th character for type of encounter A = initial encounter for closed fx B = initial encounter for open fx Include codes for any associated open wounds (S01.-) HEAD (S00-S09) 34

35. Specific codes for LeFort fx S02.411LeFort I fracture S02.412LeFort II fracture S02.413LeFort III fracture HEAD (S00-S09) 35

36. S06.0 Concussion S06.1 Traumatic cerebral edema S06.2 Diffuse traumatic brain injury S06.3 Focal traumatic brain injury Specific codes for right and left S06.4 Epidural hemorrhage S06.5 Traumatic subdural hemorrhage S06.6 Traumatic subarachnoid hemorrhage S06.8 Other specified intracranial injuries Internal carotid, intracranial portion S06.9 Unspecified intracranial injury S06 INTRACRANIAL INJURY 36

37. S06.0X Concussion S06.0X0Without LOC S06.0X1LOC 30 mins or less S06.0X2LOC 31 mins to 59 mins S06.0X3LOC 1 hr to 5 hrs 59 mins S06.0X4LOC 6 hrs to 24 hrs S06.0X5LOC>24 hrs w/return to pre-existing conscious level S06.0X6LOC >24 hrs w/o return to pre-existing conscious level with pt surviving S06.0X7LOC of any duration w/death due to TBI prior to regaining consciousness S06.0X8LOC of any duration w/death due to other cause prior to regaining consciousness S06.0X9With LOC of unspecified duration S06 INTRACRANIAL INJURY LOC MODIFIER 37

38. Unique codes for vertebral fracture and spinal cord injury No combo codes as in ICD-9-CM Specific codes for: Vertebral fracture vs spondylolisthesis Dislocation vs subluxation Minor vs major laceration of blood vessels Laterality of blood vessels NECK (S10-S19) 38

39. Detailed codes for fx of thoracic vertebrae Wedge compression, burst, unstable burst, other, unspecified fx A fx not indicated as displaced vs non-displaced should be coded to displaced Specific codes for: Laterality for rib fx Subluxation vs dislocation of thoracic vertebrae Minor vs major laceration of blood vessels Laterality of blood vessels Unilateral vs bilateral injuries to lungs and bronchi THORAX (S20-S29) 39

40. No distinction between closed vs open injuries to organs Code any associated open wounds (S31.-) Detailed codes for fx of lumbar vertebrae Wedge compression, burst, unstable burst, other, unspecified fx A fx not indicated as displaced vs non-displaced should be coded to displaced ABDOMEN, LOWER BACK, LUMBAR SPINE, PELVIS, ETC. (S30-S39) 40

41. Specific codes for: Open wound of abdomen +/- penetration into peritoneal cavity, by quadrant Minor vs major laceration of blood vessels Injuries to ovary, fallopian tube, prostate Laterality of blood vessels and organs (kidney, ovary) ABDOMEN, LOWER BACK, LUMBAR SPINE, PELVIS, ETC. (S30-S39) 41

42. Sacral fx 2 codes in ICD-9-CM (closed vs open fx) 16 codes in ICD-10-CM (Zone I-III, Type 1-4, non- displace vs minimally displaced vs severely displaced) Acetabular fx 2 codes in ICD-9-CM (closed vs open fx) 54 codes in ICD-10-CM (displaced vs non-displaced, type of fx, location, laterality) ABDOMEN, LOWER BACK, LUMBAR SPINE, PELVIS, ETC. (S30-S39) 42

43. Extensive expansion in the number of codes for all structures (bones, blood vessels, nerves, muscles, tendon, joints, etc.) e.g., Clavicle fx 2 codes in ICD-9-CM (closed vs open fx) 24 codes in ICD-10-CM (non-displaced vs displaced, location, laterality) e.g., Open wound of thumb No specific code in ICD-9-CM 36 codes in ICD-10-CM INJURIES TO EXTREMITIES (S40-S99) 43

44. e.g., Femur fx “2 pages” of codes in ICD-9-CM “6 pages” of codes in ICD-10-CM e.g., Injury to muscle, fascia, tendon “No” codes Extensive codes, by location and specific muscle e.g., Unique codes for different types of injuries to each finger and toe INJURIES TO EXTREMITIES (S40-S99) 44

45. Complete coding will require very detailed information on all extremity injuries! INJURIES TO EXTREMITIES (S40-S99) 45

46. Effects of foreign body entering through natural orifice (T15-T19) Burns and corrosions (T20-T32) Distinction between thermal and chemical burns T31 and T32 codes for %TBSA burn, corrosion Frostbite (T33-T34) Superficial (T33) vs with tissue necrosis (T34) INJURY, POISONING AND OTHER CONSEQUENCES OF EXTERNAL CAUSES (T07-T88) 46

47. Poisoning by, adverse effects of and underdosing of drugs, medicaments and biological substances (T36-T50) Toxic effects of substances chiefly nonmedicinal as to source (T51-T65) T63 Toxic effect of contact with venomous animals and plants (snake bites, scorpion stings) INJURY, POISONING AND OTHER CONSEQUENCES OF EXTERNAL CAUSES (T07-T88) 47

48. Other and unspecified effects of external causes (T66-T78) T68 Hypothermia T70 Effects of air pressure and water pressure T70.2 Effects of high altitude T70.4 Effects of high-pressure fluid injection T71 Asphyxiation (40+ codes) T75.0 Effects of lightning T75.1 Unspecified effects of drowning and nonfatal submersion INJURY, POISONING AND OTHER CONSEQUENCES OF EXTERNAL CAUSES (T07-T88) 48

49. Other and unspecified effects of external causes (T66-T78) T74 Adult and child abuse, neglect and other maltreatment, confirmed T76 Adult and child abuse, neglect and other maltreatment, suspected INJURY, POISONING AND OTHER CONSEQUENCES OF EXTERNAL CAUSES (T07-T88) 49

50. 50 QUESTIONS?

51. CHAPTER 20 EXTERNAL CAUSE CODES 51

52. General differences between ICD-9-CM and ICD-10-CM ICD-10-CM code structure for land transport Details for specific external causes SECTION OVERVIEW 52

53. ICD-9-CM VS ICD-10-CM FOR EXTERNAL CAUSE *“E” codes in ICD-10-CM describe Endocrine, Metabolic and Nutritional disorders! 53

54. ICD-9-CM: E888.0 Fall resulting in striking against sharp object ICD-10-CM: W01.110 Fall on same level from slipping, tripping and stumbling with subsequent striking against sharp glass ICD-9-CM VS ICD-10-CM FOR EXTERNAL CAUSE 54

55. ICD-10-CM EXTERNAL CAUSE OF INJURY 55

56. ICD-10-CM EXTERNAL CAUSE OF INJURY 56

57. Was a motor vehicle involved? Where did the event occur? (public roadway?) Did the event involve a single MV or 2+ MV? What did the MV do? Collide with something? Lose control, rollover? Leave roadway, re-enter and collide with 2 nd MV? Head-on, Rear-end, T-bone, hit parked car? 4 th digit to identify the injured person LAND TRANSPORT IN ICD-9-CM 57

58. Was a motor vehicle involved? Where did the event occur? (PR vs not a PR) Did the event involve a single MV vs 2+ MV? What did the MV do? Collide with something? Lose control, rollover? Leave roadway, re-enter and collide with 2 nd MV? Head-on, Rear-end, T-bone, hit parked car? 4 th digit to identify the injured person LAND TRANSPORT IN ICD-9-CM 58

59. V11.0 Pedal cycle driver injured in collision with other pedal cycle in nontraffic accident LAND TRANSPORT IN ICD-10-CM 59

60. V11.0 Pedal cycle driver injured in collision with other pedal cycle in nontraffic accident LAND TRANSPORT IN ICD-10-CM Transportation 60

61. V11.0 Pedal cycle driver injured in collision with other pedal cycle in nontraffic accident LAND TRANSPORT IN ICD-10-CM Who was hurt? 61

62. V11.0 Pedal cycle driver injured in collision with other pedal cycle in nontraffic accident LAND TRANSPORT IN ICD-10-CM Collision with? 62

63. V11.0 Pedal cycle driver injured in collision with other pedal cycle in nontraffic accident Other details 63 LAND TRANSPORT IN ICD-10-CM

64. LAND TRANSPORT 2 ND CHARACTER 64

65. LAND TRANSPORT 3RD CHARACTER 65

66. Other details: Driver, passenger, person on outside of vehicle, unspecified Boarding or alighting Traffic vs non-traffic Specific vehicle types: military vehicle, SUV LAND TRANSPORT 4 TH AND 5 TH CHARACTERS 66

67. Includes: Person changing tire on transport vehicle Person examining engine of vehicle broken down in (on side of) road Excludes: Fall due to non-transport collision with other person (W03) Pedestrian on foot falling (slipping) on ice and snow (W00.-) Struck or bumped by another person (W51) PEDESTRIAN 67

68. Types of pedestrian conveyance Rolling type: Roller skates (in-line and non-in- line), skateboard, non-motorized scooter, heelies, other Gliding type: Ice skates, sled, other Flat bottomed: Snowboard, snowskis, other Other: wheelchair (including powered), baby stroller, motorized mobility scooter, other PEDESTRIAN (CONVEYANCE) 68

69. Excludes: Collision with another person without fall (W51) Fall due to person on foot colliding with another person on foot (W03) Fall from non-moving wheelchair, nonmotorized scooter and motorized mobility scooter without collision(W05.-) Pedestrian on foot falling (slipping) on ice and snow (W00.-) PEDESTRIAN (CONVEYANCE) 69

70. A transport accident is one in which the vehicle involved must be moving or running or in use for transport purposes at the time of the accident. Use additional codes to identify: Airbag injury W22.1 Type of street or roadY92.4- Use of cell phone and other electronic equipment at time of crashY93.C- CONSIDERATIONS FOR LAND TRANSPORT ACCIDENTS 70

71. OTHER LAND TRANSPORT ACCIDENTS (V80-V89) *Includes ambulance, fire engine, snowmobile, dune buggy, military vehicle, golf cart, go-cart, dirt bike, etc. 71

72. LAND TRANSPORT (V00-V89) “51 pages” of Land Transportation codes! 72

73. WATER TRANSPORT ACCIDENTS (V90-94) *Includes burn, crush, fall, hit or struck by falling object, other 73

74. Types of events Watercraft overturning Watercraft sinking Falling or jumping from burning watercraft Falling or jumping from crushed watercraft Collision between watercraft and other watercraft or object Hit or struck by falling object due to accident to watercraft Thrown overboard by motion of watercraft Burned by localized fire on watercraft Heat exposure on watercraft Explosion on watercraft Machinery accident on watercraft AND MORE! WATER TRANSPORT ACCIDENTS (V90-94) 74

75. Types of watercraft Merchant ship Passenger ship: Ferryboat, Ocean Liner Fishing boat Other powered watercraft: Hovercraft, Jet-ski Sailboat Canoe or kayak Non-powered inflatable craft Unpowered watercraft: Surfboard, Windsurfer Water-skis WATER TRANSPORT ACCIDENTS (V90-94) 75

76. New concepts: W00Fall due to ice and snow W04Fall while being carried or supported by other person W16Falling, jumping or diving into water W17.82Fall from (out of) grocery cart SLIPPING, TRIPPING, STUMBLING AND FALLS (W00-W19) 76

77. EXPOSURE TO INANIMATE MECHANICAL FORCES (W20-W49) 77

78. New concepts: W21Striking against or struck by sports equipment (codes for specific items) W22.1Striking against or struck by automobile airbag W29.4Contact with nail gun EXPOSURE TO INANIMATE MECHANICAL FORCES (W20-W49) 78

79. Includes accidentally struck by other person W50 Accidental hit, strike, kick, twist, bite or scratch by another person W51Accidental striking against or bumped into by another person W52Crushed, pushed or stepped on by crowd or human stampede Includes injuries from contact with animals Cow, pig, raccoon, dolphin, sea lion, orca, shark, crocodile, alligator, turtle, parrot, macaw, psittacines, chicken, turkey, goose, duck, frogs AND MORE! EXPOSURE TO ANIMATE MECHANICAL FORCES (W50-W64) 79

80. Similar to ICD-9-CM but with more detail available Remember that some external causes are now captured in T-codes OTHER EXTERNAL CAUSES 80

81. Codes for child and adult abuseCodes for terrorism eventsCodes for cataclysmic eventsCodes for transport accidentAll other external causes GENERAL PRINCIPLES FOR ASSIGNING EXTERNAL CAUSE The first-listed external cause code should correspond to the cause of the most serious diagnosis due to an assault, accident, or self-harm, following the order of hierarchy listed above. 81

82. 82 QUESTIONS?

83. OTHER CONSIDERATIONS 83

84. PLACE OF OCCURRENCE (Y92) 84

85. Indicates the activity the person was engaged in when the injury occurred* ACTIVITY (Y93) *Activity contributed to the injury event 85

86. ACTIVITY (Y93) 86

87. Indicates the work status of the person at the time the event occurred Y99.0 Civilian activity done for income or pay Y99.1Military activity Y99.2Volunteer activity Y99.3Other external cause status STATUS (Y99) 87

88. How complete is the documentation in the medical record? What level of detail in coding is really needed? For your trauma service? For the state trauma registry? Requirements of ACS and NTDB OTHER CONSIDERATIONS 88

89. ICD-10-CM map to AIS NHTSA Request for Information https://www.federalregister.gov/articles/2014/06 /12/2014-13727/icd-10-cmais-mapping-software https://www.federalregister.gov/articles/2014/06 /12/2014-13727/icd-10-cmais-mapping-software Comment period ends 8/11/14 OTHER CONSIDERATIONS 89

90. 90 FOR MORE INFORMATION Holly Hedegaard, MD, MSPH National Center for Health Statistics Office of Analysis and Epidemiology 301-458-4460 hdh6@cdc.gov