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ICD-10 QUICK TIPS: Proper Episode of Care Coding for Injuries and Cause of Morbidity

Posted by National Compliance and Quality Audit Team on Sep 8, 2016 12:46:08 PM

ICD-10.pngThis week's post comes from National Compliance and Quality Audit Manager, Sharon Nichols, BSBEB, RHIT, CCS, CHTS-TR.

One trip, two trips, three trips or more, backyard fun can sure make you sore! Have you ever visited with a friend for an afternoon of food and fun by the pool only to find yourself with an injury? A quick trip to the ER or acute care clinic and you are on your way.  A follow up visit to the doctor and you are good to go. But here is where the fun begins for the coder!

The application of the 7th character for injuries and poisonings has been a source of confusion for coders since the implementation of ICD-10. To correctly code episode of care for injuries and external cause of morbidity, we must first understand the application of the characters for initial, subsequent, and sequela and what they mean for each situation.

Let’s not regurgitate what we can all read in the Coding Guidelines regarding the definitions of the initial, subsequent, and sequela episode of care because at times, they can be as clear as mud. Coders have to change gears and stop relating the verbiage of the definitions to the number of visits the patient has had. Simply put:

  • A for Initial encounter
    • Active phase of treatment
    • Same physician or a new physician during this phase of treatment
    • Examples: Surgery, wound debridement, laceration suture, burn treatment, fracture casting, etc.
    • A patient may present multiple times during this phase of treatment
  • D for Subsequent encounter
    • Healing or recovery phase of treatment
    • Same physician or a new physician during this phase of treatment
    • Examples: Cast adjustments, wound checks, dressing changes, rehab care, etc.
    • A patient may present multiple times during this phase of treatment
  • S for Sequela
    • A complication has occurred as a result of a previous condition
    • Same physician or a new physician during this phase of treatment
    • Example: Scar contracture from an old second degree burn from a BBQ grill
    • Both the injury code and external cause code have the “S” for sequela
      • The sequela injury code is sequenced first followed by the injury code with the 7th character as an “S” and an additional external cause of injury code with an “S” to show the specific injury.
    • A patient may present multiple times during this phase of treatment

What about those Z codes? When do we use those? Z codes (aftercare codes) are not appropriate for use in situations for injuries or poisonings where the 7th character identifies the appropriate episode of care. Let’s look at an example.

It’s a hot summer day, the kids are playing a game in the pool. Johnny decides to play Super Ninja and leaps from the ladder landing on top of his brother at the bottom of the pool. After a few x-rays at the ED, diagnosis of Salter-Harris IV fracture of the left lower tibia is made and he will need surgical repair. Follow up appointment is made with Ortho. The ER doctor simply places a short leg splint on his leg and sends him home.

  • S89.142A – Salter-Harris IV physeal fracture lower end left tibia, initial encounter, closed
  • W16.522A – Jumping or diving into swimming pool striking bottom causing injury, initial encounter
  • Y93.39 – Activity, other involving climbing, rappelling and jumping off
  • Y92.016 – Swimming pool in single family (private) house or garden as the place of occurrence
  • Y99.8 – Other external cause status
  • 29515-LT/2W3RX1Z – Application of short leg splint, left lower leg

**Coding tip** Because there is no manipulation of the fracture we can code the application of the splint in this case. Had there been any reduction/manipulation of the fracture, then we would have coded 27825 for closed treatment, fracture of weight bearing articular portion/distal tibia with skeletal traction/manipulation instead.

For the Ortho visit, the surgeon performed ORIF with pins and screws to the left distal tibia, there were no complications and Johnny went home.

  • S89.142A – Salter-Harris IV physeal fracture lower end left tibia, initial encounter, closed
  • W16.522A – Jumping or diving into swimming pool striking bottom causing injury, initial encounter
  • 27827 – ORIF tibia only, weight bearing articular surface or distal tibia
  • 0QSH04Z – Reposition Left tibia with internal fixation device, open approach

Johnny is now 8 weeks’ post-op and has developed a post-op redness of his surgical wound that doesn’t seem to be healing. His x-rays are clearly improved with excellent union of the fracture site and the bone is healing well. Upon closer exam of his surgical wound there is evidence of cellulitis and minor dehiscence of the surgical site so cultures are taken. Then subcutaneous excisional wound debridement is performed with scalpel to remove necrotic tissue back to fresh bleeding skin edges, the wound is cleaned with antibiotic solution, stitched closed and dressing applied. Final diagnosis: Wound dehiscence with cellulitis post ORIF Salter IV left distal tibia.  Fracture healing well.

  • T81.31XA – Disruption external surgical wound, NEC initial encounter
  • T814XXA – Infection following a procedure, initial encounter
  • L03116 – Cellulitis Left lower limb
  • Y83.1 – Surgical operation w/implant of artificial internal device as cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at time of procedure
  • S89.142D – Salter-Harris IV physeal fracture lower end left tibia, with routine healing
  • W16.522D – Jumping or diving into swimming pool striking bottom causing injury, subsequent encounter
  • 11042 – Debridement, subcutaneous tissue first 20 sq. cm
  • 0JBP0ZZ – Excision Left lower leg subcutaneous tissue & fascia, open approach

Johnny has returned two years after his Ninja jump off the pool deck. He has decided to play basketball and during tryouts he’s developed some pain in his knees and back. He presents today for an evaluation to determine if his injury may be the cause. X-rays now show he has a leg length discrepancy that has developed due to his prior Salter IV fracture through the growth plate causing partial physeal arrest.

  • M21.762 – Unequal limb length (acquired), left tibia
  • M89.167 – Partial physeal arrest, left distal tibia
  • S89.142S – Salter-Harris IV physeal fracture lower end left tibia, sequela
  • W16.522S – Jumping or diving into swimming pool striking bottom causing injury, sequela

So now that we have the injury information out of the way, let’s focus on the external causes or morbidity. A volleyball ball comes at you across the net and smacks you right between the eyes (nice broken nose). Or perhaps you trip over your neighbor’s cat, fall down the deck steps and with arms flailing, you collide with the BBQ grill and take that down with you in your descent (gracefully). Yes, we probably have an external cause code for it!  But there’s a question of where the documentation can actually come from. Can we take it from the ambulance runs, triage records and nurses’ notes or not? The external cause of morbidity codes (Y codes) are coded at initial presentation for care and documentation can be used from anywhere in the record as long as the physician has documented the injury including, but not limited to, EMT documentation, triage records and nurse’s notes. This information is consistent with Official Coding Guidelines and Coding Clinic information (CC 1Qtr. 2014). Of course, if there is conflicting information in the medical record as to the external cause of morbidity, the physician's documentation takes precedence.

A key point here – documentation for the current encounter should clearly reflect those diagnoses that are current and relevant for that encounter. Previous encounters may not be used to determine the 7th character for an injury since the key to appropriate code selection is based on whether active treatment is being provided during the current encounter. Some coders are still a little ‘foggy’ about this guideline but do not give into temptation and review past documentation…it’s a big NO NO!

“It’s the most wonderful time of the year!” (Andy Williams singing) The kids are back in school, holidays and new codes are coming, and we have a wealth of new scenarios to think about along the way. Until next time …

Topics: ICD-10, Coding