Colorado Trauma Network/ Colorado Trauma Registry

1. Colorado Trauma Network/ Colorado Trauma Registry Coding Injuries in ICD10CM 10/1/2014 Health and Safety Data Services

2. Know someone who drowned from jumping off burning water skis? Roughed up by an Orca whale? Been injured in a spacecraft? Don’t worry! There’s a code for that! Health and Safety Data Services

3. ICD10CM Conventions ICD10CM code structure • Specific injury site (e.g., head, S00-S09; neck, S10-S19) are grouped rather than grouping by injury type as in ICD9CM (e.g., fractures, 800-829; dislocations, 830-839) • More details for specific body regions (e.g., right/left, bilateral, open/closed, rupture, severity of open fractures) • Codes with no predecessor in ICD9CM • Under dosing Blood type Glasgow Coma Scale Health and Safety Data Services

4. ICD10CM Conventions One ICD9CM code can be represented by multiple ICD10CM codes Red = General Equivalence Mappings (GEMS) GEMS are not a substitute for learning how to use ICD10CM! Health and Safety Data Services

5. ICD10CM Conventions Level of Detail in Coding Composed of codes with 3, 4, 5, 6 or 7 digits • Three digits as the heading of a category • Can be followed by fourth and/or five digits which provide greater detail Seventh position and placeholders • “X” is used as a placeholder at certain codes to ensure the seventh value is always in the seventh position (also allows for future expansion) • The seventh position is the episode of care(initial, subsequent, sequela) e.g., “A” (for initial encounter) is in the seventh position in “S03.4xxA Sprain of jaw, initial encounter” Health and Safety Data Services

6. ICD10CM Coding Manual • The latest version of the ICD10CM coding manual is available at: http://www.cdc.gov/nchs/icd/icd10cm.htm • Scroll down to “FY 2015 release of ICD-10-CM” and click on “ICD-10-CM PDF Format” and then “ICD10CM_FY2015_Full_PDF.zip” file, and then the “FY15_Tabular” file and go to Chapter 19 • This website posts a new coding manual each year, which includes any new codes that have been added • The new version goes into effect on October 1 each year Health and Safety Data Services

7. Don’t worry! There’s a code for that! Exclusion: exclude tortoises – there’s a different code for that! Health and Safety Data Services

8. Chapter 19 – Injury Diagnosis Codes S52.131A Displaced fracture of neck of right radius, initial encounter for closed fracture The basic structure in ICD10CM (3-7 positions) #1 Injury chapter #2 Elbow and forearm #3 Fracture . Decimal #4 upper end of radius #5 neck of radius #6 displaced, right radius #7 Initial encounter #1-Chapter (alpha –all letters except U) #2 -Major body region (always numeric) #3 -Major nature of injury #4-6 -specific body region and nature of injury (placeholder when necessary) #7 - type of encounter A = Initial, D = Subsequent S = Sequela (with the exception of fractures) Health and Safety Data Services

9. Code Positions 1-2 1: chapter 2: major body region Health and Safety Data Services

10. Position 3 Major Nature of Injury Within each major body region, injuries are organized from superficial to deeper body structures *D/S/S = joint dislocation/sprain/strain Health and Safety Data Services

11. Position 4 4: Often a specific body region (subsection of 2 (e.g., from head to nose)). Also see “other parts” or “unspecified” – similar to what would be derived from a ICD9CM GEM Health and Safety Data Services

12. Fracture of Femoral Neck 1: chapter 2: major body region 3: major nature of injury 4: specific body region (often a subsection of 2; e.g., hip to femur) Health and Safety Data Services

13. Fracture of Rib(s), Sternum, Larynx and Trachea 1: chapter 2: major body region 3: major nature of injury 4: specific body region (e.g., from neck to trachea) Health and Safety Data Services

14. Position 5 4: specific body region 5: often a specific nature of injury (often associated with 3; e.g., from open to puncture); sometimes a cause code (e.g., bite) Health and Safety Data Services

15. Position 6 5: often a specific nature of injury (often associated with 3; e.g., from open to puncture); sometimes a cause code (e.g., bite) 6: often a more specific region or nature of injury, placeholder or LOC Health and Safety Data Services

16. Measure twice, cut once! Cookie fatigue, Santa? Y93.D1 Actively knitting and crocheting T73.3xxS Exhaustion due to excessive exertion Health and Safety Data Services

17. Epidural Hematoma with LOC 1: S 2: Head 3: Muscle and tendons + some organs 4: From head to epidural (often a subsection of 2) 5: Placeholder (often a subsection of 3) 6: LOC duration Health and Safety Data Services

18. Contusion in Head or Neck Region 1: chapter 2: major body region 3: major nature of injury 4: specific body region (often a subsection of 2 ; e.g., from head to scalp) 5: specific nature of injury (often a subsection of 3; e.g., superficial to contusion) 6: often a placeholder, location, or more injury specificity Red = GEMS equivalent Health and Safety Data Services

19. Episode of Care - Position 7 Type of encounter* A: Initial encounter Active treatment, ER encounter, evaluation and treatment by a new physician D: Subsequent encounter Routine care during healing/recovery phase (e.g., cast change/removal, removal of external fixation device, planned follow-up visits) S: Sequela Complications or conditions that arise as a direct result of the injury (e.g., scar from burn) • Sequela replaced the late effects categories (905-909) in ICD9CM • Only used with the injury code where the sequela exists *with the exception of fractures Health and Safety Data Services

20. Position 7 - Fractures Type of encounter** **for use with fractures only Note: In ICD-10-CM, a fracture not indicated as displaced or nondisplaced should be coded to displaced, and a fracture not designated as open or closed should be coded as closed. Health and Safety Data Services

21. Position 7 – OPEN Fractures Type of encounter*** Apply to categories: S52 – Fracture of forearm S72 – Fracture of femur S82 – Fracture of lower leg Gustilo open fracture classification ***for with open fractures only Health and Safety Data Services

22. Health and Safety Data Services

23. For More Information Scott Beckley, PhD Health Facilities and EMS Division Colorado Department of Public Health & Environment4300 Cherry Creek Drive SouthDenver, CO 80246-1530scott.beckley@state.co.usP: (303) 692-2851 F: (303) 691-7720 www.coems.info Health and Safety Data Services