Comprehensive Guide to Coding Traumatic Injuries and Fractures

1. Basic ICD 10-CM/PCS and ICD-9-CM Coding, 2015 Edition Chapter 19: Injury and Poisoning I

2. Learning Objectives • Review the chapter’s learning objectives • Many different injuries are described in this chapter with individual definitions and rules for coding • At the conclusion of this chapter, what must you know about the coding of traumatic injuries and related procedures?

3. ICD-9-CM Chapter 17 • ICD-9-CM Categories 800–999 • Chapter includes a wide variety of injuries, poisonings, and surgical and medical complications • This chapter will focus on injuries

4. ICD-9-CM Coding of Injuries • Traumatic injuries • Damage to a body part or destruction of a body part • Various external causes of trauma • Traumatic injuries may predispose a person to a nontraumatic illness: for example, a bacterial infection in a wound

5. ICD-9-CM Main Terms for Injuries • Alphabetic Index to Diseases classifies injuries according to the general type of injury • Main term is the type of injury • Fracture, dislocation, burn • Subterm is the anatomical site • Skull, back, leg

6. ICD-9-CM Fifth-Digit Subclassifications • Numerous ICD-9-CM fifth-digit subclassifications are used in the injuries section • ICD-9-C Fifth digits must be used to indicate • Level of consciousness • Specific anatomical site • Severity of injury

7. Instructions for Coding Injuries • A separate code is used to identify each specific injury • The code for the most severe injury is usually coded as the principal or first listed diagnosis • The most serious injury should be identified by the provider and evidenced by the treatment provided

8. ICD-9-CM Coding of Fractures (800–829) • Fracture is a break in the bone due to trauma or disease • Traumatic fractures are due to a traumatic injury • Pathological or spontaneous fractures are due to disease, such as osteoporosis • Only traumatic fractures are coded to ICD-9-CM categories 800–829 (see the “excludes note” under the Category 800–829 in Tabular List)

9. ICD-9-CM Coding of Fractures (800–829) (continued) • At the ICD-9-CM fourth-digit level, fractures are identified as closed or open • In closed fractures, the skin remains intact • In open fractures, a break in the skin occurs • See note at the beginning of the section of “Fractures” in the Tabular List • Provides terminology for closed & open fractures

10. Closed vs. Open Fracture • Closed fractures • Comminuted, depressed, elevated, fissured, greenstick, impacted, linear, simple, slipped epiphysis, spiral, or unspecified • Open fractures • Compound, infected, missile, puncture, or with foreign body

11. ICD-9-CM Coding of Aftercare for Fractures • ICD-9-CM Codes V54.0, V54.1, V54.8, V54.9 • Describe orthopedic aftercare. • Patient has received completed active treatment but requires continuing care for the fracture during the healing or recovery period. • Examples of aftercare include: • Cast change or removal • Removal of internal or external fixation device • Medication adjustments • Follow up visits following fracture treatment

12. ICD-9-CM—Closed vs. Open FractureUsing the Radiologist’s Report • Fractures that are not specified as open or closed are presumed to be closed in ICD-9-CM • A radiologist’s report of the fracture site may be used by a coder to add specificity for the precise location of a fracture site

13. ICD-9-CM Fifth Digits with Fractures • ICD-9-CM fifth-digit subclassifications are used to add more specificity to the specific bone fractured • Examples • Middle or proximal phalanx or phalanges • One, two, three ribs • Upper end • Shaft

14. ICD-9-CM Coding of Pathological Fractures • Pathological fractures are not considered traumatic fractures • Due to underlying bone disease • Pathological fractures coded to the range of ICD-9-CM diagnosis codes 733.10–733.19 and not to the traumatic fracture codes

15. ICD-9-CM Coding of Multiple Fractures • When a patient has multiple fractures, separate codes should be assigned • ICD-9-CM combination categories for multiple fractures are used when: • The health record contains insufficient detail • The reporting form limits the number of codes that can be assigned

16. ICD-9-CM Main Term—FracturesFracture/Dislocation • Alphabetic Index in ICD-9-CM’s main term for traumatic fractures is “fracture” • Subterm is the anatomic location or eponym • Note that “dislocation” is a nonessential modifier after the main term “fracture” • Fractures may also be dislocated but one ICD-9-CM code describes the fracture—dislocation

17. ICD-9-CM Coding of Dislocation (830–839) • Dislocation is the displacement of the bone from its joint (the bone is not fractured) • Most common dislocation sites: fingers, thumbs, and shoulders • Subluxation is an incomplete dislocation with the contact between the joint surfaces remaining in place • A common subluxation is a “nursemaid’s elbow”

18. ICD-9-CM Coding of Dislocation (830–839) (continued) • ICD-9-CM fourth digit differentiates between open and closed dislocations • Closed dislocation may be described as complete, partial, simple, or uncomplicated • Open dislocation may be described as compound, infected, with foreign body

19. ICD-9-CM Coding of Dislocation (830–839) (continued) • When a dislocation is not described as open or closed, it is presumed to be closed in ICD-9-CM • Fifth-digit subclassification identifies the specific anatomic site • Examples • Anterior dislocation of humerus • Metacarpal phalangeal joint

20. ICD-9-CM Coding of Dislocation (830–839) (continued) • Once a dislocation of a joint has occurred, it takes less effort to produce another dislocation • Only the initial occurrence of a joint dislocation is coded to the injury code • Recurrent dislocations are coded to the ICD-9-CM chapter on musculoskeletal diseases

21. ICD-9-CM Coding of Sprains and Strains (840–848) • Sprain • Injury of the supporting ligaments of a joint resulting from a turning or twisting of a body part • Strain • Injury to the muscles that may be the result of overstretching or overexertion

22. ICD-9-CM Coding of Sprains and Strains (840–848) (continued) • ICD-9-CM categories 840–848 represent current or acute sprains or strains • Chronic strains or derangements of joints are classified to diseases of the musculoskeletal system, ICD-9-CM categories 710–739 • Chronic strains may be described by the physician as old or recurrent

23. ICD-9-CM Main Term for Sprains and Strains • Main term is “Sprain, strain” • Subterm is the anatomical site • Note the main term of “Strain” directs the coder to “see also, Sprain, by site” • Subterms under sprain, strain include old, chronic, or recurrent and direct the coder to ICD-9-CM categories 710–739

24. ICD-9-CM Coding of Intracranial Injury (850–854) • Refer to ICD-9-CM section 850–854 in the Tabular List • Excludes note directs coder elsewhere for intracranial injuries with skull fractures and open wound of head without intracranial injury

25. ICD-9-CM Coding of Intracranial Injury (850–854) (continued) • If the diagnosis includes the phrase “with open intracranial wound,” a fourth-digit code may be used to describe the wound that is specified as open or with mention of infection or foreign body

26. ICD-9-CM Coding of Intracranial Injury (850–854) (continued) • Types of intracranial injuries • Concussion • Transient loss of consciousness for less than 24 hours after traumatic head injury • Observed for development of complications • Codes 850.0–850.9 assigned based on the exact injury that occurred and the amount of time the patient had a loss of consciousness • “Head injury” with no loss of consciousness coded to ICD-9-CM code 959.01

27. ICD-9-CM Coding of Intracranial Injury (850–854) (continued) • Types of intracranial injuries • Cerebral contusion • Bruise to the brain with bleeding into brain tissue • Loss of consciousness often lasts longer than that of a concussion • A laceration often accompanies a contusion • Some destruction of brain tissue and subsequent scarring may cause posttraumatic epilepsy • ICD-9-CM codes 851.0–851.9 with fifth digits to indicate whether loss of consciousness or concussion occurred

28. ICD-9-CM Coding of Intracranial Injury (850–854) (continued) • Types of intracranial injuries • Subdural hematoma • Formation of a hematoma between the dura and the leptomeninges • Acute form of subdural hematoma is associated with a laceration or contusion • Chronic subdural hematoma may result from closed head injuries after a fall • Not all subdural hematomas are traumatic injuries

29. ICD-9-CM Main Term for Intracranial Injury • Main term for the ICD-9-CM Alphabetic Index is the type of intracranial injury, such as concussion, subarachnoid hemorrhage • Main term of “Injury, intracranial” • Subterms identify the location or type of injury

30. ICD-9-CM Coding of Internal Injury of Thorax, Abdomen, and Pelvis (860–869) • Refer to the includes note in the ICD-9-CM Tabular List under section 860–869 • Internal injury or damage to internal organs • Blunt trauma • Concussion, crushing, hematoma • Laceration, puncture, tear • Traumatic rupture

31. ICD-9-CM Coding of Internal Injury of Thorax, Abdomen, and Pelvis (860–869) (continued) • Refer to the excludes note in the ICD-9-CM Tabular List under section 860–869 • Concussion NOS, flail chest, foreign body entering through orifice and injury to blood vessels are classified elsewhere in ICD-9-CM

32. ICD-9-CM Coding of Internal Injury of Thorax, Abdomen, and Pelvis (860–869) (continued) • Refer to the excludes note in the ICD-9-CM Tabular List under section 860–869 • Fourth-digit codes include the phrase “with open wound” which includes those with mention of infection or foreign body

33. ICD-9-CM Coding of Internal Injury of Thorax, Abdomen, and Pelvis (860–869) (continued) • Fourth-digit and fifth-digit codes describe the specific type and location of the internal organ that was injured • Organs • Heart, lung, diaphragm, bronchus, esophagus • Stomach, small intestine, colon, rectum • Pancreas, liver, spleen, kidney, ureter, bladder • Uterus, tube, ovary, prostate, gallbladder

34. ICD-9-CM Main Term for Internal Injury of Thorax, Abdomen, and Pelvis • Main term is “Injury” • Subterm is “internal” • Sub-subterms are the organ or anatomical site • Beneath the sub-subterms are phrases such as “with mention of open wound into cavity”

35. ICD-9-CM Coding of Open Wound (870–897) • Open wound: injury of the soft tissue parts associated with rupture of the skin • Categories are organized by anatomic location • Refer to the includes note in the ICD-9-CM Tabular List under section 870–897

36. ICD-9-CM Coding of Open Wound (870–897) (continued) • Open wound types • Animal bites • Avulsion • Cut • Laceration • Puncture wound • Traumatic amputation

37. ICD-9-CM Coding of Open Wound (870–897) (continued) • Open wound may be a penetrating wound that involves the passage of an object through tissue that leaves an entrance and possibly an exit wound • Penetrating wounds • Gunshot wound • Stab wound • Knife wound

38. ICD-9-CM Coding of Open Wound (870–897) (continued) • Excludes note under ICD-9-CM section 870–897 refers to the coder elsewhere for: • Burn • Crushing • Puncture of internal organ • Superficial injury • That which is incidental to dislocation, fracture, internal injury, or intracranial injury

39. ICD-9-CM Coding of Open Wound (870–897) (continued) • Seriousness of the wound depends on its site and extent • Deep wounds may damage internal organs • These are coded to internal injuries • Most open wound injuries involve damage to skin, subcutaneous tissue, and tendons

40. ICD-9-CM Coding of Open Wound (870–897) (continued) • ICD-9-CM fourth digits and fifth digits identify: • Type of open wound • Site of the wound • Complicated or uncomplicated wound • Involvement of tendons • If blood vessels are damaged in the wound, additional codes are added for injury, blood vessel, by site

41. ICD-9-CM Coding of Open Wound (870–897) (continued) • The term “complicated” open wound identifies a wound that includes mention of: • Delayed healing • Delayed treatment • Foreign body • Infection • An additional code is used to identify the type of infection, for example, staphylococcus

42. ICD-9-CM Main Term for Open Wound • Main term for the ICD-9-CM Alphabetic Index is “wound” • Subterms include the anatomic site • Sub-subterms include “complicated” or “with tendon involvement” or a more specific site

43. ICD-9-CM Main Term for Open Wound (continued) • Another main term for the ICD-9-CM Alphabetic Index is “amputation” • Subterm is traumatic • Sub-subterms include anatomic location(s) and “complicated”

44. ICD-9-CM Coding of Repair of Open Wounds • Repair of open wounds, such as lacerations of skin, are typically sutured or repaired with tissue adhesive • ICD-9-CM procedure code 86.59 includes repair by: • Suturing of skin and subcutaneous tissue • Repair by the application of Dermabond or other brand of tissue adhesive • The use of Band-aids or steri-strips is not coded

45. ICD-9-CM Coding of Burns (940–949) • Codes in this section describe: • Burns caused by • Electrical heating appliance • Electricity • Flame • Hot object • Lightning • Radiation • Chemical burns, internal and external • Scalds

46. ICD-9-CM Coding of Burns (940–949) (continued) • ICD-9-CM category codes 940–949 describe the anatomic location of the burn • Burns are classified by • Depth at location • Extent of body surface • Agent or cause (E code)

47. ICD-9-CM Coding of Burns (940–949) (continued) • Depth of burns described by the fourth digit • First degree • Second degree • Third degree • Other fourth digits describe • Deep necrosis of underlying tissue (deep third-degree) without mention of loss of a body part • Deep necrosis of underlying tissue (deep third-degree) with mention of loss of a body part

48. ICD-9-CM Coding of Burns (940–949) (continued) • First degree: Least severe, damage to epidermis or outer layer of skin alone • May be described as superficial burn • Second degree: Involves epidermis and dermis • There is edema and blistering; skin red and moist • May be described as partial thickness burn • Third degree: Most severe • Includes all layers of skin: epidermis, dermis, subcutaneous; skin is charred, white, dry • May be described as full thickness burn

49. ICD-9-CM Guidelines for Coding Burns Guidelines for coding patients with burns: 1. Code all burns with the highest degree of burn sequenced first 2. Code burns of the same local site to the highest degree recorded only 3. Code nonhealing burns as acute burn. Code necrosis of burned skin as a nonhealed burn

50. ICD-9-CM Guidelines for Coding Burns (continued) 4. Assign ICD-9-CM code 958.3 as additional code for any documented infected burn site 5. When coding multiple burns, assign separate codes for each burn site (Code 946, burns of multiple specified sites, should be used only if the locations of the burns are not documented)