Chapter 19

1. Chapter 19 Injury and Poisoning

2. Main Terms for Injuries • How do you look up injuries? • First classify injury, like wound, fracture, dislocation. • Second identify the anatomical site of injury. • Third identify simple, complex, complication • Wound, open … • Abdomen, abdominal … 879.2 • Complicated 879.3

3. Traumatic Fractures (800-829) • A fracture aka Fx is a break in the bone due to traumatic injury. The area around the site will usually have pain and swelling and may have a visible or palpable deformity, pain or weakness. X-Rays will show a partial, incomplete or complete break at the site of the fracture. • At the fourth digit level of coding fractures are identified as open or closed. • Closed fractures are where the skin remains intact. • Open fractures are where a break in the skin occurs.

4. Examples of Fractures Greenstick, Spiral, Comminuted, Transverse are closed fractures. Compound is a open fracture.

5. Coding Open or Closed • If you do not have information as to if the fracture is open or closed always code it as CLOSED. • Traumatic fractures are coded using the acute traumatic fracture codes as long as the patient is receiving active treatment for the fracture. Active treatment is surgery, ER visits, evaluation as treatment by a new physician. • Traumatic fractures aftercare coding (V54.0, V54.1, V54.8 or V54.9) for encounters when the patient has completed active treatment and is receiving routine care like cast changes, removal, removal of internal or external fixation devices, medication adjustment, follow-up treatments following fracture treatment.

6. Coding Specifically • You are permitted to use an x-ray report to assign a more specific diagnosis code. The physician may not list the specific site of the fracture but the x-ray report will show the precise site. • The fifth digit sub-classification is used to identify the specific site involved. • 816 Fracture of one or more phalanges of hand • 0 phalanx or phalanges, unspecified • 1 middle or proximal phalanx or phalanges • 2 distal phalanx or phalanges • 3 multiple areas 816.0 Closed 816.1 Open

7. Pathologic Fractures (733.10-733.19) • Pathologic fractures are from a underlying bone disease and are not traumatic in nature. • Like cancer, bone density problems, etc. This is a chronic disease process, no injury.

8. Multiple Fractures • Whenever possible separate and code fractures separately unless told otherwise by the Alphabetic Index or Tablular List. • When the health record contains insufficient detail: • Multiple fractures of right upper limb. 818.0 was assigned. • When the reporting form limits the number of codes that can be assigned. • Patient had many traumatic injuries, including several fractures of the hand bones, which were identified in the health record. Because of all the other more critical injuries space was not available on the form to code injuries separately, therefore 817.0 was coded to include all fractures of the hand bones.

9. Dislocation and Subluxations • Dislocation is a displacement of the bone from it’s joint. Most common joints affected are fingers, thumbs and shoulders. Pain and swelling occur at the site. The dislocation can be reduced and the joint immobilized by applying a cast. • A dislocation that occurs with a fracture is included in the fracture code. The reduction of the dislocation is also included in the fracture reduction. • A subluxation is a incomplete dislocation with the contact between the joint surfaces remaining in place. Subluxations can occur in the vertebra, elbow, and other areas.

10. Dislocations • When a dislocation is not classified as open or closed always code it as CLOSED. • Once a dislocation has occurred it’s easy for the joint to dislocate again. Only code the initial occurrence. All subsequent dislocations to the same joint are coded as recurrent.

11. Sprains and Strains (840-848) • Sprains are injuries to the supporting ligaments of a joint resulting from turning or twisting of a body part. Painful, accompanied by swelling and discoloration, sprains require rest to heal. • Whiplash is a specific type of sprain due to the sudden throwing of the head forward then backward. It results in a compression of the cervical spine involving the bones, joints and intravertebraldiscs. • Simply a overstretching or overexertion of some part of the muscles, strains usually respond to rest.

12. Sprains and Strains con’t • Patient may suffer from chronic strains of the neck and back or derangements of different joints. • Physician may describe as chronic, old or recurrent. • Code the initial injury as acute. • Chronic, old or recurrent code as 710-739.

13. Intracranial Injury, Excluding those with Skull Fracture • Concussion is a transient loss of consciousness for less than 24 hours after a traumatic head injury. No intracranial damage occurs but patient may experience: • Bradycardia • Hypotension • Respiratory arrest • Retrograde and posttraumatic amnesia. • MRI is done to rule out intracranial injury. • Do not assume a head injury is a cerebral concussion unless documented by physician.

14. Subdural Hematoma • The formation of a hematoma (what’s a hematoma?) between the dura and the leptomeninges. This often results from a tear in the arachnoid (remember it looks like a spider web) the acute form is usually associated with a laceration or contusion. • Symptoms include headache, increasing drowsiness, hemiparesis and seizures. These can be mild and increase to severe.

15. Internal Injuries to Thorax, Abdomen and Pelvis (860-869) • Code location first • Fourth digit describes the presence or not of a open wound. • Fifth digit identifies the specific site, specific type of injury or the severity of the injury.

16. Open Wounds (870-897) • Open wounds are injuries where the soft tissue parts associated with rupture of the skin. May be from animal bites, avulsions, cuts, lacerations, punctures and traumatic amputation. • May be a penetrating would, which involves the passage of an object through tissue which leaves an entrance and exit, like a stabbing or gunshot. • A fractured tooth or one broken due to trauma is classified as a open wound.(873.63 or 873.73)

17. Open Wounds con’t • Seriousness of an open wound depends on site and extent. • If a major organ or vessel is involved, it may be life threatening. • Significance of the hemorrhage rests on the volume of blood loss. Patient can suffer shock from large losses of blood. • Fourth digit subdivisions tell whether wound is complicated. • Can be considered complicated if wound is not healing, delayed treatment received, infection, or foreign body.

18. Burns (940-949) • Burns can be due to electrical, flames, hot objects, lightning, radiation, chemicals and scalding. • Classified as First degree (erythema), Second degree (blistering) and Third degree (full-thickness) and Fourth degree (deep full-thickness)

19. First Degree Burns • First degree- least severe, damage to the epidermis or outer layer of skin alone. Superficial burn, skin appears pink and red and painful. There may be edema but no blistering or eschar. Skin may peel off a few days later.

20. Second Degree Burns • Second degree- involves epidermis and dermis. Mild to moderate edema and blistering but no eschar. May be described as partial thickness or deep partial thickness. Superficial partial thickness burns extend into upper dermal layer and leave the skin from pink to red. Nerve endings are exposed so stimulation causes extreme pain. • Deep partial thickness burns extend to the deeper layers of the derma, skin is red to pale with moderate edema. Blisters are infrequent but there will be soft dry eschar. The patient will experience pain but not as severe because some of the nerve endings have been destroyed.

21. Third Degree Burns • Most severe, includes all layers of the epidermis, dermis and subcutaneous. Aka full thickness burn. Skin may appear black, brown, yellow, white or red. Edema is severe. Burn penetrates the derma and may reach subcutaneous fat layer. Pain is minimal because nerve endings are almost completely destroyed. No blistering but there is hard eschar.

22. Fourth Degree Burns • Burns centers will describe these as deep full thickness burns. Most severe burns. The burn extends deep through the skin into the underlying fascia and may damage the tendons and bones. Skin is black, no edema and the eschar is hard. Pain is minimal because the nerve endings have been destroyed.

23. Coding Burns • Code highest degree of burns first. • Classify burns of same site but of different degrees identifying highest degree recorded in dx. • Code non-healing burns as acute. • Code necrosis of burned skin as non-healing burn • Multiple burns, separate sites • Postraumatic wound infection as additional code for any infected burn site. 958.3 • Do not use unspecified codes! • Assign codes on the extent of body surface involved. • Use 948 additional for evaluating burn mortality. • Use 948 when there is mention of third degree burn over 20% of body surface.

24. Coding Criteria • Fourth digit codes used to identify the % of total body surface involved.(all degrees) • Fifth digits identify the % of body surface involved in a third degree burn. • Fifth digit is 0 when less than 10% of body surface is involved in a third degree burn.

25. Rules of Nines • Estimating body surface involved: • Head and neck = 9% • Each arm = 9% • Each leg = 18% • Anterior trunk = 18% • Posterior trunk = 18% • Genitalia = 1% • Physicians may change the percentages where necessary to accommodate infants, children, obese patients, etc.

26. Late Effects • Encounters for treatment of the late effects of burns (scars or joint contractures) to the residual condition followed by the late effect code (906.5-906.9) A late effect E code may also be used. • When appropriate both a sequela with a late effect code and a current burn code may be assigned on the same record. • Sunburn is caused by overexposure to uv rays from sunlight. Can be described as first, second or third degree depending on depth of burn. Code 692.70-692.79 contact dermatitis due to solar radiation.

27. Superficial Injury and Contusion with Intact Skin • Superficial injuries such as abrasions or contusions are NOT coded when associated with more sever injuries like fractures, or open wounds of the same site. • Superficial injuries are classified to 910-919, abrasions to superficial foreign bodies. The fourth digit specifies type of injury and presence/absence of infection. • Contusions are injuries to soft tissue, skin is not broken, small vessels or capillaries are ruptured resulting in bleeding into the tissue. When blood becomes trapped in interstitial spaces it results as a hematoma.

28. Crushing Injuries (925-929) • Occur when part or all of a extremity is pulled into, and compressed by, rollers in a machine found in industrial plants. A crushing injury may also occur in a non-industrial situation. Avulsion of skin and fat or a friction burn of tissues may result. Abrasion burns are often severe, including third degree. Vessels, nerves, muscles may be avulsed, bones may be dislocated or fractured. Common complication secondary congestion which can lead to paralysis, and severe muscel fibrosis and joint stiffness. Decompression of muscle compartments may be needed, muscles/ligaments may need sectioning.

29. Crushing Injuries con’t • The overall circulation of the extremity is of greater concern than definitive management of specific structures. These types of injuries may be called wringer, compression, crush, crushed or crushing injuries. • Use a additional code to identify any additional injuries such as: • Fractures 800-829 • Internal injuries 860.0-869.1 • Intracranial injuries 850.0-854.1

30. Injury to Blood Vessels (900-904), Nerves and Spinal Cord (950-957) • When a primary injury results in minor damage to peripheral nerves or blood vessels, list the primary injury first with additional codes 950-957. Also when the primary injury is to the blood vessels or nerves list the primary injury first. • Injuries can include arterial hematomas, avulsions, cuts, lacerations, ruptures and traumatic aneurysms or fistulas that are secondary to other injuries like fractures or open wounds. • Injuries to nerves and spinal cord include with/without presence of a open wound. Spinal cord injury without evidence of spinal bone injury fourth/fifth digits identify specific sites involved.