colorado trauma network/ colorado trauma registry

Colorado Trauma Network/Colorado Trauma Registry

Health and Safety Data Services

Coding Injuries

in ICD10CM10/1/2014

ICD9CM code Description ICD10CM main code

Description

820 Fracture of neck of femur S72.0 Fracture of head and neck of femur S72.1 Pertrochanteric fracture S72.2 Subtrochanteric fracture of femur S79.0 Physeal fracture of upper end of femur


Been injured in a

spacecraft?

Roughed up by an Orca whale?

Know someone who drowned from

jumping off burning water skis?

Don’t worry! There’s a code for that!

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

ICD10CM Conventions


One ICD9CM code can be represented by multiple ICD10CM codes

ICD9CM Description ICD10CM Description

807.03 Closed fracture of three ribsS22.4 Multiple fractures of ribs

S22.41 Multiple fractures of ribs, right side

S22.42 Multiple fractures of ribs, left side

S22.43 Multiple fractures of ribs, unilateral

S22.49 Multiple fractures of ribs, unspecified side

Red = General Equivalence Mappings (GEMS) GEMS are not a substitute for learning how to use ICD10CM!

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”

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


Description



Exclusion: exclude tortoises – there’s a different code for that!

Don’t worry! There’s a code for that!


Description



Chapter 19 – Injury Diagnosis Codes The basic structure in ICD10CM (3-7 positions)

#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 = SubsequentS = Sequela

(with the exception of fractures)

#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

S52.131A Displaced fracture of neck of right radius, initial encounter for closed fracture


Description



Code Positions 1-21: chapter2: major body region

2: Major Body Region of Injury Site ICD10CM positions 1-2

head S0

neck S1

thorax S2

abdomen, lower back, lumbar spine, pelvis and external genitals S3

shoulder and upper arm S4

elbow and forearm S5

wrist, hand and fingers S6

hip and thigh S7

knee and lower leg S8

ankle and foot S9


Description



3: Major nature of injury 2: Major body region

Superficial Open Fracture D/S/S Nerves Blood

vesselsMuscle and

tendons Crush Amp. Other

head S00 S01 S02 S03 S04 S05 eye/orbit

S06 intracranial S07 S08 S09

neck S10 S11 S12 S13 S14 S15 S16 S17 x S19thorax S20 S21 S22 S23 S24 S25 heart S26 S27 S28 S29abdomen, lower back, lumbar spine and pelvis S30 S31 S32 S33 S34 S35 S36

abd-organs S37 S38 S39

shoulder and upper arm S40 S41 S42 S43 S44 S45 S46 S47 S48 S49

elbow and forearm S50 S51 S52 S53 elbow S54 S55

forearmS56

forearm S57 S58 S59

wrist and hand S60 S61 S62 S63 S64 S65 S66 S67 S68 S69

hip and thigh S70 S71 S72 S73 hip S74 S75 S76 S77 S78 S79

knee and lower leg S80 S81 S82 S83 knee

S84 low-leg

S85 low-leg

S86 low-leg S87 S88 S89

ankle and foot S90 S91 S92 S93 S94 S95 S96 S97 S98 S99*D/S/S = joint dislocation/sprain/strain

Position 3 Major Nature of InjuryWithin each major body region, injuries are organized

from superficial to deeper body structures


Description



Position 4

2: Major body region

3: Major nature of injuryCommon 4th position terms

Superficial Open Fracture D/S/S

head S00 Scalp, eyelid, nose, ear, lips and oral cavity

neck S11 Larynx and trachea, thyroid, pharynx and cervical esophagus

thorax S22 Thoracic vertebra, sternum, one rib, multiple ribs, flail chest

abdomen, lower back, lumbar spine, pelvis

S33

Lumbar intervertebral disc, lumbar vertebra, sacroiliac and sacrococcygeal joint, unspecified parts of lumbar spine and pelvis, rupture of symphysis pubis, ligaments of lumbar spine

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


Description



Fracture of Femoral Neck

ICD9CM code Description ICD10CM main code Description

820 Fracture of neck of femur

S72.0 Fracture of head and neck of femur

S72.1 Pertrochanteric fracture

S72.2 Subtrochanteric fracture of femur

S79.0 Physeal fracture of upper end of femur

1: chapter 2: major body region 3: major nature of injury4: specific body region (often a subsection of 2; e.g., hip to femur)


Description



Fracture of Rib(s), Sternum, Larynx and Trachea

ICD9CM code Description ICD10CM main code Description

807

Fracture of rib(s), sternum, larynx and trachea

S12.8 Fracture of other parts of neck

S22.2 Fracture of sternum

S22.3 Fracture of one rib

S22.4 Fracture of multiple ribs

S22.5 Flail chest

1: chapter 2: major body region 3: major nature of injury4: specific body region (e.g., from neck to trachea)


Description



Position 5

3: major nature of injury 4th position Common 5th position terms

Superficial injury of head (S00)

Superficial injury of ear (S00.4)

abrasion, blister (nonthermal), contusion, external constriction, foreign body, insect bite

(nonvenomous), other bite

Open wound of neck (S11)

Open wound of thyroid gland (S11.1)

laceration or puncture w/ w/o foreign body, bite

Fracture of rib(s), sternum and thoracic spine (S22)

Multiple fracture of ribs (S22.4) Right/left side, bilateral

Dislocation and sprain of joints and ligaments of lumbar spine and pelvis (S33)

Subluxation and dislocation of lumbar vertebra (S33.1)

L1/L2…L4/L5 lumbar vertebra

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)


Description



4th position 5th position code Common 6th position terms

Superficial injury of ear (S00.4)

External constriction of ear (S00.43)

Right, left, unspecified

Open wound of thyroid gland (S11.1)

Laceration with foreign body of thyroid gland (S11.12)

X – placeholder

Multiple fracture of ribs (S22.4)

Multiple fracture of ribs, right side (S22.41)

X – placeholder

Subluxation and dislocation of lumbar vertebra (S33.1)

Subluxation and dislocation of L4/L5 lumbar vertebra (S33.14)

Select subluxation or dislocation

Position 65: 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


Description



Y93.D1Actively knitting and crocheting

Measure twice, cut once! Cookie fatigue, Santa?

T73.3xxSExhaustion due to excessive exertion


ICD9CM main code

Description ICD10CM main code

Description 5: 6: Possible ICD10CM code

852 Subarachnoid, subdural and

extradural hemorrhage

S06.4 Epidural hemorrhage

x 0-9 S06.4x3AEpidural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes

1: S2: Head 3: Muscle and tendons + some organs4: From head to epidural (often a subsection of 2)5: Placeholder (often a subsection of 3)6: LOC duration

Epidural Hematoma with LOC


Description



ICD9CM code

Description ICD10CM code

Description

920 Contusion of face, scalp, and neck except eye(s)

S00.93X Contusion of unspecified part of head S00.03 Contusion of scalp S00.33 Contusion of nose S00.43 Contusion of ear S00.431 Contusion of right ear S00.432 Contusion of left ear S00.439 Contusion of unspecified ear S00.53 Contusion of lip and oral cavity S00.531 Contusion of lip S00.532 Contusion of oral cavity S00.83 Contusion of other part of head S10.0 Contusion of throat S10.83 Contusion of other specified part of neck S10.93X Contusion of unspecified part of neck

Red = GEMS equivalent

1: chapter2: major body region 3: major nature of injury4: 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

Contusion in Head or Neck Region


Description



Type of encounter*A: Initial encounter

Active treatment, ER encounter, evaluation and treatment by a new physician

D: Subsequent encounterRoutine 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

Episode of Care - Position 7


Description



Position 7 - Fractures

A Initial encounter for closed fracture

B Initial encounter for open fracture

D Subsequent encounter for fracture with routine healing

G Subsequent encounter for fracture with delayed healing

K Subsequent encounter for fracture with nonunion

P Subsequent encounter for fracture with malunion

S Sequela

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.

Type of encounter**

**for use with fractures only


Description



Position 7 – OPEN Fractures

B Initial encounter for open fracture type I or II

C Initial encounter for open fracture type IIIA, IIIB, IIIC

E Subsequent encounter for open fracture type I or II with routine healing

F Subsequent encounter for open fracture type IIIA, IIIB, IIIC with routine healing

H Subsequent encounter for open fracture type I or II with delayed healing

J Subsequent encounter for open fracture type IIIA, IIIB, IIIC with delayed healing

M Subsequent encounter for open fracture type I or II with nonunion

N Subsequent encounter for open fracture type IIIA, IIIB, IIIC with nonunion

Q Subsequent encounter for open fracture type I or II with malunion

R Subsequent encounter for open fracture type IIIA, IIIB, IIIC with malunion

Apply to categories: S52 – Fracture of forearm S72 – Fracture of femur S82 – Fracture of lower leg

Type of encounter***

***for with open fractures only

Gustilo open fracture classification


Description




Description



For More InformationScott Beckley, PhDHealth Facilities and EMS DivisionColorado Department of Public Health & Environment4300 Cherry Creek Drive SouthDenver, CO [email protected]: (303) 692-2851F: (303) 691-7720 www.coems.info

colorado trauma network/ colorado trauma registry

Documents