external cause codes - conduent › bulletins › mag... · 2017-08-10 · icd-10-cm code fields....
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Background Information 42 C.F.R. Section 433.138(e) mandates that States identify claims resulting from a possible trauma with a high
probability of leading to third party recovery and pursuing claims for possible recovery. With ICD-9, the Centers for
Medicare and Medicaid Services (CMS) provided guidance regarding the range of diagnosis codes (800-999) requiring
follow up. However, with the implementation of ICD-10, CMS no longer provides a list of required diagnosis codes and
has turned over identification of injury and accident associated claims to the State Medicaid Agency.
Wyoming’s Remediation to Comply with the Federal Provision Beginning with dates of service October 01, 2017, Wyoming Medicaid will require external cause codes to be billed with
any accident or injury related claims submitted for services, such as fractures, wounds, other injuries, abrasions,
contusions, burns, and head injuries (priority third party liability diagnoses). Chapter 20 of the ICD-10-CM Official
Guidelines for Coding and Reporting provides that external cause codes may be billed for any diagnosis in the range of
A00.0 – T88.9, Z00-Z99. Claims submitted without external cause code(s) will be denied. By requiring the reporting of
external cause codes, Wyoming Medicaid will not only capture the trauma, accident, injury or condition diagnosis, but it
will also obtain critical information concerning the nature and intent of the accident or condition. As a result, this will
improve third party liability identification and coordination of benefits.
External cause codes provide valuable information surrounding an injury or a health condition.
External cause codes provide information concerning how the injury happened or its cause, where the injury
happened, was the injury intentional, unintentional or accidental, where the injury took place, what activity was
the patient engaged in at the time of the accident/event, and what the status of the person was at the time of
the injury (i.e. military, civilian work for pay, volunteer, or other).
Billing with external cause codes is not a new billing guideline. ICD-9-CM outlined guidelines for use of external
cause codes, and were referred to as “E” codes.
Who Will Be Most Impacted By This Change?
Emergency Rooms
Urgent Care Clinics
Ambulatory Surgical Centers
Orthopedists
Surgeons
Hospitals
Radiologists, Radiology, and Diagnostic Radiology
Skilled Nursing Facilities/Nursing Factilities
Physical Therapists
Physicians (General Practice, Pediatrics, Anesthesiology, Internal Medicine, Family Practice, Psychiatry, and
Neurology)
Rehabilitation Hospitals
External Cause Codes
Date
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Durable Medicaid Equipment and Medicaid Supplies
Federally Qualified Health Centers
Indian Health Services
Chiropractor
Ambulance
Psychiatric Residential Treatment Facilities
Home Health
Rural Health
Why Report?
External cause codes answer questions concerning who, what, where, when, why, and how.
External cause codes track the cause and other parameters of injuries to manage healthcare, improve
population safety, and lead to improved quality of care or patient treatment.
What Are The Four (4) Types of External Cause Codes (Diagnosis Code Range of V00-Y99)?
External cause
Specific cause of the injury or condition
Diagnosis code range of V00-Y849
Place of occurrence
Nature of the location where the injury took place
Diagnosis code begins with Y92 (Y9200-Y9289)
Only one (1) code from Y92 should be referenced on the claim (at the initial encounter) and in the
medical record
May be a rare instance that a new injury occurs during hospitalization, so an additional palce of
occurrence may be coded
A 7th character is not needed for Y92
Do not use place of occurrence code Y92.9 if the place is not stated or is not applicable
Activity
Specific activity the patient engaged in at the time of the injury
Only billed when relevant
Diagnosis begins with Y93 (Y9301-Y9389)
Only one (1) code from Y93 should be recorded on the claim (at the initial encounter) and in the medical
record
Do not use when billing for poisonings, misadventures, adverse effects, or sequalae
Do not assign Y93.9, Unspecified activity, if the activity is not stated.
Status
Identifies if the patient was injured during civilian employment for pay, military employment, volunteer
work, etc.
Diagnosis begins with Y99 (Y990-Y998)
Y990 – Civilian Activity done for pay
Y991 – Military Activity
Y992 – Volunteer
Y998 – Other (Not work for pay, military or volunteer related)
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Only one (1) code status code should be recorded on the claim (at the initial encounter) and in the
medical record
Do not use when billing for poisonings, misadventures, adverse effects, or sequalae
Indicates work status of the patient
How Are External Cause Codes Different From Other Diagnosis Codes?
Do not define the diagnosis or patient clinical condition, but rather the parameters around an injury
Used when billing an accident or injury code to define the nature/cause and intent of an injury or condition
Cannot be used as the primary diagnosis on an institutional or professional claim form. External cause codes are
not the reason why the patient is being treated or evaluated.
Wyoming Medicaid’s claims processing system is programmed to deny claims if the first-listed, principal,
or primary diagnosis code billed is an external cause code.
ICD-9-CM billing guidelines specify that an external cause code could not be the first-listed, primary, or
principal diagnosis.
When Are External Cause Codes Billed?
On the first encounter, visit or claim and continue to be billed for the duration of treatment (subsequent or
follow-up care) as long as the injury is the focus of the treatment or care.
The external cause must be billed for the duration of treatment
The place of occurrence, the activity and the status are billed on the initial visit or encounter. They are
not billed for any subsequent follow-up care or sequelae (late effect).
Sequencing of code
Primary: Injury or condition codes as the reason for care
Secondary: Comorbidities of additional diagnosis
Secondary: External cause codes
Patient Encounters, Visits and External Cause Codes
Initial Evaluation:
Primary Diagnosis
Most specific ICD-10 diagnosis to describe the nature of the injury or patient’s condition to
denote reason why patient is being treated.
Never use an external cause code as the primary, principle or first listed diagnosis.
Secondary Diagnosis
Most specific ICD-10 diagnosis to describe the external cause of the trauma or condition based
upon information provided by the patient and available to the provider at the conclusion of the
encounter.
Must be reported with 7th character: A – Initial Encounter
Include as many external cause codes that describe the events or circumstances of the accident,
trauma, or condition.
Place of occurrence, activity, and status codes are only reported on the initial encounter.
Subsequent Evaluation(s)
Subsequent encounters or management of sequelae (late effect) of the original condition or injury
Primary diagnosis
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Description of the original trauma or condition and identified as a subsequent visit or sequalae.
Secondary Diagnosis
Most specific ICD-10 diagnoses to describe the external cause of the trauma or condition based
upon information provided by the patient and available to the provider at the conclusion of the
encounter.
Must be reported with the 7th character:
D – Subsequent encounter
S – Sequalae
Claims
Professional or CMS – 1500
External cause code is not the first listed diagnosis code
The 837 professional HIPAA claim standards allow for submitting external cause code(s) in the secondary
ICD-10-CM code fields. Up to 11 secondary codes may be listed in the transaction.
Institutional or UB – 04
Claims processing system only requires one (1) external cause code.
The 837 institutional HIPAA claim standards allow for submission of 12 fields specifically defined
for external cause code reporting according to the X12 ANSI 5010 HIPAA transaction standards
(5010 TR3 allows for 12 external cause codes).
**However, when Wyoming Medicaid remediated its system for 5010 transaction (institutional)
it only required one (1) external cause code in the 5010 TR3. The clearinghouse will allow 12
external cause codes in the TR3, but the MMIS will only allow one (1) as it was not seen as
necessary to process claims.
In order to meet the mandate for billing with external cause codes, bill the external cause
code diagnoses in the secondary diagnoses fields.**
“Present on admission” (POA)code definition requirements apply to use of external
cause codes on the institutional claim similar to the POA requirement for other
diagnosis codes
Report external cause codes as secondary diagnoses.
Keys to Success
Learn the requirements for using external cause codes by reading and following the guidelines in the ICD-10
Coding Book.
Clarify any questions by referencing to the official ICD-10 guidelines as well as through key contacts at WDH
Obtain/Capture information at the time of patient intake and as a part of workflow.
Develop a patient intake form to collect injury related data from the patient or their representative. A
sample is included in this packet.
A patient intake form may be necessary or list of questions may be necessary during the history and physical
portion of the examination to obtain injury related information surrounding an accident or a condition.
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Clinical Scenarios
The following scenarios are provided as examples of how information captured about the injury through a standard
patient intake form and the clinical record would lead to the documentation and coding necessary to meet requirements
of reporting for injury related cases. The work flow and patient intake forms will need to be customized for each
practice, but the concepts are the same for all providers.
VEHICLE COLLISION ACCIDENT
Injury Form Data:
Injury Date: 11/12/2016
Encounter: Initial
Work Status: Military
Place of occurrence: Military base
Activity: Construction
Injury Cause: Collision / Traffic accident
Vehicle: Military vehicle / Driver
Intent: Accidental
Clinical documentation:
A 27 year old male was working on a construction project on the local military base as part of his weekend reserve duty. He was driving a military truck when he collided with another military vehicle entering the construction site. He sustained a displaced comminuted open fracture of the right femoral shaft which is classified as a type II Gustilo classification of open fracture. He was seen by the orthopedist in the emergency room for evaluation and treatment.
Assessment:
1. Displaced, comminuted, Gustilo class II open fracture of the shaft of the right femur
Coding:
Primary Diagnosis: S72351B Displaced comminuted fracture of shaft of right femur, initial encounter for open fracture type I or II
External Cause: V8604XA Driver of military vehicle injured in traffic accident, initial encounter
Place of Occurrence: Y9213 Military base as the place of occurrence of the external cause
Activity: Y93H3 Activity, building and construction
External Cause Status: Y991 Military activity
Comment:
It is up to the clinician to determine what information is relevant to include in the clinical documentation. However, the information in the interview form may be as considered part of that clinical information and is available to the clinician at the time of the patient encounter.
The same injury form information can be carried forward to subsequent encounters assuming there has been no change in the information defined in the form for that injury.
Since this is the initial encounter, all cause type codes are included.
On the hospital institutional claim there is a separate field that allows up to 12 external cause codes.
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On the professional claim, the external cause codes are to be included as one or more of the 11 allowed secondary diagnosis codes.
KNEE MENISCUS INJURY
Injury Form Data:
Injury Date: 8/12/2016
Encounter: Subsequent
Work Status: Working for pay
Place of occurrence: Dock
Activity: N/A
Injury Cause: Twisting / without fall
Intent: Accidental
Clinical documentation:
22 y/o male dock worker is seen in follow up with complaints of pain, swelling and locking of the right knee. His initial injury occurred on 8/12/2016 while he was at work and twisted his knee when he tripped on an object at work on the dock. He nearly fell, but caught himself and twisted his right knee. Physical exam shows an effusion, tenderness and inability to fully extend the knee. A recent MRI scan shows a bucket handle tear of the lateral meniscus consistent with the clinical diagnosis.
Assessment:
1. Displaced, symptomatic bucket handle tear of the right lateral meniscus
Comment:
Since this is a subsequent or follow up exam for this provider, only the external cause is coded as secondary. Place of occurrence and external cause status would be reported on the initial encounter but not on this subsequent encounter
Coding:
Primary Diagnosis: S83251D Bucket-handle tear of lateral meniscus, current injury, right knee, subsequent encounter
External Cause: W1841 Slipping, tripping and stumbling without falling due to stepping on object
Place of Occurrence: Y9262 Dock or shipyard as the place of occurrence of the external cause (reported on the initial encounter this claim)
Activity: N/A
External Cause Status: Y990 Civilian activity done for income or pay (reported on the initial encounter this claim)
GROWTH PLATE INJURY
Injury Form Data:
Injury Date: 9/30/2016
Encounter: Initial
Work Status: Other1
Place of occurrence: Elementary school yard
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Activity: Children’s play
Injury Cause: Fell from swing
Intent: Accidental
Clinical documentation:
A 9 y/o male was playing on the swing at his elementary school at recess and fell from the swing. He presented to the emergency room where x-rays revealed a closed, displaced Salter-Harris IV Physeal (growth plate) fracture of the left proximal tibia.
Assessment:
1. Closed, displaced Salter-Harris IV fracture of the physis of the left proximal tibia.
Comment:
Since this is an initial encounter for the provider, all appropriate external cause type codes are used.
While there is no code that explicitly states “displaced” for these growth plated type injuries, the coding assumption is that these are growth plate fractures are displaced by default.
Coding:
Primary Diagnosis: S89042A Salter-Harris Type IV physeal fracture of upper end of left tibia, initial encounter for closed fracture
External Cause: W091XXA Fall from playground swing, initial encounter
Place of Occurrence: Y92211 Elementary school as the place of occurrence of the external cause
Activity: Y936A Activity, physical games generally associated with school recess, summer camp and children
External Cause Status: Y998 Other external cause status
ASSAULT - KNIFE:
Injury Form Data:
Injury Date: 10/3/2016
Encounter: Initial
Work Status: Working for pay
Place of occurrence: Construction site
Activity: N/A
Injury Cause: Knife wound
Intent: Assault
Clinical documentation:
A 45 year-old male is admitted for an assault with a knife wound to the back. He was working at the time on a commercial building construction site. The patient demonstrated a drop in blood pressure of 40 mm of mercury shortly after admission and was noted to have minimal urinary output. He had a dramatic drop of his hematocrit to 22 consistent with a post hemorrhagic anemia. The patient was also noted to have tachypnea, tachycardia and signs of decreased peripheral perfusion consistent with hypovolemic shock. He had an open left nephrectomy for massive damage from a major laceration of the left kidney.
Assessment:
1. Knife wound assault with a major laceration of the left kidney
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2. Acute anemia due to blood loss 3. Hypovolemic shock 4. Status post nephrectomy
Comment:
To properly code this case, the documentation will need to include the intent (assault in this case) as well as the fact that this is knife wound
Coding:
Primary Diagnosis: S37062A Major laceration of left kidney, initial encounter
Secondary Diagnosis: D62 Acute posthemorrhagic anemia
Secondary Diagnosis: R571 Hypovolemic shock
Secondary Diagnosis: Z905 Acquired absence of kidney
External Cause: X991XXA Assault by knife, initial encounter
Place of Occurrence: Y9261 Building [any] under construction as the place of occurrence of the external cause
Activity: N/A
External Cause Status: Y990 Civilian activity done for income or pay
NURSING HOME FALL:
Injury Form Data:
Injury Date: 11/2/2016
Encounter: Initial
Work Status: Volunteer
Place of occurrence: Nursing home/Bathroom
Activity: N/A
Injury Cause: Fall/toilet
Intent: Accidental
Clinical documentation:
75 y/o male volunteer fell from a toilet in the nursing home and hit his head on the tub. He had a prior total hip replacement. He had a loss of consciousness reported as less than 30 minutes. Initial evaluation in the emergency room revealed a Periprosthetic fracture of the left hip. The patient also had a skull x-ray demonstrating a closed fracture of the vault of the skull and MRI revealing a small subdural hemorrhage.
Comment:
This case is presented from the perspective of the orthopedic surgeon seeing the patient, so the fracture of the hip is considered primary for that provider.
A neurosurgeon seeing the patient would code the traumatic subdural as the primary code since that is the primary reason the neurosurgeon would be treating this patient.
The hospital would bill as primary the code that was felt to be the primary reason for hospital care as assessed at the time of discharge
Coding:
Primary Diagnosis: T84041A Periprosthetic fracture around internal prosthetic left hip joint,
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initial encounter
Secondary Diagnosis: S020XXA Fracture of vault of skull, initial encounter for closed fracture
Secondary Diagnosis: S065X1A Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, initial encounter
External Cause: W1812XA Fall from or off toilet with subsequent striking against object, initial encounter
Place of Occurrence: Y92121 Bathroom in nursing home as the place of occurrence of the external cause
Activity: N/A
External Cause Status: Y992 Volunteer activity
SPORTS INJURY:
Injury Form Data:
Injury Date: 11/5/2016
Encounter: Sequela
Work Status: Other
Place of occurrence: Racquet cord
Activity: Squash
Injury Cause: Hit by a racket
Vehicle: N/A
Intent: Accidental
Clinical documentation:
A 37 year-old male is being seen for treatment of an enlarged firm mass in his right thigh. He had a history of an accidental blow to the right thigh by his opponent’s racket when he was playing squash. Though the patient had quite a bit of pain and a large bruise, he continued to play. He later applied heat to the site, did vigorous stretching despite the pain and did not limit any activity despite recommendations of his physician. On subsequent follow up the patient was noted to have a firm mass near the site of the injury with progressive decreased in the range of motion of the muscle and a firm mass. X-rays demonstrated evidence of progressive ossification of the muscle tissue near the injury.
Assessment:
1. Severe contusion to the right thigh 2. Myositis ossificans
Comment:
Since this patient is seen for a sequela of an injury, this is not considered an initial encounter and only the external cause of injury is coded. Activity place of occurrence and external cause status should have been reported on the initial injury claim.
Since the evaluation and treatment for the encounter is primarily related to the patient’s sequelae of traumatic myositis ossificans, the code for the myositis is primary and the initial injury that resulted in the sequela is coded secondary.
Coding:
Primary Diagnosis: M61051 Myositis ossificans traumatic, right thigh
Secondary Diagnosis: S7011XS Contusion of right thigh, sequela
External Cause: W2119XA Struck by other bat, racquet or club, sequela
Place of Occurrence: Y92311 Squash court as the place of occurrence of the external cause
Activity: Y9373 Activity, racquet and hand sports
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External Cause Status: Y998 Other external cause status
Sample Injury Related Patient Intake Data Collection Form
This form is designed to capture key medical concepts that may be relevant to patients who are injured. Boxes in the
following form should be checked where relevant to the patient or where the noted alternative clinical term is used to
describe the patient’s condition. All terms or medical concepts that apply should be checked.
Injury Date: MM/DD/YYYY
ENCOUNTER
Terms or Concept Alternate Terms (Includes)
Initial encounter
Subsequent encounter
Sequela related encounter
INJURY TYPE
Terms or Concept Alternate Terms (Includes)
Fracture (See fracture template) Break or broken bone
Ligament or tendon injury (See joint injury template) Sprain, rupture, tear
Dislocation (See joint injury template)
Subluxation (See joint injury template)
Tear (See joint injury Template) As in meniscal tear
Muscular strain Muscle pull
Laceration Cut
Contusion Bruise
Pressure related Air, water or atmospheric
- Describe:
Crushing
Bite Sting, animal toxin
Foreign body
Blast
Birth Injury Birth injury unspecified
Brain injury (See head injury template)
Diffuse
Focal
Superficial
Abrasion
Burn
Heat
Corrosion Chemical
Other
- Describe:
Cold
- Describe:
Other injury type
- Describe:
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WORK STATUS
Terms or Concept Alternate Terms (Includes)
Work related On the job
Military related Active duty, reserves, national guard
Volunteer related Unpaid community work
Other status (personal)
ANATOMICAL REGION
Terms or Concept Alternate Terms (Includes)
Head Skull, face, nose, ears…
Spine
Cervical Neck, cervical region, occipito-atlanto-axial region, cervicothoracic
Thoracic Thoracolumbar, cervicothoracic
Lumbar Lower back, thoracolumbar, lumbosacral
Sacrum Lumbosacral, sacrococcygeal
Coccyx Tail bone, sacrococcygeal
Upper extremity
Shoulder region
Arm Upper arm
Forearm Lower arm
Hand
Chest
Abdomen
Pelvis
Lower extremity
Hip region
Thigh Upper leg
Leg Lower leg, calf
Foot Ankle region
Describe specific location where possible:
PLACE OF OCCURRENCE
Terms or Concept Alternate Terms (Includes)
Commercial Business
Public
Patient private property Home, personal private residence
Other private property
- Describe place of occurrence:
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ACTIVITY
Terms or Concept Alternate Terms (Includes)
Working activity type
- Describe activity:
Sports or recreational activity type
- Describe activity:
Other activity
- Describe activity:
CAUSE
Terms or Concept Alternate Terms (Includes)
Collision
Non-collision
Vehicle related Car, Bus, Cycle…
Patient was the passenger
Patient was the driver
- Describe vehicle:
Other vehicle involved Vehicle involved other than the one the patent was in
- Describe vehicle:
Multiple vehicles
No other vehicle or pedestrian
- Collided with:
Public transportation vehicle
Private transportation vehicle
Pedestrian involved
Patient was the pedestrian
Someone else was the pedestrian
Struck by
- Describe:
Fall
- Describe:
Legal action
- Describe:
Sports, recreational or entertainment related
- Describe:
Military or war related
- Describe:
Natural disaster related
- Describe:
Animal related
- Describe:
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Contacts & Resources Wyoming Medicaid Provider Relations
1-800-251-1268 Press 2, 1, and 2 to speak to an agent
ICD-10-CM Coding Guidelines - WDH has adopted the standard ICD-10-CM official guidelines for coding traumas as published on the CMS website. (This is a companion guide to the official version of ICD-10-CM.)
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2017-ICD-10-CM-Guidelines.pdf
“What’s New” Web Page Current Provider Bulletins and Newsletters
http://wyequalitycare.acs-inc.com/new.html
Sheila McInerney TPL & Estate Recovery Specialist
[email protected] or (307) 777-5389