by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
August 30th, 2016
ICD-10 expands sections on poisonings and toxins.
When documenting injuries, include the following:
1. Episode of Care e.g. Initial, subsequent, sequelae
2. Injury site Be as specific as possible
3. Etiology How was the injury sustained (e.g. sports, motor vehicle crash, pedestrian, slip and fall, environmental exposure, etc.)?
4. Place of Occurrence e.g. School, work, etc.
Initial encounters may also require, where appropriate:
1. Intent e.g. Unintentional or accidental, self-harm, etc.
2. Status e.g. Civilian, military, etc.
ICD-10 Code Examples
Example 1: A left knee strain injury that occurred on a private recreational playground when a child landed incorrectly from a trampoline:
Injury: S86.812A, Strain of other muscle(s) and tendon(s) at lower leg level, left leg, initial encounter
External cause: W09.8xxA, Fall on or from other playground equipment, initial encounter
Place of occurrence: Y92.838, Other recreation area as the place of occurrence of the external cause
Activity: Y93.44, Activities involving rhythmic movement, trampoline jumping
Example 2: On October 31st, Kelly was seen in the ER for shoulder pain and X-rays indicated there was a fracture of the right clavicle, shaft. She returned three months later with complaints of continuing pain. X-rays indicated a nonunion. The second encounter for the right clavicle fracture is coded as S42.021K, Displaced fracture of the shaft of right clavicle, subsequent for fracture with nonunion.