by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Jan 3rd, 2018
There is important information that must be included when documenting injuries and external cause codes in ICD-10-CM. There are expanded sections on poisonings and toxins making it more convenient to code, as ICD-10-CM is very specific.
When using a code from Chapter 19. Injury, Poisoning and Certain other Consequences of External causes (S00-T88), consider also using a secondary code from Chapter 20. External Causes of Morbidity to clearly report the cause of injury.
Tips:
- You must also report a code to identify any retained foreign body if applicable to the injury (Z18.-).
- If you are coding from section T, it is not necessary to use an additional external cause code.
- These rules exclude birth trauma (P10-P15) or obstetric trauma (O70-O71).
Injuries Documentation
When documenting injuries, include the following:
- Episode of care (e.g., initial, subsequent, sequela)
- Injury site: Be as specific as possible
- Etiology: How was the injury sustained? (e.g., sports, motor vehicle crash, pedestrian, slip and fall, environmental exposure, etc.)
- Place of Occurrence (POA) (e.g., school, work, etc.) Note that initial encounters may also require, where appropriate:
- Intent (e.g., unintentional or accidental, self-harm, etc.)
- Status (e.g., civilian, military, etc.)
About Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Christine Woolstenhulme, CPC, QCC, CMCS, CMRS, is a Certified coder and Medical Biller currently employed with Find-A-Code. Bringing over 30 years of insight, business knowledge, and innovation to the healthcare industry. Establishing a successful Medical Billing Company from 1994 to 2015, during this time, Christine has had the opportunity to learn all aspects of revenue cycle management while working with independent practitioners and in clinic settings. Christine was a VAR for AltaPoint EHR software sales, along with management positions and medical practice consulting. Understanding the complete patient engagement cycle and developing efficient processes to coordinate teams ensuring best practice standards in healthcare. Working with payers on coding and interpreting ACA policies according to state benchmarks and insurance filings and implementing company procedures and policies to coordinate teams and payer benefits.