Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88)
By: Chris Woolstenhulme, QCC, CMCS, CPC, CMRS Published: January 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.
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).
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.)
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