Knowledge Base Article

One of the greatest features pertaining to ICD-10-CM/PCS that we as coders can look forward to is greater specificity. For the most part, the coding guidelines for ICD-10-CM regarding poisonings and injuries will remain the same as they are now in ICD-9-CM. A seventh character extension which identifies the encounter is one of the new features in ICD-10-CM. Refer to Section I.C.19.a of ICD-10-CM Official Guidelines for Coding and Reporting.

1. A - Initial encounter:     Used while patient is receiving active treatment for the condition. Examples of active treatment:
2. surgical treatment
3. emergency department encounter
4. evaluation and treatment by a new physician
5. D - Subsequent encounter:     Used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Examples of subsequent care:
6. cast change or removal
7. removal of external or internal fixation device
8. medication adjustment
9. S – Sequela:     Used for complications or conditions that arises as a direct result of a condition or injury. Example of sequel care:
10. painful scar formation secondary to 3rd degree burn right lower leg
11. complete quadriplegia secondary to traumatic C2 displaced vertebral fracture - G82.51 & S12.100S

FROM THE AUTHOR

Please note the last paragraph of Section I.C.19. a of ICD-10-CM Official Guidelines for Coding and Reporting regarding application of “S” as the seventh character.

When using 7th character “S”, it is necessary to use both the injury code that precipitated the sequel and the code for the sequel itself.     The “S” is added only to the injury code, not the sequel code. The 7th character “S” identifies the injury responsible for the sequel.   The specific type of sequel is sequenced first, followed by the injury code.

Injuries – Section I.C.19.b of the ICD-10-CM Official Guidelines for Coding and Reporting

• A separate code should be assigned for each individual injury unless a combination code is provided.
• Code T07 for Unspecified multiple injuries should not be assigned in the inpatient setting unless supporting documentation for a more specific code is not available. Always query the MD in an attempt to gain information to support a more specific diagnosis code.
• Do not assign traumatic injury codes (S00-T14.9) for normal healing surgical wounds or to identify complications of surgical wounds.
• Sequence first the more serious injury as determined by the MD/provider and receiving main focus of treatment.
• Do not assign a code for superficial injuries (abrasions or contusions) when a more severe injury is associated with the same site.
• When a primary injury results in minor damage to peripheral nerves or blood vessels, the primary injury is sequenced first with additional code(s) for injuries to nerves and spinal cord and/or injury to blood vessels. When the primary injury is to the blood vessels or nerves, that injury should be sequenced first.

Traumatic Fractures – Section I.C.19.c of the ICD-10-CM Official Guidelines for Coding and Reporting

• Once again, specificity is the name of the game. ICD-10-CM fracture codes can now indicate the fracture type:
• Greenstick
• Transverse
• Oblique
• Spiral
• Comminuted
• Segmental
• Documentation should specify:
• Displaced
• Non-displaced
• Open
• Closed
• Laterality
• Specific anatomical site
• Routine vs delayed healing
• Non-union
• Mal-union
• Type of encounter
• A fracture not indicated as displaced or non-displaced should be coded as displaced.
• A fracture not indicated as open or closed should be coded to closed.
• Multiple fractures are sequenced in accordance with the severity of the fracture.
• Fracture extensions are expanded to include:
• 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 non-union
• P – Subsequent encounter for fracture with Mal-union
• S – Sequela
• Fractures in a patient with known Osteoporosis should be assigned a code from category M80 (non-traumatic fracture), even if the patient had a minor fall or trauma. Refer to Section I.C.13 of the ICD-10-CM Official Guidelines for Coding and Reporting.

Open Fracture Classification System

The Gustilo open fracture classification system is utilized in the 7th character extender lists for some fractures. This indicates the energy of the fracture, soft tissue damage and the degree of contamination. The Gustilo classification system is divided into 3 major categories.

Facilities will need to educate their providers on using the scale below to ensure supporting documentation for proper code assignment. This will also help lessen the number of queries sent to the provider.

Grade I

• Low energy, wound less than 1 cm with minimal soft tissue damage
• Wound bed is clean
• Bone injury is simple with minimal comminution
• With intramedullary nailing, average time to union is 21–28 weeks

Grade II

• Wound is > than 1cm with moderate soft tissue damage
• High energy wound > than 1cm with extensive soft tissue damage
• Wound bed is moderately contaminated
• fracture contains moderate comminution
• With intramedullary nailing, average time to union is 26-28 weeks

Grade III

The following fracture types automatically results in classification as type III.

• Segmental fracture with displacement
• Fracture with diaphyseal segmental loss
• Fracture with associated vascular injury requiring repair
• Farmyard injuries or highly contaminated wounds
• High velocity gunshot wound
• Fracture caused by crushing force from fast moving vehicle

Grade IIIA

• Wound less than 10cm with crushed tissue and contamination
• Adequate soft tissue coverage of bone is usually possible
• With intramedullary nailing, average time to union is 30-35 weeks

Grade IIIB

• Wound greater than 10cm with crushed tissue and contamination
• Inadequate soft tissue coverage and requires regional or free flap
• With intramedullary nailing, average time to union is 30-35 weeks

Grade IIIC

• Associated major arterial injury with fracture which requires repair for limb salvage
• In some cases it will be necessary to consider BKA following tibial fracture

Seventh character extensions to designate the specific type of open fracture – based on the Gustilo open fracture classification.

• B – Initial encounter for open fracture type I or II (open fracture NOS )
• C – Initial encounter for open fracture type IIIA, IIIB, or IIIC
• E – Subsequent encounter for open fracture type I or II with routine healing
• F – Subsequent encounter for open fracture type IIIA, IIIB, or 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, or IIIC with delayed healing
• M – Subsequent encounter for open fracture type I or II with non-union
• N – Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with non-union
• Q – Subsequent encounter for open fracture type I or II with mal-union
• R – Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with mal-union

The Gustilo classification is not used for all bones or all fracture types (such as Greenstick fracture or Torus fracture). Coders will need to be sure to look at each 7th character extender box for correct assignment.

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful