When we first implemented ICD-10, we all had a lot of fun with the ICD-10-CM external cause codes. But, do we need to use them?
The answer to that is no according to the official guidelines and yes if your payers require them.
Here is what the official ICD-10-CM guidelines say,
“There is no national requirement for mandatory ICD-10-CM external cause code reporting. Unless a provider is subject to a state-based external cause reporting mandate or these codes are required by a particular payer, reporting ICD-10-CM codes in Chapter 20, External Causes of Morbidity is not required.”
Workers comp claims and third party liability claims will require external cause codes. Many insurance companies and Medicare Administrative Contractors require them. The difficulty with these codes is the level of granularity in their descriptions. Coding from the record doesn’t always allow a coder to select a specific code. In the ED and for inpatient admissions, clinicians at this point have learned that they need to add detail or receive a coding inquiry from health information.
Assign the injury in the first position of the claim form: laceration, contusion, fracture. The patient’s injury goes in the first position of the claim form. The second code is the external cause code. Let’s say that cute parrot (or is it a parakeet?) struck my right forearm and caused a contusion. The contusion is reported first, and the cause second. When the physician sees me for the first time, she reports:
S50.11xA Contusion of the right forearm, initial encounter.
W61.02xA Struck by a parrot, initial encounter
The x is a placeholder code because there is no sixth character, and the A is the seventh character extender that tells the payer it was the physician’s first encounter with me for this issue. Both the injury and the external cause require a seventh character.
In an office, a clinician will sometimes search for “fall” and find an unspecified code in category W19. Of course, using that in the first position will cause a claim to be denied, because the injury that was the result of the fall needs to go first.
ICD-10-CM also has three additional OPTIONAL occurrence codes. The first reports where the injury occurred. In my case, let’s call it at a zoological garden. How did it happened? That’s the second occurrence code. Finally, was I doing the activity for work, as a member of the military or voluntarily. These three occurrence codes are only reported on the first claim (if you want to report them) and do not require seventh character extenders.
Y92.834 Zoological garden as the place of occurrence of the external cause
Y93.82 Activity, spectator at an event
Y99.2 Activity, volunteer
If I return for treatment to the same physician, the subsequent encounter is reported with the same ICD-10-CM code, S50.11xS. The subsequent encounter doesn’t indicate I’ve been pecked by a parrot a second time (I learned my lesson the first time) but that I’m being seen in follow up care.
My daughter took this picture of me while we were on vacation, and I’m happy to report the parrot didn’t really bite, strike or peck.
Coding for injuries can be confusing for clinicians and often require coders to review the documentation, check the accuracy of the ICD-10 code and sequence the codes correctly.