May 25, 2009

Coding for Injuries
For The Record
Vol. 21 No. 11 P. 28

When multiple injuries occur, a separate ICD-9-CM code should be assigned for each injury whenever possible. However, there are times when ICD-9-CM directs the coder to assign a combination code, which is used when a single code can completely identify two diagnoses. For example, if a patient was admitted with a fracture of the proximal end of the tibia and fibula, ICD-9-CM directs the coder to use code 823.02 to identify both fractures.

The coder should avoid using the nonspecific multiple injury code to identify injuries of multiple sites. A code for multiple injuries may be used when there is insufficient data available in the medical record. If there is adequate information provided, the coder should be as specific as possible. For example, if a patient is admitted with contusions of the back, forearm, face, and abdomen, then a separate code should be assigned for each documented site. If, however, the patient is admitted with multiple contusions of the trunk, with no further information of affected sites documented, then multiple contusions of the trunk, code 922.8, may be assigned.

It should be noted that superficial injuries, such as abrasions or contusions, are not coded when associated with more severe injuries of the same site.

When multiple injuries exist, the code for the most severe injury as determined by the physician and the treatment provided is sequenced as the principal diagnosis (AHA Coding Clinic for ICD-9-CM, 2006, first quarter, page 66).

Open Wounds
Open wounds such as animal bites, avulsions, cuts, lacerations, puncture wounds, and traumatic amputations are classified to categories 870 to 897. However, it excludes open wounds associated with the following: burn (940.0 to 949.5); crushing (925 to 929.9); puncture of internal organs (860.0 to 869.1); superficial injury (910.0 to 919.9); and that incidental to dislocation (830.0 to 839.9), fracture (800.0 to 829.1), internal injury (860.0 to 869.1), and intracranial injury (851.0 to 854.1).

The fourth-digit subcategory pertaining to open wounds may identify whether the open wound is complicated or without mention of complication. A complicated open wound is one that includes mention of delayed healing, delayed treatment, foreign body retention, or infection. There is no strict definition of delayed healing or treatment. If a patient delays seeking treatment by one week, for example, and the wound does not seem to be healing appropriately, then the complicated code should be used. If the coder is unsure, the physician should be asked for clarification. The delayed treatment and healing tends to lead to infections, which then qualifies as a complicated open wound.

Internal Injuries
Internal injury of thorax, abdomen, and pelvis is classified to categories 860 to 869. Injuries to internal organs include injuries from blast injuries, blunt trauma, bruise, concussion injuries (except cerebral), crushing, hematoma, laceration, puncture, tear, and traumatic rupture.

The coding directive before category 860 states, “The description ‘with open wound,’ used in the fourth-digit subdivisions, includes those with mention of infection or foreign body.” Categories 860 to 969 do not include the following injuries: concussion, not otherwise specified (850.0 to 850.9); flail chest (807.4); foreign body entering through orifice (930.0 to 939.9); and injury to blood vessels (901.0 to 902.9).

Concussion
Concussions are classified into three categories: grade 1, in which a person may appear dazed but does not lose consciousness; grade 2, where a patient will remain conscious but is confused and amnestic of the event causing the injury; and the most severe, grade 3, where the injured person loses consciousness, typically for a brief period of time and has amnesia of the event.

Concussion not further specified is classified to category 850. The fourth-digit subcategory will identify loss of consciousness, if any, and the length of time. If the concussion is further specified as a cerebral contusion, laceration, or hemorrhage, it is classified to categories 851 to 853. A code from category 850 is not assigned with a code from categories 851 to 853. Category 854 is used when the head injury is not classifiable to categories 850 to 853. A closed head injury described as a concussion is classified to the appropriate code in category 850. “When the head injury is specified as concussion, a code from category 854, Intracranial injury of other and unspecified nature or code 959.01, Head injury, unspecified, is inappropriate” (AHA Coding Clinic for ICD-9-CM, 1999, first quarter, page 10). Patients with concussions usually recover completely within 24 to 48 hours.

Coding and sequencing for injuries are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 4,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.