June 2017

External Cause Codes in the Courtroom
By Susan Chapman
For The Record
Vol. 29 No. 6 P. 24

A high-profile case raised the possibility that a coder's decision could be instrumental in determining whether a retrial was in order.

In April 2016, former New Orleans Saints lineman Will Smith was shot and killed by Cardell Hayes in a road rage incident in which Smith's wife, Racquel, was also injured. In the aftermath of Hayes' manslaughter and attempted manslaughter convictions, Hayes' attorneys requested a hearing to argue that their client deserved a new trial based on the hospital having coded Racquel Smith's injuries as the result of an "accidental discharge of a gun."

According to the New Orleans Advocate, three employees of University Medical Center, the facility that treated Racquel Smith, testified during the hearing. Those witnesses told the court that the code the attorneys referred to was an external cause code, nothing about Racquel Smith's injuries supported the determination of "accidental," and the code was likely entered in error, although no witness during the hearing claimed to have entered it.

As it turns out, the request for a new trial was denied and Hayes was eventually sentenced to 25 years for manslaughter for killing Will Smith and 15 years for attempted manslaughter for wounding Racquel Smith. Nevertheless, the case caught the attention of coding and documentation experts and raised the profile of external cause codes.

The Proper Use of External Cause Codes
External cause codes are used to report injuries, poisonings, and other external causes. (They are also valid for diseases that have an external source and health conditions such as a heart attack that occurred while exercising.)

The main purpose of the codes is to provide information for research and injury prevention strategy. "Different states track injury prevention. For example, when there was a spate of ATV accidents, an external cause code was added to track these accidents. They were looking at the number of those types of injuries, and researchers were looking at what types of strategies could prevent them," explains Sarah Glass, MA, RHIA, CCS, FAHIMA, an AHIMA-approved ICD-10-CM/PCS trainer.

Such codes are now used to determine the circumstances surrounding an incident—how it happened, the cause, the intent, the place, and the activity of the patient at the time of the event. The codes come into play during both the initial time of care and follow-up treatment. However, according to AHIMA's "Coding Injuries in ICD-10-CM (update)," there are different external cause codes used for follow-up care: "Subsequent encounter (D) is used for encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase (eg, cast change or removal, an X-ray to check healing status of fracture, removal of external or internal fixation device, medication adjustment, other aftercare and follow-up visits following injury treatment). Sequela (S) is used for complications or conditions that arise as a direct result of an injury, such as scar formation after a burn."

External cause codes are different from sign/symptom and unspecified codes in that there is no national requirement for their reporting. In its publication "ICD-10-CM Classification Enhancements," the Centers for Medicare & Medicaid Services states, "Unless you are subject to a state-based external cause code reporting mandate or these codes are required by a particular payer, you are not required to report ICD-10-CM codes found in Chapter 20 of the ICD-10-CM, External Causes of Morbidity. … In the absence of a mandatory reporting requirement, you are encouraged to voluntarily report external cause codes, as they provide valuable data for injury research and evaluation of injury prevention strategies."

While the use of external cause codes is not a federal requirement, it can be necessary in some states. For instance, the Louisiana Health Care Specifications Manual, issued by the Louisiana Department of Health and Hospitals, addresses the use of external cause codes, stating, "Diagnosis codes reported in the range of 800.00–999.99 (ICD-9) or S00.00xx–T88.99XXS (ICD-10) require the reporting of a valid External Cause-of-Injury Code." Per the publication, while external cause codes are not valid as principal diagnosis codes, if the principal diagnosis code is trauma-related and there is no external cause code, then the record will be rejected.

"In the Smith case, they were focusing on the intent, which at the time of Racquel Smith's arrival in the emergency department (ED), the physicians probably did not know. They simply had a patient who had been shot," Glass says. "Coding Clinic has a rule regarding coding accidental intent when the documentation is unspecified: 'If the intent (accident, self-harm, assault) of the cause of an injury or other condition is unknown or unspecified, code the intent as accidental intent.' And, if Louisiana has a requirement to include the external cause code and the intent was unknown and not in the medical record, then the coder would have no choice but to code the incident as accidental."

Whether the coder used a codebook or coding software, the result would be the same. "If you start out with shooting, it takes you to discharge, firearm by type, then himself or herself, which applies to self-inflicted gunshot wounds or homicide," Glass says. "If you choose homicide, the physician has to say, 'homicide.' There are also choices for legal shooting, which is an execution, a self-inflicted wound, a suicide, or a suicide attempt. However, the physician who is treating the individual would have to have that information and very often does not."

Glass says the same coding rule applies for other injuries and accidents. Take overdose as an example. The attending physicians in the ED wouldn't necessarily know at the time the patient arrived whether the overdose was accidental or intentional or even if the patient was prescribed too high of a dose.

"We see this ambiguity a lot in things like abuse cases," says Nathan McWilliams, director of the technology/trauma registry for the Pennsylvania Trauma Systems Foundation and an AHIMA-approved ICD-10-CM/PCS trainer. "The coder has to make a decision and would possibly query some individuals. We have a suspected abuse code, which tends to be used by coders when it's not confirmed in the medical record. But it all comes down to the documentation. If it was unknown, undetermined, or unspecified, the coder would say it was accidental."

"Physicians are solely there to provide patient care, and investigations are left to other authorities," Glass says. "Yet, in the Smith case, Hayes' attorneys called upon the medical record as a tool to support their argument. But the medical record is not like a police report, which is investigative and hence dynamic. The medical record stands as it is at the time of treatment. When Racquel Smith arrived in the ED, for example, the physician would not likely have known the circumstances. Additionally, external cause codes are purely supplemental. Either way, the facility wouldn't go back and change the medical record based on police reports."

"Any coder wants to see the documentation," says Laurie Johnson, MS, RHIA, FAHIMA, director of HIM consulting services at Panacea Healthcare Solutions and an AHIMA-approved ICD-10-CM/PCS trainer. "At the time that patient was treated, they may have not had the investigation completed. It was a gunshot wound, and the default was 'accidental.' As the investigation continued, and they found out someone else was involved, they very rarely would go back and change the external cause code. It would be difficult to track. The police investigation documents are not part of the medical record documentation. It's not part of patient care. We treat patients as patients, and we don't think about the legal ramifications of what is going on.

"Very often, coding decisions are made based on productivity and reimbursement, and we may not be able to report one detail over another because coders are making decisions on how to keep productivity moving along," she adds.

Querying for Additional Information
McWilliams notes that it would be possible to query for additional information. "The coders can, and do, certainly query in many cases when a cause is not immediately determined," he says. "It probably doesn't happen as often with external cause codes as it does with diagnosis codes. Facilities are not getting reimbursed for external cause codes, unlike other coding. Instead, coders may choose to query someone else, other than the physician, such as ancillary services—social workers, for example."

"Typically, if it's an ED case, querying the physician won't gain more information since their information is gathered at the point of care," Glass says. "For further information, from a legal standpoint, documents would need to be retrieved from the police. The police reports would have more information on this, not the medical records. However, coding may only be performed from medical record documentation."

Johnson adds, "I have seen people write queries on external cause codes, but it's not a big focus because it doesn't impact the DRG [diagnosis-related group] assignment, reimbursement, or outpatient side. It's more data that are used by state and federal offices to get an understanding of injuries with things like toys, for example—what age range, what kind of injuries—to help manufacturers mitigate injury. They use it also for injuries like falls in facilities to determine how they can be prevented."

Courtroom Validity
The external cause code Hayes' attorneys cited pertains only to the initial encounter with Racquel Smith. Therefore, given the four criteria required for external cause codes—how the injury happened, where it occurred, what the patient was doing, and whether or not the injury was intentional—there likely would be little or no specific information available at the time Racquel Smith arrived in the ED.

"I'm surprised this topic came up in this type of legal argument," Johnson says. "I've heard of external cause codes being used to determine the impact of injury or the lifetime cost of injury, such as in a malpractice case, as they're trying to understand the reimbursement methodology, but I've not heard of them being used like this. I would think that as soon as an attorney or judge learns that these codes are administrative data and not physician documentation, he or she would probably rule it out as a legal argument. And, so often, because these codes are based on ED documentation, they are assigned before there is any real legal investigation."

"There is flexibility among coders," McWilliams says. "You could have different coders who have a different take on that documentation depending on how ambiguous it is. Consequently, using external cause codes as a legal argument to me seems very weak. It's really the coder's opinion and discretion, and they are not involved in the criminal investigation of a case."

"It looks like the attorneys are not aware of the coding rule, although I don't know what the medical records in this case say," Glass says. "Since the intent was likely not known at the time, the coder coded the case appropriately."

Michael D. Miscoe, Esq, CPC, CASCC, CUC, CCPC, CPCO, CPMA, president-elect of AAPC's National Advisory Board, believes the defense's argument in the Smith case was thin at best. "It's an interesting theory, but it was a Hail Mary argument by Hayes' defense attorneys," he says. "While this does demonstrate the need for correct coding and an unusual but significant result of ultimately incorrect coding, in the end, the cause—accidental or intentional—is a matter for the jury, not the physician."

In all likelihood, the hospital reported W34.09XA [Accidental discharge from other specified firearms], which would have been incorrect, Miscoe says. "If the record was not clear regarding whether the shooting was intentional or not then Y22.XXXA [Handgun discharge, undetermined intent, initial encounter] would have been the appropriate causation code," he says. "To the extent the intent was not known by the physician at the time, now that intent has been determined at trial, an amendment of whatever code was reported would be appropriate and would defeat the argument of defense counsel. At this point, the verdict at trial has revealed that the correct causation code is X95.9XXA [Assault by unspecified firearm discharge, initial encounter]."

Miscoe says even if the physician believed the shooting to be accidental at the time of treatment, coding would not change the facts of the case, which would be determined at trial.

"Trauma centers are focused on treating the injury. The accidental or intentional cause of the injury is not germane to their treatment of the injury," he says. "A person was shot, and they may have coded the incident as accidental to avoid presuming guilt. One could reasonably presume that the coding department could have a policy of not presuming guilt where the intent was not detailed in the record. In the interest of fair play, for instance, the media have to say something was alleged. In the same way, the defense would not be able to point to a media report—as it's doing now with the external cause code—and say, 'Look, it was only alleged. The media say so.'"

As Miscoe points out, judges and juries make their decisions regarding intent based on facts in evidence. "But in this case, they tried to put the determination of intent on the coder," he says.

Miscoe questions whether the attorneys in this case understood ICD-10 coding well enough to properly articulate their case to a judge. "In trials, it always comes down to who can make the best argument," he notes. "The defense did what they could to win. If you can muddy the waters enough, you can maybe get a judge to give the case a second look, which is really what these attorneys tried to do. They want to say that the initial case was flawed in order to get their client a new trial. What is unclear is why they didn't raise this issue at trial."

— Susan Chapman is a Los Angeles-based freelance writer.