external cause codes - conduent › bulletins › mag... · 2017-08-10 · icd-10-cm code fields....

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Background Information 42 C.F.R. Section 433.138(e) mandates that States identify claims resulting from a possible trauma with a high

probability of leading to third party recovery and pursuing claims for possible recovery. With ICD-9, the Centers for

Medicare and Medicaid Services (CMS) provided guidance regarding the range of diagnosis codes (800-999) requiring

follow up. However, with the implementation of ICD-10, CMS no longer provides a list of required diagnosis codes and

has turned over identification of injury and accident associated claims to the State Medicaid Agency.

Wyoming’s Remediation to Comply with the Federal Provision Beginning with dates of service October 01, 2017, Wyoming Medicaid will require external cause codes to be billed with

any accident or injury related claims submitted for services, such as fractures, wounds, other injuries, abrasions,

contusions, burns, and head injuries (priority third party liability diagnoses). Chapter 20 of the ICD-10-CM Official

Guidelines for Coding and Reporting provides that external cause codes may be billed for any diagnosis in the range of

A00.0 – T88.9, Z00-Z99. Claims submitted without external cause code(s) will be denied. By requiring the reporting of

external cause codes, Wyoming Medicaid will not only capture the trauma, accident, injury or condition diagnosis, but it

will also obtain critical information concerning the nature and intent of the accident or condition. As a result, this will

improve third party liability identification and coordination of benefits.

External cause codes provide valuable information surrounding an injury or a health condition.

External cause codes provide information concerning how the injury happened or its cause, where the injury

happened, was the injury intentional, unintentional or accidental, where the injury took place, what activity was

the patient engaged in at the time of the accident/event, and what the status of the person was at the time of

the injury (i.e. military, civilian work for pay, volunteer, or other).

Billing with external cause codes is not a new billing guideline. ICD-9-CM outlined guidelines for use of external

cause codes, and were referred to as “E” codes.

Who Will Be Most Impacted By This Change?

Emergency Rooms

Urgent Care Clinics

Ambulatory Surgical Centers

Orthopedists

Surgeons

Hospitals

Radiologists, Radiology, and Diagnostic Radiology

Skilled Nursing Facilities/Nursing Factilities

Physical Therapists

Physicians (General Practice, Pediatrics, Anesthesiology, Internal Medicine, Family Practice, Psychiatry, and

Neurology)

Rehabilitation Hospitals

External Cause Codes

Date

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Durable Medicaid Equipment and Medicaid Supplies

Federally Qualified Health Centers

Indian Health Services

Chiropractor

Ambulance

Psychiatric Residential Treatment Facilities

Home Health

Rural Health

Why Report?

External cause codes answer questions concerning who, what, where, when, why, and how.

External cause codes track the cause and other parameters of injuries to manage healthcare, improve

population safety, and lead to improved quality of care or patient treatment.

What Are The Four (4) Types of External Cause Codes (Diagnosis Code Range of V00-Y99)?

External cause

Specific cause of the injury or condition

Diagnosis code range of V00-Y849

Place of occurrence

Nature of the location where the injury took place

Diagnosis code begins with Y92 (Y9200-Y9289)

Only one (1) code from Y92 should be referenced on the claim (at the initial encounter) and in the

medical record

May be a rare instance that a new injury occurs during hospitalization, so an additional palce of

occurrence may be coded

A 7th character is not needed for Y92

Do not use place of occurrence code Y92.9 if the place is not stated or is not applicable

Activity

Specific activity the patient engaged in at the time of the injury

Only billed when relevant

Diagnosis begins with Y93 (Y9301-Y9389)

Only one (1) code from Y93 should be recorded on the claim (at the initial encounter) and in the medical

record

Do not use when billing for poisonings, misadventures, adverse effects, or sequalae

Do not assign Y93.9, Unspecified activity, if the activity is not stated.

Status

Identifies if the patient was injured during civilian employment for pay, military employment, volunteer

work, etc.

Diagnosis begins with Y99 (Y990-Y998)

Y990 – Civilian Activity done for pay

Y991 – Military Activity

Y992 – Volunteer

Y998 – Other (Not work for pay, military or volunteer related)

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Only one (1) code status code should be recorded on the claim (at the initial encounter) and in the

medical record

Do not use when billing for poisonings, misadventures, adverse effects, or sequalae

Indicates work status of the patient

How Are External Cause Codes Different From Other Diagnosis Codes?

Do not define the diagnosis or patient clinical condition, but rather the parameters around an injury

Used when billing an accident or injury code to define the nature/cause and intent of an injury or condition

Cannot be used as the primary diagnosis on an institutional or professional claim form. External cause codes are

not the reason why the patient is being treated or evaluated.

Wyoming Medicaid’s claims processing system is programmed to deny claims if the first-listed, principal,

or primary diagnosis code billed is an external cause code.

ICD-9-CM billing guidelines specify that an external cause code could not be the first-listed, primary, or

principal diagnosis.

When Are External Cause Codes Billed?

On the first encounter, visit or claim and continue to be billed for the duration of treatment (subsequent or

follow-up care) as long as the injury is the focus of the treatment or care.

The external cause must be billed for the duration of treatment

The place of occurrence, the activity and the status are billed on the initial visit or encounter. They are

not billed for any subsequent follow-up care or sequelae (late effect).

Sequencing of code

Primary: Injury or condition codes as the reason for care

Secondary: Comorbidities of additional diagnosis

Secondary: External cause codes

Patient Encounters, Visits and External Cause Codes

Initial Evaluation:

Primary Diagnosis

Most specific ICD-10 diagnosis to describe the nature of the injury or patient’s condition to

denote reason why patient is being treated.

Never use an external cause code as the primary, principle or first listed diagnosis.

Secondary Diagnosis

Most specific ICD-10 diagnosis to describe the external cause of the trauma or condition based

upon information provided by the patient and available to the provider at the conclusion of the

encounter.

Must be reported with 7th character: A – Initial Encounter

Include as many external cause codes that describe the events or circumstances of the accident,

trauma, or condition.

Place of occurrence, activity, and status codes are only reported on the initial encounter.

Subsequent Evaluation(s)

Subsequent encounters or management of sequelae (late effect) of the original condition or injury

Primary diagnosis

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Description of the original trauma or condition and identified as a subsequent visit or sequalae.

Secondary Diagnosis

Most specific ICD-10 diagnoses to describe the external cause of the trauma or condition based

upon information provided by the patient and available to the provider at the conclusion of the

encounter.

Must be reported with the 7th character:

D – Subsequent encounter

S – Sequalae

Claims

Professional or CMS – 1500

External cause code is not the first listed diagnosis code

The 837 professional HIPAA claim standards allow for submitting external cause code(s) in the secondary

ICD-10-CM code fields. Up to 11 secondary codes may be listed in the transaction.

Institutional or UB – 04

Claims processing system only requires one (1) external cause code.

The 837 institutional HIPAA claim standards allow for submission of 12 fields specifically defined

for external cause code reporting according to the X12 ANSI 5010 HIPAA transaction standards

(5010 TR3 allows for 12 external cause codes).

**However, when Wyoming Medicaid remediated its system for 5010 transaction (institutional)

it only required one (1) external cause code in the 5010 TR3. The clearinghouse will allow 12

external cause codes in the TR3, but the MMIS will only allow one (1) as it was not seen as

necessary to process claims.

In order to meet the mandate for billing with external cause codes, bill the external cause

code diagnoses in the secondary diagnoses fields.**

“Present on admission” (POA)code definition requirements apply to use of external

cause codes on the institutional claim similar to the POA requirement for other

diagnosis codes

Report external cause codes as secondary diagnoses.

Keys to Success

Learn the requirements for using external cause codes by reading and following the guidelines in the ICD-10

Coding Book.

Clarify any questions by referencing to the official ICD-10 guidelines as well as through key contacts at WDH

Obtain/Capture information at the time of patient intake and as a part of workflow.

Develop a patient intake form to collect injury related data from the patient or their representative. A

sample is included in this packet.

A patient intake form may be necessary or list of questions may be necessary during the history and physical

portion of the examination to obtain injury related information surrounding an accident or a condition.

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Clinical Scenarios

The following scenarios are provided as examples of how information captured about the injury through a standard

patient intake form and the clinical record would lead to the documentation and coding necessary to meet requirements

of reporting for injury related cases. The work flow and patient intake forms will need to be customized for each

practice, but the concepts are the same for all providers.

VEHICLE COLLISION ACCIDENT

Injury Form Data:

Injury Date: 11/12/2016

Encounter: Initial

Work Status: Military

Place of occurrence: Military base

Activity: Construction

Injury Cause: Collision / Traffic accident

Vehicle: Military vehicle / Driver

Intent: Accidental

Clinical documentation:

A 27 year old male was working on a construction project on the local military base as part of his weekend reserve duty. He was driving a military truck when he collided with another military vehicle entering the construction site. He sustained a displaced comminuted open fracture of the right femoral shaft which is classified as a type II Gustilo classification of open fracture. He was seen by the orthopedist in the emergency room for evaluation and treatment.

Assessment:

1. Displaced, comminuted, Gustilo class II open fracture of the shaft of the right femur

Coding:

Primary Diagnosis: S72351B Displaced comminuted fracture of shaft of right femur, initial encounter for open fracture type I or II

External Cause: V8604XA Driver of military vehicle injured in traffic accident, initial encounter

Place of Occurrence: Y9213 Military base as the place of occurrence of the external cause

Activity: Y93H3 Activity, building and construction

External Cause Status: Y991 Military activity

Comment:

It is up to the clinician to determine what information is relevant to include in the clinical documentation. However, the information in the interview form may be as considered part of that clinical information and is available to the clinician at the time of the patient encounter.

The same injury form information can be carried forward to subsequent encounters assuming there has been no change in the information defined in the form for that injury.

Since this is the initial encounter, all cause type codes are included.

On the hospital institutional claim there is a separate field that allows up to 12 external cause codes.

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On the professional claim, the external cause codes are to be included as one or more of the 11 allowed secondary diagnosis codes.

KNEE MENISCUS INJURY

Injury Form Data:


Encounter: Subsequent

Work Status: Working for pay

Place of occurrence: Dock

Activity: N/A

Injury Cause: Twisting / without fall

Intent: Accidental


22 y/o male dock worker is seen in follow up with complaints of pain, swelling and locking of the right knee. His initial injury occurred on 8/12/2016 while he was at work and twisted his knee when he tripped on an object at work on the dock. He nearly fell, but caught himself and twisted his right knee. Physical exam shows an effusion, tenderness and inability to fully extend the knee. A recent MRI scan shows a bucket handle tear of the lateral meniscus consistent with the clinical diagnosis.

Assessment:

1. Displaced, symptomatic bucket handle tear of the right lateral meniscus

Comment:

Since this is a subsequent or follow up exam for this provider, only the external cause is coded as secondary. Place of occurrence and external cause status would be reported on the initial encounter but not on this subsequent encounter

Coding:

Primary Diagnosis: S83251D Bucket-handle tear of lateral meniscus, current injury, right knee, subsequent encounter

External Cause: W1841 Slipping, tripping and stumbling without falling due to stepping on object

Place of Occurrence: Y9262 Dock or shipyard as the place of occurrence of the external cause (reported on the initial encounter this claim)

Activity: N/A

External Cause Status: Y990 Civilian activity done for income or pay (reported on the initial encounter this claim)

GROWTH PLATE INJURY

Injury Form Data:


Encounter: Initial

Work Status: Other1

Place of occurrence: Elementary school yard

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Activity: Children’s play

Injury Cause: Fell from swing

Intent: Accidental


A 9 y/o male was playing on the swing at his elementary school at recess and fell from the swing. He presented to the emergency room where x-rays revealed a closed, displaced Salter-Harris IV Physeal (growth plate) fracture of the left proximal tibia.

Assessment:

1. Closed, displaced Salter-Harris IV fracture of the physis of the left proximal tibia.

Comment:

Since this is an initial encounter for the provider, all appropriate external cause type codes are used.

While there is no code that explicitly states “displaced” for these growth plated type injuries, the coding assumption is that these are growth plate fractures are displaced by default.

Coding:

Primary Diagnosis: S89042A Salter-Harris Type IV physeal fracture of upper end of left tibia, initial encounter for closed fracture

External Cause: W091XXA Fall from playground swing, initial encounter

Place of Occurrence: Y92211 Elementary school as the place of occurrence of the external cause

Activity: Y936A Activity, physical games generally associated with school recess, summer camp and children

External Cause Status: Y998 Other external cause status

ASSAULT - KNIFE:

Injury Form Data:


Encounter: Initial

Work Status: Working for pay

Place of occurrence: Construction site

Activity: N/A

Injury Cause: Knife wound

Intent: Assault


A 45 year-old male is admitted for an assault with a knife wound to the back. He was working at the time on a commercial building construction site. The patient demonstrated a drop in blood pressure of 40 mm of mercury shortly after admission and was noted to have minimal urinary output. He had a dramatic drop of his hematocrit to 22 consistent with a post hemorrhagic anemia. The patient was also noted to have tachypnea, tachycardia and signs of decreased peripheral perfusion consistent with hypovolemic shock. He had an open left nephrectomy for massive damage from a major laceration of the left kidney.

Assessment:

1. Knife wound assault with a major laceration of the left kidney

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2. Acute anemia due to blood loss 3. Hypovolemic shock 4. Status post nephrectomy

Comment:

To properly code this case, the documentation will need to include the intent (assault in this case) as well as the fact that this is knife wound

Coding:

Primary Diagnosis: S37062A Major laceration of left kidney, initial encounter

Secondary Diagnosis: D62 Acute posthemorrhagic anemia

Secondary Diagnosis: R571 Hypovolemic shock

Secondary Diagnosis: Z905 Acquired absence of kidney

External Cause: X991XXA Assault by knife, initial encounter

Place of Occurrence: Y9261 Building [any] under construction as the place of occurrence of the external cause

Activity: N/A

External Cause Status: Y990 Civilian activity done for income or pay

NURSING HOME FALL:

Injury Form Data:


Encounter: Initial

Work Status: Volunteer

Place of occurrence: Nursing home/Bathroom

Activity: N/A

Injury Cause: Fall/toilet

Intent: Accidental


75 y/o male volunteer fell from a toilet in the nursing home and hit his head on the tub. He had a prior total hip replacement. He had a loss of consciousness reported as less than 30 minutes. Initial evaluation in the emergency room revealed a Periprosthetic fracture of the left hip. The patient also had a skull x-ray demonstrating a closed fracture of the vault of the skull and MRI revealing a small subdural hemorrhage.

Comment:

This case is presented from the perspective of the orthopedic surgeon seeing the patient, so the fracture of the hip is considered primary for that provider.

A neurosurgeon seeing the patient would code the traumatic subdural as the primary code since that is the primary reason the neurosurgeon would be treating this patient.

The hospital would bill as primary the code that was felt to be the primary reason for hospital care as assessed at the time of discharge

Coding:

Primary Diagnosis: T84041A Periprosthetic fracture around internal prosthetic left hip joint,

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initial encounter

Secondary Diagnosis: S020XXA Fracture of vault of skull, initial encounter for closed fracture

Secondary Diagnosis: S065X1A Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, initial encounter

External Cause: W1812XA Fall from or off toilet with subsequent striking against object, initial encounter

Place of Occurrence: Y92121 Bathroom in nursing home as the place of occurrence of the external cause

Activity: N/A

External Cause Status: Y992 Volunteer activity

SPORTS INJURY:

Injury Form Data:


Encounter: Sequela

Work Status: Other

Place of occurrence: Racquet cord

Activity: Squash

Injury Cause: Hit by a racket

Vehicle: N/A

Intent: Accidental


A 37 year-old male is being seen for treatment of an enlarged firm mass in his right thigh. He had a history of an accidental blow to the right thigh by his opponent’s racket when he was playing squash. Though the patient had quite a bit of pain and a large bruise, he continued to play. He later applied heat to the site, did vigorous stretching despite the pain and did not limit any activity despite recommendations of his physician. On subsequent follow up the patient was noted to have a firm mass near the site of the injury with progressive decreased in the range of motion of the muscle and a firm mass. X-rays demonstrated evidence of progressive ossification of the muscle tissue near the injury.

Assessment:

1. Severe contusion to the right thigh 2. Myositis ossificans

Comment:

Since this patient is seen for a sequela of an injury, this is not considered an initial encounter and only the external cause of injury is coded. Activity place of occurrence and external cause status should have been reported on the initial injury claim.

Since the evaluation and treatment for the encounter is primarily related to the patient’s sequelae of traumatic myositis ossificans, the code for the myositis is primary and the initial injury that resulted in the sequela is coded secondary.

Coding:

Primary Diagnosis: M61051 Myositis ossificans traumatic, right thigh

Secondary Diagnosis: S7011XS Contusion of right thigh, sequela

External Cause: W2119XA Struck by other bat, racquet or club, sequela

Place of Occurrence: Y92311 Squash court as the place of occurrence of the external cause

Activity: Y9373 Activity, racquet and hand sports

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External Cause Status: Y998 Other external cause status

Sample Injury Related Patient Intake Data Collection Form

This form is designed to capture key medical concepts that may be relevant to patients who are injured. Boxes in the

following form should be checked where relevant to the patient or where the noted alternative clinical term is used to

describe the patient’s condition. All terms or medical concepts that apply should be checked.

Injury Date: MM/DD/YYYY

ENCOUNTER

Terms or Concept Alternate Terms (Includes)

Initial encounter

Subsequent encounter

Sequela related encounter

INJURY TYPE


Fracture (See fracture template) Break or broken bone

Ligament or tendon injury (See joint injury template) Sprain, rupture, tear

Dislocation (See joint injury template)

Subluxation (See joint injury template)

Tear (See joint injury Template) As in meniscal tear

Muscular strain Muscle pull

Laceration Cut

Contusion Bruise

Pressure related Air, water or atmospheric

- Describe:

Crushing

Bite Sting, animal toxin

Foreign body

Blast

Birth Injury Birth injury unspecified

Brain injury (See head injury template)

Diffuse

Focal

Superficial

Abrasion

Burn

Heat

Corrosion Chemical

Other

- Describe:

Cold

- Describe:

Other injury type

- Describe:

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WORK STATUS


Work related On the job

Military related Active duty, reserves, national guard

Volunteer related Unpaid community work

Other status (personal)

ANATOMICAL REGION


Head Skull, face, nose, ears…

Spine

Cervical Neck, cervical region, occipito-atlanto-axial region, cervicothoracic

Thoracic Thoracolumbar, cervicothoracic

Lumbar Lower back, thoracolumbar, lumbosacral

Sacrum Lumbosacral, sacrococcygeal

Coccyx Tail bone, sacrococcygeal

Upper extremity

Shoulder region

Arm Upper arm

Forearm Lower arm

Hand

Chest

Abdomen

Pelvis

Lower extremity

Hip region

Thigh Upper leg

Leg Lower leg, calf

Foot Ankle region

Describe specific location where possible:

PLACE OF OCCURRENCE


Commercial Business

Public

Patient private property Home, personal private residence

Other private property

- Describe place of occurrence:

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ACTIVITY


Working activity type

- Describe activity:

Sports or recreational activity type


Other activity


CAUSE


Collision

Non-collision

Vehicle related Car, Bus, Cycle…

Patient was the passenger

Patient was the driver

- Describe vehicle:

Other vehicle involved Vehicle involved other than the one the patent was in

- Describe vehicle:

Multiple vehicles

No other vehicle or pedestrian

- Collided with:

Public transportation vehicle

Private transportation vehicle

Pedestrian involved

Patient was the pedestrian

Someone else was the pedestrian

Struck by

- Describe:

Fall

- Describe:

Legal action

- Describe:

Sports, recreational or entertainment related

- Describe:

Military or war related

- Describe:

Natural disaster related

- Describe:

Animal related

- Describe:

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Contacts & Resources Wyoming Medicaid Provider Relations

1-800-251-1268 Press 2, 1, and 2 to speak to an agent

ICD-10-CM Coding Guidelines - WDH has adopted the standard ICD-10-CM official guidelines for coding traumas as published on the CMS website. (This is a companion guide to the official version of ICD-10-CM.)

https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2017-ICD-10-CM-Guidelines.pdf

“What’s New” Web Page Current Provider Bulletins and Newsletters

http://wyequalitycare.acs-inc.com/new.html

Sheila McInerney TPL & Estate Recovery Specialist

[email protected] or (307) 777-5389



http://wyequalitycare.acs-inc.com/new.html

mailto:[email protected]

external cause codes - conduent › bulletins › mag... · 2017-08-10 · icd-10-cm code fields....

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