Okay, we're going to continue our
discussion of Chapters 19 and 20, Injuries
and fractures, Part 2 using our external
cause codes. The next guideline we're
going to talk about is the coding of
injuries. Here I have a diagnostic
statement where the patient has sustained
third-degree burns to the back of her
hand. I've highlighted just the
injury itself. The principal diagnosis, in
this case, is that skin graft failing
because that's why she's come back into
the hospital to have her allograft
removed and her artificial skin graft
put over the burn area so it will heal
better. So the complication code is the
principal diagnosis, and then the burn
code. Now, we're going to add the
external causes- the boiling liquid
splashing from a pot on the kitchen
stove. I've added here those two
codes- the burn from a hot liquid and the
place of occurrence in the family
kitchen. On the next slide I just want to
show you when something changes. This
time we are looking at, we've been given
the status that this is a person working
as a chef and while she's at work. this
boiling liquid pops out of the stove, out
of the pot and hits her on the back of
her hand so that changes our codes. We
still have the boiling liquid cause code
but the place of occurrence is now a
restaurant and the status is the
civilian activity done for her pay, her
job. The next guideline has to do with
making sure your most severe cause of
injury is the principal (diagnosis). The case that
I've given you here in the diagnostic
statement, the fact that this patient
needed an open reduction internal
fixation (ORIF) of his left hip fracture
tells you that is the most serious
injury. You also see here it is displaced.
The other two fractures are
non-displaced, so the displaced fracture
that lands him in the OR (operating room) is going to be
the principal code, principal diagnosis
here. The next two, either one of them
because they're both non-displaced,
either one of them could
be the second or third code. What really
matters is that principal diagnosis has
been designated and you've included them
as secondary codes along with the
external cause codes. Here I have the
next guideline talking about superficial
injuries and I have a very same
diagnostic statement but at the very
bottom of that diagnostic statement, it
says he suffered multiple bruises and
abrasions on his left side. We do not
code those. When you have something as
serious as the left hip fracture needing
it needing to go to the OR for fixation,
you are not going to code those bruises
and abrasions. You're just going to focus
on the more severe injuries. The next
diagnostic
statement has to do with a person
getting their arm caught in some farm
equipment and it caused an open fracture
of the right head of the ulna with
injury to the ulnar artery at the
forearm level. It is a Gustillo open
fracture, type IIIC. Look at this one for a
couple of reasons. One is that you have a
different 7th character that we
may not have used before and the
fact that it is injury to the ulnar
artery as well so that second code gets
a 7th character "A" for initial
encounter because when you look at the
category code for S55, there's no
option to put a "C" so you have to just
use the characters with the codes that are available to you.
In this case, the ulnar artery gets the "A"
as the 7th character and the open fracture
of the head of the ulna gets the 7th
character "C". Here we have the same
diagnostic statement but we have added
our external cause codes- caught in farm
machinery, occurring in the field and for
activity, I put land maintenance. I
couldn't find farming which surprised
me so i went this route. It may be
that the next 2017 codes are going to
have more options for us
but this is what I chose. The next coding
guideline has to do with coding
traumatic fractures. When a
fracture is not specified as open or
closed, you're going to code it as "closed"
and if it's not indicated as to whether
it is displaced or non-displaced, it is
coded as "displaced". In the diagnostic
statement I've given you, the child was
playing ice hockey when he was struck by
another player causing him to fall and
he fractured his wrist bone. The
diagnostic statement does not tell us if
this break is displaced or non-displaced
so we are going to code it as "displaced"
according to our coding guideline.
Then we also do assign the 7th
character "A" for the initial encounter.
The same diagnostic statement, now we're
going to add our external cause codes.
We have them here with the pathway on
the right. You notice that the W03 code
does use a 7th character but the two
Y codes, the place of occurrence and the
activity, do not offer you the option of
adding a 7th character. Just for
a reminder, the place of occurrence is
only coded on the initial encounter. If
this patient is seen in follow-up in his
physician's office, that place
of occurrence code is never going to be
part of the codes, just the initial
encounter. Okay, here's another guideline
talking about when we use "active
treatment". The options are given for A, B
or C as our 7th character. I use the same
diagnostic statement we used earlier
with the farm equipment and I show here
in our pathway how I used those. The Gustillo
open fracture type IIIC is there for the
7th character "C". In the past, I
don't recall before ICD-10 I don't
recall fractures up very often being
stated
as being a "Gustillo type" but we
certainly are seeing it in ICD-10.
Here we're going to look at the
subsequent encounter we've talked about,
I'm sorry I'm wrong, we're talking about
the initial encounter still but when a
person has delayed seeking treatment.
That's what this diagnostic statement
refers us to. The patient is complaining of
left foot and ankle pain, fell down the
steps three weeks ago but didn't seek
any care and now when we x-ray her, she's
got a malunion of a non-displaced
fracture of the posterior process of the
left talus, a very specific place where
her ankle is not healing. I have the
codes here and a reminder that we have
to use "A" even though she fell down three
weeks ago. It's "A" for initial encounter
because this is the first time she has
sought medical treatment and now she's
got a malunion
of that talus fracture. Here
I've added the category, I'm sorry the
external cause codes- she fell down the
steps and it's in the public library.
Now we are going to talk about the
subsequent encounter and how that is
broken out. There are more options than
just "D" for subsequent encounter depending
on the code. In this case, that ulnar
fracture, the Gustillo open fracture type
IIIC, when you go to the subsequent
encounter for that same type IIIC with
routine healing, you're now going to get
a 7th character of an "F" as in "frank"
instead of the "D", however, the ulnar
artery code retains the "D" for
subsequent encounter because
there's no other option. Also, for the W30
code, "D" subsequent encounter, there's no
other options for other than "A", "D" or "S"
and then we do not code the place of
occurrence. That is only coded in that
initial encounter. This encounter is -he's
in the doctor's office to have his pins
removed (remember the surgery he had).
He's in the doctor's office now,
having those pins removed and whenever
we are coding a complication of surgical
treatment for a fracture repair, we're
going to use a complication code. In this
case, it's a complication of the fixation
device. I have the T84 code that would
be your principal diagnosis, then we have
the injury to the right tibial shaft S82.201A
"A" for initial encounter and then
the W code (W27.0xxA) for struck by an axe bounced
off of a rock. I think the next slide is
where I add that, yes, here's where I add
the external cause code, contact with an
ax.
The next guideline has to do with the
malunion and the non-union, something
we've already talked about but in this
case, the patient did seek treatment. If
you read the diagnostic statement, he was
brought to the ED by family and they
reported his hip was broken during
Hurricane Diane a month ago and he was
struck by falling debris during the
hurricane. He was seen in this hospital
on the day the hurricane hit. We checked
the records and the original fracture
was a closed fracture of the left
femoral neck. X-rays today revealed
there's a malunion of the fracture of
the left femoral neck and orthopedics was
consulted. So we do still have an
injury code but we're going to assign
the 7th character "P" as in Paul because
this is a "subsequent encounter for a
closed fracture with malunion", If we go
to the S72 category, we see the pink
box just under the category code telling
us that, yes, we can use the 7th character
"P". The next guideline has to do, I'm doing it
again. I'm jumping ahead of myself. These
are the external cause codes for this
gentleman. We've added the hurricane
there (X37.-), subsequent encounter "D" because
remember, he was seen originally so it is
a subsequent encounter. Then the W20
is the flying debris, also a subsequent
encounter and the place of occurrence,
where he fell, is not coded because this is
the subsequent encounter, not the initial
encounter.
The next coding guideline talks about
osteoporosis. When someone has
osteoporosis and either do or do not
have a history of pathological fractures,
they can do something as simple as
stepping off the curb and a bone will
break. We do not use external cause codes
because this is a very unusual case but
the patient does not get the Chapter 19
"S" code for the injury. We go back to the
"M" category M80 which is used for anyone
with known osteoporosis who suffers a
fracture. We are going to use the history,
personal of healed fractures from
osteoporosis because it just gives more
information and tells the story of this
patient's encounter. No external cause
codes are used. The last one has to
do with multiple fractures, going back to
the motorcycle accident where he had all
those fractures. You're just going to
make sure that the most serious
fracture is the principal (diagnosis). The fact that
he had to go the OR tells you that the
left hip fracture was the most serious
and is the principal (diagnosis). The two
non-displaced fractures of the clavicle
and the upper end of the humerus, either
one of those could be second or third
because they are the same in severity,
but the hip gets the principal diagnosis.
I know I've gone through this very
quickly so please take your time and
read through the Coding Handbook
chapters. Review the codes, the pink boxes
that tell you your options for 7th
characters and always read all your
guidelines related to injuries and
fractures.The next thing I'll be talking
about will be Chapter 19 Burns and
External causes. Thank you.