September 18, 2006

Coding for Injuries
For The Record
Vol. 18 No. 19 P. 48

When multiple injuries occur, a separate AHA Coding Clinic for ICD-9-CM code should be assigned for each injury whenever possible. There are times, however, when ICD-9-CM directs the coder to assign a combination code, such as when a single code can completely identify two diagnoses. For example, 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).

Fractures
Fractures are classified as either open or closed. If the medical record does not provide specificity, the fracture is classified as closed. The following terms are descriptions of a closed fracture:

• comminuted;

• depressed;

• elevated;

• fissured;

• fracture not otherwise specified;

• greenstick;

• impacted;

• linear;

• simple;

• slipped epiphysis; and

• spiral.

The following terms describe an open fracture:

• compound;

• infected;

• missile;

• puncture; and

• with foreign body.

Coding of multiple fractures should follow the same guidelines as coding for multiple injuries.

Concussion
A concussion results from a blow to the head severe enough to cause a transient or prolonged alteration of consciousness, which may be followed by amnesia, vertigo, nausea, and weak pulse. 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 851-853.

A code from category 850 is not assigned with a code from categories 851-853. Category 854 is used when the head injury is not classifiable to categories 850-853. 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.

Open Wounds
Open wounds such as animal bites, avulsions, cuts, lacerations, puncture wounds, and traumatic amputations are classified to categories 870-897. However, it excludes open wounds associated with the following:

• Burn (940.0-949.5);

• Crushing (925-929.9);

• Puncture of internal organs (860.0-869.1);

• Superficial injury (910.0-919.9); and

• That incidental to: dislocation (830.0-839.9), fracture (800.0-829.1), internal injury (860.0-869.1), and intracranial injury (851.0-854.1).

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.

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 nearly 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payors 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.

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