A.
Injury Guidelines:
1. If the
combination code is not available – we can assign separate codes.
2. Superficial
injuries – Should not be coded with severe injuries of the same site.
3. If the
primary injury is to the blood vessels or nerves – that should be coded first.
4. The Injury that occurs
during or as a result of medical intervention – Should be coded as a complication.
B.
Fracture
Guidelines:
1. A fracture
not indicated as open or closed – Should be coded as closed fracture.
2. A fracture
not indicated as displaced or non-displaced – Should be coded as displaced.
3. Aftercare
“Z’ codes - Should not be used with fracture code during a follow-up.
4. Usage of 7th
Character (Initial / Subsequent / Sequela)
Initial encounter (A, B, C) –
During active treatment for the fracture (A patient may be seen by a new
provider over the course of treatment, the 7th character is based on
whether the patient is undergoing active treatment or not).
Subsequent encounter (Patient has completed active treatment for fracture and is
receiving care for the fracture during the healing phase) In case of any
complication (Nonunion, Malunion or delayed healing) during the subsequent
encounter should be reported with appropriate 7th character. Otherwise
we can assign it as routine healing.
Sequela (7th Character “S”) is for use for conditions that arise as a direct result of a condition. We need to code two codes (Sequela code should be reported first followed by injury code). The 7th character “S” is used only with the injury code, not with the sequela code.
C.
Burns
Guidelines
1. Burns codes are
due to thermal heat (Except sunburns), electricity and radiation.
2. Corrosions
are due to chemicals.
Burns
and corrosions are classified by depth,
1.
First degree
– Erythema
2.
Second
degree – Blistering
3.
Third-degree
– Full
thickness involvement
Note: For
internal organs – Degree is not applicable.
Sequencing
Guidelines:
1. For multiple sites - highest degree should be coded first if more
than one degree is present.
2.
Assign only the highest degree if more than one degree is present
at the same site.
3.
Non-healing
burns are
coded as acute burns.
4.
Infected
burn site - use an additional code for the infection.
5.
Extent of
body surface involved – Category T31 and T32 are based on “Rule of Nine”.
6.
External
cause code – An external cause and place of occurrence should be used with
burns/corrosions codes.
D. Adverse
effects, Poisoning, Underdosing and Toxic effects
1. Combination
codes (Substance and the intent).
2. No
additional external cause code is required.
A.
Poisoning
(Overdose, the wrong substance is given or taken in error, the wrong route of administration)
First, assign
poisoning code from category (T36-T50)
If the intent of the poisoning is unknown or unspecified – Code it as accidental
intent
If the
intent cannot be determined – Code it as undetermined.
B.
Adverse
effect
Nature
of the adverse effect (Tachycardia, vomiting, renal failure or respiratory
failure) should be coded first followed by a code for the adverse effect of the
drug (T36-T50).
C.
Underdosing:
(Taking less
of a medication than is prescribed (Or) discontinuing the use of a prescribed
medication on the patient’s own initiative)
Never be assigned as principal or first-listed code. (The medical condition for which the drug is prescribed should be coded as the first diagnosis).
E. Complications:
1. Pain due to medical devices: First assign from “T” series and use
additional codes from category G89 (acute or chronic pain)
2. Kidney transplant complications: T86.1-
should be assigned for documented complications of a kidney transplant.
F. Abuse and
other maltreatment
1. Sequence
first
T74-
(Adult and child abuse, neglect and other maltreatment, Confirmed)
T76- (Adult
and child abuse, neglect and other maltreatment Suspected)
-
Followed by any accompanying mental health or injury codes.
2. For cases of
confirmed abuse or neglect an external cause code from the assault section
(X92-Y09) should be added to identify the cause of any physical injuries.
3. For
suspected cases of abuse or neglect – Don’t report external cause code.
4. If a suspected case of abuse or neglect is ruled out during an encounter – Report,
A. Code Z04.71 –
Encounter for examination and observation of Adult physical abuse
B. Code Z04.72 –
Encounter for examination and observation of Child physical abuse
5. If a suspected case of alleged rape or sexual abuse is ruled out during an encounter
– Report,
A. Code Z04.41 –
Encounter for examination and observation of Adult sexual abuse
B. Code Z04.42 –
Encounter for examination and observation of Child sexual abuse
6. If a suspected case of forced sexual exploitation or forced labor exploitation is ruled
out during an encounter – Report,
A. Z04.81 - Encounter
for examination and observation of Sexual
exploitation
B. Z04.82 – Encounter
for examination and observation of Labor
exploitation
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