Injury Guidelines: If the combination code is not available – we can assign separate codes. Superficial injuries – Should not be coded with severe injuries of the same site. If the primary injury is to the blood vessels or nerves – that should be coded first. The Injury that occurs during or as a result of medical intervention – Should be coded as a complication. Fracture Guidelines: A fracture not indicated as open or closed– Should be coded as closed fracture. A fracture not indicated as displaced or non-displaced– Should be coded as displaced. Aftercare “Z’ codes - Should not be used with fracture code during a follow-up. Usage of 7thCharacter (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 7thcharacter 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 Otherwise we can assign it as routine healing. Sequela(7thCharacter “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. Burns Guidelines Burns codes are due to thermal heat (Except sunburns), electricity and radiation. Corrosions are due to chemicals. Burns and corrosions are classified by depth, First degree – Erythema Second degree – Blistering Third-degree – Full thickness involvement Note: For internal organs – Degree is not applicable. Sequencing Guidelines: For multiple sites - highest degree should be coded first if more than one degree is present. Assign only the highest degree if more than one degree is present at the same site. Non-healing burns are coded asacute burns. Infected burn site - usean additional code for the infection. Extent of body surface involved – Category T31 and T32 are based on “Rule of Nine”. External cause code – An external cause and place of occurrence should be used with burns/corrosions codes. Adverse effects, Poisoning, Underdosing and Toxic effects Combination codes (Substance and the intent). No additional external cause code is required. 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. 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). 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). Complications: Pain due to medical devices: First assign from “T” series and use additional codes from category G89 (acute or chronic pain) Kidney transplant complications: T86.1- should be assigned for documented complications of a kidney transplant. Abuse and other maltreatment 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. 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. For suspected cases of abuse or neglect – Don’t report external cause code. If a suspected case of abuse or neglect is ruled out during an encounter – Report, Code Z04.71 – Encounter for examination and observation of Adult physical abuse Code Z04.72 – Encounter for examination and observation of Child physical abuse If a suspected case of alleged rape or sexual abuse is ruled out during an encounter – Report, Code Z04.41 – Encounter for examination and observation of Adult sexual abuse Code Z04.42 – Encounter for examination and observation of Child sexual abuse If a suspected case of forced sexual exploitation or forced labor exploitation is ruled outduring an encounter – Report, Z04.81 - Encounter for examination and observation of Sexual exploitation Z04.82 – Encounter for examination and observation of Labor exploitation
