Chapter 20 External Causes of Morbidity Guideline Differences

8/12/2019 Chapter 20 External Causes of Morbidity Guideline Differences

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ICD-9 and ICD-10 Chapter Guideline Comparison Table- Chapter 20 External Causes of Morbidity

C. Chapter-Specific Coding for the ICD-9-CM C. Chapter-Specific Coding for the ICD-10-CMIn addition to general coding guidelines, there are guidelines forspecific diagnoses and/or conditions in the classification. Unlessotherwise indicated, these guidelines apply to all health care

settings. Please refer to Section II for guidelines on the selectionof principal diagnosis.

In addition to general coding guidelines, there are guidelines for specificdiagnoses and/or conditions in the classification. Unless otherwise indicated,these guidelines apply to all health care settings. Please refer to Section II for

guidelines on the selection of principal diagnosis.

19. Supplemental Classification of External Causes of Injurand !oisoning "E-codes# E$00-E999%

Introduction: These guidelines are provided for those who arecurrently collecting E codes in order that there will bestandardiation in the process. If your institution plans to begincollecting E codes, these guidelines are to be applied. The use ofE codes is supple!ental to the application of I"#$%$"&

diagnosis codes.

E'ternal causes of in(ury and poisoning codes )categories E***and E+**$E%%% are intended to provide data for in(ury researchand evaluation of in(ury prevention strategies. -ctivity codes)categories E**$E** are intended to be used to describe theactivity of a person see0ing care for in(uries as well as otherhealth conditions, when the in(ury or other health conditionresulted fro! an activity or the activity contributed to a condition.E codes capture how the in(ury, poisoning, or adverse effecthappened )cause, the intent )unintentional or accidental1 or

intentional, such as suicide or assault, the person2s status )e.g.civilian, !ilitary, the associated activity and the place where theevent occurred.

So!e !a(or categories of E codes include:

&0. Chapter &0' External Causes of Mor(idit ")00-*99%

The e'ternal causes of !orbidity codes should never be se3uenced as thefirst$listed or principal diagnosis.

E'ternal cause codes are intended to provide data for in(ury research andevaluation of in(ury prevention strategies. These codes capture how the in(uryor health condition happened )cause, the intent )unintentional or accidental1

or intentional, such as suicide or assault, the place where the event occurredthe activity of the patient at the ti!e of the event, and the person2s status )e.g.,civilian, !ilitary.There is no national re3uire!ent for !andatory I"#$*$"& e'ternal causecode reporting. Unless a provider is sub(ect to a state$based e'ternal causecode reporting !andate or these codes are re3uired by a particular payer,reporting of I"#$*$"& codes in "hapter 4*, E'ternal "auses of &orbidity, isnot re3uired. In the absence of a !andatory reporting re3uire!ent, providersare encouraged to voluntarily report e'ternal cause codes, as they providevaluable data for in(ury research and evaluation of in(ury prevention strategies.

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transport accidents

poisoning and adverse effects of drugs, !edicinal

substances and biologicals

accidental falls

accidents caused by fire and fla!es accidents due to natural and environ!ental factors

late effects of accidents, assaults or self$in(ury

assaults or purposely inflicted in(ury

suicide or self$inflicted in(ury

These guidelines apply for the coding and collection of E codesfro! records in hospitals, outpatient clinics, e!ergencydepart!ents, other a!bulatory care settings and provider offices,and nonacute care settings, e'cept when other specificguidelines apply.

a. +eneral E Code Coding +uidelines a. +eneral External Cause Coding +uidelines

1% ,sed ith an code in the range of 001-)91

-n E code fro! categories E+**$E%%% !ay be used with anycode in the range of **$9%, which indicates an in(ury,poisoning, or adverse effect due to an e'ternal cause.

-n activity E code )categories E**$E** !ay be used with any

code in the range of **$9% that indicates an in(ury, or otherhealth condition that resulted fro! an activity, or the activitycontributed to a condition.

1% ,sed ith an code in the range of 00.0-/$$.9# 00-99

-n e'ternal cause code !ay be used with any code in the range of -**.*$T++.%, **$%%, classification that is a health condition due to an e'ternalcause. Though they are !ost applicable to in(uries, they are also valid for use

with such things as infections or diseases due to an e'ternal source, and otherhealth conditions, such as a heart attac0 that occurs during strenuous physical

activity.

&% ssign the appropriate E code for all initial treatments

-ssign the appropriate E code for the initial encounter of anin(ury, poisoning, or adverse effect of drugs, not for subse3uent

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treat!ent.E'ternal cause of in(ury codes )E$codes !ay be assigned whilethe acute fracture codes are still applicable.

See Section I.C.17.b.1 for coding of acute fractures.

&% External cause code used for length of treatment

-ssign the e'ternal cause code, with the appropriate ;th character )initialencounter, subse3uent encounter or se3uela for each encounter for whichthe in(ury or condition is being treated.

% ,se the full range of E codes

Use the full range of E codes )E+** < E%%% to co!pletelydescribe the cause, the intent and the place of occurrence, ifapplicable, for all in(uries, poisonings, and adverse effects ofdrugs.

See a.1.), j.), and k.) in this section for information on the use ofstatus and activity E codes.

% ,se the full range of external cause codes

Use the full range of e'ternal cause codes to co!pletely describe the cause,the intent, the place of occurrence, and if applicable, the activity of the patientat the ti!e of the event, and the patient2s status, for all in(uries, and otherhealth conditions due to an e'ternal cause.

2% ssign as man E codes as necessar

-ssign as !any E codes as necessary to fully e'plain eachcause.

2% ssign as man external cause codes as necessar

-ssign as !any e'ternal cause codes as necessary to fully e'plain eachcause. If only one e'ternal code can be recorded, assign the code !ostrelated to the principal diagnosis.

3% /he selection of the appropriate E code

The selection of the appropriate E code is guided by the Inde' toE'ternal "auses, which is located after the alphabetical inde' todiseases and by Inclusion and E'clusion notes in the Tabular

3% /he selection of the appropriate external cause code

The selection of the appropriate e'ternal cause code is guided by the-lphabetic Inde' of E'ternal "auses and by Inclusion and E'clusion notes inthe Tabular 5ist.



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5ist.

4% E code can ne5er (e a principal diagnosis

-n E code can never be a principal )first listed diagnosis.

External cause code"s% ith sstemic inflammatorresponse sndrome "SI6S%

-n e'ternal cause code is not appropriate with a code fro!subcategory %%=.%, unless the patient also has another conditionfor which an E code would be appropriate )such as an in(ury,poisoning, or adverse effect of drugs.

4% External cause code can ne5er (e a principal diagnosis

-n e'ternal cause code can never be a principal )first$listed diagnosis.

7% Multiple Cause E Code Coding +uidelines

&ore than one E$code is re3uired to fully describe the e'ternalcause of an illness, in(ury or poisoning. The assign!ent of E$codes should be se3uenced in the following priority:

If two or !ore events cause separate in(uries, an E code shouldbe assigned for each cause. The first listed E code will beselected in the following order:

E codes for child and adult abuse ta0e priority over all other Ecodes.

See Section I.C.19.e., Chid and !dut abuse guideines.

E codes for terroris! events ta0e priority over all other E codese'cept child and adult abuse.E codes for cataclys!ic events ta0e priority over all other Ecodes e'cept child and adult abuse and terroris!.

E codes for transport accidents ta0e priority over all other Ecodes e'cept cataclys!ic events, child and adult abuse andterroris!.

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-ctivity and e'ternal cause status codes are assigned followingall causal )intent E codes.

The first$listed E code should correspond to the cause of the

!ost serious diagnosis due to an assault, accident, or self$har!,following the order of hierarchy listed above.

$% If the reporting format limits the num(er of E codesIf the reporting for!at li!its the nu!ber of E codes that can beused in reporting clinical data, report the code for thecause/intent !ost related to the principal diagnosis. If the for!atper!its capture of additional E codes, the cause/intent, including!edical !isadventures, of the additional events should bereported rather than the codes for place, activity or e'ternalstatus.

7% Com(ination external cause codes

"ertain of the e'ternal cause codes are co!bination codes that identifyse3uential events that result in an in(ury, such as a fall which results in stri0ingagainst an ob(ect. The in(ury !ay be due to either event or both. Theco!bination e'ternal cause code used should correspond to the se3uence ofevents regardless of which caused the !ost serious in(ury.

$% 8o external cause code needed in certain circumstances

8o e'ternal cause code fro! "hapter 4* is needed if the e'ternal cause andintent are included in a code fro! another chapter )e.g. T?.*@$ Poisoningby penicillins, accidental )unintentional.

(. !lace of ccurrence +uideline (. !lace of ccurrence +uideline

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Use an additional code fro! category E+>% to indicate the Placeof Accurrence. The Place of Accurrence describes the place

where the event occurred and not the patient2s activity at the ti!eof the event.

#o not use E+>%.% if the place of occurrence is not stated.

"odes fro! category B%4, Place of occurrence of the e'ternal cause, aresecondary codes for use after other e'ternal cause codes to identify thelocation of the patient at the ti!e of in(ury or other condition.- place of occurrence code is used only once, at the initial encounter for

treat!ent. 8o ;th characters are used for B%4. Anly one code fro! B%4should be recorded on a !edical record.#o not use place of occurrence code B%4.% if the place is not stated or is notapplicable.

c. d5erse Effects of Drugs# Medicinal and :iologicalSu(stances +uidelines

1% Do not code directl from the /a(le of Drugs

#o not code directly fro! the Table of #rugs and "he!icals.

-lways refer bac0 to the Tabular 5ist.

&% ,se as man codes as necessar to descri(e

Use as !any codes as necessary to describe co!pletely alldrugs, !edicinal or biological substances.

If the reporting for!at li!its the nu!ber of E codes, and thereare different fourth digit codes in the sa!e three digit category,use the code for CAther specifiedD of that category of drugs,!edicinal or biological substances. If there is no CAtherspecifiedD code in that category, use the appropriateCUnspecifiedD code in that category.If the reporting for!at li!its the nu!ber of E codes, and thecodes are in different three digit categories, assign theappropriate E code for other !ultiple drugs and !edicinalsubstances.

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% If the same E code ould descri(e the causati5e agent

If the sa!e E code would describe the causative agent for !orethan one adverse reaction, assign the code only once.

2% If to or more drugs# medicinal or (iological su(stances

If two or !ore drugs, !edicinal or biological substances arereported, code each individually unless the co!bination code islisted in the Table of #rugs and "he!icals. In that case, assign

the E code for the co!bination.

3% ;hen a reaction results from the interaction of a drug"s%

hen a reaction results fro! the interaction of a drug)s andalcohol, use poisoning codes and E codes for both.

4% Codes from the E90-E929 series

"odes fro! the E%*$E%>% series !ust be used to identify thecausative substance for an adverse effect of drug, !edicinal andbiological substances, correctly prescribed and properlyad!inistered. The effect, such as tachycardia, deliriu!,gastrointestinal he!orrhaging, vo!iting, hypo0ale!ia, hepatitis,renal failure, or respiratory failure, is coded and followed by theappropriate code fro! the E%*$E%>% series.

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c. cti5it Code

-ssign a code fro! category B%, -ctivity code, to describe the activity of thepatient at the ti!e the in(ury or other health condition occurred.-n activity code is used only once, at the initial encounter for treat!ent. Anly

one code fro! B% should be recorded on a !edical record.The activity codes are not applicable to poisonings, adverse effects,!isadventures or se3uela .

#o not assign B%.%, Unspecified activity, if the activity is not stated.- code fro! category B% is appropriate for use with e'ternal cause andintent codes if identifying the activity provides additional infor!ation about theevent.

d. !lace of ccurrence# cti5it# and Status Codes ,sed ith otherExternal Cause Code

hen applicable, place of occurrence, activity, and e'ternal cause statuscodes are se3uenced after the !ain e'ternal cause code)s. 6egardless ofthe nu!ber of e'ternal cause codes assigned, there should be only one placeof occurrence code, one activity code, and one e'ternal cause status codeassigned to an encounter.

e. If the 6eporting


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cause of an illness or in(ury. The assign!ent of e'ternal cause codes shouldbe se3uenced in the following priority:If two or !ore events cause separate in(uries, an e'ternal cause code shouldbe assigned for each cause. The first$listed e'ternal cause code will beselected in the following order:

E'ternal codes for child and adult abuse ta0e priority over all other e'ternalcause codes.

See Section I.C.19., Chid and !dut abuse guideines.

E'ternal cause codes for terroris! events ta0e priority over all other e'ternalcause codes e'cept child and adult abuse.E'ternal cause codes for cataclys!ic events ta0e priority over all othere'ternal cause codes e'cept child and adult abuse and terroris!.E'ternal cause codes for transport accidents ta0e priority over all other

e'ternal cause codes e'cept cataclys!ic events, child and adult abuse andterroris!.

-ctivity and e'ternal cause status codes are assigned following all causal)intent e'ternal cause codes.

The first$listed e'ternal cause code should correspond to the cause of the

!ost serious diagnosis due to an assault, accident, or self$har!, following theorder of hierarchy listed above.

d. Child and dult (use +uideline g. Child and dult (use +uideline

-dult and child abuse, neglect and !altreat!ent are classified as assault. -nyof the assault codes !ay be used to indicate the e'ternal cause of any in(uryresulting fro! the confir!ed abuse.For confir!ed cases of abuse, neglect and !altreat!ent, when the

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perpetrator is 0nown, a code fro! B*;, Perpetrator of !altreat!ent andneglect, should acco!pany any other assault codes.

See Section I.C.19. !dut and chid abuse, negect and other matreatment

1% Intentional injur

hen the cause of an in(ury or neglect is intentional child or adultabuse, the first listed E code should be assigned fro! categoriesE%?*$E%?+, 7o!icide and in(ury purposely inflicted by otherpersons, )e'cept category E%?;. -n E code fro! categoryE%?;, "hild and adult battering and other !altreat!ent, shouldbe added as an additional code to identify the perpetrator, if0nown.

&% ccidental intent

In cases of neglect when the intent is deter!ined to beaccidental E code E%*>.*, -bandon!ent or neglect of infant andhelpless person, should be the first listed E code.

e. ,n>non or Suspected Intent +uideline h. ,n>non or ,ndetermined Intent +uideline

If the intent )accident, self$har!, assault of the cause of an in(ury or othercondition is un0nown or unspecified, code the intent as accidental intent. -lltransport accident categories assu!e accidental intent.

1% If the intent "accident# self-harm# assault% of the cause ofan injur or poisoning is un>non

If the intent )accident, self$har!, assault of the cause of anin(ury or poisoning is un0nown or unspecified, code the intent asundeter!ined E%+*$E%+%.

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&% If the intent "accident# self-harm# assault% of the cause ofan injur or poisoning is ?uestiona(le

If the intent )accident, self$har!, assault of the cause of anin(ury or poisoning is 3uestionable, probable or suspected, code

the intent as undeter!ined E%+*$E%+%.

f. ,ndetermined Cause

hen the intent of an in(ury or poisoning is 0nown, but the causeis un0nown, use codes: E%4+.%, Unspecified accident, E%=+.%,Suicide and self$inflicted in(ury by unspecified !eans, andE%?+.%, -ssault by unspecified !eans.These E codes should rarely be used, as the docu!entation inthe !edical record, in both the inpatient outpatient and othersettings, should nor!ally provide sufficient detail to deter!ine

the cause of the in(ury.

1% ,se of undetermined intent

E'ternal cause codes for events of undeter!ined intent are only for use if thedocu!entation in the record specifies that the intent cannot be deter!ined.

g. =ate Effects of External Cause +uidelines i. Se?uelae "=ate Effects% of External Cause +uidelines

1% =ate effect E codes

5ate effect E codes e'ist for in(uries and poisonings but not foradverse effects of drugs, !isadventures and surgicalco!plications.

1% Se?uelae external cause codes

Se3uela are reported using the e'ternal cause code with the ;th character CSDfor se3uela. These codes should be used with any report of a late effect orse3uela resulting fro! a previous in(ury.

&% =ate effect E codes "E9&9# E939# E949# E977# E9$9# or

E999.1%

- late effect E code )E%4%, E%=%, E%?%, E%;;, E%+%, or E%%%.should be used with any report of a late effect or se3uelaresulting fro! a previous in(ury or poisoning )%*=$%*%.

% =ate effect E code ith a related current injur

- late effect E code should never be used with a related current

&% Se?uela external cause code ith a related current injur

- se3uela e'ternal cause code should never be used with a related



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nature of in(ury code. current nature of in(ury code.

2% ,se of late effect E codes for su(se?uent 5isits

Use a late effect E code for subse3uent visits when a late effect

of the initial in(ury or poisoning is being treated. There is no lateeffect E code for adverse effects of drugs.#o not use a late effect E code for subse3uent visits for follow$upcare )e.g., to assess healing, to receive rehabilitative therapy ofthe in(ury or poisoning when no late effect of the in(ury has beendocu!ented.

% ,se of se?uela external cause codes for su(se?uent 5isits

Use a late effect e'ternal cause code for subse3uent visits when a late effect

of the initial in(ury is being treated. #o not use a late effect e'ternal causecode for subse3uent visits for follow$up care )e.g., to assess healing, toreceive rehabilitative therapy of the in(ury when no late effect of the in(ury hasbeen docu!ented.

h. Misad5entures and Complications of Care +uidelines

1% Code range E$70-E$74

-ssign a code in the range of E+;*$E+;? if !isadventures arestated by the provider. hen applying the E code guidelinespertaining to se3uencing, these E codes are considered causalcodes.

&% Code range E$7$-E$79

-ssign a code in the range of E+;+$E+;% if the providerattributes an abnor!al reaction or later co!plication to a surgicalor !edical procedure, but does not !ention !isadventure at theti!e of the procedure as the cause of the reaction.

i. /errorism +uidelines j. /errorism +uidelines

1% Cause of injur identified ( the


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Unli0e other E codes, activity E codes !ay be assigned toindicate a health condition )not (ust in(uries resulted fro! anactivity, or the activity contributed to the condition.

The activity codes are not applicable to poisonings, adverse

effects, !isadventures or late effects.

#o not assign E**, Unspecified activity, if the activity is notstated.

>. External cause status

- code fro! category E***, E'ternal cause status, should beassigned whenever any other E code is assigned for anencounter, including an -ctivity E code, e'cept for the eventsnoted below. -ssign a code fro! category E***, E'ternal cause

status, to indicate the wor0 status of the person at the ti!e theevent occurred. The status code indicates whether the eventoccurred during !ilitary activity, whether a non$!ilitary person

was at wor0, whether an individual including a student orvolunteer was involved in a non$wor0 activity at the ti!e of thecausal event.

- code fro! E***, E'ternal cause status, should be assigned,when applicable, with other e'ternal cause codes, such astransport accidents and falls. The e'ternal cause status codesare not applicable to poisonings, adverse effects, !isadventures

or late effects.#o not assign a code fro! category E*** if no other E codes)cause, activity are applicable for the encounter.

#o not assign code E***.%, Unspecified e'ternal cause status, ifthe status is not stated.

>. External cause status

- code fro! category B%%, E'ternal cause status, should be assignedwhenever any other e'ternal cause code is assigned for an encounter,including an -ctivity code, e'cept for the events noted below. -ssign a codefro! category B%%, E'ternal cause status, to indicate the wor0 status of the

person at the ti!e the event occurred. The status code indicates whether theevent occurred during !ilitary activity, whether a non$!ilitary person was at

wor0, whether an individual including a student or volunteer was involved in anon$wor0 activity at the ti!e of the causal event.

- code fro! B%%, E'ternal cause status, should be assigned, whenapplicable, with other e'ternal cause codes, such as transport accidents andfalls. The e'ternal cause status codes are not applicable to poisonings,adverse effects, !isadventures or late effects.

#o not assign a code fro! category B%% if no other e'ternal cause codes

)cause, activity are applicable for the encounter.

-n e'ternal cause status code is used only once, at the initial encounter fortreat!ent. Anly one code fro! B%% should be recorded on a !edical record.

#o not assign code B%%.%, Unspecified e'ternal cause status, if the status isnot stated.

>-!anda 5owery, 67IT "oding Supervisor 8oland 7ealth Services

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Chapter 20 External Causes of Morbidity Guideline Differences