Proposed ICD-10-CM External Cause of Injury Framework for Presenting Injury Data

J. Lee Annest, PhD, MS

Chief, Statistics, Programming, and Economics Branch Division of Analysis, Research and Practice Integration

National Center for Injury Prevention and Control Atlanta, GA

January 15, 2013

National Center for Injury Prevention and Control Division of Analysis, Research and Practice Integration

Acknowledgments Collaborators:

Holly Hedegaard, MD, MSPH (NCHS)

Margaret Warner, Ph.D. (NCHS)

Lily Chen, Ph.D. (NCHS)

Ann Smalls (NCIPC)

Overview

• Differences between ICD-9-CM and ICD-10-CM for external cause of injury codes

• How proposed ICD-10-CM matrix was constructed

• What’s new in this ICD-10-CM matrix compared to the ICD-9-CM Matrix?

• Some issues & proposed resolutions

Why construct the ICD-10-CM matrix now?

• ICD-10-CM scheduled to replace ICD-9-CM for morbidity coding in the U.S. on Oct 1. 2014

• Need time to educate the injury field about coding changes

• Need time for pilot testing with real data and publication of the external cause framework

Comparison of ICD-9-CM & ICD-10-CM Highlighting Major Differences

ICD-9-CM ICD-10-CM

~ 14,000 codes ~ 68,000 codes

E-cause preceded with an “E” E-cause preceded with “V, W, X, or Y”

E + 3-5 digits in the code 3-7 digits in the code

Poisoning/Toxic Effects e-cause codes No Poisoning/Toxic Effects e-cause codes; T codes (T36-T65) with intent

Suffocation e-cause codes (E911-E913; E953; E963; E983)

No Suffocation e-cause codes; Asphyxiation (T71) codes with intent

No designation of initial and subsequent encounter

Most e-cause/injury diagnosis codes have designation of initial and subsequent encounter (A or D in 7th digit)

Late effects e-cause codes (E929.0-.9) limited

Most e-cause & injury diagnosis codes have a sequelae (late effects) designation (“S” in 7th digit)

Foreign body e-cause codes limited to E914 and E915; general diagnosis codes (930-939)

No foreign body e-cause codes; detailed foreign body diagnosis codes (T15-T19)

Note: Asphyxiation includes strangulation, suffocation, systemic oxygen deficiency

ICD-9-CM ICD-10-CM

Suicide/Self-inflicted Intentional self-harm

No diagnosis code for suicide attempt Suicide attempt diagnosis code (T14.91)

Homicide & injury purposely inflicted by other persons

Assault

E-cause codes for child and adult abuse, neglect, & other maltreatment (E967.0-.9) limited

Expanded E-cause codes for perpetrator of assault, maltreatment, and neglect (Y07)

Child/adult abuse & maltreatment diagnosis codes (995.50-59; 995.80-.85) limited

Expanded child/adult abuse, neglect, and other maltreatment diagnosis codes – confirmed (T74) and suspected (T76). (NOTE: E-cause codes not recorded for suspected cases)

E-cause codes for deprivation & other selected natural environmental factors (e.g., lightning, vibration)

No e-cause codes for deprivation & other selected natural environmental factors (e.g., lightning, vibration); coded as “effects of e-causes” diagnosis codes

The Proposed ICD-10-CM Matrix How Codes Were Placed

Process

GEM* ICD-10-CM source

GEM* ICD-9-CM source

Spreadsheets of Major

Mechanism by Intent

SAS Program independent source

of code sets

Codes reviewed independently by

NCHS and NCIPC staff

Discrepancies discussed &

consensus reached for placement

* GEM = General Equivalence Mapping (conceptual).

Guiding Principles for Determining Placement in the Framework

1) Initially assigned the ICD-10-CM “child” e-cause code

to the same mechanism X intent as the “parent” e-cause code (1st three characters) in ICD-10.

2) Reassigned “child” e-cause code to different mechanism by intent category if

o “child” code provides greater detail/specificity

o “child” code represents a different mechanism

Example of ICD-10-CM “child’ e-cause code that is a subset of ICD-10 “parent” code

Struck by

W50. Hit,struck,

kicked, twisted, bitten or

scratched by another person

W503xx. Accidental

bite by another person

Example of ICD-10-CM “child” e-cause code that is NOT a subset of ICD-10 “parent” code

Drowning

W16511. Jumping or diving into

swimming pool striking water

surface causing

drowning and submersion

Falls

W16 Diving or jumping into

water causing injury other

than drowning or submersion

W16 specifically excluded W16511

Example of ICD-10-CM “child” e-cause code that has more detail than ICD-10 “parent” code

Unspecified, Legal intervention or war

Y3692x. War operations involving friendly fire

Y36.9 War operations, unspecified

Firearm, Legal intervention/war

Guiding Principles for Determining Placement in the Framework

3) For ICD-10-CM e-cause codes with no ICD-10 “parent” code o Place the code based on the injury description (V00xxx –

Pedestrian Conveyance)

4) ICD-10-CM T (diagnosis) codes included if o Associated with a deactivated ICD-10 e-cause code (e.g.,

foreign body)

o Intent of Injury indicated with a digit in the code (e.g., poisoning)

o Intent of Injury indicated in description (e.g., abuse)

Results

• ICD-10-CM All but Poisoning Matrix (includes e-cause codes (V, W, X, Y codes) and selected diagnosis codes (T codes)

• ICD-10-CM Poisoning Matrix (poisoning & toxic effects T codes)

• NOT INCLUDED (for now): Adverse Effects of Therapeutic Drugs and Medical/Surgical Care

What’s new about the ICD-10-CM Matrix compared to the ICD-9-CM matrix?

• New Transport mechanism categories (added to be consistent with ICD-10 matrix):

o MVT-Other (collision of MV with animal rider, occupant of animal drawn vehicle, rail train/vehicle, steet car)

o MV-nontraffic (MV collision in nontraffic incident)

o Other Land Transport

What’s new about the ICD-10-CM Matrix compared to the ICD-9-CM matrix?

• New Natural/Environmental mechanism categories:

o Bites/Stings - nonvenomous

o Bites/Stings - venomous

o Other Natural/Environmental

What’s new about the ICD-10-CM Matrix compared to the ICD-9-CM matrix?

• New Poisoning categories:

o Poisoning – Drug

o Poisoning – Non-Drug

Issue #1

• How do we count inpatient or ED encounters?

o Counts and rates should be based on the initial encounter, if possible

Note: ICD-10-CM codes identify the initial encounter (A), subsequent encounter (D) and sequela (S) (late effects) of an injury incident.

Issue #2

• What about sequela (late effects) codes?

o Sequela codes will not be included in the matrix.

o Sequela codes can be identified using the “S” character at the end of the code for use in analysis

Note: Most individual external cause (V, W, X, Y) and diagnosis (T) codes in the ICD-10-CM external cause matrix have sequela codes.

Issue #3

• Where should ICD-10-CM W16 (parent – Fall) and W22 (parent – Struck by/against) codes that specify Drowning/Submersion be placed in the matrix?

o Placed in Drowning/Submersion

o Also, a sub-matrix will be created inclusive of all Drowning/Submersion codes.

Note: In ICD-10, W16 = Diving or jumping into water causing injury other than drowning or submersion; W22 = striking by/against other objects.

Issue #4

• Where should Toxic Effects of Phenol and Phenol Homologues (T54.0xx) be placed in the matrix?

o These codes will be placed in Non-drug Poisoning

Note: Toxic effects of organic and inorganic corrosive compound, other than phenol, have been placed in Non-drug Poisoning.

Phenols can cause both chemical burns or poisoning (neurotoxin)

Issue #5

• Where should Transportation codes (V90xxx – V94xxx) involving watercraft that result in drowning/submersion or other mechanism of injury (e.g., burn, crush, fall, struck by/against) be placed in the matrix?

o Placed in Unintentional, Other Transport

o Also, these codes will be included in a Drowning/Submersion sub-matrix

Note: In the ICD-10 matrix, these transportation codes involving watercraft (less specific), were placed in “Unintentional, Other Transport.”

Issue #6 • Where should Pedestrian Conveyance codes (V00xxx)

be placed in the matrix?

o Placed with other major mechanism categories (e.g., Unintentional Struck by/against, Unintentional Fall)

o Not counted as Transportation

Note: These pedestrian conveyance codes are new, were not in ICD-9-CM or ICD-10, and do not involve collisions with traditional transportation vehicles.. They help identify sports- and recreation-related (skateboarder, ice skater, scooter) and other conveyance-related (motorized mobility scooter, baby stroller, wheelchair) injuries.

Issue #7

• Should Effects of Vibration (T752xx), Motion Sickness (T753xxx), and Prolonged Stay in Weightless Environment (X52xxx) codes be:

o Placed with Natural/Environmental

Note: These mechanisms—vibration, travel and motion, prolonged stay in weightless environment – represent external cause codes in either ICD-9-CM and/or ICD-10. We propose to include them in the matrix for completeness and consistency.

Issue #8

• Where should Foreign Body codes (T codes) be placed in the matrix?

o Unintentional Foreign Body (separate category)

o Will they be assigned external cause codes (pilot test)?

Note: ICD-9-CM Foreign Body E-codes (E914, E915) were very limited and were place with Unintentional, Other Specified in the ICD-9-CM matrix. ICD-10-CM has no Foreign Body e-cause codes, but has more detailed foreign body diagnosis codes (T15-T19).

Issue #9

• Should a Suicide Attempt code (T14.91) be:

o Placed with Unspecified Self-Harm

o Will they be assigned external cause codes (pilot test)?

Note: An ICD-10-CM injury diagnosis code specifically states suicide attempt (T14.91). It is not clear how this code will be used or if an intentional self-harm external cause code will accompany this code. If so, they will be placed in the ICD-10-CM matrix based on the external cause code.

Issue #10 • Should Adult/Child Abuse, Neglect and Other

Maltreatment include both confirmed (T74) and suspected (T76) codes in the matrix?

o Yes, place T74 & T76 codes together in a separate Assault mechanism category

Note: ICD-10-CM provides the option to code confirmed or suspected abuse. Coding guidelines state that confirmed cases should be assigned an assault e-cause code (X92-Y08) and when known, a perpetrator code (Y07). For suspected cases of abuse, e-cause or perpetrator codes are not reported.

Data Base Issue #11 • How will mechanisms that are classified as T codes

(Poisoning, Asphyxiation, selected Natural/Environmental, Foreign Body) be captured in state-based administrative data bases?

o Hopefully, in both the diagnosis and designated external cause code fields

Note: In ICD-9-CM, external cause codes cannot be the first-listed or principal diagnosis. In ICD-10-CM, poisonings and asphyxiations (with intent designations) are “combination” codes and could represent the principal diagnosis and the external cause.

Steps

• Informal comment period through January, 2013

• Publish proposed External Cause Framework report

• Pilot test (state grantees/others)

• Develop preliminary SAS code for data analysis

• Make adjustments

• Formal CDC review process

• Publish final External Cause Framework report

• Make the external cause matrix and SAS code available on NCHS’s web site

Questions?

For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348

E-mail: cdcinfo@cdc.gov Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Thank You

National Center for Injury Prevention and Control Division of Analysis, Research and Practice Integration

J. Lee Annest, Ph.D., M.S. lannest@cdc.gov