For the purposes of time and space the guidelines for

coding injuries are described as they relate to the “coding of an injury to the internal carotid artery, intracranial portion in both ICD-9 CM and ICD-10 CM. Only the initial encounter of the injury will be discussed without mention of external cause codes or surgical procedure codes. The ICD-10 CM guidelines instruct the coder to assign separate codes for each injury unless a combination code is provided. The coder is cautioned against using T07 in the inpatient setting and codes (S00-T14.9) are not to be used for normal, healing surgical wounds or to capture any complications of surgical wounds. As it relates to sequencing, the coder is instructed to sequence first the most serious injury determined by the physician and the focus of the treatment. As it pertains to damage to nerves or blood vessels, the coder is instructed to sequence the primary injury first when minor injuries occur to the nerves, blood vessels and spinal cord. If, however, the primary injury is the blood vessel or nerve, then it should be sequenced first. These guidelines apply to both ICD-9 CM and ICD-10 CM.

CODING GUIDELINE

WHAT TO EXPECT

1 Coding Guideline

2 Coding Scenario

3 About CCHIS

4 Requests for Coding Topics

“Sequencing is

important!

Determine whether the

blood vessel/nerve is

the primary injury.”

JANUARY 2014

Volume 1 Issue 1

By Cynthia Brown, MBA, RHIT, CCS

www.cyntcodinghealthinformationservices.com

CCHIS, P.O. Box 3019, Decatur, GA 30031 404-992-8984 http://www.cyntcodinghealth informationserv ices.com Cynth ia@cyntcodinghealthinformat ionserv ices.com [phone ]

CODING YESTERDAY’S NOMENCLATURE TODAY®

Coding Traumatic Injury to Internal Carotid Artery

with Skull Fracture in both ICD-9 CM & ICD-10 CM

CODING NEWSLETTER FOR HEALTHCARE

CODING PROFESSIONALS

Page 2 Coding Yesterday’s Nomenclature Today

An unconscious 25-year old male patient involved in a motorcycle racing accident reports to the ER of a Level I Trauma Center. Upon further examination, the patient is found to have an open temporal bone fracture of his skull along with a life-threatening laceration to the internal carotid artery, intracranial portion. The patient requires surgery to stop the epidural hemorrhage and is admitted for further treatment of his injuries. The physician has deemed the internal carotid artery injury to be the primary injury. After surgery, the patient remained unconscious and expires on the third day of admission.

ICD-9 CM Code: 801.75 ICD-10 CM Code: S02.19xB; S06.4x7A

In ICD-9 CM, the skull fracture, epidural hemorrhage, loss of consciousness and resulting death are all captured in one code. The coder should go to the alphabetical index under the term fracture; temporal bone where they are further instructed to “see fracture, skull base.” From there the coder can find the subterms open, with epidural hemorrhage, 801.7. Upon checking the code in the tabular index the coder will find that the code requires a fifth digit The fifth digit subclassification 5 further captures the patient’s conscious level and eventual death. In ICD-10 CM, the same injuries are captured using two codes. As stated above the coder should go to the alphabetical index and locate the term fracture; then temporal bone where the partial code S02.19 is found. Upon finding the code S02.19xB in the tabular index of the ICD-10 codebook, the coder can see that there is a seventh character requirement needed to complete the code. The letter B is the correct seventh character for “initial encounter for open fracture.” The coder is also reminded to add the placeholder “x” before the seventh character to complete the seven digit requirement for a complete code. The coder is also instructed to “Code also any associated intracranial injury (S06.-).” See injury, intracranial, epidural hemorrhage in the alphabetical index. S06.4X is noted and after checking the tabular index, the coder would find S06.4X7 would be appropriate to further capture the patient’s continual unconscious state resulting in death. The letter A is added to indicate “Initial Encounter” for episode of care.

www.cyntcodinghealthinformationservices.com

Prolonged Unconsciousness

without return to pre-existing

conscious level resulting in death.

“Injury to the internal

carotid artery,

intracranial portion is

considered the primary

injury.”

Coding Scenario

Coding Yesterday’s Nomenclature Today

CyntCoding Health Information Services (CCHIS) specializes in all aspects of coding and reimbursement. Nearly 30 years in the Health Information field gives CCHIS the edge in knowing the ins & outs of coding. CCHIS is dedicated to assisting healthcare providers in optimizing their reimbursement through the reinforcement of accurate and complete coding practices. The challenges of inadequate staffing and changing coding rules and regulations will be minimized by reliable coding and/or training. It is the goal of CCHIS to reduce areas of concern in coding backlogs, insufficient cash flow, inefficient coding practices, and potential non-compliance risks.®

Accurate and complete coding is a must in today’s economically challenged healthcare environment. The uncertainties of the future for healthcare providers have raised the awareness to achieve optimal reimbursement while ensuring medical care is both cost-effective and medically necessary. CCHIS is dedicated to helping providers achieve optimal reimbursement through accurate and complete coding. ®

CCCHIS has an in-depth knowledge of coding guidelines; NCCI edits; and CPT/HCPCS codes. Coding is performed in compliance with CMS, Coding Clinic, and AMA guidelines. Coding services can be performed onsite within industry standards, productivity, and accuracy. ®

Cynthia Brown, MBA, RHIT, CCS is the company’s AHIMA approved ICD-10 CM/PCS Trainer. Ms. Brown began her career a Health Information Management professional in 1981. Since then she has developed a passion for the HIM field that is second to none. Excellence has always been the center of her motivation to serve in areas of management, training, education, and coding.

Cynthia Brown has nearly 20 years of hands on coding experience which gives her the knowledge and expertise needed to identify and relate to the needs of your coding staff. She has added instructional training to her extensive lists of capabilities along with her years in coding and management.

Coding

Yesterday’s Nomenclature

Today Coding Health Information Services ®

AHIMA approved ICD-10 CM/PCS

Trainer

About CCHIS “All Things Coding”®

“Accurate and

complete coding is a

must in today’s

economically

challenged healthcare

environment.”

Page 4 Coding Yesterday’s Nomenclature Today

CCHIS Professional Affiliates

AHIMA GHIMA AHIMA approved ICD-10 CM/PCS

Trainer EDWOSB/WOSB VOSB SCORE Atlanta

CyntCoding Health Information Services

P.O. BOX 3019 Decatur, GA 30031

Phone: 404-992-8984

E-Fax: 678-805-4919

E-mail: cyntcoder1@aol.com or cyntcoder1@gmail.com

Requests for Coding Topics E-mail your coding topics using the format below to: cyntcoder@cyntcodinghealthinformationservices.com

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All content provided in this “CCHIS Newsletter” is for informational purposes only. The owner of this newsletter makes no representations as to the accuracy or completeness of any information in this newsletter or found by following any link in this newsletter. The owner of http://cyntcodinghealthinformationservices.com will not be liable for any errors or omissions in information nor for the availability of this information. The owner will not be liable for any losses, injuries, or damages from the display or use of this information. The terms and conditions are subject to change at any time with or without notice.

CODING YESTERDAY’S NOMENCLATURE TODAY® www.cyntcodinghealthinformationservices.com