Health Information Management

New E codes require detailed documentation

JustCoding News: Inpatient, January 6, 2010

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We’ve all read or seen news reports about horrific accidents that occur when people send text messages while driving. Previously, no E code existed to assist with data collection regarding these accidents. Now, coders can report E011.1 (handheld interactive electronic device), which includes cell phones and communication devices, to describe the activity that caused these accidents.

Code E011.1 is one of 170 new E codes that help provide a more detailed narrative about a particular accident or injury. The codes became effective October 1, 2009.

The intent of many of these new codes is to facilitate transition to ICD-10 and to enhance research and evaluation of injury prevention strategies, says Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc., in Marblehead, MA.

Along with the changes come new ICD-9-CM guidelines and concepts for coders. “This year, it was a big deal for E codes. There are some brand-new concepts with E codes that we’ve never had to deal with before,” says Nelly Leon-Chisen, RHIA, director of coding and classification at the American Hospital Association in Chicago.

Identify external cause status
One new concept is that there are now E codes that denote external cause status (code category E000). These codes include a fourth digit extension that distinguishes among the following:

  • Civilian activity performed for income or pay (E000.0)
  • Military activity (E000.1)
  • Other external cause status (e.g., hobby not performed for income, leisure activity, or volunteer activity) (E000.8)
  • Unspecified external cause status (E000.9)

The new ICD-9-CM Official Guidelines for Coding and Reporting, which also took effect October 1, 2009, provides instruction. Coders should report a code from category E000 in conjunction with the other applicable E codes assigned to a record to indicate the individual’s work status when the event occurred. The guidelines also state that:

  • Providers should assign a single code from category E000 whenever they assign any other E code for an encounter, with the exception of poisonings, adverse effects, misadventures, or late effects
  • When a physician does not document a status, coders should not assign code E000.9 (unspecified external cause status)

Assign E codes to denote activity
Another new concept is that there are now E codes to denote the activity of the person seeking healthcare for an injury or health condition (code categories E001–E030). The ICD-9 Manual includes 21 broad activity categories, including but not limited to those involving walking and running, playing musical instruments, and animal care.

Coders must assign an activity E code for any health conditions—not only injuries—when that activity contributed to the injury or health condition, says McCall.

The ICD-9-CM Official Guidelines for Coding and Reporting, p. 84/112, states:

An activity E code (categories E001–E030) may be used with any code in the range of 001–V89 that indicates an injury, or other health condition that resulted from an activity, or the activity contributed to a condition.

Coders should report activity E codes for acute injuries (i.e., those listed in Chapter 17) and conditions due to long-term, cumulative effects of an activity (i.e., those listed in Chapter 13), according to tabular notes in the ICD-9 Manual.

Before October 1, 2009, E codes described the cause, intent (unintentional, intentional, or accidental), and place of occurrence of an accident, injury, adverse effect, or poisoning. Coders generally needed to report them only in conjunction with codes from the 800 or 900 series.

For example, a patient presents to the hospital after suffering a heart attack while shoveling snow. The heart attack either resulted from the activity or the activity was a contributing factor. Before October 1, 2009, coders wouldn’t have reported an E code because the heart attack wasn’t a trauma or poisoning, says Leon-Chisen. Now, coders can report code E016.0 (activities involving digging, shoveling, and raking).

A patient who presents with carpal tunnel syndrome due to computer keyboarding performed at work for compensation is another example. Coders should report ICD-9 code 354.0 for the carpal tunnel, E011.0 (activities involving computer keyboarding), and E000.0 (civilian activity done for income or pay), says McCall. 

Determining whether an activity caused or contributed to an injury or health condition may be difficult when physician documentation is lacking, says Leon-Chisen. A problem with using activity codes for other health conditions is the need for physicians to link the two, she says.

For example, a physician who doesn’t clearly link the activity of shoveling snow to a patient’s heart attack leaves the coder in limbo. “Maybe the patient already had a history of heart disease, and it may not be entirely clear whether the shoveling of snow caused the heart attack,” she says. Querying physicians in this situation is the best practice. 

Coders should note that activity E codes are not applicable to poisonings, adverse effects, misadventures, or late effects, according to the new official guidelines.

Consider this example. A patient has an adverse reaction after mixing medication and alcohol while attending a baseball game. Coders should not assign an activity E code because this is an adverse effect, and attending the game was not a factor, says Leon-Chisen.

Among the most notable activity E codes are those that pertain to military-related activities, says Leon-Chisen. Examples include:

  • E993.2: Injury due to war operations by mortar
  • E998.0: Injury due to war operations but occurring after cessation of hostilities by explosion of mines

U.S. military officials specifically requested creation of these codes to assist with data collection, says Leon-Chisen.

Coders should note that no new activity E codes specifically denote driving. When an accident or injury occurs while a patient is driving, coders should refer to codes E800–E848, says Leon-Chisen.

Other notable changes include two new E codes that denote never events:

  • E876.6: Performance of operation (procedure) on patient not scheduled for surgery
  • E876.7: Performance of correct operation (procedure) on wrong side/body part

Code E876.5 was revised to denote performance of the wrong operation (procedure) on the correct patient.

Note guidelines for multiple causes
When more than one E code is necessary to fully capture the external cause of an illness, injury, or poisoning, the new guidelines prescribe these rules:

  • E codes for child and adult abuse take priority over all other E codes
  • E codes for terrorism events take priority over all other E codes except those for child and adult abuse
  • E codes for cataclysmic events take priority over all other E codes except those for child and adult abuse and terrorism
  • E codes for transport accidents take priority over all other E codes except those for cataclysmic events, child and adult abuse, and terrorism

Coders should also remember:

  • If two or more events cause separate injuries, assign an E code for each cause according to the previously listed hierarchy
  • Activity and external cause status codes are assigned after all causal (intent) E codes 
  • The first-listed E code should correspond to the cause of the more serious diagnosis due to an assault, accident, or self-harm, following the order of the previously listed hierarchy

Know how to handle format limitations
When the reporting format limits the number of reportable E codes, coders should give priority to the code that denotes the cause and intent most closely related to the principal diagnosis, says Leon-Chisen.

The new guidelines also describe what coders should do when the format permits capture of additional E codes. In this situation, report the codes that denote cause/intent, including medical misadventures, of the additional events rather than codes that denote place, activity, or external status.

For example, a patient presents with a leg injury after having been in a vehicular accident. A physician performs surgery on the patient’s leg; however, the physician performs the procedure on the wrong leg.

Leon-Chisen notes multiple considerations: Some E codes pertain to the accident and location, a never event has occurred, and external cause status may be a factor if the victim was driving pursuant to employment. In this scenario, coders should assign an E code for the cause or intent most closely related to the car accident. The next code should denote the misadventure rather than the external cause status that relates to the accident.

Consider these compliance tips
Consider the following tips to ensure overall E code compliance:

  • Remember that some E codes are exempt from POA reporting, but many are not. For example, when a patient falls in a hospital, coders should report place of occurrence code E849.7 to denote a residential institution.

A present on admission (POA) indicator is also necessary for this code to describe whether the fall occurred before admission or while the individual was hospitalized, says McCall. Similarly, coders must report a POA indicator for codes E850–E858 to indicate whether an accidental poisoning occurred prior to admission or while the patient was hospitalized, she says.

Conversely, place of occurrence E codes E849.0–E849.6, E849.8, and E849.9 are exempt from POA reporting. Access a complete list of codes that are exempt from POA reporting (Scroll to p. 106). 

  • Query physicians when necessary. When physicians don’t document clearly, coders can’t report E codes, which defeats the purpose of creating them, says McCall. Coders should query physicians for confirmation when information in the nursing notes may indicate the need for an E code, she says. Querying for never events is especially important, she adds, because of the effect on physician profiles and hospital reimbursement.

Editor’s note: This article was originally published in the December issue of Briefings on Coding Compliance Strategies. E-mail your questions to Contributing Editor Lisa Eramo at

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