Health Information Management

Identify all injuries and conditions to correctly code for multiple significant trauma

JustCoding News: Inpatient, February 29, 2012

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by Joel Moorhead, MD, PhD, CPC, and Beverly (Cross) Selby, RHIT, CCS

"You can see a lot just by looking."

This frequently cited Yogi Berra quote can also be a helpful coding principle. We see what we look for.

Coders who keep in mind the clinical elements of syndromes such as dysmetabolic syndrome X (277.7) and more conceptual ICD-9 constructs such as functional quadriplegia (780.72) are more likely to identify these conditions and their significance to hospital admissions. Likewise coders who keep in mind the injuries that define multiple significant trauma (MST) are more likely to identify these cases and assign DRGs based on this classification when present.

Note definition of multiple significant trauma

CMS defines Major Diagnostic Category (MDC) 24, multiple significant trauma, as any diagnosis of significant injury to the head, chest, abdomen, kidney, urinary system, pelvis or spine, or upper or lower limb.

The ICD-9-CM Alphabetic Index directs coders to nonspecific multiple injury codes, including:

  • Injury (code 959.9)
  • Internal injury (code category 869, includes multiple internal injury)
  • Intracranial injury (code 854.0)
  • Superficial injury (code category 919)

The ICD-9-CM Official Guidelines for Coding and Reporting Section I.C.17.1.instructs coders not to use these nonspecific injury and multiple injury codes unless there is no information available from which to assign more specific injury codes.

The official guidelines also instruct coders to assign separate codes for each injury unless a combination code is available, and not to use the traumatic injury codes to identify complications of surgical wounds or for normal, healing surgical wounds.

Understand DRG pathways

The DRG Expert specifies two pathways that lead to DRGs based on MDC 24. The DRG Expert notes these pathways under DRG 963 (other MST with MCC):

  • Select a principal diagnosis from the list of trauma diagnoses (provided under DRG 963), with at least two different diagnoses from two different significant trauma body site categories (also provided under DRG 963), or
  • Select a principal diagnosis from one significant trauma body site category and two or more significant trauma diagnoses from different significant trauma body site categories.

Take note of seemingly mild conditions

Coders are unlikely to overlook major traumatic conditions such as long bone fractures when reviewing medical records. However, some relatively benign conditions appear in the trauma diagnosis list, including:

  • Closed fracture of nasal bones (code 802.0)
  • Closed fracture of the mandible (code 802.2)
  • Concussion without loss of consciousness (code 850.0)
  • Various sprains and strains (code 840.x–848.x)
  • Assorted superficial injuries (code 910.x–919.x)
  • Contusions (code 920.x–924.x)
  • Injuries (code 959.x)

Even though these conditions may seem relatively mild, the circumstances of admission might support any one of them as principal diagnosis. Remember that the ICD-9-CM Official Guidelines for Coding and Reporting (Section I.C.17.a.) direct coders to sequence the most severe injury first.

The significant trauma body site categories provide both alternative principal diagnoses (the second pathway to DRGs based on MDC 24) and diagnoses from different significant trauma body sites. The official guidelines (Section I.C.17.a) again direct coders to code the primary injury first, with additional codes for injuries to nervous system structures (categories 950–957) and blood vessels (categories 900–904).

For example, consider the following relatively benign nervous system injuries:

  • Injury to the brachial plexus (code 953.4)
  • Injury to the peroneal nerve (code 956.3)

It is easy to overlook both of these injuries, in part because both can occur after the initial trauma. A patient with an altered level of consciousness could fall in a position with outstretched arm, resulting in an injury to the lower trunk of the brachial plexus (code 953.4, in significant trauma body site category 7). Similarly, a patient's leg could rest against an object that could compress the peroneal nerve below the knee, resulting in a peroneal nerve compression injury (code 956.3, in significant trauma body site category 8).

Apply the principles when coding multiple fractures

The ICD-9-CM Official Guidelines for Coding and Reporting (Section I.C.17.b) instruct coders to apply the principles of multiple coding of injuries when coding multiple fractures. These principles include assignment of individual fracture codes for fractures of specified sites. Traumatic fractures are to be coded as acute fractures for the initial encounter when the patient receives active treatment. The official guidelines (Section I.C.17.b.1.) also provide examples of active treatment, including "surgical treatment, emergency department encounter, and evaluation and treatment by a new physician." The ICD-9-CM Official Guidelines for Coding and Reporting (Section I.C.17.b.5) instruct coders to sequence multiple fractures in descending order of severity.

Patients sometimes add to their injury burden

Patients can also add to their injury burden by pulling out their catheters. Coding Clinic November–December 1985 advises assigning codes for injury to urethra and/or bladder (code 867.0) and for hematuria (code 599.7x) for patients who sustain trauma from pulling out a Foley catheter. Note that this coding sequence is only appropriate for trauma from pulling out the Foley, not for trauma related to inserting the Foley.

Consider relatively mild injuries in significant trauma body site Category 1 (including code 850.2 for a concussion with moderate [1–24 hours] loss of consciousness) and significant trauma body site Category 6 (including code 954.x for injuries to nerves of trunk, excluding shoulder and pelvis).

Bear in mind that surgical DRGs can change in response to a designation of MDC 24. An injury burden that establishes MST can result in the following conditions when the patient undergoes a surgical procedure from MDC 21 (Injury, Poisoning, and Toxic Effects of Drugs). Look for these procedures under MDC 21 in resources such as the DRG Expert:

  • DRG 955 (craniotomy for multiple significant trauma)
  • DRG 956 (limb reattachment, hip and femur procedures for multiple significant trauma)
  • DRG 957–DRG 959 (other operating room [OR] procedures for multiple significant trauma)

As a side note, coders may notice that their encoder will not return a "with CC" MS-DRG unless they add another appropriate CC condition. CC conditions that are elements of the MST designation will not also add a CC or MCC to the DRG assignment.

Case example

A physician admits a patient who sustained a concussion after a fall related to a syncopal episode. The physician designates concussion as principal diagnosis, a diagnosis that the medical record strongly supports. The neurology consultant documents a probable lower trunk brachial plexopathy sustained during the patient's fall. The patient was confused on the night after admission, and pulled out his Foley catheter. The urology consultant diagnosed traumatic hematuria secondary to removal of the Foley catheter with the bulb inflated.

The addition of secondary diagnoses codes 953.4 (injury to brachial plexus) and 867.0 (injury to urethra or bladder) to principal diagnosis code 850.0 (concussion without loss of consciousness) results in DRG 965 (other multiple significant trauma without CC/MCC).

Looking ahead to ICD-10-CM

ICD-10-CM codes are very specific codes that often identify details such as laterality, with or without foreign body, and closed versus open fracture. Keeping in mind that ICD-10-CM codes can be up to seven characters, ICD-10-CM diagnosis codes for previously discussed traumatic injuries use a seventh character to specify whether the encounter is the initial encounter (which may include designation of closed or open fracture), a subsequent encounter (which may include routine or delayed healing), or a sequela. For example, consider the following ICD-10-CM codes:

  • S01.441A (puncture wound with foreign body of right cheek and temporomandibular area, initial encounter)
  • S02.411A (LeFort I fracture, initial encounter for closed fracture)

The ICD-10 codes that will contribute to a MST DRG are not yet known. Assessment of support for MST DRGs will be yet another challenge under ICD-10-CM.

Editor’s Note: Joel Moorhead MD, PhD, CPC, is an adjunct assistant professor at the Rollins School of Public Health at Emory University in Atlanta. Dr. Moorhead is also Clinical Director of Research and Development for FairCode Associates in Baltimore, MD. E-mail him at jmoorhead@faircode.com.

Beverly Selby, RHIT, CCS, is coding manager at Cookeville Regional Medical Center in Cookeville, TN. Mrs. Selby is co-chair of the Tennessee Health Information Management Association (THIMA) ICD-10 Task Force, and is also an AHIMA-Certified ICD-10 Trainer. E-mail her at bselby@crmchealth.org.



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