External Cause Codes and Their Many Uses in Utah
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External Cause Codes and Their Many Uses in Utah
Cristy Sneddon, RHIT
Utah Department of Health
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Objectives
• External Cause of Injury Codes (E Codes)
• Mandates and Administrative Code
• Data and the Violence and Injury Prevention Program (VIPP)
• Opiate/Opioid Overdose Project
• Unspecified Elderly Falls Project
• ED Concussion Data
• ICD-10 External Cause Codes
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External Cause of Injury Codes
• E Codes help us:– Describe the magnitude of injury morbidity by
cause of injury– Identify population subgroups at high risk for a
particular cause of injury• Bicycle related injuries in children 5 – 14 years
– Identify the place of occurrence for specific types of injuries/populations
• Elderly falls 65 and older
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External Cause of Injury Codes
• Develop prevention strategies targeting specific causes of injury and specific population groups at risk• Helmet give-away and educational programs
to school-aged children• Exercise programs for elderly adults at risk
for falls
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External Cause of Injury Codes
• Evaluate the effectiveness of the intervention programs• Cost-effectiveness of helmet programs and
education in reducing bicycle-related injuries in school-aged children
• Monitor elderly fall injury trends to see if rates are decreasing
Source: Public Health Data Standards Consortium. The Importance of Understanding External Cause of Injury Codes Tutorial, 2006.
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Historical Perspective
• In 1991, the National Committee on Vital and Health Statistics (NCVHS) recommended that external cause of injury codes (E Codes) be included in hospital discharge (HDD) data sets• At that time only 5 states had HDD systems
which collected E Codes
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Utah Mandates
• Utah passed legislation requiring the routine collection of E Codes statewide:
• In 1995 for Hospital Discharge Data (HDD)
• In 1996, for Hospital Emergency Department Data (HEDD)
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Utah Administrative Code
• Rule 428-10• Health Data Authority Hospital Inpatient
Reporting Rule• HDD Code
• Rule 386-703• Injury Reporting Rule
• Injury Reporting Rule
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A Snapshot of 2011
• 11,571 Utahns were hospitalized due to an injury or violent act
• 31 people hospitalized every day
• 154,047 Utahns were treated in an ED
• Enough people to fill Energy Solutions Arena 8 times
Source: Violence and Injury Prevention Program website, http://www.health.utah.gov/vipp/index.html; and Utah’s Indicator Based Information System for Public Health (IBIS-PH), 2011 data [cited 2013 August]
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VIPP Background
• The Violence and Injury Prevention Program (VIPP) has been gathering Injury data and providing prevention resources for 30 years.
• Majority of programs are Federally funded from the Centers for Disease Control and Prevention (CDC)
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VIPP Background
• Prevention Programs include:– Traumatic Brain Injury– Spinal Cord Injury– Falls Among Older Adults– Prescription Drug Overdose– Rape and Sexual Assault– Student Injury– Infant Sleep Death
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VIPP Background
• Prevention Programs include:– Teen Driving– Safe Kids– Child Abuse and Maltreatment– Dating and Domestic Violence– Motor Vehicle Crashes– Violent Death (Homicide, Suicide,
Undetermined)
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Current Projects
• Opiate/Opioid Overdose Hospitalization Project
• Unspecified Elderly Falls Project
• Traumatic Brain Injury (TBI) Surveillance, Emergency Department Concussion Data
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Current Projects
Opiate/Opioid Overdose Hospitalizations
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Surveillance Quality Improvement (SQI)
• In 2011, Utah was one of four states to receive Surveillance Quality Improvement (SQI) Grant– UT, CO, NC, MA– 5 year grant cycle
• Every year the multi-state group, including CDC, decides on a project pertinent to emerging public health conditions
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Surveillance Quality Improvement (SQI)
• Year 2 Multi-State Project– Accidental Opiate/Opioid Overdose– ED or Inpatient (Utah chose inpatient)
• Year 2 Individual State Project– Suicide and Undetermined intent
– Determine the complete inpatient overdose picture
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Criteria
• Report from the Injury Surveillance Workgroup on Poisoning (ISW-7) for National and State Poisoning Surveillance
• ISW-7
• The Safe States Alliance is a national non-profit 501(c)(3) organization and professional association whose mission is to strengthen the practice of injury and violence prevention
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Criteria
• Standardized code set for ICD-9-CM opiate/opioid poisoning and associated E Codes
– 965.00, 965.01, 965.02, 965.09– Accidental; E850.0, E850.1, E850.2– Suicide; E950.0, E950.4, E950.5– Undetermined; E980.0, E980.4, E980.5
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Criteria
– Determine PPV (Positive Predictive Value) for both sets of codes
– Documentation of one or more of the following clinical signs to verify Opioid Analgesic Overdose:– Respiratory depression– Miosis– Stupor– Rhabdomyolysis– Myoglobinuric Renal Failure– Compartment Syndrome
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Criteria
– Use of Naloxone as treatment for overdose either given in the hospital or prior to arrival
– Medical record documentation to support coded intention
Clinical Signs Source: The New England Journal of Medicine, Management of Opioid Analgesic Overdose, July 12, 2012
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Opiate/Opioid Overdose
• Pulled code criteria from 2011 data year
• Total of 842 inpatient hospitalizations for record review– Accidental – 346– Suicide – 224– Undetermined – 77– Cases with ICD-9 poison code, but no E code
for intent - 195
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Opiate/Opioid Overdose
• PPV Results for ICD-9 Poison codes
Positive Predictive Value
Intent PPV
Accident 99.6
Therapeutic 100.0 (only 1 case)
Suicide 93.5
Assault 0 (no cases)
Undetermined 95.2
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Opiate/Opioid Overdose
• PPV for E Codes and intent of injury
Sensitivity: actual positive cases which are correctly identified as such
2011 E Code Sensitivity E code PPV E Code
E850087% 96%
E850193% 100%
E850297% 100%
E950098% 94%
E980097% 95%
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Uses for Opiate/Opioid Data
• Information shared with the Prescription Drug Task Force
• Multi-state Special Emphasis Report – Drug Overdose Morbidity
• Naloxone study
• Naloxone study results presented at the Safe States Alliance Conference
• Naloxone poster presented at the Council of State and Territorial Epidemiologist (CSTE)
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Uses for Opiate/Opioid Data
• Naloxone Study– Medical record review process included
administration of Naloxone– 57% of hospitalizations given Naloxone– Findings: Early administration of drug
associated with discharge to home instead of other location or death
– Helped inform legislators and supports new Naloxone law passed last session
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Uses for Opiate/Opioid Data
• H.B. 119 – Opiate Overdose Emergency Treatment– Permits administration of Naloxone to
someone experiencing overdose– Immunity for good faith– Doctors can prescribe Naloxone to:
• Person at risk of opiate-related overdose• Family member, friend or other person in a position
to assist someone who is a user of pain killers or Heroin
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Findings
• 842 cases reviewed, 2 cases found to be false positive (FP) – First FP case coded - 965.09, Other opiate
(Codeine, Morphine Meperidine); E850.2, Accidental Other opiate and related narcotic; E850.4, Accidental Aromatic analgesics
– On review, case was found to be accidental Methamphetamine overdose (969.2, E854.2)
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Findings
– Second FP case coded - 965.09, Other opiate (Codeine, Morphine Meperidine); E950.0, Suicide and self-inflicted Analgesics, Antipyretics and Antirheumatics
– On review, patient admitted for suicidal ideation – No mention of overdose – No medication mentioned – All lab results negative
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Findings
• Total positive cases - 840– Found documentation to ‘revise’ 42 cases
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No Reason to be Alarmed
Please remember and don’t panic
When talking about ‘revising’ or ‘being able to revise’ E Codes we don’t remove or change original coding
We add additional variables for surveillance coding comparison
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Findings
• Total positive cases - 840– Found documentation to ‘revise’ 42 cases
• 5 with correct poison code, no E codes listed• 2 coded as accidental, but documentation stated
suicide intent• 1 case had both suicide and undetermined intent
codes listed• 2 cases had correct poison, but listed E858.8 other
specified drug– One case had diagnosis of Opiates and Benzodiazipines
NOS (E850.2, E853.2)– One case had diagnosis of Opiates NOS (E850.2)
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Findings
• Most alarming– Found 15 cases coded as Suicide
• 35.7% of total cases ‘revised’• Documentation found stated Accidental• Verified with individual hospital coding supervisors
– Wanted to make double sure we didn’t miss anything– Determined to be confusion and coding training issue
– On a larger scale…• Total of 224 inpatient suicide overdose cases• 15 cases represents 6.7% which has potential to
affect (skew) our percentage and rates nationally
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Findings
• ICD-9 poisoning codes– Several cases had missing or incorrect codes
• Had Opiate code, missed Methadone • Had Heroin coded as 965.00 instead of 965.01• Had Heroin listed on diagnosis, not coded
• 965.00 vs. 965.09 – Found multiple cases where original code was
965.00– On case review felt should be coded as
965.09 as there was a ‘named’ drug
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Discussion
• 965.00 vs. 965.09– Under the impression that a drug that is NOS
or generic is coded 965.00– Named drugs, such as Oxycodone would be
coded as 965.09
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Current Projects
Unspecified Elderly Fall Hospitalizations
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Surveillance Quality Improvement (SQI)
• Year 3 Individual SQI State Project
• Elderly falls is an emerging public health condition
• Project focused in this area
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Standard Definitions
• Standard Definitions– Fall:
• An event which results in a person coming to rest on the ground or other lower level precipitated by a misstep such as a slip, trip, stumble; from loss of grip or balance; from jumping; or from being pushed, bumped, or moved by another person, animal or inanimate object or force
– Fall-Related Injury:• An injury precipitated by a fall (as defined above)
and caused by striking an injury-producing surface
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Criteria
• National Report from the Injury Surveillance Workgroup on Falls (ISW-4)
• ISW-4– Specific set of fall related E Codes
• E880-E886, E888, E957, E968.1, E987• Also included Utah identified codes; E917.8, Striking against
other stationary object with fall; and E917.7 Striking against furniture with fall
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Criteria
• Utah specific Criteria– Utah resident– 65 and older– Acute care inpatient hospitalization
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Unspecified Falls Project
• Data taken from 2012 HDD
• Total of 4,369 cases met criteria
• Significant issue to explore– 1,682 identified cases had an Unspecified Fall
E Code (E888.9)– 38.5% of total fall cases
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Unspecified Falls Project
• Random Sample of 350 cases (20.8%)– Determine if documentation available for more
specific E Code
• Identified 137 cases with documentation for more specific code (39.1%)– Utah refers to ‘revise’– Don’t remove or change original coding, add
additional variables for surveillance coding comparison
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Unspecified Falls Project
• Graph showing 137 cases before
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Unspecified Falls Project
• Referring to the previous graph what kind of information can you get?
• In terms of fall prevention, what information can you get?– What type of falls are happening?
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Unspecified Falls Project
• Graph showing 137 cases before
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Unspecified Falls Project
• Now using ‘revised’ codes……..
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Uses for Unspecified Falls Data
• Information shared with Utah Falls Prevention Coalition
• Fact Sheets to share data with local health departments and other partners
• Multi-state Special Emphasis Report on Elderly Falls
• Show need for programs such as Stepping On and Matter of Balance• Scientifically tested and proven interventions
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Current Projects
Traumatic Brain Injury
Surveillance
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Traumatic Brain Injury (TBI)
• Previous presentations looked at Inpatient hospital data• Focus on E Codes from reviewed cases• Specifically looking at coding differences and
findings
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TBI ED Data
• Standard case definition for TBI Surveillance taken from the Center for Disease Control and Prevention (CDC) – Same code set as Inpatient– Code sets for both Morbidity and Mortality
(our focus for this presentation is Morbidity)
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Criteria
• Opiate/Opioid project used both ICD-9-CM and E Codes to determine injury
• Unspecified Elderly Falls Project used only E Codes to determine injury
• TBI data for both inpatient and ED is pulled strictly by ICD-9-CM diagnosis codes
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Criteria
• ICD-9-CM codes to Identify TBI include:• 800.0 – 801.9 (Fracture of the vault or base of the
skull)• 803.0 – 804.9 (Other and unqualified and multiple
fractures of the skull)• 850.0 – 854.1 (Intracranial injury, including
concussion, contusion, laceration, and hemorrhage)• 950.1 – 950.3 (Injury to the optic chiasm, optic
pathways and visual cortex)• 959.01 (Head injury, unspecified)• 995.55 (Shaken Infant Syndrome)
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Traumatic Brain Injury (TBI)
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Traumatic Brain Injury (TBI)
• Snapshot of 2011 ED data specific to Concussion • Code set 850.0-850.9• Emerging public health condition• Not chart reviewed• Information based solely on E Codes
received from HEDD
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TBI ED Data
• Total of 19,968 TBI visits in the Emergency Department – Determine by entire code set criteria
• Total of 6,228 Concussion Only– 850.0 - 850.9
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ED Concussion Data
• Total 6,228 cases – 188 no E Code to identify external cause (3%)
• Discharge Status– 6,088 to home– 87 admitted for additional treatment
• Total Cost for Concussion – $19,042,148.68– Median (average) cost $2,434.59– Highest cost $53,930.36
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ED Concussion Data
• Rely on E Codes to determine cause of injury – Some give good information– Some are fairly vague
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ED Concussion Data
• Transport Related E Codes (E800-E829)– Motor Vehicle Crashes
– Driver, Passenger, Pedestrian related
– Traffic or off-road related
– Bicycle crashes related
– Horseback Riding related
• Easy to pull code sets for data– Crashes (all positions), pedestrians, bikes
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ED Concussion Data
N = 817
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ED Concussion Data
• Looking at the data from a public health standpoint………………
• Could we determine the age group or groups at the highest risk for motor vehicle injury by rate?
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ED Concussion Data
N = 817
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ED Concussion Data
• Sports-Related E Codes – Diving or Swimming (E883.0)– Roller Skating (E885.1)– Scooter - Non-motorized (E885.0)– Skiing (E885.3)– Skateboarding (E885.2)– Snowboarding (E885.4)
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ED Concussion Data
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ED Concussion Data
• Put your public health surveillance glasses on again….
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ED Concussion Data
What snow sport has the highest injury count?
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ED Concussion Data
• Would roller skating be considered a top 5 priority for injury prevention?
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ED Concussion Data
• When coding, most E Codes can be very informative and describe the injury well
• BUT when it comes to injury surveillance, some codes can be a bit vague
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Enough Information?
• E884.9 Other fall from one level to another
• E885.9 Other fall from slipping, tripping or stumbling
• E886.0 Fall on the same level from collision, pushing, shoving by or with another person, In sports
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Enough Information?
• E917 Striking against or struck accidentally by objects or persons– E917.0 In sports without fall– E917.5 Object in sports with fall– E917.9 Other striking against with or without
fall
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ED Concussion Data
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Scenario
A football player for the University of Utah received a hard tackle and was taken out of the game due to severe concussion. The story was carried by several local news stations.
Now…..
A news reporter is calling wanting to know how many concussions occur in football and how many people were diagnosed with a concussion in 2011.
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ED Concussion Data
• Of the 2,109 injuries represented on the previous chart could you determine how many were:– Football related
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ED Concussion Data
Number of Football-related injury? Soccer-related injury? La Crosse/Field Hockey-related injury?
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Importance of Activity Codes
• Using a combination of E Codes and Activity codes for the same 2,109 cases from the previous chart
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Importance of Activity Codes
• How many football related concussion occurred?
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Importance of Activity Codes
• Activity Code Guidelines– Assign a code from category E001-E030 to
describe the activity that caused or contributed to the injury or other heath condition
– Appropriate for use if identifying the activity provides additional information on the event
– Not applicable with poisoning, adverse effects, misadventures or late effects
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Importance of Activity Codes
• How many La Crosse/Field Hockey related concussion occurred?
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Importance of Activity Codes
• What sport had the highest number of injuries for water or snow related injuries?
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Importance of Activity Codes
• Able to identify individual sport-related injury
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Uses for TBI Surveillance Data
• Brain Injury Alliance of Utah (BIAU)
• Local health departments to show injury rates by age for focused prevention efforts
• Non-profit agencies to show need for funding for patient care and rehabilitation
• UDOH Small Area Report
• Data to submit to CDC for inclusion in national rates (WISQARS)
• IBIS-PH (Utah’s Public Health Data Resource)
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Projects on the Horizon
• Upcoming Year 4 SQI Projects
• ‘No E Code’ Project– Over 2,000 cases that have an injury code,
but no external cause coding– Determine if codes are available in record
• Elderly Falls with ICD-10 Project– Review records for elderly falls– Assign ICD-10 External Cause Codes– Determine if compatible and complete– Give better more accurate detail of injury
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Current Projects
ICD-10-CM
External Cause Codes
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External Cause ICD-10-CM
• Codes range from V00 – Y99– Greatly expanded– 7th digit encounter codes
– (A) Initial Encounter– (D) Subsequent Encounter– (S) Sequela
– Late Effect Codes now Sequela– Means more codes to use rather than
general category codes
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External Cause ICD-10-CM
• Transport Accidents– ICD-9-CM was categorized by type of injury– ICD-10-CM by who was injured how– More classifications of transport vehicles
– Heavy Transport Vehicle (Semi-truck or Bus)– Pedestrians on roller skates
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ICD-9 vs. ICD-10
Motorcycle driver collided with a semi-truck on the freeway
ICD-9
E812.2 - Other motor vehicle traffic accident involving collision with motor vehicle; Motorcyclist
E849.5 - Street or Highway
ICD-10
V24.4xxA - Motorcycle driver injured in collision with heavy transport vehicle or bus in traffic accident
Y92.411 – Interstate highway
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External Cause ICD-10-CM
• Place of Occurrence (Location) Codes– Y92 codes– Much more detail and classifications– Only list for initial encounter– Should only be 1 Place of Occurrence code
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ICD-9 Codes
ICD-9 Place of Occurrence
E849.0 – Home (includes apartment, house, farm house, driveway, garden, garage yard etc.)
E849.6 – Public Building (includes bank, airport, courthouse, church, theater, store etc.)
E849.4 – Place for recreation or sport (includes baseball field, golf course, skate rink, vacation resort, etc.)
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ICD-10 Codes
ICD-10 Place of Occurrence
Home
Y92.012 – Bathroom of single family house
Y92.027 – Garden or yard of mobile home
Public Building
Y92.253 – Opera House
Y92.240 – Courthouse
Recreation or Sport
Y92.312 – Tennis Court
Y92.322 – Soccer Field
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ICD-9 vs. ICD-10
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External Cause ICD-10-CM
• Poisoning Codes– Drug combination codes include intent
• Additional intent code– Accidental (Unintentional)– Self-Harm (Intentional)– Assault– Undetermined– Adverse Effect– Underdosing
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External Cause ICD-10-CM
• Combination codes for poisoning and intent
• ICD-9– Accidental Heroin overdose– 965.01, E850.0
• ICD-10– Accidental Heroin overdose, initial encounter– T40.1x1A
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ICD-10-CM Activity Codes
• Y93
• Similar to ICD-9-CM
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Remember….
External cause codes (E Codes) capture the “who, what, why, where and how” an injury occurs
Activity codes are used to help provide additional information when applicable
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So remember….
When grandma gets on her mobility scooter and goes wheeling around the art gallery while she is knitting a sweater for Aunt Jane and crashes into a statue…
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There’s a Code for That….
V00.832A – Motorized mobility scooter colliding with stationary object
Y92.250 – Art Gallery
Y93.D1 – Activity, Knitting and Crocheting
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In Summary
• E Codes are required by Utah law
• Given a picture of how external cause codes are used for surveillance in Utah
• Why they are important
• Why good documentation
• Leads to good coding
• Leads to good surveillance data
• Accurate prevention focus
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In Summary
• Good documentation is an issue
• Can only code what is available in the record
• What can we do?
• Education of physicians on importance of E Codes
• Show need for better documentation
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In Summary
• ICD-10-CM is coming and everyone is preparing
• We are good at using E Codes
• Now is a good time to get better and in a good routine of using external cause codes
• Get familiar with Activity Codes
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In Summary
Soap Box
Okay, hopping off my E Code
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Web Links
• http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/Injury/ISW7.pdf
• http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/Injury/isw4.pdf
• http://www.rules.utah.gov/publicat/code/r428/r428-010.htm
• http://www.rules.utah.gov/publicat/code/r386/r386-703.htm
• http://www.health.utah.gov/vipp/
• http://ibis.health.utah.gov/
• http://www.cdc.gov/injury/wisqars/index.html
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Contact Information
Cristy Sneddon, RHITData Abstraction Lead
Violence and Injury Prevention ProgramUtah department of Health
Office phone: 801-538-6550Fax: 801-538-9134
http://health.utah.gov/vipp/