2015 Part B Insider Survival Guide

Transcription

1 2015 Part B Insider Survival Guide Chapter 6: E Codes Coders generally use E codes in addition to standard ICD-9-CM diagnosis codes to offer more detailed information. These codes indicate the nature of the diagnosed condition and help classify environmental events, circumstances and conditions that cause injury, poisoning and other adverse effects. Who Uses E Codes? Emergency departments and other practices specializing in trauma cases use E codes the most, but E codes come in handy in all types of practices from family physicians to psychiatric specialists. E codes help insurers understand how and where an accident happened and provide vital information when you submit certain claims for treating injuries that occur on the job (workers compensation) or in a motor vehicle accident. E codes can also be valuable when a patient intentionally inflicts harm upon himself, such as a suicide attempt. In addition, you are required to report E codes if a patient experiences an adverse effect due to prescription medication, according to ICD-9-CM coding conventions (see below for more details). Sequencing Matters for E Codes If you have to indicate two or more separate injuries using E codes, you must sequence the codes in a particular order, according to ICD-9-CM coding guidelines. Here is the order of importance for E codes: 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 child and adult abuse E codes for cataclysmic events take priority over all other E codes except child and adult abuse and terrorism E codes for transport accidents take priority over all other E codes except cataclysmic events and child and adult abuse and terrorism. In addition, ICD-9-CM guidelines specify, the first-listed E code should correspond to the cause of the most serious diagnosis due to an assault, accident, or self-harm, following the order of hierarchy listed above. Workers' Comp Legal Concerns E codes have no effect on the reimbursement you will receive, but they can facilitate payment, help determine who is responsible for payment and possibly affect legal situations down the line. Example: Suppose a patient decides to sue his employer for unsafe working conditions. The worker's case can suffer when the claim goes to court if the doctor recorded incomplete information on the workers' compensation claim. Also, a patient might need workers' comp coverage again for future treatment of more work-related injuries. Correct E code information in the patient's records might allow for speedier claim processing and payment. Accidents Involving Machinery Are Unique Machinery accidents are classifiable to category E919 in which the fourth digit allows a broad classification of the type of machinery involved. If you need a more detailed classification of machinery type, you can also use the Classification of Industrial Accidents according to Agency, prepared by the International Labor Office. This is often available in Appendix D of the ICD-9-CM manual. Tips to Remember for Properly Using E Code

2 The next time you encounter a claim that merits E codes, keep these tips in mind: Tip 1: Never report an E code as the primary or only diagnosis code. You must include a standard ICD-9-CM code to indicate the patient's condition. E codes are only a supplement to your claim, not the main event. For example, a patient reports to the emergency department complaining of pain in her shoulder after a basketball game. The physician believes the patient sprained her rotator cuff. You would report E927.x (Overexertion and strenuous movements) to describe the type of injury, but the E code cannot stand alone. You should also use a code that identifies the site of the injury from the series (injury and poisoning) as the primary diagnosis. In this case, (Sprains and strains of shoulder and upper arm; rotator cuff [capsule]) would be appropriate, depending on the physician's documentation and whether the tear is complete. Tip 2: Don't restrict yourself to one E code. You can and often should report multiple E codes for one claim. The exception is if you use an E code that includes the place of occurrence in the descriptor, such as E816.x (Motor vehicle traffic accident due to loss of control, without collision on the highway). For example, a fire causes an explosion in an auto shop garage and throws a shop employee against a tire balancing machine and onto the ground. He suffers a broken lower leg and second degree burns on his face and hands. For this claim, you would report diagnosis codes (Burns of face, head, and neck; blisters, epidermal loss [second degree]; multiple sites [except with eye] of face, head, and neck), (Burns of wrists and hands; blisters, epidermal loss [second degree]; multiple sites of wrist[s] and hand[s]) and (Closed fracture of unspecified part of tibia), along with these E codes: E891.0 Conflagration in other and unspecified building or structure; Explosion caused by conflagration E888.1 Other and unspecified fall; Fall resulting in striking against other object E891.3 Conflagration in other and unspecified building or structure; burning caused by conflagration E849.3 Place of occurrence; industrial place and premises. Order matters: ICD-9-CM guidelines direct coders to sequence the most serious injury, as determined by the provider and focus of treatment, first. In this case, you should consider second-degree facial burns the most severe injury, followed by second-degree burns of the hands and then the closed lower leg fracture. Note: If there is insufficient room on the claim form to report all the codes, you can attach supplemental documentation listing the extra diagnoses. Tip 3: Assign the appropriate E code for all initial treatments only. ICD-9-CM coding guidelines direct you to assign the appropriate E code for the initial encounter of an injury, poisoning, or adverse effect of drugs, not for subsequent treatment. E Codes for Motor Vehicle Accidents Motor vehicle insurers often require E codes to prove the patient's injury and treatment are related to a motor vehicle accident (MVA). When you file a claim to an MVA carrier, remember to fill in Box 10b on the CMS-1500 form. The box asks if the claim is for an auto accident, and you should check yes. Fourth digits are vital when reporting MVA claims. For example, suppose an accident involves a car hitting a pedestrian. You would need to identify the patient as the driver, passenger or pedestrian. The fourth digit indicates who the injured person is. You would code the drivers claim with E814.0 (Motor vehicle traffic accident involving collision with pedestrian; driver of motor vehicle other than motorcycle) and the pedestrians claim as E814.7 (. pedestrian). The following categories fall under MVAs and other traffic-related accidents: Railway Accidents: E800-E807. A railway accident is a transportation accident involving a railway train or other railway vehicle operated on rails, whether in motion or not. Railway vehicles are classified as any device designed for traffic on a railway, including electric cars, streetcars, trains, funiculars, and monorail or two-rails. A railway or railroad is a right-o- -way designed for traffic on rails, which is used by carriages or wagons transporting passengers or freight, and by other rolling stock, and which is not open to other public vehicular traffic. You should identify the injured person in a railway accident with a fourth digit code as either a railway employee (0), a

3 passenger (1), pedestrian (2), pedal cyclist (3), other specified person (8) such as bystander waiting at station, or unspecified person (9). ICD-9-CM divides railway injuries into different categories based on the type of accident and railway equipment involved. For example, a passenger falls and twists her ankle when boarding a train. You would use E804.1 (Fall in, on, or from railway train; injuring passenger on railway). Motor Vehicle Traffic Accidents: E810-E819. A motor vehicle traffic accident is any MVA occurring on a public highway. A carrier will assume it occurred on the highway unless you specify another place, except in the case of accidents involving only off-road motor vehicles. You should identify the injured person in a motor vehicle traffic accident using the following fourth digit codes that you would append to the E code for the accident: 0 Driver of motor vehicle other than motorcycle 1 Passenger in motor vehicle other than motorcycle 2 Motorcyclist 3 Passenger on motorcycle 4 Occupant of streetcar 5 Rider of animal; occupant of animal-drawn vehicle 6 Pedal cyclist 7 Pedestrian 8 Other specified person, (namely a person in a railway train involved in an accident or an unauthorized rider of a motor vehicle) 9 Unspecified person. The ICD-9-CM manual further divides motor vehicle traffic accident codes into categories based on the type of accident and other environmental factors. For example, if the driver of a motor vehicle is injured when he strikes a car parked on the side of the highway, you would use E812.0 (Other motor vehicle collision with motor vehicle, injuring driver of motor vehicle other than motorcycle). Motor Vehicle Non-traffic Accidents: E820-E825. A motor vehicle non-traffic accident is an accident that occurs entirely in any place other than a public highway. These accidents include motor vehicles used in off-highway recreational or sporting activities. Again, you'll need a fourth digit number to identify the injured person: 0 Driver of motor vehicle other than a motorcycle 1 Passenger in motor vehicle other than motorcycle 2 Motorcyclist 3 Passenger on motorcycle 4 Occupant of streetcar 5 Rider of animal; occupant of animal-drawn vehicle 6 Pedal cyclist 7 Pedestrian 8 Other specified person,( namely a person in a railway train involved in an accident or an unauthorized rider of a motor vehicle) 9 Unspecified person. Non-traffic accidents occur entirely off of the highway and can involve motor-driven vehicles and other moveable objects that were not in motion at the time of the accident. For example, if a car struck a bicyclist in a driveway, you would use E822.6 (Other motor vehicle non-traffic accident involving collision with moving object injuring pedal cyclist) for the injured cyclist. Other Road Vehicle Accidents: E826-E829. Other road vehicle accidents are transport accidents involving road vehicles other than motor vehicles. The most common type of other road vehicle is a bicycle, but this category also includes animal-drawn vehicles and ridden animals.

4 Patients involved in other road vehicle accidents should be identified with one of the following fourth digit modifiers: 0 Pedestrian 1 Pedal cyclist 2 Rider of animal 3 Occupant of animal-drawn vehicle 4 Occupant of streetcar 8 Other specified person 9 Unspecified person. For example, if a horse-drawn carriage hit a pedestrian in the park, you would use E827.0 (Animal-drawn vehicle accident injuring pedestrian). Other Transport-related E Codes Water Transport Accidents: E830-E838. Water transport accidents involve any device for transporting passengers or goods on the water. These devices include small boats propelled by paddle, oars or a small motor with a passenger capacity of fewer than 10, and larger boats such as barges and yachts. This category does not include accidents involving both aircraft and watercraft. You should identify persons injured in water transport accidents using the following fourth-digit modifiers appended to the E code: 0 Occupant of small boat, unpowered 1 Occupant of small boat, powered 2 Occupant of other watercraft - crew 3 Occupant of other watercraft- other than crew 4 Water skier 5 Swimmer 6 Dockers, stevedores ( longshoreman employed on the dock loading and unloading ships) 7 Occupant of military watercraft, any type 8 Other specified person (such as an immigration official, pilot or visitor) 9 Unspecified person. Water transport accidents include accidents between two watercraft, as well as accidents that occur on the watercraft itself. For example, for a waiter aboard a dinner cruise ship who is thrown overboard and is injured, you would use E832.2 (Other accidental submersion or drowning in water transport accident injuring occupant of other watercraft crew). Air and Space Transport Accidents: E840-E845. An air and space transport accident involves any device for transporting passengers or goods in the air. These include airplanes, hot air balloons, military aircraft, hang gliders and parachutes. Note that not all of these devices are motor-powered. The following fourth-digit modifiers should identify injured persons involved in air and space transport accidents: 0 Occupant of spacecraft 1 Occupant of military aircraft, any 2 Crew of commercial aircraft (powered) in surface-to-surface transport 3 Other occupant of commercial aircraft (powered) in surface-to-surface transport (this includes flight personnel on familiarization flight) 4 Occupant of commercial aircraft (powered) in surface to air transport (this includes activities such as aerial spraying, crop dusting, air drops, lowering of construction material[bridge or telephone pole], and sky writing) 5 Occupant of other powered aircraft (involved in activities such as aerobatic flying, aircraft racing, rescue operation, and storm or traffic surveillance; also includes occupant of a private plane) 6 Occupant of un-powered aircraft, except parachutist(this can only be used in conjunction with code E842 [accident to un-powered aircraft; includes hot air balloon, hang glider, glider, kite carrying a person and being hit by an object that fell from an un-powered aircraft]) 7 Parachutist (military and other) (does not include person making a descent after accident to aircraft) 8 Ground crew, airline employee 9 Other person.

5 Accidents injuring other person in this category include incidents during take-off and landing, accidents in-transit, injuries sustained while on-board an aircraft and even injuries resulting from a voluntary parachute descent. For example, if a piece of debris from a commercial plane strikes and injures a person on the ground, you would use E844.9 (Other specified air transport accident injuring other person) because the falling debris was not the result of an accident involving the aircraft. Vehicle Accidents Not Elsewhere Classifiable: E846-E848. These accidents involve powered vehicles used solely within the buildings and premises of industrial or commercial establishments. Vehicles include battery-powered trucks, coal cars used in a mine, ski lifts and cable cars not on rails. There are no fourth-digit modifiers for this category. For example, if a battery-powered forklift strikes a person in a production plant, you would use E846 (Accidents involving powered vehicles used solely within the buildings and premises of industrial or commercial establishment). Watch for Place of Occurrence Modifier Injury and poisoning locations are key components of many insurance claims, especially workers compensation claims. Use the following codes with the appropriate fourth-digit modifiers to identify where accidents occurred: E849.0 Home E849.1 Farm E849.2 Mine and quarry E849.3 Industrial place and premises E849.4 Place for recreation and sport E849.5 Street and highway E849.6 Public building E849.7 Residential institution E849.8 Other specified places (includes canal, derelict house, desert, dock, forest, harbor, mountain, railway line, river, swamp and trailer court) E849.9 Unspecified place. For the above example where a battery-powered forklift strikes a person in a production plant, you would use E849.3 (Industrial place and premises) in addition to E846. Injuries and Poisoning Under Medical Care Unfortunately, some accidents occur while a patient is under a physician's care. These can range from adverse drug reactions to surgical items left in a patient after surgery. Below are E code categories for these instances. Misadventures to Patients During Surgical and Medical Care: E870-E876. This category covers wrongdoings suffered by patients while in a hospital setting, either from surgical mishaps or incorrect medical procedures. This does not include accidental drug overdose or administering the wrong drug, nor does the category include surgical and medical procedures as the cause of adverse patient reaction. Specifically, this category includes the following: E870.x Accidental cuts, punctures, perforation, or hemorrhage during medical care E871.x Foreign objects left in the patient s body during procedure E872.x Failure of sterile precautions during a procedure E873.x Failure in dosage E874.x Mechanical failure of an instrument or apparatus during a procedure E875.x Contaminated or infected blood, other fluid, drug, or biological substanc E876.x Other and unspecified misadventures during medical care.

6 For example, if a patient with blood type A negative receives a blood transfusion from a donor with blood type B positive, you would use E876.0 (Mismatched blood in transfusion). Surgical and Medical Procedures as the Cause of Abnormal Reaction of Patient or Later Complication, Without Mention of Misadventure at the Time of Procedure: E878- E879. This category covers procedures as the cause of an abnormal reaction. These include displacement or malfunction of a prosthetic device, postoperative hepatorenal failure, malfunction of external stoma, postoperative intestinal obstruction and rejection of a transplanted organ. The category does not cover adverse reactions to properly administered anesthesia or infusions and transfusions. For example, a patient has routine colostomy surgery with no complications and later develops a blockage in the colostomy stoma. In this case, you would use E878.3 (Surgical operation and other surgical procedures as the cause of abnormal reaction of patient or of later complication, without mention of misadventure at the time of operation, surgical operation with formation of external stoma). Other Accidents May Also Apply The following categories cover accidents such as falls, smoke inhalation and choking. Accidental Falls: E880-E888. This category is pretty self-explanatory, except it does not cover falls on or from aircraft, watercraft or motor vehicles. Nor does it cover falls in or from burning buildings, water, machinery or sharp objects. Covered accidental falls include those on or from stairs or steps, on or from ladders or scaffolding, from or out of buildings or other structures, into holes or other surface openings, other falls from one level to another, on the same level from tripping, slipping or stumbling, on the same level from collision, pushing or shoving by or with another person, fractures with unspecified causes, and other, unspecified falls. For example, for a high-school football player who sustains an injury after being tackled, you would use E886.0 (Fall on same level from collision, pushing or shoving by or with another person, in sports). Accidents Caused by Fire and Flames: E890-E899. Accidents causing injuries in this category result from burning by fire, asphyxia or poisoning due to conflagration or ignition and secondary fires resulting from explosions. Fires that occur on or from machinery, arson, and transport and other vehicles are not covered by these codes. Codes in this category cover: E890.x Conflagration in private dwelling E891.x Conflagration in other and unspecified building or structure E892 Conflagration not in a building or structure (includes forest fires and burning vehicles that are stationary) E893.x Accident caused by ignition of clothing E894 Ignition of highly flammable material E895 Accident caused by controlled fire in private dwelling E896 Accident caused by controlled fire in other and unspecified building or structure (for instance, a church furnace) E897 Accident caused by controlled fire not in building or structure (for instance a bonfire) E898.x- Accident caused by other specified fire and flames (includes burning bedding, candle, welding torch, pipe, matches and cigarettes) E899 Accident caused by unspecified fire. For example, if a woman falls asleep and leaves a candle burning, which starts a fire, and she sustains burns and smoke inhalation as a result, you would use E898.1 (Accident caused by other specified fire and flames, other). Accidents Due to Natural and Environmental Factors: E900-E909. Codes in this category address weather-related injuries, accidents caused by animals, adverse reactions to venom and plants, earthquakes, and volcanic eruptions. Natural and environmental accident factors include excessive heat, excessive cold, high and low air pressure and changes in air pressure, travel and motion, hunger, thirst, exposure and neglect, venomous animals and plants, other injuries caused by animals, lightning, cataclysmic storms and floods resulting from storms and cataclysmic earth surface movements and eruptions.

7 For example, if a moray eel bites a woman while she is scuba diving, you would use E906.3 (Bite of other animal except arthropod). Accidents Caused by Submersion, Suffocation and Foreign Bodies: E910-E915. Accidents in this category cover drowning, suffocation, inhalation and ingestion of objects that block airways, and foreign objects entering the body. The codes include the following: E910.x Accidental drowning and submersion (not involving diving, machinery or transport accidents or natural effects) E911 Inhalation and ingestion of food causing obstruction of respiratory tract or suffocation E912 Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation E913.x Accidental mechanical suffocation E914 Foreign body accidentally entering eye and adnexa (except corrosive liquid) E915 Foreign body accidentally entering other orifice For example, if a laborer visits an ophthalmologist because he has a metal shaving stuck in his eye, you would use E914 (Foreign body accidentally entering eye and adnexa) Other Accidents: E916-E928. This category covers accidents not mentioned in previous categories and includes the following codes: E916 Struck accidentally by falling object E917.x Striking against or struck accidentally by objects or persons E918 Caught accidentally in or between objects E919.x Accidents caused by machinery E920.x Accidents caused by cutting and piercing instruments or objects E921.x Accident caused by explosion of pressure vessel E922.x Accident caused by firearm and air gun missile E923.x Accident caused by explosive material E924.x Accident caused by hot substance or object, caustic or corrosive material and steam E925.x Accident caused by electric current E926.x Exposure to radiation E927.x Overexertion and strenuous and repetitive movements or loads. E928.x Other and unspecified environmental and accidental causes. For example, a patient visits the emergency department after stubbing his toe on a table leg. The patient didn't fall, but sustained a broken toe. In this case, you would use E917.3 (Striking against or struck accidentally by objects or persons; furniture without subsequent fall). Late Effects of Accidental Injury: E929. You should use this category to indicate accidental injury as the cause of death or disability from late effects, which ICD-9-CM classifies elsewhere. The late effects include conditions reported as such, or as sequelae, which may occur at any time after the attempted suicide or self-inflicted injury. Codes in this category are differentiated with a fourth digit that indicates the type of initial accident: E929.0 Late effects of motor vehicle accident E929.1 Late effects of other transport accident E929.2 Late effects of accidental poisoning E929.3 Late effects of accidental fall E929.4 Late effects of accident caused by fire E929.5 Late effects of accident due to natural and environmental factors E929.8 Late effects of other accidents. E929.9 Late effects of unspecified accident For example, if a patient suffers severe brain injuries from an accidental fall from a ladder and dies several weeks later due to complications, you would use E929.3 (Late effects of accidental fall). Choose Your Poison Code Carefully E codes are valuable for future insurance coverage in cases of poisoning and adverse drug effects. The ICD-9-CM Table of

8 Drugs and Chemicals contains five E code categories for each drug and chemical substance a patient might ingest or otherwise encounter: accident, therapeutic use, suicide attempt, assault and undetermined. Adverse Affects vs. Poisoning: Here's What ICD-9-CM Says You have to be careful when choosing between adverse affects and poisoning. The examples below should help you make this distinction, but here's what ICD-9-CM guidelines specify: When the drug was correctly prescribed and properly administered, code the reaction plus the appropriate code from the E930-E949 series. Codes from the E930-E949 series must be used to identify the causative substance for an adverse effect of drug, medicinal and biological substances correctly prescribed and properly administered. The effect, such as tachycardia, delirium, gastrointestinal hemorrhaging, vomiting, hypokalemia, hepatitis, renal failure, or respiratory failure, is coded and followed by the appropriate code from the E930-E949 series. Adverse effects of therapeutic substances correctly prescribed and properly administered (toxicity, synergistic reaction, side effect, and idiosyncratic reaction) may be due to (1) differences among patients, such as age, sex, disease, and genetic factors, and (2) drug- related factors, such as type of drug, route of administration, duration of therapy, dosage, and bioavailability An adverse effect is the only instance that requires the secondary coding of an E code with the effect itself as primary. Information on Poisoning from Guidelines: (a) Error was made in drug prescription Errors made in drug prescription or in the administration of the drug by provider, nurse, patient, or other person, use the appropriate poisoning code from the series. (b) Overdose of a drug intentionally taken If an overdose of a drug was intentionally taken or administered and resulted in drug toxicity, it would be coded as a poisoning ( series). (c) Nonprescribed drug taken with correctly prescribed and properly administered drug If a nonprescribed drug or medicinal agent was taken in combination with a correctly prescribed and properly administered drug, any drug toxicity or other reaction resulting from the interaction of the two drugs would be classified as a poisoning. (d) Sequencing of poisoning When coding a poisoning or reaction to the improper use of a medication (e.g., wrong dose, wrong substance, wrong route of administration) the poisoning code is sequenced first, followed by a code for the manifestation. If there is also a diagnosis of drug abuse or dependence to the substance, the abuse or dependence is coded as an additional code. Coders sometimes confuse the accidental poisoning, therapeutic use and suicide attempt categories. If you mistakenly code an intentional poisoning suicide attempt as an adverse reaction, for example, that information could cause problems later in authorizing patient psychiatric services. Without the proper E code, the insurance carrier would not be aware the patient had intentionally inflicted harm upon himself. To prevent such mishaps, know these distinctions: Accidental poisoning E codes (E850-E869) are for when a patient accidentally takes too much of a drug, takes the wrong drug or takes a drug inadvertently. For instance, when a college student drinks too much at a party and develops alcohol poisoning, you would report E860.0 (Accidental poisoning by alcohol, not elsewhere classified; alcoholic beverage). Therapeutic E codes (E930-E949) are used when a patient suffers an adverse reaction to a properly administered drug. For example, when a patient suffers severe nausea and vomiting from codeine administered for a shoulder injury, you would report E935.2 (Drugs, medicinal and biological substances as the cause of adverse effects in therapeutic use; analgesics, antipyretics and antirheumatics; other opiates and related narcotics). Suicide and self-inflicted injury E codes (E950-E959) indicate cases of intentional drug overdose on codeine for example, for which you should select E950.0 (Suicide and self-inflicted poisoning by solid or liquid substances; analgesics, antipyretics and antirheumatics). Accidental Poisoning by Drugs, Medicinal Substances and Biologicals: E850- E858. This category includes accidental drug overdose, wrong drug given or taken in error, and drugs taken inadvertently. Also included are accidental

9 drug and biological uses in medical and surgical procedures. ICD-9-CM also divides this category based on the type of drug, medicinal substance or biological used: analgesics, antipyretics and antirheumatics; barbiturates; sedatives and hypnotics; tranquilizers; other psychotic agents; other drugs acting on the central and autonomic nervous system; and other drugs. Fourth-digit modifiers are assigned to specific drugs. For example, if a patient is accidentally injected with an excess amount of lidocaine during a surgical procedure, you would use E855.2 (Accidental poisoning by other drugs acting on central and autonomic nervous system, local anesthetics). Accidental Poisoning by Other Solid and Liquid Substances, Gases and Vapors: E860-E869. Categories in this section are intended primarily to indicate the external cause of poisoning states classifiable to in the ICD-9-CM manual. You can also use them to indicate external causes of localized effects classifiable to in the ICD-9- CM manual. The substances addressed in this section include alcohol, cleansing and polishing agents, disinfectants, paints, varnishes, petroleum products, other solvents and their vapors, agricultural and horticultural chemical and pharmaceutical preparations other than plant foods and fertilizers, corrosives and caustics, poisonous foodstuffs, poisonous plants, other and unspecified solid and liquid substances, other utility gas and other carbon monoxide and other gases and vapors. For example, a patient comes in complaining of asthma like symptoms resulting from second-hand smoke. In this case, you would use E869.4 (Accidental poisoning by other gases and vapors, second-hand tobacco smoke). Drugs, Medicinal and Biological Substances Causing Adverse Effects in Therapeutic Use: E930-E949. This category covers drugs and other medicinal substances correctly administered in therapeutic or prophylactic dosage as the cause of any adverse effect including allergic or hypersensitivity reactions. Not included are accidental overdoses, incorrect drug administration, or administration with suicidal or homicidal intent. You should classify specific using a fourth digit. These fourth digits are available in Section 2 Table of Drugs and Chemicals in the Alphabetic Index. For new drugs, the American Hospital Formulary Service (AHFS) has assigned specific numbers that you can use if they aren't listed in the drug list. ICD-9-CM divides the drugs into the following categories, which are further divided by specific drugs: E930.x E931.x E932.x E933.x E934.x E935.x E936.x E937.x E938.x E939.x E940.x E941.x E942.x Antibiotics Other anti-infectives Hormones and synthetic substitutes Primarily systemic agents Agents primarily affecting blood constituents Analgesics, antipyretics and antirheumatics Anticonvulsants and anti-parkinsonism drugs Sedatives and hypnotics Other central nervous system depressants and anesthetics Psychotropic agents Central nervous system stimulants Drugs primarily affecting the autonomic nervous system Agents primarily affecting the cardiovascular system

10 E943.x E944.x E945.x E946.x dental drugs E947.x E948.x E949.x Agents primarily affecting gastrointestinal system Water, mineral, and uric acid metabolism drugs Agents primarily acting on the smooth and skeletal muscles and respiratory system Agents primarily affecting skin and mucous membrane, ophthalmological, otorhinolaryngological, and Other and unspecified drugs and medicinal substances Bacterial vaccines Other vaccines and biological substances Example: A young child comes into to see the pediatrician with complaints of hives after starting a sulfa prescription. The doctor documents allergic urticaria reaction due to sulfa. In this case, you would use (Allergic urticaria) as the primary diagnosis with E931.0 (Sulfonamides causing adverse effects in therapeutic use) as the required secondary diagnosis. Suicide and Self-Inflicted Injury: E950- E959. This category covers injuries due to suicide, attempted suicide and intentional self-inflicted injuries. These can be acts of harm to oneself or harmful effects of self-administered drugs with the intent of personal harm. ICD-9-CM breaks down the codes in this category by method, and most require a fourth digit. Methods covered include suicide and self-inflicted poisoning by solid or liquid substances, gases in domestic use, other gases and vapors, hanging, strangulation and suffocation, submersion (drowning, this category requires no fourth digit), firearms, air guns and explosives, cutting and piercing instrument (this category requires no fourth digit), jumping from high places, and other and unspecified means. The category also includes late effects of self-inflicted injury, which indicates circumstances classifiable to E950-E958 as the cause of death or disability from late effects, which are themselves classifiable elsewhere. The late effects include conditions reported as such, or as sequelae that may occur at any time after the attempted suicide or self-inflicted injury. For example, a tranquilizer-overdose patient has to have his stomach pumped in the emergency department. The correct code for this is E950.3 (Suicide and self-inflicted poisoning by solid or liquid substances, tranquilizers and other psychotropic agents). Acts of Violence Have Separate Categories Some patients are victims of violent acts from other persons, law enforcement agents and terrorists. These include attempted homicide, legal interference, acts of war and terrorist acts. Homicide and Injury Purposely Inflicted by Other Persons: E960-E969. Injuries in this category are inflicted by another person with the intent to injure or kill by any means. Acts from legal intervention, war or terrorism are not included. Violent acts in this category include the following: E960.x Fight, brawl or rape E961 Assault by corrosive or caustic substance except poisoning E962.x Assault by poisoning E963 Assault by hanging and strangulation E964 Assault by submersion (drowning) E965.x Assault by firearms and explosives E966 Assault by cutting and piercing instrument

11 E967.x Perpetrator of child and adult abuse E968.x Assault by other and unspecified means E969 Late effects of injury purposely inflicted by another person You should use this category to indicate circumstances classifiable to E960-E969 as the cause of death or disability from late effects, which are themselves classifiable elsewhere. The late effects include conditions reported as such, or as sequelae that may occur at any time after injury purposely inflicted by another person. For example, a man douses his ex-wife with accelerant and sets her on fire. The correct code for woman s injuries sustained from the accident is E968.0 (Assault by other and unspecified means, fire including arson and homicidal burns). Legal Intervention: E970-E978. Acts associated with legal intervention are injuries inflicted by the police or other lawenforcing agents, including on-duty military, in the course of arresting or attempting to arrest lawbreakers, suppressing disturbances, maintaining order and other legal action. Legal intervention acts include injury due to legal intervention by firearms, explosives, gas, blunt objects, cutting and piercing objects, other specified means, unspecified means, and legal execution. The category also includes late effects of injuries due to legal intervention, which indicate circumstances classifiable to E970-E976 as the cause of death or disability from late effects, which are themselves classifiable elsewhere. The late effects include conditions reported as such or as sequelae that may occur at any time after the injury due to legal intervention. For example, a patient has injuries due to blows from a nightstick received during an attempted arrest. In this instance, you would use E973 (Injury due to legal intervention by blunt object). Terrorism: E979. Acts of terrorism, according to ICD-9-CM, involve the unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population or any segment thereof in furtherance of political or social objectives. Injuries in this category are classified with a fourth digit that indicates the type of terrorist act at fault. E979.0 Terrorism involving explosion of marine weapons E979.1 Terrorism involving destruction of aircraft E979.2 Terrorism involving other explosions and fragments E979.3 Terrorism involving fires, conflagration and hot substances E979.4 Terrorism involving firearms E979.5 Terrorism involving nuclear weapons E979.6 Terrorism involving biological weapons E979.7 Terrorism involving chemical weapons E979.8 Terrorism involving other means E979.9 Terrorism, secondary effects Code E979.9 identifies conditions occurring subsequent to a terrorist attack, not those that are due to the initial terrorist attack. But it does not include the late effects of terrorism. For example, a subway passenger experiences breathing difficulties after a terrorist releases anthrax in a subway car. In this case, use E979.6 (Terrorism involving biological weapons). Injury Resulting From Operations of War: E990-E999. This category includes injuries to military personnel and civilians caused by war and civil insurrections and occurring during the time of war and insurrection. Not included are accidents during training of military personnel or manufacture of war material and transport, unless attributable to enemy action. Included are injuries due to war operations by fires and conflagration, bullets and fragments, explosions of marine

12 weapons, other explosions, destruction of aircraft, other and unspecified forms of conventional warfare, nuclear weapons, and other forms of unconventional warfare. Also included are injuries due to war operations that occur after hostilities cease, such as mines or bombs placed during the war exploding. The category covers late effects of injury due to war operations and terrorism, which indicate circumstances classifiable to E979, E990-E998 as the cause of death or disability from late effects, which are themselves classifiable elsewhere. The late effects include conditions reported as such, or as sequelae that may occur at any time after the injury, resulting from operations of war or terrorism. For example, a soldier serving in Iraq is injured when his helicopter is shot down. Here, you would use E994.x (Injury due to war operations by destruction of aircraft). Injuries with Questionable Causes Some patients sustain injuries that you cannot easily categorize as an accident or as purposefully inflicted. For these injuries, there is a separate category of codes. Specific injuries are identified with a fourth digit. Injury Undetermined Whether Accidentally or Purposely Inflicted: E980-E989. You should use the codes in this category when the provider doesn't specify or you otherwise cannot determine whether the injuries are accidental (unintentional), suicide (attempted) or assault. E980.x Poisoning by solid or liquid substances, undetermined whether accidentally or purposely inflicted; E981.x Poisoning by gases in domestic use, undetermined whether accidentally or purposely inflicted; E982.x Poisoning by other gases, undetermined whether accidentally or purposely inflicted; E983.x Hanging, strangulation or suffocation, undetermined whether accidentally or purposely inflicted; E984 Submersion[drowning], undetermined whether accidentally or purposely inflicted; E985.x Injury by firearms, air guns and explosives, undetermined whether accidentally or purposely inflicted; E986 Injury by cutting and piercing instruments, undetermined whether accidentally or purposely inflicted; E987.x Falling from high place, undetermined whether accidentally or purposely inflicted; E988.x Injury by other and unspecified means, undetermined whether accidentally or purposely inflicted; E989 Late effects of injury, undetermined whether accidentally or purposely inflicted. You should use the E989 category to indicate circumstances classifiable to E980-E988 as the cause of death or disability from late effects, which are classifiable elsewhere. The late effects include conditions reported as such, or as sequelae that may occur at any time after the injury, undetermined whether accidentally or purposely inflicted. For example, if a patient is treated for arsenic exposure and you cannot determine how the patient came into contact with the substance, use E980.8 (Poisoning by solid or liquid substances, undetermined whether accidentally or purposely inflicted, arsenic and its compounds). - Published on