Revenue Cycle Insider

Use them to paint the patient’s complete picture … most of the time.

You’re probably familiar with the ICD-10-CM guidelines for reporting external cause. In part, they state that “there is no national requirement for mandatory ICD‐10‐CM external cause code reporting.” However, the guidelines go on to note that external cause codes may be required when subject to “a state‐based … reporting mandate” or by “a particular payer.” Otolaryngology coders tend to encounter such mandates when dealing with injuries resulting accidents, especially from vehicle accidents.

So, when must you report a code from the Chapter 20, External Causes of Morbidity, codes (V00-Y99)? And why should you use one of the codes to describe an injury’s cause, intent, place, and/or the injured individual’s status and activity at the time of the injury? Read on, and get the answers to all your external cause code questions.

What Are External Cause Codes?

ICD-10-CM defines external cause codes as codes that “capture how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event, and the person's status (e.g., civilian, military).”

Examples of external cause codes that describe these five factors that you might use in an otolaryngology setting include the following:

• Cause: V13.4- (Pedal cycle driver injured in collision with car, pick-up truck or van in traffic accident)
• Intent: Y04.0- (Assault by unarmed brawl or fight)
• Place: Y92.003 (Bedroom of unspecified non-institutional (private) residence as the place of occurrence of the external cause)
• Activity: Y93.11 (Activity, swimming)
• Individual’s status: Y99.8 (Other external cause status) (Includes individuals involved in hobby or leisure activities, including amateur recreation or sports)

Remember to go to seven characters when required. Many external cause codes must be seven characters in length. This means you must use one or more X-character extensions when necessary, and 7^th -character codes A (initial encounter), D (subsequent encounter), or S (sequela) as appropriate.

How Do I Use the External Cause Codes?

Code this: A young female patient reports to your practice complaining of sharp ear pain and a decrease in hearing in their left ear. Your otolaryngologist notes there is drainage in the ear and diagnoses the patient with a ruptured left ear drum. During the encounter history, the patient notes they were struck by their brother during an argument in their bedroom. The patient also notes she did not go to the emergency room (ER) for treatment.

In this scenario, along with coding H72.02 (Central perforation of tympanic membrane, left ear), you’ll report the following external cause codes:

• Y04.0XXA (Assault by unarmed brawl or fight, initial encounter) to document the intent behind the injury and the fact this is the patient’s first time being seen for it
• Y92.003 to document the location (bedroom) where the injury took place
• Y07.410 (Brother, perpetrator of maltreatment and neglect) to further document the intent behind the injury

Why Should I Report Them?

While ICD-10-CM guidelines for reporting external cause state, in part, that “there is no national requirement for mandatory ICD‐10‐CM external cause code reporting,” the guidelines go on to note that external cause codes may be required when subject to “a state‐based … reporting mandate” or by “a particular payer.” This means doing your research and knowing what your state may require. For example, Louisiana requires you to report an external cause code whenever you report a trauma-related code from the range of S00.00XX–T88.99XX.

At the payer level, there are also good reasons for using the codes. “The use of the external cause codes is necessary to ensure accurate billing and application of benefits,” explains Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/ auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California. “These codes will allow an insurance carrier or billing department to clearly see when there may be a third-party payer involved. In the case of benefits, it may affect the patient liability, as it could affect the application of the deductible or co-insurance allowance,” Johnson adds. For instance, using an external cause code to denote a patient’s injury is due to an auto accident will let the patient’s health insurance carrier know that an automobile insurance carrier (e.g. the patient’s or that of another driver) may be liable for the cost of the services.

Regardless of mandates, the codes have tremendous meaning for governments and agencies at the local, state, and national level. Put simply, the codes provide “valuable data for injury research and evaluation of injury prevention strategies,” according to the Centers for Medicare & Medicaid Services (CMS). So, it’s worth you and your provider spending a few extra minutes to choose an external cause code and document it when the opportunity arises.

When and Why Should I Report Them?

Just as the external cause codes support research at the national level, they can support practice-based research and quality improvement, too. For one thing, they “can be useful for understanding the conditions you’re treating, as quality-improvement opportunities might reveal themselves,” according to Jan Blanchard, CPC, CPMA, pediatric solutions consultant at Vermont-based PCC. For example, your practice could use codes like Y92.003 to track locations where an elderly patient is most likely to fall and incorporate that information into fall prevention counseling for the patient.

Additionally, “efforts towards qualifying for things such as patient-centered medical home [PCMH] recognition and value-based care incentives can be bolstered by detailed external cause reporting,” Blanchard points out.

When Should I Not Report Them?

More than likely, many of the injured patients your otolaryngologist sees have already been treated at an emergency department (ED) or an urgent care facility and are seeing your provider for follow-up care. This means that some external cause codes, such as the ones related to “the place of occurrence, activity and status” are only documented “at the initial injury encounter (i.e., only reported once per injury),” according to one professional medical association, the American Academy of Pediatrics (AAP).

“Therefore, if the patient was seen in the emergency department for an injury, your office would not code the additional details, only the external cause,” which you would only do throughout the length of the injury, the AAP goes on to note.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC