Outpatient Facility Coding Alert

Add clarity and context to your primary diagnoses with external cause codes.

Although not nationally mandated, external cause codes V00- (Pedestrian conveyance accident) through Y99- (External cause status) can be vitally important to your claims because they show a broader picture of patients’ health conditions.

These codes, which offer supplementary information surrounding the patient’s symptoms or condition, are useful in painting a complete picture of the patient’s clinical encounter.

Read on to make sure you understand how to correctly report external cause codes.

External Cause Codes Suggested, Not Required

There are no national requirements that mandate you to report external cause codes V00- through Y99-. However, providers are still encouraged to voluntarily report these codes because they “provide valuable data for injury research and evaluation of injury prevention strategies,” per the ICD-10 Official Guidelines for Coding and Reporting.

Although external cause codes are not payment codes, they can add important supplemental information to your claims.

“I do think it is important to use external cause codes,” says Arnold Beresh, DPM, CPC, CSFAC, in West Bloomfield, Michigan. “Though not mandated, it is suggested, and it will add to the coding scenario, making the incident more specific,” relays Beresh.

“I always recommend including external cause codes when applicable to the treatment being rendered,” adds J. Paul Spencer, CPC, COC, senior compliance consultant for DoctorsManagement, LLC in Knoxville, Tennessee. “I wish I could say that insurance companies treat all claims equally, and that with the minimal information required, all claims would be paid on first pass. Having spent over six years in the insurance industry, I know that not to be the case.”

Spencer goes on to explain his point of why reporting external cause codes is important: “Including this information from the initial claim gives the provider the first chance to submit a description of the external cause and can also provide a layer of argument for future appeals in cases where payment is continually denied or pended for this information. In the end, it’s a display of a good faith effort by the provider to voluntarily provide this information.”

Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California, agrees with the importance of reporting external cause codes.

“The use of the external cause codes is necessary to ensure accurate billing and application of benefits,” Johnson explains. “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 on account as it could affect the application of the deductible or co-insurance allowance.”

Don’t miss:  While there is no current national requirement for mandatory ICD-10-CM external cause code reporting, some payers and/or states do require them, cautions Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Nebraska.

So, you should always check with your payers and/or know if your state requires you to report external cause codes.

Never Sequence External Cause Codes as Principal Diagnosis

You should never sequence an external cause code as the first-listed or principal diagnosis, according to the guidelines. Instead, you should use these external cause codes as secondary codes to provide additional information. External cause codes can tell you the following helpful information:

• The cause, which explains how the injury or health condition happened. For example: W55.12XA (Struck by horse, initial encounter).
• The intent, whether the injury or health condition was unintentional or accidental or intentional. For example: X81.0XXA (Intentional self-harm by jumping or lying in front of motor vehicle, initial encounter).
• The place where the event occurred. For example: Y92.322 (Soccer field as the place of occurrence of the external cause)
• The activity of the patient at the time of the event. For example: Y93.18 (Activity, surfing, windsurfing and boogie boarding).
• The patient’s status.  For example: Y99.8 (Other external cause status).

Report External Cause Codes With Injuries, Infections, and More

Although external cause codes are most applicable to injuries, you can also report them with conditions like infections, diseases due to an external source, or other health conditions, like a heart attack that happens during strenuous physical activity, according to the guidelines.

Bottom line: You can report external cause codes with any code in the range A00.0 (Cholera due to Vibrio cholerae 01, biovar cholerae) through T88.9XXS (Complication of surgical and medical care, unspecified, sequela) and Z00- (Encounter for general examination without complaint, suspected or reported diagnosis) through Z99- (Dependence on enabling machines and devices, not elsewhere classified) that represents a health condition due to an external cause.

Example: A patient experiences sudden idiopathic hearing loss of the right ear while swimming laps at the local public swimming pool. You will report H91.21 (Sudden idiopathic hearing loss, right ear) as the primary diagnosis code, along with secondary codes Y93.11 (Activity swimming) and Y92.34 (Swimming pool (public) as the place of occurrence of the external cause).

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