Pediatric Coding Alert

Question: One of our pediatricians recently performed a reduction of a traumatic fracture in our office. I want to bill an evaluation and management (E/M) service with the reduction code using the fracture diagnosis code, but should I also include an external cause code? If so, should I attach it to the E/M or the reduction procedure code?

Michigan Subscriber

Answer: ICD-10 guidelines for the Chapter 20: External Causes of Morbidity (V00-Y99) codes tell you that “there is no national requirement for mandatory ICD-10-CM external cause code reporting.” However, the guidelines go on to tell you that “unless a provider is subject to a state-based external cause code reporting mandate or these codes are required by a particular payer, reporting [these codes] is not required.”

Payers especially may want you to report external cause codes to establish liability in cases where the patient’s injury occurred in a location such as a school or municipal playground, where use of the code could shift responsibility for payment from the carrier to the owner of the place of occurrence. So, you will need to determine if you are mandated to report the external cause or not.

Even if you are not, there may be other good reasons to report an external cause. Payers may want to see an external cause code to justify whether the level of care your pediatrician has provided is appropriate. They may also expedite claims with external cause codes. And, regardless of mandates, reporting external causes is important as it provides “valuable data for injury research and evaluation of injury prevention strategies,” according to ICD-10 guidelines.

No guideline exists as to whether you should attach an external cause code to an E/M service or a procedure code. However, there are plenty of other ICD-10 guidelines that you follow in order to report them correctly:

• Guideline 20.a.2 tells you to use the correct seventh character – A for the initial encounter, D for the subsequent encounter, and S for sequela – that matches the course of treatment for the encounter.
• Guideline 20.a.6 tells you to never use an external cause code as a principal, or first-listed, diagnosis.
• Guideline 20.a.8 tells you that external cause codes are not needed when the external cause is itself an integral part of another code (e.g. a code from T36.- [Poisoning by, adverse effect of and underdosing of systemic antibiotics]).
• Guidelines 20.b. and 20.c tells you to report a place of occurrence external cause code (Y92.- [Place of occurrence of the external cause]) or an activity code (Y93.- [Activity codes]) “only once, at the initial encounter for treatment.”
• Guideline 20.f. tells you how to sequence multiple external causes, with codes for child and adult abuse taking precedence over all other external cause codes.