Primary Care Coding Alert

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

You’re probably familiar with the ICD-10 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.”

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 let our experts explain.

What Are External Cause Codes?

ICD-10 defines the 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 a primary care setting include the following:

• Cause: V28.4XXD (Motorcycle driver injured in noncollision transport accident in traffic accident, subsequent encounter).
• Intent: Y07.01 (Husband, perpetrator of maltreatment and neglect).
• 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 seventh-character codes A (initial encounter), D (subsequent encounter), or S (sequela) as appropriate.

When and Why You Must Report Them

While ICD-10 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.”

On a larger scale, the codes have tremendous meaning for governments and agencies at the local, state, and national level. Put simply, the codes provide “the opportunity to report enhanced detail [and] improve the process of data collection for researchers and policy makers,” according to Evan M. Gwilliam, writing in the American Academy of Professional Coders’ (AAPC) blog.

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 (Source: http://www.fortherecordmag.com/archives/0617p24.shtml).

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 causes 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.

When and Why You Should 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, a physician 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.

And When and Why You Should Never Report Them

More than likely, many of the injured patients your primary care provider (PCP) sees have already been treated at an emergency department (ED) or an urgent care facility and are seeing their PCP 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 an encounter coding document prepared by the American Academy of Pediatrics (AAP) (Source: https://www.aap.org/en-us/Documents/coding_faq_coding_encounters_icd_10.pdf).

“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.