Radiology Coding Alert

Use these 2 examples to steer home the point.

Following a tumultuous 2018 hurricane season, now is a better time than ever to detail an important addendum to the 2019 ICD-10-CM guidelines involving hurricane external cause of morbidity codes. Before 2019, the ICD-10-CM neglected to instruct coders on when and how to properly report hurricane-induced external cause of morbidity codes.

With this new set of guidelines comes a detailed guide on how you should use and sequence these external cause of morbidity codes. Catch up here for a breakdown of these 2019 guidelines and scenario-specific examples to make hurricane coding a breeze.

Begin With the Basics

Section I.19.a, b, and c introduce an entirely new set of guidelines on how coders should report patients affected by a hurricane. First, it’s important to revisit the guidelines that state that external cause are “supplemental to the application of ICD-10-CM codes.” That is, external cause codes are secondary codes that you will use to further elaborate on a patient’s injury or condition. Specifically, in the 2019 ICD-10-CM guidelines, ICD-10-CM instructs coders that external cause codes should “not be assigned for encounters to treat hurricane victims’ medical conditions when no injury, adverse effect or poisoning is involved.”

Note Cataclysmic Event Sequencing Guidelines

First, have a look at the new guidelines on how to code “cataclysmic events” as Section I.19.b notes. To start, the ICD-10-CM instructs you on how to prioritize these codes over other external cause codes:

• “Codes for cataclysmic events, such as a hurricane, take priority over all other external cause codes except child and adult abuse and terrorism and should be sequenced before other external cause of injury codes.”

This means that if a patient is injured from a fall due to a hurricane, code X37.0XXA (Hurricane, initial encounter) is the first external cause code you should report. »

Next, ICD-10-CM goes into further detail explaining when subcategory codes X37.0-, X38.-, and X36.0- should and should not be assigned:

• “Code X37.0- also should be assigned when an injury is incurred as a result of flooding caused by a levee breaking related to the hurricane. Code X38.-, Flood (with the appropriate 7th character), should be assigned when an injury is from flooding resulting directly from the storm. Code X36.0.-, Collapse of dam or man-made structure, should not be assigned when the cause of the collapse is due to the hurricane. Use of code X36.0- is limited to collapses of man-made structures due to earth surface movements, not due to storm surges directly from a hurricane.”

In a sense, coding hurricane external cause codes isn’t that dissimilar from coding underlying versus secondary conditions and diseases codes. These guidelines are instructing you to code the underlying etiology (hurricane) rather than the resulting symptoms or manifestations (levee breaking, for example). However, the guidelines don’t fully elaborate on whether you should code subsequent external cause codes that are a known result of the hurricane. For instance, if a hurricane causes a patient to fall while evacuating their house, there are no guidelines that explain whether external cause code X37.0 satisfactorily encompasses both the hurricane and the fall — or whether it’s appropriate to code the hurricane first and the fall second. Until you receive clarification, you may consider it appropriate to code supplementary external cause codes that further elaborate on the patient’s status (unless specified in the second guideline).

Finally, ICD-10-CM offers new instructions on how to address injuries that are, or are not, a result of a hurricane:

• “For injuries that are not a direct result of the hurricane, such as an evacuee that has incurred an injury as a result of a motor vehicle accident, assign the appropriate external cause of morbidity code(s) to describe the cause of the injury, but do not assign code X37.0-, Hurricane. If it is not clear whether the injury was a direct result of the hurricane, assume the injury is due to the hurricane and assign code X37.0-, Hurricane, as well as any other applicable external cause of morbidity codes.”

As these guidelines relay, in the event of an injury occurring during a hurricane, but not directly resulting from the hurricane itself, you’ll want to report the respective external cause code for the circumstances surrounding the injury. “These new guidelines simply echo guidance from the AHA’s Coding Clinic for ICD-10-CM and ICD-10-PCS, issued in October of 2017,” says Sheri Poe Bernard, CPC, of Poe Bernard Consulting in Salt Lake City, Utah. “The purpose of this guidance is to help coders understand how to sequence injuries and external cause codes for injuries that occur during a hurricane,” Bernard explains.

Test Hurricane Coding Knowledge With These 2 Examples

Example: Male patient fractures his right femoral shaft in car accident during the hurricane evacuation process.

You’ll want to refer to the third listed guideline when deciding how to code this particular example. Unless there is further documentation supporting that the car accident is a result of the hurricane, you should not assign external cause code X37.0-. First, you will report the fracture of the femoral shaft using code S72.301A (Unspecified fracture of shaft of right femur, initial encounter for closed fracture). Next, you will report the car accident using external cause code V49.9XXA (Car occupant (driver) (passenger) injured in unspecified traffic accident, initial encounter). Remember to report the external cause code to a greater degree of specificity if the documentation allows for it.

Example: Patient lacerates right foot after a hurricane shatters window, sending glass falling from skylight.

Here, you will first report the foot laceration using code S91.311A (Laceration without foreign body, right foot, initial encounter). Next, you’ve got to make a decision as to whether to report both the code for the hurricane and the shattered glass — or just the code for the hurricane. Using the first guideline instruction, you will first report code X37.0XXA since the hurricane external cause code takes priority over all other external cause codes (except child/adult abuse and terrorism). You may also report the shattered glass falling from the skylight window by searching the external cause index for Struck (accidentally) ⇒ object ⇒ falling ⇒ from, in, on ⇒ building which leads you to code W20.1XXA (Struck by object due to collapse of building, initial encounter).