Wiki External cause codes

[TIFFANYC]

Good Afternoon,

My question is what is the proper way to handle and code no known injury. I was under the impression you had to have 3 external cause codes on any and every accident or injury.

For example we see stuff like this all of the time.

Wrist pain, no known injury
My ankle has been hurting for 2 weeks I don’t know why, I didn’t hurt it
Sharp shoulder pain started 2 days ago I didn’t do anything to myself

The providers will diagnose wrist pain, ankle sprain, shoulder pain/strain

I have been using Y93.9 activity, unspecified and Y99.9 external cause status unspecified. I know that is only two but I don’t know what I should use for the 3rd. I don’t even know if this correct. Do you have any suggestions or know the proper way to handle these types of situations.

Thanks
Tiffany Carlson, CPC
208-745-8747
tcarlson@mvhospital.net

 

[CodingKing]

I'd probably just leave off the external cause codes since there is no external cause. Some exceptions:

I.C.20

There is no national requirement for mandatory ICD-10-CM external cause
code reporting. Unless a provider is subject to a state-based external cause
code reporting mandate or these codes are required by a particular payer,
reporting of ICD-10-CM codes in Chapter 20, External Causes of Morbidity, is
not required. In the absence of a mandatory reporting requirement, providers
are encouraged to voluntarily report external cause codes, as they provide
valuable data for injury research and evaluation of injury prevention strategies.

 

[AlanPechacek]

External Cause Codes

If there is no clear, documented history of injury, then External Cause Codes would not be required. Most of what you describe are Signs or Symptoms/Complaints, R Codes, which should not be submitted as a final/definitive diagnosis code unless absolutely no more exact, specific diagnosis is made after completion of the patient's evaluation. If a more specific diagnosis is made, then it should be coded and used.
Respectfully submitted, Alan Pechacek, M.D.

 

[TIFFANYC]

Thank you both so much!

Tiffany Carlson, CPC