Wiki ICD 10 Place of Occurance

[bosco]

There are times when coding our ED accounts that the physician does not state a place of occurance in the chart on an initial encounter for an injury.

Per the coding guidelines a place of occurance is to be used once at the initial encounter. The guidelines then states not to use the occurance code
Y92.9 if the place is not stated.

My question is, is Y92.9 to be used because it's the initial encounter or not because where it happened is not documented.

thanks so much!

 

[mbucknam]

ICD-10 Place of Occurance

No, you should not apply the place of occurance code unless it is specified in the record. The direction to apply the code only once and only for the first encounter is a limitor, not an instruction. In other words, it should be used for the first encounter if known and should not be used after the first encounter. It should not be coded if not documented.

Unknown in coding doesn't mean the coder doesn't know, it means that the provider doesn't know (e.g., patient was found unconscious, doesn't know where accident occurred).

Marcella