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In our previous article, titled “ICD-10: the Axis of Classification,” we had indicated that one method for preparing your key stakeholders for the transition to ICD-10 was to break ICD-10-CM down into its basic components: chapters and axes of classification. This article will continue that theme by reviewing changes we will encounter in ICD-10-CM’s Chapter 19: Injury, Poisoning & Certain Other Consequences of External Causes.

In the 2012 fiscal-year version of ICD-9-CM, the code range for Chapter 19 is 800-999, a grouping that consists of 2,587 codes. Compare this to the same year’s version of ICD-10-CM, where Chapter 19’s code range is S00-T98, a grouping that consists of 39,869 codes. This comparison nets us an increase of 37,282 additional codes, or a rise of 1,441 percent.

The ICD-10-CM version of Chapter 19 contains 57 percent of the total volume of codes available, ranking it first among chapters with the most codes. Having digested those staggering numbers, you likely are wondering why the significant increase exists. The answer to that can be explained by reviewing the general changes that have occurred in this chapter. We start by noting that there are 20 subchapters used to report type of injury, poisoning or complications of trauma or surgical and medical care.

Chapter 19 Chapter Blocks

S00-S09    Injuries to the head

S10-S19    Injuries to the neck

S20-S29    Injuries to the thorax

S30-S39    Injuries to the abdomen, lower back, lumbar spine, pelvis and external genitals

S40-S49    Injuries to the shoulder and upper arm

S50-S59    Injuries to the elbow and forearm

S60-S69    Injuries to the wrist and hand

S70-S79    Injuries to the hip and thigh

S80-S89    Injuries to the knee and lower leg

S90-S99    Injuries to the ankle and foot

T07           Unspecified multiple injuries

T14           Injury of unspecified body region

T15-T19    Effects of foreign body entering though natural orifice

T20-T32    Burns and corrosions

T33-T34    Frostbite

T36-T50    Poisoning by, adverse effect of, and underdosing of drugs, medicaments and biological substances

T51-T65    Toxic effects of substances chiefly nonmedical as to source

T66-T78    Other and unspecified effects of external causes

T79           Certain early complications of trauma

T80-T88    Complications of surgical and medical care, not elsewhere classified



In general, the changes to note when reviewing Chapter 19 are:

  • Category title changes have been made to better reflect the medical terminology used today.

An example is that the terms “displaced” and “non-displaced” are used to classify fractures. If the documentation does not include this detail, the “displaced” option is the default code.

  • Seventh characters report if the encounter is initial, subsequent or sequela.

Just as in Chapter 20, an external cause code is assigned for each encounter during which an injury or condition is treated — not just for the initial treatment. To accomplish this, as few as three to as many as 16 new seventh-character extensions were added to identify the episode of care for the current encounter and/or to provide specific details regarding the classification of fracture type and complication. The three primary extensions include:

  • A (initial encounter);
  • D (subsequent encounter); and
  • S (sequelae).

The seventh character “A” is to be used for as long as the patient continues to receive active treatment (i.e. emergency department care, surgical treatment or evaluation and management by a new physician) of the external cause of morbidity. The seventh character “D” is used for encounters occurring after the patient has completed active treatment; this would include services such as a cast change or removal, an encounter for the removal of an internal or external fixation device, medication adjustment, or other aftercare or follow-up visits. The seventh character “S” is used to report encounters for the care of a late effect, or sequel. These seventh-character extensions are a major contributor to code volume in Chapter 19.

In exploring Chapter 19 in greater detail, you will note the following:

  • Injuries are grouped by body part affected, not by categories of injury (different injuries of the foot, for example, are all found together).
  • The first axis of classification of injuries indicates the body region affected (head, neck, thorax, etc.).
  • The second axis of classification of injuries indicates the specific type of injury (superficial, open wound, fracture, dislocation/sprain, injuries to nerves/blood vessels/muscle and tendons/ crushing injuries, traumatic amputation, other and unspecified injuries, etc.).
  • Laterality is used for most Chapter 19 codes that include options for right, left, bilateral or unspecified.
  • Burns are now classified by heat source: thermal (T20-32) versus sunburn (L55.-) versus radiation (L55- L59).
  • Traumatic fractures require documentation of specific anatomical site, or you are relegated to assign a less specified or unspecified code.
    • Traumatic fractures also require documentation of the type of fracture (displaced or non-displaced).
    • Seventh-character extensions are required to capture the following:
    • Closed or open fracture (closed is the default).

Open also requires documentation of Gustilo Type I, II, IIIA, IIIB, IIIC.

  • Episode of care (3-16 options):
    • Initial, subsequent or sequela.
    • Subsequent also requires documentation of routine or delayed healing, nonunion or malunion.

ICD-9-CM had one code option for reporting a nonunion or malunion of a fracture. In contrast, ICD-10-CM offers hundreds of code options for these types of complications.

  • Fracture of the surgical neck of the humerus requires documentation of whether it is a two-, three- or four-part fracture.
  • Fracture of the humeral shaft requires documentation of whether the fracture is classified as greenstick, transverse, oblique, spiral, comminuted, segmental, other or unspecified.
  • Poisonings by and adverse effects of drugs, medical and biological substances are combined under a single category, grouped by specific drug.
  • Underdosing is added as new terminology and combined with poisonings by and adverse effects of drugs, medical and biological substances, grouped by specific drug.
    • In ICD-10-CM the term “underdosing” is defined as taking less of a medication than is prescribed by a provider’s or manufacturer’s instructions, resulting in negative health consequences.

These are just some of the examples of changes one can anticipate when reporting injuries, poisoning and certain other consequences of external causes using ICD-10-CM.

About the Author

Angela Carmichael, MBA, RHIA, CCS, CCS-P, is director of HIM compliance for J.A. Thomas & Associates. Angela earned a Bachelor of Science degree, in Health Services Administration from Barry University and a MBA from Nova Southeastern University. She is a Registered Health Information Administrator and also has achieved the designations of Certified Coding Specialist, and Certified Coding Specialist-Physician and AHIMA Approved ICD-10-CM/PCS Instructor.

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