December 2002 Bulletin

Accurately code external causes of injury

Learn E codes

By Margie Scalley Vaught, CPC, CCS-P, MCS-P and reviewed by Alan H. Morris, MD, and Dan Sung

This is the first of a two-part series of articles that addresses ICD-9 coding related to injuries. It provides a basic understanding of E code classification. Part II will address instructions and examples of orthopaedic fracture coding related to hip fracture, osteoporosis and falls.

Over the years, diagnostic ICD-9 coding has taken on a more active and critical role in reporting physician services. Not only do physicians need to provide and document the medical necessity of services and/or procedures (CPT code), but that documentation must also support an ICD-9 code.

ICD-9 codes are not used solely to classify medical conditions. E codes can be used to further describe external causes of injury and other adverse effects. These codes "paint" a better picture of what happened to a patient on a given date of service. E codes permit "classification of environmental events, circumstances, and conditions as to the cause of injury, poisoning, and other adverse effects." When it comes to orthopaedic coding, it is essential that physicians become aware of these additional codes.

Many times, third party payers will request and need information that can be supplied by an E code. If E codes are not placed on a claim, especially when there is an accident ICD-9 code reported (800-900 series), it can delay reimbursement until the payer can determine if there is another party responsible for the claim.

Payers usually will contact the patients for this information, which can further delay the reimbursement process. Medical software programs for submitting electronic claims also have internal edits placed so that if ICD-9 codes in the 800-900 range are reported, it flags the claim noting that it needs a date of injury before it can be sent electronically.

In the ICD-9-CM Expert for Physicians, Volumes 1 & 2 (see reference at end of article) an alphabetical index lists these E codes under Section 3 at the end of Volume 2, just before the Tabular Index. The instructions state: "Where a code from this section is applicable, it is intended that it shall be used in addition to a code from one of the main chapters of ICD-9-CM, indicating the nature of the condition. The ‘E’ Code classification should be used as an additional code for more detailed analysis." If you use an E code, you must always report it with an appropriate ICD-9 code.

E codes are broken down into several categories

Here’s a limited list of E code categories (for a full description, refer to the ICD-9 manual):

For the E codes located in the range of E800-E845, there are specific fourth-digit subdivisions that need to be applied following a decimal point.

An example would be in the range of E810-E825:

.0 Driver of motor vehicle other than motorcycle

.1 Passenger in motor vehicle other than motorcycle

.2 Motorcyclist

.3 Passenger on motorcycle

.4 Occupant of streetcar

.5 Rider of animal; occupant of animal-drawn vehicle

.6 Pedal cyclist

.7 Pedestrian

.8 Other specified person

.9 Unspecified person

Further E code definitions and instructions

In the E code section, further definitions and instructions on how to use and report these codes can be located. There are categories for "late effects" of accidents and other external causes that can be found under sections E929, E959, E969, E977, E989 and E999. A late effect is the residual effect after the acute phase of an illness or injury has terminated. When using codes located in the E929 section, reference is given to the need of an additional E code. For example if a patient had a late effect from an accidental fall E929.3, an additional E code such as E880.1 (fall on or from sidewalk curb) would also need to be reported.

Everyday events result in the addition of new E codes

E codes have been added and evolved from circumstances experienced in daily life and changes that take place. The E code database helps in forming many of the federal and state regulations regarding things such as helmet laws, recalls for equipment failure, playground equipment modifications and other statues.

For example, in 2003, there will now be an E code for terrorist acts. New codes were added for 2002–such as "E917.0 Struck by hockey stick or puck; Struck by hit or thrown ball; Kicked or stepped on during game (football) (rugby)" and "E917.6 Crushed or pushed by a crowd or human stampede."

General guidelines for E codes

Here are seven general guidelines when using E codes:

  1. An E code may be used with any ICD-9 code in the range of 001-V83.02, which indicates an injury, poisoning, or adverse effect due to an external cause.
  2. Assign the appropriate E code for all initial treatments of an injury, poisoning or adverse effect of drugs.
    Example: Patient presents with avascular necrosis of the femoral head due to osteoporosis from long-term corticosteroid use. The appropriate ICD-9 codes would be 733.42, Avascular necrosis femoral head; 733.09, Osteoporosis drug induced; E932.0, Adverse effects of therapeutic use of adrenal cortical steroids.
  3. Use a late effect E code for subsequent visits when a late effect of the initial injury or poisoning is being treated. There is no late effect E code for adverse effects of drugs.
    Example: Patient has developed a nonunion of the radius with broken plate and screws and will now undergo repair of this nonunion. The original injury was the result of an accidental fall. The ICD-9 codes could be 733.81, Nonunion radius fracture; 905.2, Late effects of upper extremity fracture; 996.4, Mechanical complication of internal orthopedic device; E929.3 Late effects of accidental fall.
  4. Use the full range of E codes to completely describe the cause, the intent and the place of occurrence, if applicable, for all injuries, poisonings and adverse effects of drugs.
    Example: Patient fell from scaffolding at work in the warehouse resulting in an open femoral shaft fracture. The ICD-9 codes could be: 821.11, Open femur fracture shaft; E881.1; Fall from scaffolding; E849.3, Place of occurrence warehouse.
  5. Assign as many E codes as necessary to fully explain each cause. If only one E code can be recorded, assign the E code most related to the principal diagnosis.
  6. The selection of the appropriate E code is guided by the Index to External Causes, which is located after the alphabetical index to diseases, and by Inclusion and Exclusion notes in the Tabular List.
  7. An E code can never be a principal (first listed) diagnosis.

Importance of reporting E codes

As you can see, the reporting of E codes becomes just as important as assigning the appropriate medical diagnosis codes located in the ICD-9 manual.

Reference

ICD-9-CM Expert for Physicians, St. Anthony Publishing, Medicode, Ingenix Companies,Volumes 1 & 2, 2003

Margie Scalley Vaught, CPC, CCS-P, MCS-P, is an independent coding specialist in Ellensburg, Wash. She is also a member of the American Academy of Professional Coders’ National Advisory Board. She can be reached at vaught@kvalley.com.

Alan H. Morris, MD, is chair of the AAOS Council on Health Policy and Practice. He has over 12 years of experience with AAOS health policy and payment issues. Dr. Morris can be reached via e-mail at NemoMorris@aol.com.

Dan Sung is a policy analyst, AAOS health policy department.


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