What you need to know about ICD-10-CM

for injury research, surveillance and epidemiology

Holly Hedegaard, MD, MSPH

Society for the Advancement of Violence and Injury ResearchJuly 20, 2016

National Center for Health StatisticsOffice of Analysis and Epidemiology

Webinar Overview Overview of ICD-10-CM

ICD-10-CM injury diagnosis codes• General description• Proposed CDC surveillance case definitions for

─ Injury hospitalizations ─ Traumatic Brain Injury (TBI)

• Proposed ICD-10-CM injury diagnosis matrix

ICD-10-CM external cause codes• General description• Proposed ICD-10-CM external cause matrix

Testing and evaluation

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Clinical modification of ICD-10

First draft for public comment in 1997

Field tested by the AHA and AHIMA in 2003

New concepts/codes added annually through the ICD Coordination and Maintenance Committee at NCHS/CMS

Implemented on October 1, 2015

ICD-10-CM

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Relevant codes for ambulatory care encounters

Code structure provides greater specificity

Addition of sixth and seventh characters

Expanded number and detail in injury codes─ Of the approx. 70,000 codes in ICD-10-CM, 43,000 are

in the injury chapter!

What’s new in ICD-10-CM?

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http://www.cdc.gov/nchs/icd/icd10cm.htm

1. Scroll down to “FY 2017 release of ICD-10-CM”

2. Select “ICD-10-CM Full PDF”

3. Select “ICD10CM_FY2017_Full_PDF.zip”

4. Select “ICD10CM_Tabular_2017.PDF”

5. Select Chapter 19 (injury diagnosis) or Chapter 20 (external cause)

ICD-10-CM Online

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ICD-10-CM Injury Diagnosis Codes and Reporting Matrix

National Center for Health StatisticsOffice of Analysis and Epidemiology

Differences between ICD-9-CM and ICD-10-CM for injury diagnoses

2,600 codes 43,000 codesCode range 800-959 “S” and “T” codes3-5 characters 3-7 characters; “X” placeholderPrimary axis is nature of injury Primary axis is body regionNo character to indicate laterality Characters in the code indicate left,

right, bilateral, unspecifiedLimited detail on type of fracture Detailed info on type of fractureLacerations only Lacerations +/- foreign bodyLimited info on superficial injuries Detailed info on superficial injuriesCodes for poisoning and adverse effects of drugs

Codes for poisoning, adverse effects and underdosing of drugs

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Differences between ICD-9-CM and ICD-10-CM for injury diagnoses

Poisoning: Both diagnosis code and external cause code

Poisoning: diagnosis code only (T code) with character to specify intent

Asphyxiation: 994.7 40 diagnosis codes for asphyxiation/ strangulation by different mechanisms & intent

Child/adult abuse New codes to distinguish between suspected vs confirmed abuse

No designation of initial vssubsequent encounter

Most codes have 7th character indicating initial vs subsequent encounter

Limited late effect codes Most codes have 7th character indicating sequelae (late effects)

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ICD-9-CM: 813.22Fracture of shaft of ulna, closed

ICD-10-CM: S52.244ANondisplaced spiral fracture of shaft of ulna, right arm, initial encounter for closed fracture

Example of an ICD-9-CM code vs an ICD-10-CM code for an injury diagnosis

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S52.244ANondisplaced spiral fracture of shaft of ulna, right arm, initial encounter for closed fracture

Injury Chapter

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S52.244ANondisplaced spiral fracture of shaft of ulna, right arm, initial encounter for closed fracture

Major Body Region

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S52.244ANondisplaced spiral fracture of shaft of ulna, right arm, initial encounter for closed fracture

Major Nature of Injury

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S52.244ANondisplaced spiral fracture of shaft of ulna, right arm, initial encounter for closed fracture

Specific details on body region and nature of injury

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S52.244ANondisplaced spiral fracture of shaft of ulna, right arm, initial encounter for closed fracture

Type of Encounter

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ICD-9-CMFractures 800-829

Dislocations 830-839Sprains/Strains 840-848

Change in Primary Axis of Injury Diagnosis Codes

ICD-10-CMInjuries to head S00-S09Injuries to neck S10-S19

Injuries to thorax S20-S29

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Injury Diagnosis Codes in ICD-10-CMInjury to: Code Range

Head S00-S09Neck S10-S19Thorax S20-S29Abdomen, lower back, lumbar spine, pelvis,and external genitals

S30-S39

Shoulder and upper arm S40-S49Elbow and forearm S50-S59Wrist, hand and fingers S60-S69Hip and thigh S70-S79Knee and lower leg S80-S89Ankle and foot S90-S99

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Type of Encounter 7th character*

A, B, C: Initial encounterActive treatment, ED encounter, evaluation and treatment by new physician

D to R: Subsequent encounterRoutine care during healing phase (e.g., cast change/removal, removal of external fixation device)

S: SequelaComplications or conditions that arise as a direct result of an injury

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*Assigned to all S codes and most T codes except T07, T14, and T30-T32

T-codes for Drug Poisoning (T36-T50)

“Intent” captured in 6th character* 1 = Accidental (unintentional)2 = Intentional self-harm3 = Assault4 = Undetermined5 = Adverse effect6 = Underdosing

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*except for T36.9, T37.9, T39.9, T41.4, T42.7, T43.9, T45.9, T47.9, and T49.9, where intent is captured in the 5th character

T-codes for Asphyxiation (T71)

“Intent” captured in 6th character 1 = Accidental (unintentional)2 = Intentional self-harm3 = Assault4 = Undetermined

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Proposed ICD-10-CM Surveillance Definition for Injury Hospitalizations

NCHS/NCIPC workgroup

Reviewed existing definitions1

Applied GEMs2 equivalents to ICD-9-CM surveillance definition

Reviewed resulting codes and developed a proposed code set

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1 Consensus Recommendations for Using Hospital Discharge Data for Injury Surveillance. Marietta (GA): State and Territorial Injury Prevention Directors Association; 2003. https://c.ymcdn.com/sites/safestates.site-ym.com/resource/resmgr/imported/HospitalDischargeData.pdf2 General Equivalence Mappings. See http://www.ohima.org/quiz/courses6/22.1.html.

Proposed ICD-10-CM Surveillance Definition for Injury Hospitalizations

ICD-10-CM codes Types of injuriesAll S codes Anatomic injuries

T07-T34 Foreign bodies, burns, corrosions, frostbite

T36-T50 (except for codes below) with a 6th character of 1, 2, 3, or 4

Drug poisoning (excludes adverse effects and underdosing)

T36.9, T37.9, T39.9, T41.4, T42.7, T43.9, T45.9, T47.9, and T49.9 with a 5th character of 1, 2, 3, or 4

Drug poisoning (excludes adverse effects and underdosing)

T51-T65 Toxic effects of substances nonmedicinal as to sourceT66-T77 Other and unspecified effects of external causes

(radiation, heat, light, hypo/hyperthermia, asphyxiation, child/adult abuse, lightning, drowning, motion sickness, etc.)

T79 Certain early complications of trauma, not elsewhere classified

*Principal diagnosis only. Any 7th character except “S” (sequela from previous injury). T07, T14, and T30-T32 do not have a 7th

character.

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Proposed ICD-10-CM Surveillance Definition for TBI

NCHS/NCIPC workgroup

Reviewed existing definitions and ICD-10-CM codes

Applied GEMs equivalents to ICD-9-CM surveillance definition for TBI morbidity1

Draft being reviewed by other federal and military partners

Input from researchers and epidemiologists

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1 Proposed Framework for Presenting Injury Data Using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD–10–CM) Diagnosis Codes. Technical Notes. http://www.cdc.gov/nchs/data/nhsr/nhsr089.pdf

Proposed ICD-10-CM Surveillance Definition for Traumatic Brain Injury

ICD-10-CM code Description

S02.0, S02.1- Fracture of skull

S02.8, S02.91 Fracture of other specified skull and facial bones; Unspecified fracture of skull

S04.02, S04.03-, S04.04-

Injury of optic chiasm; injury of optic tract and pathways; injury of visual cortex

S06- Intracranial injuryS07.1 Crushing injury of skullT74.4 Shaken infant syndrome

“-” indicates any 5th or 6th character

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What are the ICD Injury matrices?

Nature of injury codes and external cause codes are multi-axial (i.e., describe more than one dimension)

The ICD Injury matrices are frameworks designed to organize ICD coded injury data into meaningful groups and to standardize tabulations in either dimension

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Purpose of ICD matrices

To facilitate comparability in the presentation of injury statistics

To standardize retrieval of injury cases for epidemiological, clinical and management oriented analyses

To create a bridge between classification systems (e.g., ICD-9 and ICD-10)

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Proposed ICD-10-CM Injury Diagnosis Matrix

Used to categorize injury by body region and nature of injury

Two existing injury diagnosis matrices:─ Barell Matrix for ICD-9-CM (morbidity)─ Injury Mortality Diagnosis (IMD) Matrix for ICD-10

For more info: http://www.cdc.gov/nchs/injury/injury_matrices.htm

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Body Region of Injury Nature of Injury

Fracture Dislocation Internalorgan

Openwound

etc.

Head/Neck

TBI

Other head

Neck

Spine/Upper Back

Spinal cord

Vertebral column

Torso

Thorax

Abdomen

Pelvis/lower back

Extremity Upper extremity

Lower extremity

etc.

Basic Framework for Injury Diagnosis Matrices

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Available at http://www.cdc.gov/nchs/data/nhsr/nhsr089.pdf

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National Center for Health StatisticsOffice of Analysis and Epidemiology

ICD-10-CM External Cause Codes and Reporting Matrix

Differences between ICD-9-CM and ICD-10-CM for external cause

1,300 codes 7,500 codesExternal cause codes begin with “E”

External cause codes begin with “V”, “W”, “X” or “Y”

E-codes for Poisoning/Toxic Effects Diagnosis codes for Poisoning/Toxic Effects (T36-T65, by intent)

E-codes for Suffocation Diagnosis codes for Suffocation(T71, Asphyxiation, by intent)

Foreign body: E-codes (E914, E915) + diagnosis codes (930-939)

Diagnosis codes for Foreign body (T15-T19)

E-codes for deprivation & other natural/environmental factors (e.g., lightning, vibration)

Diagnosis codes (T codes)

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Differences between ICD-9-CM and ICD-10-CM for external cause

Suicide/self-inflicted Intentional self-harmHomicide and injury purposely inflicted by other persons

Assault

E-codes for child & adult abuse, neglect & other maltreatment (E967.0-.9)

Expanded external cause codes for assault, maltreatment & neglect

No designation of initial vs subsequent encounter

7th character indicates initial vs subsequent encounter

Limited external cause codes for late effect

7th character indicates sequelae (late effects)

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ICD-10-CM External Cause of Injury

External Cause Code RangeTransportation V00-V99Slipping, tripping, stumbling & falls W00-W19Exposure to inanimate mechanical forces W20-W49Exposure to animate mechanical forces W50-W64Accidental non-transport drowning and submersion

W65-W74

Exposure to electric current, radiation and extreme ambient air temperature and pressure

W85-W99

Exposure to smoke, fire and flames X00-X08Contact with heat and hot substances X10-X19Exposure to forces of nature X30-X39Accidental exposure to other specified factors X52-X58

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ICD-10-CM External Cause of Injury

(continued)

External Cause Code RangeIntentional self-harm X71-X83Assault X92-Y08Event of undetermined intent Y21-Y33Legal intervention, operations of war, military operations, and terrorism

Y35-Y38

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ICD-10-CM External Cause (continued) (T codes)

External cause ICD-10-CM codesSuicide attempt T14.91Effects of foreign body entering through natural orifice

T15-T19

Poisoning by drugs, medicaments, and biological substances

T36-T50 (except for codes below) with a 6th character of 1, 2, 3, or 4

T36.9, T37.9, T39.9, T41.4, T42.7, T43.9, T45.9, T47.9, and T49.9 with a 5th character of 1, 2, 3, or 4

Toxic effects of substances chiefly non-medicinal as to source

T51-T65

Asphyxiation T71Effects of deprivation T73Adult and child abuse, neglect, and other maltreatment, confirmed or suspected

T74, T76

Effects of lightning, Effects of vibration, Motion sickness

T75.0, T75.2, T75.3

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Proposed ICD-10-CM External Cause Matrix

Used to categorize injury by mechanism and intent of injury

Basis of injury mechanism categories used in WONDER and WISQARS

Need for comparability with ICD-9-CM and ICD-10 external cause matrices

For more info, see http://www.cdc.gov/nchs/injury/injury_matrices.htm

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Mechanism of Injury

Intent of Injury

Uninten-tional

IntentionalSelf-harm

Assault Legal Intervention

WarOperations

Cut/pierce

Drowning/submersion

Fall

Fire/Flame

Hot object/substance

Firearm

Machinery

Transportation

etc.

Basic Framework for External Cause Matrices

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Available at http://www.cdc.gov/injury/wisqars/pdf/ICD-10-CM_External_Cause_Injury_Codes-a.pdf

Available OnlineProposed Framework for Presenting Injury Data using ICD-10-CM External Cause of Injury Codes

http://www.cdc.gov/injury/wisqars/pdf/ICD-10-CM_External_Cause_Injury_Codes-a.pdf

ICD-10-CM All but Poisoning Matrix http://www.cdc.gov/injury/wisqars/dataandstats.html

ICD-10-CM Poisoning Matrixhttp://www.cdc.gov/injury/wisqars/dataandstats.html

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ICD-10-CM All but Poisoning Matrix

• Screen shots of links

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Future Matrix Productsimilar to ICD-9-CM

Portion of ICD-9-CM External Cause Matrix

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National Center for Health StatisticsOffice of Analysis and Epidemiology

Testing and Evaluation

Testing and Evaluation Efforts

Armed Forces Health Surveillance Center and other military injury surveillance groups ‒ Proposed ICD-10-CM surveillance case definition for TBI‒ Proposed ICD-10-CM injury diagnosis matrix

Safe States Alliance Injury Surveillance Workgroup (ISW9)‒ Consensus Methods for Initial Testing and Validation of the ICD-10-CM

External Cause Matrix (report available in fall 2016)

Council of State and Territorial Epidemiologists (CSTE)‒ Testing of Proposed ICD-10-CM External Cause Matrix‒ Development of ICD-10-CM Injury indicators

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Questions?

National Center for Health StatisticsOffice of Analysis and Epidemiology

National Center for Health Statistics Office of Analysis and Epidemiology

Holly Hedegaard, MD, MSPH

CDC/National Center for Health StatisticsOffice of Analysis and Epidemiology

Injury Statistics ProgramPhone: 301-458-4460Email: hdh6@cdc.gov

For more information

Additional Resources

General Equivalence Mappingshttp://www.cdc.gov/nchs/icd/icd10cm.htm

MapIt tool (to map between ICD-9-CM and ICD-10-CM)http://www.ahrq.gov/news/qi-mapit.htmlhttps://www.nahdo.org/node/250