By Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA
You may not consider yourself to be a ‘trauma coder’ but in fact you may be. If you code for your community hospital’s emergency room or a stand-alone urgent care center, trauma cases are in your queue every day. Patients who are seen in the ER or Trauma center for traumatic injuries will certainly end up later at a physician office for follow-up. If you are a physician coder, especially orthopedic but others as well, you need to know this stuff!
Anatomy is complex and there are thousands of ways for patients to hurt themselves. That translates to thousands of codes, with the trauma and external cause codes making up about one-third of the code set. Some traumatic injury cases are easy but some can be really challenging. I’ll agree that coding one laceration or one fracture is not always that complex, but when there are multiple interrelated and complicating injuries involved, it’s harder.
Understanding the relationship between fractures and open wounds, superficial injuries and injuries to organs or superficial and intracranial injuries is the challenging part. Think of this as a coding puzzle: Trauma has its own set of rules that must be followed to correctly form an accurate picture of the patient’s injuries.
Let’s look at an example. The patient accidentally cut himself in the right lateral leg while using a machete knife to clear tall grass from his backyard garden. He had a deep laceration of his extensor digitorum longus muscle and was seen by the orthopedic surgeon in the ER and possibly admitted. How many diagnosis codes are needed to describe this encounter?
- The minimum number of diagnosis codes is two – the laceration of the anterior muscle group of the lower leg and the associated open wound.
- If your state requires assignment of external cause codes, the real answer can be six – the how, where, when and why of the injury.
- When this turns into a follow-up visit with the orthopedic surgeon in the office, three codes are required and the 7th characters change, that’s all.
Trauma coding is an opportunity for the thoughtful and skilled coder to ensure that the care and treatment provided to the patient is accurately represented in the codes applied to the case. The impact on your organization’s data and reimbursement can be significant.
A word about muscles and tendons: One of the particular challenges of coding traumatic injuries is determining where the affected muscle or tendon is located. In the case described above, the surgeon indicated repair of the extensor digitorum longus muscle which is in the lower leg. Detailed documentation of trauma cases will often specify muscles or tendons that may be unfamiliar to the coder. Our ICD-10-CM: Trauma Diagnosis Coding course includes a very useful downloadable guide for locating muscles and tendons. (small picture below)
The Libman Education Trauma Coding curriculum
Coding of traumatic injuries is challenging! Libman Education online and on-demand courses will help ensure accurate and complete coding of diagnoses and procedures seen in trauma and emergency room settings.
The full Trauma Coding curriculum includes the following:
- ICD-10-CM: Trauma Diagnosis Coding is comprised of two courses:
- ICD-10-CM: Introduction to Trauma Diagnosis Coding
- ICD-10-CM: Advanced Trauma Diagnosis Coding
- ICD-10-PCS: Trauma Procedure Coding is comprised of four courses:
- ICD-10-PCS: Soft Tissue Reconstruction
- ICD-10-PCS: Orthopedic Procedures for Trauma
- ICD-10-PCS: Spinal Procedures for Trauma
- ICD-10-PCS: Neurosurgery Procedures for Trauma
- CPT Coding of Traumatic Injuries:
- CPT®: Coding of Skin Graft Procedures
- Outpatient: Fracture Care Coding
- Practical Coding Experience: Inpatient Trauma is comprised of four courses:
- Practical Coding Experience: Inpatient Trauma 1
- Practical Coding Experience: Inpatient Trauma 2
- Practical Coding Experience: Inpatient Trauma 3 (coming soon!)
- Practical Coding Experience: Inpatient Trauma 4 (coming soon!)
- Practical Coding Experience: Emergency Department
