Template:ICD10 Guideline Trauma w mechanism: Difference between revisions

Revision as of 12:21, 2019 February 1

Explanation of trauma and mechanism co-coding.

Traumas and their Mechanisms

There are numerous codes for "mechanical" injuries to various body parts.
You can recognize these codes because their names include one or another term such as: "injury/trauma" or "traumatic".

Trauma codes:
Abdomen or lower back or pelvis NOS, wound/injury/trauma Abdomen or lower back or pelvis, nerves NOS, injury/trauma Abdomen or lower back or pelvis, soft tissues, open wound, injury/trauma Abdomen or lower back or pelvis, superficial injury/trauma (minor, contusion) Abdomen or pelvic, blood vessels NOS, injury/trauma Air embolism, traumatic Ankle or foot or toes, amputation, injury/trauma Ankle or foot or toes, blood vessels, wound/injury/trauma Ankle or foot or toes, fracture, injury/trauma Ankle or foot or toes, joints or ligaments, dislocation/sprain/strain, injury/trauma Ankle or foot or toes, muscles/tendons, wound/injury/trauma Ankle or foot or toes, nerves, wound/injury/trauma Ankle or foot or toes, open wound, injury/trauma Ankle or foot or toes, superficial injury/trauma (minor, contusion) Ankle or foot or toes, wound/injury/trauma, NOS Aorta, abdominal, injury/trauma Aorta, thoracic, injury/trauma Bladder, traumatic laceration/rupture Bladder, wound/injury/trauma Brain injury, diffuse (TBI), injury/trauma Brain injury, focal (TBI), injury/trauma Brain, cerebral edema, injury/trauma Brain, concussion, injury/trauma Brain/intracranial injury NOS, injury/trauma Carotid artery, injury/trauma Clavicle or scapula or humerus, fracture, injury/trauma Colon (large intestine), traumatic laceration/rupture Colon (large intestine), wound/injury trauma Cranial nerve, wound/injury/trauma Ear, foreign body in Eardrum (tympanic membrane), rupture, injury/trauma Elbow or forearm, superficial injury/trauma (minor, contusion) Elbow or forearm, wound/injury/trauma, NOS Elbow, joints or ligaments, dislocation/sprain/strain, injury/trauma Elbow, open wound, injury/trauma Epidural hemorrhage, injury/trauma Esophagus, wound/injury/trauma Eye (globe), wound/injury/trauma Eye, foreign body in Fat embolism, traumatic Femur, fracture, injury/trauma Flail chest, injury/trauma Forearm, amputation, injury/trauma Forearm, blood vessels, wound/injury/trauma Forearm, muscles/tendons, wound/injury/trauma Forearm, nerves, wound/injury/trauma Forearm, open wound, injury/trauma Gallbladder or bile ducts, traumatic laceration/rupture Gallbladder or bile ducts, wound/injury/trauma Gastrointestinal (GI) tract, foreign body in Genitorurinary tract, foreign body in Head NOS, wound/injury/trauma Head bones NOS, fracture, injury/trauma Head, joints or ligaments, dislocation/sprain/strain, injury/trauma Head, open wound, injury/trauma Head, superficial injury/trauma (minor, contusion) Heart, wound/injury/trauma Hemothorax, traumatic Hip or thigh, amputation, injury/trauma Hip or thigh, blood vessels, wound/injury/trauma Hip or thigh, muscles/tendons, wound/injury/trauma Hip or thigh, nerves, wound/injury/trauma Hip or thigh, open wound, injury/trauma Hip or thigh, superficial injury/trauma (minor, contusion) Hip or thigh, wound/injury/trauma, NOS Hip, joints or ligaments, dislocation/sprain/strain, injury/trauma Inferior vena cava (IVC), injury/trauma Intra-abdominal organ NOS, wound/injury/trauma NOS Intracranial hemorrhage, injury/trauma Intrathoracic organ/structure NOS, wound/injury/laceration Kidney, wound/injury/trauma Knee or lower leg, blood vessels, wound/injury/trauma Knee or lower leg, muscles/tendons, wound/injury/trauma Knee or lower leg, open wound, injury/trauma Knee or lower leg, superficial injury/trauma (minor, contusion) Knee or lower leg, wound/injury/trauma, NOS Knee, joint or ligaments or cartilage, dislocation/sprain/strain/tear, injury/trauma Knee, nerves, wound/injury/trauma Liver, wound/injury/trauma Lower leg, amputation, injury/trauma Lower leg, fracture, injury/trauma Lower limb (leg) bones, level not specified/NOS, fracture, injury/trauma Lower limb (leg), level not specified/NOS, amputation, injury/trauma Lower limb (leg), level not specified/NOS, blood vessels, wound/injury/trauma Lower limb (leg), level not specified/NOS, joints or ligaments, dislocation/sprain/strain, injury/trauma Lower limb (leg), level not specified/NOS, muscles/tendons, wound/injury/trauma Lower limb (leg), level not specified/NOS, nerves, wound/injury/trauma Lower limb (leg), level not specified/NOS, open wound, injury trauma Lower limb (leg), level not specified/NOS, superficial injury/trauma (minor, contusion) Lower limb (leg), level not specified/NOS, wound/injury/trauma, NOS Lumbar spine or pelvis, joints or ligaments, dislocation/sprain/strain, injury/trauma Lung NOS, wound/injury/trauma Multiple trauma Muscle, strain Neck structures NOS, wound/injury/trauma Neck, blood vessels NOS, injury/trauma Neck, joints or ligaments, dislocation/sprain/strain, injury/trauma Neck, nerves NOS, injury/trauma Neck, open wound, injury/trauma Neck, superficial injury/trauma (minor, contusion) ... further results

What these have in common is that they are caused by an "external agent" -- such as being hit by a car, falling on your head, etc.
For these codes, it is required that the injury be combined with the external mechanism of the injury:

Mechanism codes:
Mechanism of injury: animal rider or occupant of animal-drawn vehicle Mechanism of injury: assault with bodily force Mechanism of injury: bus occupant Mechanism of injury: crushed or jammed or pinched in or between objects Mechanism of injury: driver or occupant of ATV or off-road vehicle or snowmobile Mechanism of injury: driver or occupant of watercraft Mechanism of injury: explosion Mechanism of injury: fall or jump (not necessarily from a height) Mechanism of injury: firearm (GSW) Mechanism of injury: hanging or strangulation (accidental or intentional) Mechanism of injury: hypodermic needle Mechanism of injury: knife or other sharp object, stabbing Mechanism of injury: machinery Mechanism of injury: motorcyclist Mechanism of injury: occupant or driver of car or truck Mechanism of injury: other NOS Mechanism of injury: pedal cyclist vs powered vehicle Mechanism of injury: pedal cyclist, not with powered vehicle Mechanism of injury: pedestrian vs powered vehicle Mechanism of injury: pilot or occupant of aircraft Mechanism of injury: struck by an inanimate moving object/blunt trauma Mechanism of injury: train occupant Mechanism of injury: transport or vehicle accident NOS

In some cases, the mechanism is actually iatrogenic, see Iatrogenic codes in ICD10.

Iatrogenic codes:
Acetaminophen (tylenol, paracematol), adverse effect Adrenal insufficiency, drug-induced (i.e. due to steroid administration) Anesthetic gas, adverse effect Anti-arrhythmic, adverse effect Anti-arrhythmic, overdose/toxicity Antibiotic/antimicrobial, adverse effect Antibiotic/antimicrobial, overdose/toxicity Anticoagulant, adverse effect Anticoagulant, overdose/toxicity Antidepressant drug NOS, adverse effect Antineoplastic/chemotherapy or immunosuppressive drugs, adverse effect Antineoplastic/chemotherapy or immunosuppressive drugs, overdose/toxicity Antiseizure drug NOS, adverse effect Antiseizure drug NOS, overdose/toxicity Aspirin or other salicylate or NSAID, adverse effect Benzodiazepine, adverse effect Bone marrow transplant, failure or rejection Calcium channel blocker drug, adverse effect Cardiac/cardiovascular drug NOS, adverse effect Cardiac/cardiovascular drug NOS, overdose/toxicity Cerebrospinal fluid (CSF) leak Complication associated with artificial fertilization, NOS Complication of anesthesia, NOS Cushing's syndrome, drug-induced Decubitus (pressure) ulcer, Stage I (surface reddening) Decubitus (pressure) ulcer, Stage II (to fascia, just under skin) Decubitus (pressure) ulcer, Stage III (deep, to but not including muscle) Decubitus (pressure) ulcer, Stage IV (involves muscle, tendon, or bone) Decubitus (pressure) ulcer, stage not indicated Drug or biological substance/agent NOS, adverse effect Failed/difficult intubation, or complication of intubation Graft-versus-host disease/reaction (GVHD) Hallucinogen, adverse effect Heart transplant, failure or rejection or unspecified complication Heart-lung transplant, failure or rejection or unspecified complication Hemorrhage, due to anticoagulant or thrombolytic drug Heparin-induced thrombocytopenia (HIT) Hormone or hormone agonist NOS, overdose/toxicity Hormone or hormone agonist drug, adverse effect Hypotension, drug-induced Iatrogenic problem NOS, related to a surgery or procedure, NOS Iatrogenic, air embolism, as complication of line/infusion/transfusion/injection Iatrogenic, complication NOS, cardiac or vascular prosthetic device or implant or graft Iatrogenic, complication of medical or surgical care NOS Iatrogenic, dehiscence or rupture or disruption, surgical wound NOS Iatrogenic, hemorrhage or hematoma, related to a procedure or surgery NOS Iatrogenic, hypotension/shock, postoperative/post-procedural Iatrogenic, infection, cardiac or vascular prosthetic device or implant or graft NOS Iatrogenic, infection, central venous catheter-related bloodstream infection (CVC-BSI, CLI) Iatrogenic, infection, following a procedure or surgery, NOS Iatrogenic, infection, heart valve prosthesis (incl prosthetic valve endocarditis) Iatrogenic, infection, internal orthopedic prosthetic device or implant or graft or bone device Iatrogenic, infection, internal prosthetic device or implant or graft NOS Iatrogenic, infection, related to vascular access other than central line Iatrogenic, infection, urinary catheter Iatrogenic, malignant hyperthermia, due to anesthesia Iatrogenic, mechanical complication/dysfunction, cardiac electronic device Iatrogenic, mechanical complication/dysfunction, cardiac or vascular prosthetic device or implant or graft, NOS Iatrogenic, mechanical complication/dysfunction, dialysis catheter Iatrogenic, mechanical complication/dysfunction, heart valve prosthesis Iatrogenic, mechanical complication/dysfunction, internal orthopedic prosthetic device or implant or graft or bone device Iatrogenic, mechanical complication/dysfunction, internal prosthetic device or implant or graft NOS Iatrogenic, mechanical complication/dysfunction, urinary catheter Iatrogenic, puncture or laceration, related to a procedure or surgery NOS Iatrogenic, thromboembolism, as complication of line/infusion/transfusion/injection Iatrogenic, transfusion reaction (incompatibility reaction) (any type) Insulin or antidiabetic drug, adverse effect Liver transplant, failure or rejection or unspecified complication Lung transplant, failure or rejection or unspecified complication Neuropathy, peripheral, drug-induced Nosocomial infection, NOS Opioid/narcotic, adverse effect Pancreas transplant, failure or rejection or unspecified complication Pneumonia, ventilator-associated (VAP) Psychiatric drug NOS, adverse effect Psychiatric drug NOS, overdose/toxicity Rib fracture(s) due to CPR Sedative or hypnotic, adverse effect Skin rash, drug-induced (drug eruption) Stimulants incl. methamphetamine, poisoning Subglottic (tracheal) stenosis or tracheomalacia, iatrogenic Thrombolytic drug, adverse effect Thrombolytic drug, overdose/toxicity Transfusion-related acute lung injury (TRALI, form of ARDS) Transplanted organ NOS, failure or rejection or unspecified complication Tricyclic antidepressant, adverse effect Xray contrast agent, adverse effect

Regarding Multiple Trauma

When a person has multiple body areas traumatized, code Multiple trauma
When using Multiple trauma also code the individual things traumatized, e.g. leg, arm, head, etc.
Code Multiple trauma and all the individual things traumatized as Combined ICD10 codes
- And in this case, assuming that they all have the same mechanism of injury (e.g. Mechanism of injury: motorcyclist), then you'd also code that Mechanism code as the same Combined ICD10 codes.
If the multiple trauma is the primary admit diagnosis, then among this group of linked ICD10 codes, the Primary Admit Diagnosis would be either the Multiple trauma or the "worst" thing injured, e.g. Brain injury, diffuse (TBI), injury/trauma

@@ Line 18: / Line 18: @@
 === Regarding Multiple Trauma ===
-*When a person has multiple body areas traumatized, there is a code '''[[Multiple trauma]]''' you should use.
+*When a person has multiple body areas traumatized, code '''[[Multiple trauma]]'''
-*When you use this, you should ALSO code the individual things traumatized, e.g. leg, arm, head, etc.
+*When using [[Multiple trauma]] '''also code the individual things traumatized''', e.g. leg, arm, head, etc.
-*With multiple trauma you should link the '''[[Multiple trauma]]''' code and all the individual things traumatized with the same priority
+*Code '''[[Multiple trauma]]''' and all the individual things traumatized as [[Combined ICD10 codes]]
-**And in this case, assuming that they all have the same mechanism of injury (e.g. '''[[Mechanism of injury: motorcyclist]]'''), then you'd also link with that mechanism code.
+**And in this case, assuming that they all have the same mechanism of injury (e.g. '''[[Mechanism of injury: motorcyclist]]'''), then you'd also code that [[:Category:Mechanism|Mechanism]] code as the same [[Combined ICD10 codes]].
-*If the multiple trauma is the primary admit diagnosis, then among this group of linked ICD10 codes, you the choice of what is '''[[Primary Admit Diagnosis]]''' would be either the [[Multiple trauma]] or the "worst" thing injured, e.g. '''[[Brain injury, diffuse (TBI), injury/trauma]]
+*If the multiple trauma is the primary admit diagnosis, then among this group of linked ICD10 codes, the '''[[Primary Admit Diagnosis]]''' would be either the [[Multiple trauma]] or the "worst" thing injured, e.g. '''[[Brain injury, diffuse (TBI), injury/trauma]]

Template:ICD10 Guideline Trauma w mechanism: Difference between revisions

Revision as of 12:21, 2019 February 1

Traumas and their Mechanisms

Regarding Multiple Trauma

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