This installment in Family Practice Management's series on ICD-10 documentation and coding will focus on the minor trauma family physicians tend to see in an office setting – knee injuries, wrist fractures, bruised fingers, etc. More complicated injuries seen in some rural practice settings, urgent care facilities, or emergency departments are beyond the scope of this article.

Injuries are typically coded from Chapter 19 of the ICD-10 manual, “Injury, Poisoning, and Certain Other Consequences of External Causes” (codes S00-T88). In addition, Chapter 13, “Diseases of the Musculoskeletal System and Connective Tissue” (codes M00-M99), which deals with nontraumatic diseases, includes some of the consequences of the Chapter 19 injuries that a primary care physician would see. (See “Common family medicine codes from Chapter 13.”)

Almost every body area includes multiple codes for minor injuries. For example, there are 12 codes for superficial abrasion of the finger – one for each of the 10 digits, one for unspecified thumb, and one for unspecified finger. Be careful, though: If you submit a claim using one of the unspecified codes, it indicates a lack of documentation. There are no codes for multiple fingers, so you must separately code each finger that suffered an abrasion.

Although I just said there are 12 codes for a superficial finger abrasion, technically there are 36 codes because each code needs a seventh character: “A” for initial encounter, “D” for subsequent encounter, or “S” for sequelae. This seems fairly straightforward, except the terms “initial” and “subsequent” reference the phase of treatment from the patient's perspective, not yours:

• “A,” initial encounter, means the patient is receiving active treatment for the condition, regardless of whether the service is rendered by the initial physician or a new one. If you see a patient in the office for the first time after a finger fracture is treated in the emergency department and you do not actively change the treatment, the encounter would not be considered initial. If you see a patient in the office after initial treatment for an infected wound and you continue to debride and flush the wound, each visit would be considered initial as long as you continue to perform active intervention.

• “D,” subsequent encounter, is for routine care for the condition during the healing or recovery phase. In the above example, once the wound is clean and you are not actively treating it, the visit converts to subsequent.

• “S,” sequelae, indicates complications or conditions that arise as a direct result of an injury, e.g., chronic back pain following an accident.

A quick note about Chapter 20 codes

Chapter 20 in the ICD-10 manual, “External Causes of Morbidity” (codes V00-Y99), contains thousands of codes describing every conceivable environmental event that might cause an injury. Here's an example: V43.21S, “Person on outside of car injured in collision with sport utility vehicle in nontraffic accident, sequelae.” ICD-10 then defines when a person is outside a vehicle (not occupying the space normally reserved for the driver or passengers), what a sport utility vehicle is (special design that enables it to negotiate over rough or soft terrain, snow, or sand), and what a nontraffic accident is (any place other than a public highway).

Now the good news: ICD-10 external cause code reporting is not mandatory at the national level. Unless you are subject to a state-based mandate for external cause code reporting, a particular payer requires these codes, or you are performing a worker's compensation examination or an independent medical examination, it is unlikely you will need to use the codes in Chapter 20. Still, it remains good practice to document in your medical record the details surrounding an injury. This detail will allow a coder to add the Chapter 20 code in the event it is required.

How ICD-10 codes are structured

To make sense of the injury codes, it is important to remember how ICD-10 codes are structured. In the case of finger injuries, the coding scheme works like this:

• First three characters: General category,

• Fourth character (to the right of the decimal): The type of injury,

• Fifth character: Which finger was injured,

• Sixth character: Which hand was injured,

• Seventh character: The type of encounter (A, D, or S) as discussed above.

Here's a code example:

• S60, Superficial injury of wrist, hand, and fingers,

• S60.0, Contusion of finger without damage to nail,

• S60.02, Contusion of index finger without damage to nail,

• S60.021, Contusion of right index finger without damage to nail,

• S60.021A, Contusion of right index finger without damage to nail, initial encounter.

While it is tempting to use just the first subcategory (S60.0), ICD-10 requires additional characters for these codes. S60.0 notes that a fifth character is required, S60.02 notes that a sixth character is required, and so on.

It would be impossible for this article to go into depth regarding the coding of all minor injuries seen in a family physician's office-based practice or to assemble a superbill that includes all of the codes you might need. Therefore, let's focus on the subcategories beneath code S60, “Superficial injury of the wrist, hand, and fingers,” to highlight the type of documentation that facilitates correct coding.

Beneath code S60, there are the following subcategories, which would each require additional characters as discussed earlier:

• S60.0, Contusion of finger without damage to nail,

• S60.1, Contusion of finger with damage to nail,

• S60.2, Contusion of wrist and hand,

• S60.3, Other superficial injuries of thumb,

• S60.4, Other superficial injuries of other fingers,

• S60.5, Other superficial injuries of hand,

• S60.8, Other superficial injuries of wrist,

• S60.9, Unspecified superficial injury of wrist, hand, and fingers.

“Other superficial injuries” includes abrasions, blisters, external constrictions, superficial foreign bodies, insect bites, etc.

Additional general categories related to injuries of the wrist, hand, and fingers include these:

• S61, Open wound of wrist, hand, and fingers,

• S62, Fracture at wrist and hand level,

• S63, Dislocation and sprain of joints and ligaments at wrist and hand level,

• S64, Injury of nerves at wrist and hand level,

• S65, Injury of blood vessels at wrist and hand level,

• S66, Injury of muscle, fascia and tendon at wrist and hand level,

• S67, Crushing injury of wrist, hand, and fingers,

• S68, Traumatic amputation of wrist, hand, and fingers,

• S69, Other and unspecified injuries of wrist, hand, and fingers.

All of the above codes are then repeated in three major sections for the lower extremities: S70–S79, Superficial injury of hip and thigh; S80–S89, Superficial injury of knee and lower leg; and S90–S99, Superficial injury of ankle, foot, and toes.

There are a couple things to note about the fracture codes. Remember the A, D, and S characters noted earlier? For fractures, ICD-10 adds more seventh character codes. Here is a complete list:

• A, Initial encounter for closed fracture,

• B, Initial encounter for open fracture,

• D, Subsequent encounter for fracture with routine healing,

• G, Subsequent encounter for fracture with delayed healing,

• K, Subsequent encounter for closed fracture with nonunion,

• P, Subsequent encounter for closed fracture with malunion,

• S, Sequelae.

ICD-10 also includes codes for displaced and nondisplaced fractures and breaks down some fractures by the portion of the fractured bone (for example, distal pole, middle third, and proximal third of the navicular).

Sign and symptom codes

Most family physicians do not have immediate access to imaging services or interpretation before the patient leaves the office. Therefore, while you may be reasonably certain of your diagnosis, you may not consider it to be “definitive” but merely the best on your list of differential diagnoses. In such cases, ICD-10 allows you to report codes for signs or symptoms in lieu of a definitive diagnosis. (See “Orthopedic sign and symptom codes.”)

Moving forward

By now, you may be feeling that if you do not have an electronic health record (EHR) with automated ICD-10 coding, it could take longer to code minor injuries than to care for them. But before you curse and write a letter to the editor, please remember that ICD-10 was not created by the author (or this journal, the American Academy of Family Physicians, the American Medical Association, or even the insurance industry). The transition to ICD-10 will require some hard work, but you can do this. I hope that, with the help of this article series, you will be able to greet October 2015 without fear.