ICD-9-CM E codes classify the cause of injuries and other adverse effects to:
o Environmental events
o Other conditions
• ICD-9-CM E codes describe the injury or poisoning by:
o How it happened (cause)
o The intent (intentional or unintentional)
o The place where the event occurred (location)
o The external cause status of the person involved
o The activity of the person seeking healthcare for an injury or health condition
ICD-9 E codes do what?
-Provide valuable public health information
-Describe the types of accidents and other events that bring patients to a healthcare facility.
E codes are never used as:
o Principal or first listed diagnosis
o Only code reported
• Used as additional codes with a diagnosis or condition code from the main chapters of ICD-9-CM.
Volume 2 of ICD-9-CM
• Separate Alphabetic Index exists: Index to External Causes
• Organized by main terms that describe how the injury or adverse effect occurred
• Main terms describe "events"; examples include
o Dog bite
Mandatory E-codes are ICD-9 CM categories...
E930-E949 that identify the drug, medicinal, or biological substance responsible for an adverse effect.
A point to remember....
• Facility policy identifies other E codes to be used
• State regulations may require the use of all ICD-9-CM E codes for certain hospitals, such as patients admitted through the emergency department in regional trauma centers
• Documentation in the health record must identify the external cause to be coded.
ICD-9-CM Guidelines apply when coding and collecting E codes from health records in:
o Outpatient clinics
o Emergency departments
o Other ambulatory care settings
o Physicians' offices, except where other specific guidelines apply
General E Code Guidelines...
• E code from ICD-9-CM may be used as an additional code with any code in the ICD-9-CM categories 001-V86 to indicate the injury, poisoning, or adverse effect due to external cause
• Assign the appropriate ICD-9-CM E code for all initial treatments of an injury, poisoning, or adverse effect of drugs
• Do not use an ICD-9-CM E code or repeat the E code for subsequent treatment (encounters) of the same injury, poisoning, or adverse effect of drugs.
• Use an ICD-9-CM late effect E code for subsequent visits when a late effect of the initial injury or poisoning is being treated
• Do not use a late effect E code for subsequent visits for follow up care when no late effect of the injury has been documented
• There is no late effect E code for adverse effects of drugs.
• Use the full range of the ICD-9-CM E codes to completely describe the cause, intent, and place of occurrence, if applicable, for all injuries, poisonings, and adverse effects of drugs.
• Assign as many ICD-9-CM E codes as necessary to fully explain each external cause.
• If only one E code can be recorded, assign the one most related to the principal.
Select the appropriate E code by referring to and reading the ICD-9-CM:
o Alphabetic Index to External Causes
o Tabular List's inclusion and exclusion notes
ICD-9-CM Multiple-Cause Guidelines:
• If two or more events cause separate injuries, an E code from ICD-9-CM should be assigned for each cause.
• The E code from ICD-9-CM to be listed first will be selected on the following basis:
1. E codes for child and adult abuse take priority over all other E codes, except as described in the child and adult abuse guidelines (to follow)
2. E codes for terrorism events take priority over all other E codes except child and adult abuse
• ICD-9-CM Multiple-Cause Guidelines (continued)
3. E codes for cataclysmic events take priority over all other E codes, except for child and adult abuse and terrorism
4. E codes for transport accidents take priority over all other E codes, except for cataclysmic events, for child and adult abuse, and terrorism
• ICD-9-CM Child and Adult Abuse E Codes:
• First E code listed with ICD-9-CM
• When the cause of an injury or neglect is intentional child or adult abuse (ICD-9-CM codes 995.5-995.59, 995.80-995.85) the first.
E code listed should be assigned from the categories E960-E968, Homicide and injury purposely inflicted by other persons.
• An additional E code should identify the perpetrator, if known, from the ICD-9-CM category E967, Child or adult battering and other maltreatment
• The identity of the perpetrator is based on the relationship between the victim and the perpetrator
• In cases of neglect when the intent is determined to be accidental, the first E code listed should be E904.0, Abandonment or neglect of infants and helpless persons.
ICD-9-CM Guidelines for Unknown or Suspected Intent:
• If the intent (accident, self-harm, assault) of the cause of the injury or poisoning is unknown or unspecified, assign codes from ICD-9-CM categories E980-E989, Injury undetermined whether accidentally or purposely inflicted.
• If the intent (accident, self-harm, assault) of the cause of the injury or poisoning is questionable, probable, or suspected, assign codes from ICD-9-CM categories E980-E989, Injury undetermined whether accidentally or purposely inflicted.
ICD-9-CM Guidelines for Undetermined Cause:
• If the intent (accident, self-harm, assault) is known, but the cause is unknown, use ICD-9-CM codes
o E928.9, Unspecified accident;
o E958.9, Suicide and self-inflicted injury by unspecified means; or
o E968.9, Assault by unspecified means
• These codes should be rarely used
• Documentation must provide sufficient details.
ICD-9-CM Definitions and Instructions Related to Transport Accidents:
• Refer to the beginning of the E code Tabular List in ICD-9-CM for definitions and examples related to transport accidents.
ICD-9-CM Place of Occurrence E Codes:
• ICD-9-CM Category E849: Place of occurrence
• Describes where the event occurred, not the patient's activity at the time of the event
• Do not use E849.9 if the place of occurrence is not stated—only code the specific place of occurrence as documented in the patient's record.
• ICD-9-CM E849 are italicized codes to indicate that this code is not to be used for primary coding
• The E code identifying the cause of the accident, event, or adverse effect is assigned first
• The place of occurrence code, E849.x, is used in addition to the cause of the accident, poisoning, or adverse effect E code
• ICD-9-CM Main Term - Place of Occurrence E Codes
• Place of occurrence E codes can be located in the ICD-9-CM Index to External Causes under the main term
o Accident occurring (at) (in)
ICD-9-CM Classification of Death and Injury Resulting from Terrorism
• E codes for terrorism were created in ICD-9-CM after the September 11, 2001 event
• Guidelines exist for the use of these E codes
• When the cause of the injury is identified by the Federal Bureau of Investigation (FBI) as terrorism, the first-listed E code should be from the ICD-9-CM category E979, Terrorism
• The definition of terrorism employed by the FBI is found in the inclusion note at E979 in the Tabular List of ICD-9-CM
Things to remember about using terrorism codes...
• The terrorism E code is the only E code assigned
• An E code for terrorism should not be assigned if the cause of the injury is only suspected to be the result of terrorism
The ICD-9-CM terrorism E codes, E979.0-979.9 including the following:
o Explosion of marine weapons
o Destruction of aircraft
o Other explosions and fragments
o Fires, conflagration, and hot substances
o Nuclear weapons
o Biological weapons
o Chemical weapons
o Other means
o Secondary effect
Fourth-Digit Codes for Many E Codes in ICD-9-CM:
• Identify the injured person
• All fourth-digit codes, defined by section, appear at the end of the ICD-9-CM Alphabetic Index to External Causes
• Fourth-digit codes also appear in the ICD-9-CM Tabular List at the section or category level
Fourth-digit subdivisions are specific to:
o Railway Accidents (E800-E807)
o Motor Vehicle Traffic and Nontraffic Accidents (E810-E825)
o Other Road Vehicle Accidents (E826-E829)
o Water Transport Accidents (E830-E838)
o Air and Space Transport Accidents (E840-E845)
Late Effect E Codes in ICD-9-CM:
• When the condition being coded is a late effect of an illness or injury, the E code for the late effect is assigned rather than a current event
ICD-9-CM Late effect E codes:
• E929, Late effects of accidental injury
• E959, Late effects of self-inflicted injury
• E969, Late effects of injury purposely inflicted by other persons
• E977, Late effects of injury due to legal intervention
• E989, Late effects of injury, undetermined whether accidentally or purposely inflicted
• E999, Late effect of injury due to war operations
A few things to remember about later effects:
• Late effect E codes exist for injuries and poisonings in ICD-9-CM
• There are no late effect E codes for adverse effects of drugs, misadventures, and surgical complications in ICD-9-CM
Guidelines for late effects:
• A late effect E code (E929, E959, E977, E989, E999) should be used with any report of a late effect resulting from a previous injury or poisoning with ICD-9-CM
• Late effect E codes are used with diagnosis codes for the late effect (905-909) with ICD-9-CM
• A late effect E code should never be used with a related current nature of injury code in ICD-9-CM
• 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 in ICD-9-CM
• Do not use a late effect E code for subsequent visits for follow up care (for example, to assess healing or to receive rehabilitation therapy) of the injury or poisoning when no late effect of the injury has been documented
ICD-9-CM Coding of Late Effects:
1. Code the residual effect or the condition the patient has at present
o This condition is found in the ICD-9-CM Alphabetic Index to Diseases
2. Code the late effect or the condition the patient originally had that produced the residual
o The late effect code is found in the ICD-9-CM Alphabetic Index to Diseases under the main term "Late, effect"
3. Assign an E code for the late effect of the original accident or event
o The late effect E code is found in the ICD-9-CM Index to External Causes under the main term "Late, effect"
• External cause codes to identify the occurrence of wrong site surgery, wrong surgery and wrong patient having surgery
• Never events are a list of adverse medical events that are serious but largely preventable and of concern to patients and healthcare providers
• Joint Commission, Federal government and state governments use the never events list as the basis of quality indicators and state-based reporting systems
• National Quality Forum's "Never Events"
• Federal government's Department of Health and Human Services' Agency for Healthcare Research and Quality.
E Codes in ICD-9-CM for Never Events:
o Foreign object left in body during procedure
• E876.5 Performance of wrong operation on correct patient
o Wrong surgery
• E876.6 Performance of operation on patient not scheduled for surgery
o Wrong patient having surgery
• E876.7 Performance of correct operation on wrong side/body part
o Wrong site surgery
ICD-9-CM External Cause Status:
• E000 codes are used with external cause codes to indicate the status of the person at the time the event occurred.
• A single code from category E000 should be assigned for an encounter
Activity E Codes in ICD-9-CM
• Activity E Codes, E000-E030, indicate the activity of the person seeking healthcare for an injury or health condition in ICD-9-CM
• E000-E030 codes are appropriate for use for both acute injuries, such as those in Chapter 17 of ICD-9-CM, and conditions that are due to long-term cumulative effects of an activity, such as those in Chapter 13 of ICD-9-CM.
• Activity E codes in ICD-9-CM should be used in conjunction with other external cause codes for cause and intent if identifying the activity provides additional information on the event
• Activity E codes in ICD-9-CM should be used in conjunction with other external cause codes for external cause status (E000) and place of occurrence (E849)
Activity E codes in ICD-9-CM identify a wide range of activities, for example:
o Walking and running
o Sports and athletics
o Computer technology and electronic devices
o Arts and handcrafts
o Personal hygiene and household maintenance
o Food preparation
o Property and land maintenance, building and construction
• Requested by U. S. Department of Defense
• Identification of the cause of injuries among the military population to assist with the prevention of such injuries
• Among the air, space, and water transport vehicles listed, a fourth digit is used to identify a military type vehicle involved in a transport accident
• ICD-9-CM categories E990-E999, Injuries resulting from operations of war
• Applies to injuries to military personnel and civilians caused by war and civil insurrections and occurring during the time of war and insurrection, and peacekeeping missions.
• Examples include injury from fragments from vehicle-borne improvised explosive device (IED), sea-based artillery shell, mortar, destruction of aircraft from enemy fire, etc.
External cause of injury codes in ICD-10-CM appear in Chapter 20, External Causes of Morbidity, in the range of codes V00-Y99
• External cause codes start with characters V, W, X, and Y
• These are used as additional codes to follow a code from another chapter that indicates the nature of the injury or condition
• External cause of injury codes in ICD-10-CM appear in Chapter 20, External Causes of Morbidity, in the range of codes V00-Y99
the cause of injury or health condition, the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event, and the person's status (namely, civilian, military.)
Coding Guidelines and Instructional Notes for Chapter 20, External Causes of Morbidity
• New notes have been added to show which categories require the 7th character extensions to indicate whether the episode of care being identified was the initial, subsequent, or the condition is a result of an event or sequelae
• The 7the character to be added are:
A - Initial encounter
D - Subsequent encounter
S - Sequela
• Category Y92, Place of occurrence of the external cause, is used in conjunction with activity code
• The activity code from category Y93 indicates the activity of the person seeking healthcare for an injury or health condition
Chapter-specific guidelines were published for Chapter 20 addressing:
o General external cause coding guidelines
o Place of occurrence guideline
o Activity code
o Place of occurrence, activity, and status codes used with other external cause code
o If the reporting format limits the number of external cause codes
o Multiple external cause coding guidelines
o Child and adult abuse guideline
o Unknown or undetermined intent guideline
o Late effects of external cause guidelines
o Terrorism guidelines
o External cause status
Coding Overview for Chapter 20, External Causes of Morbidity
• External cause codes are intended to be used as a secondary code with another code from other chapters in ICD-10-CM
• Most often, the condition will be coded from Chapter 19, Injury, poisoning and certain other consequences of external causes (S00-T88)
• The Chapter 20 codes provide additional information as to the cause of the condition.
• External cause codes contain the 1st character of V, W, X and Y
• These codes are a massive expansion of codes compared to ICD-9-CM
• A review of the Tabular List helps the coder gain an understanding of all of the possible codes available
Coding Overview for Chapter 20, External Causes of Morbidity CONTINUED...
• ICD-10-CM contain an Index to External Causes with main terms identify the event
• Such entries are accident, drowning, exposure, forces of nature, falling, slipping, and other events that can cause an injury
• Other entries exist for assignment of the activity of the person, place of occurrence and status of external cause, such as civilian, leisure, or student activity
• Many, but not all, of the V00-Y99 codes require a 7th character to indicate whether the healthcare encounter was the initial encounter (A), subsequent encounter (D), or sequela (S).
• Late effects of external causes of morbidity in ICD-10-CM are reported using the external cause code with the 7th character of S for sequela. These codes are used with any report of a later effect or sequela resulting from a previous injury
• Certain external cause codes are only used once at the initial encounter:
o The place of occurrence
o The activity code(s)
• The transport accident section V00-V99) is structure in 12 groups• Land transport accidents reflect the victim's mode of transport, and are subdivided to identify the victim's counterpart or the type of event
• The vehicle of which the injured person is an occupant is identified by the first 2 characters since it is seen as the most important factor to identify for prevention purposes.
• A transport accident is one in which the vehicle involved must be moving or running or in use for transport purposes at the time of the accident
• The definitions of transport vehicles are provided in the ICD-10-CM book and should be reviewed
• Examples of the Chapter 20 blocks include
o V00-V99, Transport accidents
o W00-W19, Slipping, tripping, stumbling and falls
o W20-W49, Exposure to inanimate mechanical forces
o W50-W64, Exposure to animate mechanical forces
o X00-X08, Exposure to smoke, fire and flames
o X10-X19, Contact with heat and hot substances
o X71-X83, Intentional self harm
o X92-Y08, Assault
o Plus numerous other blocks of codes
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