There is important information that must be included when documenting injuries and external cause codes in ICD-10-CM. There are expanded sections on poisonings and toxins making it more convenient to code, as ICD-10-CM is very specific.
When using a code from Chapter 19 (Injury, Poisoning and Certain other Consequences of External Causes (S00-T88)), consider also using a secondary code from Chapter 20 (External Causes of Morbidity) to clearly report the cause of injury.
You must also report a code to identify any retained foreign body if applicable to the injury (Z18.-).
If you are coding from section T, it is not necessary to use an additional external cause code.
These rules exclude birth trauma (P10-P15) or obstetric trauma (O70-O71).
When documenting injuries, include the following:
Episode of care (e.g., initial, subsequent, sequela)
Injury site: Be as specific as possible
Etiology: How was the injury sustained? (e.g., sports, motor vehicle crash, pedestrian, slip and fall, environmental exposure, etc.)
Place of Occurrence (POA) (e.g., school, work, etc.) - Note that initial encounters may also require, where appropriate:
Intent (e.g., unintentional or accidental, self-harm, etc.)
Status (e.g., civilian, military, etc.)
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