Q. When coding the craniotomy/burr hole procedure, is there any additional code needed if the patient has a subdural drain left in after surgery?

ICD-10 Q&A

Disclaimer: All of the ICD-10 codes within this document were chosen by PTSF registry staff and reflect our opinion of the best code using standard ICD-10-CM/PCS guidelines and coding norms. As all good coders and trauma registrars do, you are more than welcome to disagree with any of the information contained in this document.
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(3/17/2016)

Q. When coding the craniotomy/burr hole procedure, is there any additional code needed if the patient has a subdural drain left in after surgery?
Answer: Craniotomy of the subdural space should be coded to 0094_0Z. Be sure to select 0 for the sixth character in this situation. Since character 6 is drainage device, no additional code is needed if a subdural drain is left in after surgery. Please note that table 009 takes up multiple pages. Be certain you are on the correct page of table 009 in ICD-10-PCS.
Q. When coding meniscectomy, what is the most appropriate code? Table OSB or table OST?
Answer: The alphabetic index of ICD-10-PCS directs users to table 0SB when looking up the main term meniscectomy. Table OSB (excision) should be used since the meniscus is a portion of the knee joint.
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(3/10/2016)

Q. List B of the PTOS Manual codes FAST exam to BW40ZZZ. Would BW41ZZZ fit better?
Answer: There is not a specific code for FAST in ICD-10. PTSF staff recommends coding BW40ZZZ and the appropriate code from table B24 based on your documentation. If your documentation states the FAST was extended to the pelvis, you may use BW41ZZZ instead of BW40ZZZ. Per the American College of Emergency Physicians (ACEP), there is no single, defined code for the clinical FAST exam. Rather, the exam is reportable as either two or three distinct limited ultrasound examinations. The cardiac component of the exam is coded to transthoracic echocardiogram. The abdominal component of the exam is coded to abdominal ultrasound. The thoracic component (e.g. hemothorax or pneumothorax evaluation, if performed) of the exam is coded to chest ultrasound. The PTOS manual will be updated accordingly.
Q. Should code 0WJP7ZZ be coded for re-exploratory laparotomy?
Answer: PTSF staff agrees with code 0WJP7ZZ.
Q. What procedure code would we use if there were no procedures done during the patient’s stay?
Answer: If no procedures are performed during the acute care phase, please select ‘n/a’ from procedure code drop-down. Please refer to page 95 of the 2016 PTOS manual.
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(3/3/2016)

Q. If a patient receives a CT scan with contrast and a CT scan without contrast of a specified body part, does PTOS still only want the first CT per body region or both since they are different codes?
Answer: This question will be discussed further at the Trauma Registry Committee in March 2016.
Q. A young child puts a piece of a plastic toy in his mouth, is running, falls and the plastic toy strikes the back of the patient’s throat. What is the correct mechanism of injury code?
Answer: In this situation, PTSF staff recommends W01.198A (fall on same level from slipping, tripping and stumbling with subsequent striking against other object).
Q. What is the correct code for a patient that has hurt themselves by “stretching” or doing “strenuous movements?”
Answer: In this situation, PTSF staff recommends X58.XXXA (exposure to other specified factors, accident NOS).
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(2/23/16)

Q. When coding central lines, are we to code where the line was inserted (right jugular) or where the tip terminates (superior vena cava)?
Answer: Percutaneous placement of venous central line in right internal jugular, with tip in superior vena cava should be coded to 05HM33Z and 02HV33Z.
Q. How would you code right-sided frontotemporoparietal decompressive hemicraniectomy (burr holes) with evacuation of an acute subdural hematoma? Are we to only code the evacuation of the SDH?
Answer: In this situation, only the evacuation of the acute subdural hematoma needs to be coded (00940ZZ).
Q. What ICD-10 code would I use for ct pelvis, no contrast?
Answer: CT of the pelvis without contrast should be coded to BW2GZZZ (pelvic region), BR2CZZZ (pelvic bones only), or BW21ZZZ (pelvis and abdomen). Select the most appropriate code based on your documentation.
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(2/18/2016)

Q. What is the correct code for interosseous line placement of the R lower leg? Would you also code the infusion?
Answer: In this situation the PTSF recommends 0YHH33Z (insertion, R lower leg, percutaneous, infusion device) and 3E0A3GC (introduction, bone marrow, percutaneous, therapeutic substance, other substance). The PTSF has also submitted this question to Coding Clinic for guidance to determine if both codes should be coded.
Q. What is the correct code for a wound vac?
Answer: This is no code for wound vac in ICD-9 or ICD-10. You must code the procedure(s) performed, such as inspection.
Q. A patient was burned when Freon leaked out of a refrigerator and onto the patient’s skin. Is W93.8XXA the appropriate code? There is also a T code for Freon. Should this code be used? When is it appropriate to use a T code for the primary mechanism injury?
Answer: PTSF staff agrees that W93.8XXA is the appropriate code in this situation. The T code is not required in this situation, but may be recorded as the secondary mechanism. T codes can be recorded as the primary mechanism by coding guidelines. The registry committee will discuss T codes as primary mechanisms further at the Trauma Registry Committee meeting in February 2016.
Q. A patient was snowboarding at high speed and the board “kicked up” and hit the patient causing the patient to fall. Would this be coded to V00.311A (fall from snowboard) or V00318A (other snowboard accident)?
Answer: PTSF staff recommends V00.311A (fall from snowboard) in this situation.
Q. Is there a code for pelvic binders?
Answer: The PTSF recommends 0QS2XZZ and 0QS3XZZ. PTSF has also submitted this questions to Coding Clinic for further guidance.
Q. What is the correct code for CT Angio Abd and Pelvis w/wo Contrast?
Answer: ICD-10 does not seem to have specific codes for CTAs. PTSF staff has submitted this question to Coding Clinic and is awaiting a response. Once a response is received, it will be posted here.
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(2/16/2016)

Q. A patient had fracture of 2 left ribs and went to the OR for plating of those ribs. The ICD10 PCS code used is 0PS204Z – Reposition left rib with internal fix, open approach. Since the word “rib” does not address more than one left rib, do I enter the code twice for the single operation that plated two ribs?
Answer: PTSF staff recommend coding 0PS204Z once in this situation. Please refer to guideline B3.2 for scenarios in which more than one procedure should be coded.
Q. CT –angio’s are done at our facility but we don’t see codes with “angio” in any of the ICD-10 imaging codes. Are there specific codes for these?
Answer: ICD-10 does not seem to have specific codes for CTAs. PTSF staff has submitted this question to Coding Clinic and is awaiting a response. Once a response is received, it will be posted here.
Q. If the ED or Ortho physician at the referring facility documents “attempted reduction of a fracture,” should this be coded within the referring facility procedures?
Answer: Per guideline B3.3, “If the intended procedure is discontinued, code the procedure to the root operation performed. If a procedure is discontinued before any other root operation is performed, code the root operation inspection of the body part or anatomical region inspected.” The attempted reduction is not required to be captured; however, if you choose to capture this, code to inspection of the body part.
Q. What is the ICD-10 code for MRA of the neck?
Answer: For the time being, PTSF recommends coding BW3F_ _Z for Magnetic Resonance Angiogram (MRA) of the Neck. PTSF staff has also submitted this question to Coding Clinic and is awaiting a response. Once a response is received, it will be posted here.
Q. What is the ICD-10 code for MRA of the head without contrast?
Answer: For the time being, PTSF recommends coding BW38ZZZ for Magnetic Resonance Angiogram (MRA) of the head without contrast. PTSF staff has also submitted this question to Coding Clinic and is awaiting a response. Once a response is received, it will be posted here.
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(2/9/2016)

Q. What is the place of occurrence code for a homeless shelter?
Answer: The PTSF recommends Y92.19_ (other specified residential institution). Record the appropriate sixth digit to specify the location within the shelter.
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(2/4/2016)

Q. What is the best ICD-10 code for open reduction and internal fixation of right bimalleolar ankle fracture?
Answer: In this situation both 0QSJ04Z and 0QSG04Z should be coded.
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(2/2/2016)
Q. What is the correct ICD-10 code for a patient smoking while on oxygen that sustains burns to the skin from a flash? Would we use W40.1 (explosion of explosive gas) or X04 (ignition of highly flammable material)?
Answer: X04.XXXA is the appropriate ICD-10 code in this situation.
Q. Would a box truck (ie delivery truck or moving truck that people rent) be considered a transport vehicle (o)?
Answer: Yes, a box truck would fall under transport vehicle (o). Please refer to the beginning of category V00-V99 in your ICD-10 coding book for definitions of transport vehicles.
Q. How should a CT scan done on a patient at an outside facility that we cannot get information on the type of contrast or if contrast was used be coded?
Answer: The PTSF recommends that you code Z, none when information regarding contrast is unknown.
Q. How would you code an escharotomy in a burn patient on multiple sites?
Answer: An excisional escharotomy or excisional debridement of the skin should be coded to table 0HB. Assuming the escharotomy in this example is excisional, it should be coded to 0HB_ _ZZ. Multiple codes may have to be recorded to capture multiple body parts.
Q. How would the following scenario be coded?

The neck laceration was inspected. We verified that the platysma had not been violated. We then inspected to borders of the laceration which we found to be irregular. The edges were trimmed with tenotomy scissors to provide better approximation. The superficial fascia was then reapproximated with simple interrupted 3-0 vicryl sutures. The skin was closed with 4-0 nylon sutures in a vertical mattress fashion. The incision was dressed with bacitracin, xeroform, a 4x4, and a tegaderm. Drapes were then removed and the wrists prepped and draped.
Answer: Based on the information provided, the PTSF recommends coding 0JQ_0ZZ. The ICD-10 code for inspection should not be included. The root operation inspection represents procedures where the sole objective is to examine a body part. Inspection is not coded separately for procedures that are continued with any other root operation being performed. Also according to guideline B3.11a, inspection of a body part(s) performed in order to achieve the objective of a procedure is not coded separately.

Q. Do we always try to code to a body part if possible vs a region?
Answer: A specific body part should be coded instead of an anatomical region if documented. However, typically in trauma not one specific body part is examined. An entire anatomical region will be examined to diagnose an injury. For example, the entire arm will be x-rayed, not just the humerus. This question has also been submitted to Coding Clinic for further explanation.
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(1/28/2016)
Q. What is the best ICD-10 code for injured hand in snow blower?
Answer: The best ICD-10 code in this situation is W29.3XXA.
Q. If a patient falls out of bed and strikes an object such as a table, should we be coding both the fall from bed and striking an object?
Answer: At this time there is no single code in ICD-10 for a fall from other level and striking an object. In this situation code W06.XXA for the fall from bed and then W22.09 to capture striking against other stationary object. Since you have two codes to record, code the mechanism which resulted in the most severe injury first.
Q. Is V48.5XXA the correct ICD-10 code for a vehicle that ran off the road into a ditch?
Answer: Yes, V48.5XXA is the correct code for a car driver that is injured due to driving off the road into a ditch.
Q. Is X08.8 the appropriate code for a burning by an exploding e-cigarette?
Answer: The PTSF recommends coding W40.9 in this situation. W40.9 is the ICD-10 code for explosion NOS and should be used since “exploding” is used within the documentation. X08.8 is the appropriate code for a burn to the face. If the e-cigarette caught on fire and burned the patient, this code could be appropriate. However, in this situation it appears the e-cigarette physically exploded.
Q. Is there a specific ICD-10 code for ECHO? Should separate codes be used for heart, arteries, and pericardium?
Answer: ECHO ICD-10 codes can be found in table B24. If the entire heart is being examined, code B246_Z_. Select the appropriate 5^th and 7^th characters based on your documentation. You would also not have to code the coronary arteries or pericardium separately.
Q. The PTSF has recommended that BW0_ZZZ be used for plain film x-rays. What is difference between BW0 and BN0, BP0, or BQ0 codes for plain radiography?
Answer: Table BW0 is plain radiography of anatomical regions. Tables BN0, BP0 and BQ0 are tables containing codes for plain radiography of specific body parts. Typically, in trauma care an entire anatomical region will be x-rayed to determine the appropriate diagnosis. For example, the entire lower extremity will be x-rayed, not specifically the femur. If you have the appropriate detail in your documentation that a specific body part is the only focus of the plain radiography, you are able to use the codes for specific body parts.
Q. What is the correct ICD-10 code for a bar/tavern?
Answer: The correct ICD-10 code for a bar/tavern is Y92.511.
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(1/21/2016)
Q. What is the correct ICD-10 code for a hip arthroplasty with a Zimmer 10mm extended -offset, proximal coated Press-fit; a 28 mm inner liner; a 48-mm liner; negative -3 femoral head?
Answer: Based on the information provided, we recommend navigating to table 0SR and determining the correct body part, device and qualifier based on your documentation.
Q. What is the correct ICD-10 code for a Spica cast and a Pavlik Harness?
Answer: The correct ICD-10 code for a Spica Cast and a Pavlik Harness is 2W3_X_Z. Select the appropriate body part and device based on your documentation. The 6th character (Device) should be recorded as 2, cast for the Spica Cast and Y, Other Device for the Pavlik Harness.
Q. What is the correct ICD-10 code for CT of the thorax without contrast?
Answer: The correct ICD-10 code for CT of the thorax without contrast is BW24ZZZ. We recommend that BP2W_ZZ not be used. This table is used for CT’s in which a specific bone or bones are being looked at. A CT of the thorax in trauma is typically looking at a certain anatomical region in general.
Q. What is the correct ICD-10 code for chest needle decompression?
Answer: Needle decompression of the chest should be coded to OW9B3ZZ. In the alphabetic index both “thoracentesis” and “thoracotomy” will direct you to table OW9. Within the alphabetic index, “throacostomy” will direct you to table 0B9. This table should only be used when a drainage device is used.
Q. Does ICD-10 separate CT vs CTA?
Answer: When coding in ICD-10 it appears that code BW291ZZ should be used for both CT and CTA of the head and neck. ICD-10 does not seem to have a separate code for CTA or “other tomography.” PTSF staff is verifying this response with coding clinic. Once a response is received, it will be posted here.
When coding in ICD-9 the PTSF instructed PA trauma centers to utilize 87.04 for CTA of the head and/or neck. A separate code of 87.03 was utilized for CT of the head. Please note that code 87.04 is used for “other tomography,” not just CTAs in ICD-9. Therefore, ICD-9 did not have a specific code for CTAs either.
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(1/19/2016)
Q. We used to utilize ICD-9 code 88.39 to record all x-rays taken at a referring facility. Do we now have to code every x-ray that was performed at a referring facility?
Answer: Each ICD-10 anatomical region x-rayed at the referring facility should be coded to BW0_ZZZ using the appropriate 4^th character.
Q. What is the correct ICD-10 code for CT scan of the facial bones?
Answer: The correct ICD-10 code for CT scan of the facial bones is BN25_ZZ using the appropriate 5^th character.
Q. When coding head and neck CT’s, should we be coding head and neck (combination code) or head and C-spine (two separate codes)?
Answer: If the CT encompasses the entire anatomic region, which in trauma it typically does, we recommend using a combination code. Therefore, BW29_ _Z would be appropriate.
Q. What is the correct ICD-10 code for a PICC line insertion?
Answer: The insertion of a PICC line is not required to be captured by the PTSF. If recording the insertion, we recommend using the 05H, 06H or 0JH tables.
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(1/14/2016)
Q. What is the correct ICD-10 code for an exploratory laparotomy for inspection of upper, lower, and mesentery?
Answer: The correct ICD-10 code in this situation is 0WJG_ZZ.
Q. What is the correct ICD-10 code for an accident NOS or a specified injury NEC?
Answer: The correct ICD-10 code for Accident NOS or specified injury NEC is X58.XXXA.
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(1/12/2016)
Q. Should the T code for child abuse (T74.12XA) be recorded in the Primary ICD-10 Mechanism field? If not, which code should be used for child abuse?
Answer: For cases of confirmed abuse or neglect an external cause code from the assault section (X92-Y08) should be recorded in the Primary ICD-10 Mechanism field to identify the cause of any physical injuries. The appropriate “T” code, T74 for confirmed abuse or T76 for suspected abuse, should be recorded in the Secondary ICD-10 Mechanism field. This question will be discussed further at the Trauma Registry Committee in February 2016.
Q. What is the difference between an assault code and an abuse code?
Answer: In order to code abuse it must be documented as suspected or confirmed within the medical record. If you are unsure whether or not to code abuse or assault, look for specific documentation of abuse within the medical record, multiple visits, or old contusions or abrasions that may alert you to suspect abuse as opposed to assault. Query the physician if you are suspicious of abuse but do not see documentation of confirmed or suspected abuse within the medical record.
Q. ICD-10 code BW251ZZ includes CT of the chest, abdomen and pelvis. In ICD-9 these were coded separately. Should these be coded separately in ICD-10 as well?
Answer: PTSF staff recommends that the combination code BW25_ _Z be used to code CT of the chest, abdomen and pelvis. They should not be coded separately. This question will be discussed further at the Trauma Registry Committee meeting in February 2016.
Q. Is there an ICD-10 code for CT of the chest?
Answer: Per convention A10, “and,” when used in a code description, means “and/or.” Therefore, the correct ICD-10 code for CT of the chest is BW24_ _Z. You must select the correct contrast (character 5) and qualifier (character 6) based on your documentation.
Q. Should the ICD-10 code for CT of the thorax be used in addition to the ICD-10 code for CT of the chest, abdomen and pelvis when thorax is stated within the dictation?
Answer: PTSF staff recommends that you do not include an additional code for CT of the thorax in this situation. Code only BW25_ _Z for the CT of the chest, abdomen and pelvis.
Q. What is the correct code for an orogastric tube placed on an intubated patient for drainage?
Answer: The correct ICD-10 code in this situation is OD9_ _ _ _. The body part, approach, device and qualifier must be determined based on your documentation.
Q. What is the correct ICD-10 code for a fall from a hover board?
Answer: The correct ICD-10 code in this situation is V00.181A.

Q. What is the correct ICD-10 code for internal cardiac massage?
Answer: The correct ICD-10 code in this situation is 02QA0ZZ. The root operation repair involves restoring the body part to its normal function.
Q. What is the correct ICD-10 code for a CTA of upper extremity (L) brachial artery?
Answer: This question was taken to Coding Clinic on 1/12/2016. Once a response is received, the answer will be posted here.
Q. What is the correct ICD-10 code for placement of an IVC filter with direct ultrasound guidance, percutaneous, with infusion device?
Answer: The correct ICD-10 code in this situation is 06H03DZ. An additional code for ultrasound guidance is not needed.
Q. For ICD-10 code B54DZZ_, what does the 7^th character qualifier “Intravascular” mean?
Answer: Intravascular ultrasound (IVUS) is a medical imaging methodology using a specially designed catheter with a miniaturized ultrasound probe attached to the distal end of the catheter. The proximal end of the catheter is attached to computerized ultrasound equipment. If this technique was used, record 3, intravascular as the 7^th character qualifier.
Q. Should we be coding all CT scans in ICD-10 now that there are specific codes for other body parts/regions?
Answer: PTSF staff recommends that you code all CT scans using the specific appropriate code(s) in ICD-10. This question will be discussed further at the Trauma Registry Committee meeting in February 2016.