Injuries Documentation

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Sep 17th, 2015 - Reviewed/Updated Aug 7th

ICD-9 used separate “E codes” to record external causes of injury. ICD-10 better incorporates these codes and expands sections on poisonings and toxins.

When documenting injuries, include the following:

1. Episode of Care e.g. Initial, subsequent, sequelae

2. Injury site Be as specific as possible

3. Etiology How was the injury sustained (e.g. sports, motor vehicle crash, pedestrian, slip and fall, environmental exposure, etc.)?

4. Place of Occurrence e.g. School, work, etc. Initial encounters may also require, where appropriate:    

  1. Intent e.g. Unintentional or accidental, self-harm, etc. 2. Status e.g. Civilian, military, etc.

  2. Status e.g. Civilian, military, etc.

Example 1: A left knee strain injury that occurred on a private recreational playground when a child landed incorrectly from a trampoline:

• Injury: S86.812A, Strain of other muscle(s) and tendon(s) at lower leg level, left leg, initial encounter

• External cause: W09.8xxA, Fall on or from other playground equipment, initial encounter

• Place of occurrence: Y92.838, Other recreation area as the place of occurrence of the external cause

• Activity: Y93.44, Activities involving rhythmic movement, trampoline jumping

Example 2: On October 31st, Kelly was seen in the ER for shoulder pain and X-rays indicated there was a fracture of the right clavicle, shaft. She returned three months later with complaints of continuing pain. X-rays indicated a nonunion.

The second encounter for the right clavicle fracture is coded as S42.021K, Displaced fracture of the shaft of right clavicle, subsequent for fracture with nonunion.