Burns, Adverse Effects, and Poisonings
(ICD-10-CM Chapters 19 and 20, Codes S00-Y99)
Learning Objectives
2. Identify the various types of burns
3. Differentiate between an adverse effect and a poisoning
6. Explain the importance of documentation in relation to MS-DRGs for reimbursement
Abbreviations/Acronyms
COPD chronic obstructive pulmonary disease
HBOT Hyperbaric oxygen therapy
ICD-9-CM International Classification of Diseases, 9th Revision, Clinical Modification
ICD-10-CM International Classification of Diseases, 10th Revision, Clinical Modification
ICD-10-PCS International Classification of Diseases, 10th Revision, Procedure Coding System
MS-DRG Medicare Severity diagnosis-related group
SIRS systemic inflammatory response syndrome
ICD-10-CM Official Guidelines for Coding and Reporting
Please refer to the companion Evolve website for the most current guidelines.
19. Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88)
d. Coding of Burns and Corrosions
The ICD-10-CM makes a distinction between burns and corrosions. The burn codes are for thermal burns, except sunburns, that come from a heat source, such as a fire or hot appliance. The burn codes are also for burns resulting from electricity and radiation. Corrosions are burns due to chemicals. The guidelines are the same for burns and corrosions.
Current burns (T20-T25) are classified by depth, extent and by agent (X code). Burns are classified by depth as first degree (erythema), second degree (blistering), and third degree (full-thickness involvement). Burns of the eye and internal organs (T26-T28) are classified by site, but not by degree.
1) Sequencing of burn and related condition codes
Sequence first the code that reflects the highest degree of burn when more than one burn is present.
2) Burns of the same local site
Classify burns of the same local site (three-character category level, T20-T28) but of different degrees to the subcategory identifying the highest degree recorded in the diagnosis.
3) Non-healing burns
Non-healing burns are coded as acute burns.
Necrosis of burned skin should be coded as a non-healed burn.
4) Infected Burn
For any documented infected burn site, use an additional code for the infection.
5) Assign separate codes for each burn site
When coding burns, assign separate codes for each burn site. Category T30, Burn and corrosion, body region unspecified is extremely vague and should rarely be used.
6) Burns and Corrosions Classified According to Extent of Body Surface Involved
Assign codes from category T31, Burns classified according to extent of body surface involved, or T32, Corrosions classified according to extent of body surface involved, when the site of the burn is not specified or when there is a need for additional data. It is advisable to use category T31 as additional coding when needed to provide data for evaluating burn mortality, such as that needed by burn units. It is also advisable to use category T31 as an additional code for reporting purposes when there is mention of a third-degree burn involving 20 percent or more of the body surface.
Categories T31 and T32 are based on the classic “rule of nines” in estimating body surface involved: head and neck are assigned nine percent, each arm nine percent, each leg 18 percent, the anterior trunk 18 percent, posterior trunk 18 percent, and genitalia one percent. Providers may change these percentage assignments where necessary to accommodate infants and children who have proportionately larger heads than adults, and patients who have large buttocks, thighs, or abdomen that involve burns.
7) Encounters for treatment of sequela of burns
Encounters for the treatment of the late effects of burns or corrosions (i.e., scars or joint contractures) should be coded with a burn or corrosion code with the 7th character “S” for sequela.
8) Sequelae with a late effect code and current burn
When appropriate, both a code for a current burn or corrosion with 7th character “A” or “D” and a burn or corrosion code with 7th character “S” may be assigned on the same record (when both a current burn and sequelae of an old burn exist). Burns and corrosions do not heal at the same rate and a current healing wound may still exist with sequela of a healed burn or corrosion.
9) Use of an external cause code with burns and corrosions
An external cause code should be used with burns and corrosions to identify the source and intent of the burn, as well as the place where it occurred.
e. Adverse Effects, Poisoning, Underdosing and Toxic Effects
Codes in categories T36-T65 are combination codes that include the substance that was taken as well as the intent. No additional external cause code is required for poisonings, toxic effects, adverse effects and underdosing codes.
A code from categories T36-T65 is sequenced first, followed by the code(s) that specify the nature of the adverse effect, poisoning, or toxic effect. Note: This sequencing instruction does not apply to underdosing codes (fifth or sixth character “6”, for example T36.0x6-).
1) Do not code directly from the Table of Drugs
Do not code directly from the Table of Drugs and Chemicals. Always refer back to the Tabular List.
2) Use as many codes as necessary to describe
Use as many codes as necessary to describe completely all drugs, medicinal or biological substances.
3) If the same code would describe the causative agent
If the same code would describe the causative agent for more than one adverse reaction, poisoning, toxic effect or underdosing, assign the code only once.
4) If two or more drugs, medicinal or biological substances
If two or more drugs, medicinal or biological substances are reported, code each individually unless a combination code is listed in the Table of Drugs and Chemicals.
5) The occurrence of drug toxicity is classified in ICD-10-CM as follows:
(a) Adverse Effect
When coding an adverse effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug (T36-T50). The code for the drug should have a 5th or 6th character “5” (for example T36.0X5-) Examples of the nature of an adverse effect are tachycardia, delirium, gastrointestinal hemorrhaging, vomiting, hypokalemia, hepatitis, renal failure, or respiratory failure.
(b) Poisoning
When coding a poisoning or reaction to the improper use of a medication (e.g., overdose, wrong substance given or taken in error, wrong route of administration), first assign the appropriate code from categories T36-T50. The poisoning codes have an associated intent as their 5th or 6th character (accidental, intentional self-harm, assault and undetermined. Use additional code(s) for all manifestations of poisonings.
If there is also a diagnosis of abuse or dependence of the substance, the abuse or dependence is assigned as an additional code.
Examples of poisoning include:
(i) Error was made in drug prescription
Errors made in drug prescription or in the administration of the drug by provider, nurse, patient, or other person.
(ii) Overdose of a drug intentionally taken
If an overdose of a drug was intentionally taken or administered and resulted in drug toxicity, it would be coded as a poisoning.
(iii) Nonprescribed drug taken with correctly prescribed and properly administered drug
If a nonprescribed drug or medicinal agent was taken in combination with a correctly prescribed and properly administered drug, any drug toxicity or other reaction resulting from the interaction of the two drugs would be classified as a poisoning.
(iv) Interaction of drug(s) and alcohol
When a reaction results from the interaction of a drug(s) and alcohol, this would be classified as poisoning.
See Section I.C.4. if poisoning is the result of insulin pump malfunctions.
(c) Underdosing
Underdosing refers to taking less of a medication than is prescribed by a provider or a manufacturer’s instruction. For underdosing, assign the code from categories T36-T50 (fifth or sixth character “6”).
Codes for underdosing should never be assigned as principal or first-listed codes. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose, then the medical condition itself should be coded.
Noncompliance (Z91.12-, Z91.13-) or complication of care (Y63.61, Y63.6-Y63.9) codes are to be used with an underdosing code to indicate intent, if known.
(d) Toxic Effects
When a harmful substance is ingested or comes in contact with a person, this is classified as a toxic effect. The toxic effect codes are in categories T51-T65.
Toxic effect codes have an associated intent: accidental, intentional self-harm, assault and undetermined.
f. Adult and child abuse, neglect and other maltreatment
Sequence first the appropriate code from categories T74.- (Adult and child abuse, neglect and other maltreatment, confirmed) or T76.- (Adult and child abuse, neglect and other maltreatment, suspected) for abuse, neglect and other maltreatment, followed by any accompanying mental health or injury code(s).
If the documentation in the medical record states abuse or neglect it is coded as confirmed (T74.-). It is coded as suspected if it is documented as suspected (T76.-).
For cases of confirmed abuse or neglect an external cause code from the assault section (X92-Y08) should be added to identify the cause of any physical injuries. A perpetrator code (Y07) should be added when the perpetrator of the abuse is known. For suspected cases of abuse or neglect, do not report external cause or perpetrator code.
If a suspected case of abuse, neglect or mistreatment is ruled out during an encounter code Z04.71, Encounter for examination and observation following alleged physical adult abuse, ruled out, or code Z04.72, Encounter for examination and observation following alleged child physical abuse, ruled out, should be used, not a code from T76.
If a suspected case of alleged rape or sexual abuse is ruled out during an encounter code Z04.41, Encounter for examination and observation following alleged physical adult abuse, ruled out, or code Z04.42, Encounter for examination and observation following alleged rape or sexual abuse, ruled out, should be used, not a code from T76.
See Section I.C.15. Abuse in a pregnant patient.
20. Chapter 20: External Causes of Morbidity (V01-Y99)
g. Child and Adult Abuse Guideline
Adult and child abuse, neglect and maltreatment are classified as assault. Any of the assault codes may be used to indicate the external cause of any injury resulting from the confirmed abuse.
For confirmed cases of abuse, neglect and maltreatment, when the perpetrator is known, a code from Y07, Perpetrator of maltreatment and neglect, should accompany any other assault codes.
See Section I.C.19. Adult and child abuse, neglect and other maltreatment
Apply the General Coding Guidelines as found in Chapter 5 and the Procedural Coding Guidelines as found in Chapters 6 and 7.
At the beginning of Chapter 19 in the ICD-10-CM code book, special instructions say, “Use secondary code(s) from Chapter 20 to indicate cause of injury” (Figure 24-1).
Anatomy and Physiology
All areas of the body may be involved in an injury. These are outlined in their respective body system chapters.
Disease Conditions
Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88), Chapter 19 in the ICD-10-CM code book, is divided into the following categories:
| CATEGORY | SECTIDN TITLES |
| T20-T32 | Burns and corrosions |
| T33-T34 | Frostbite |
| T36-T50 | Poisoning by, adverse effect of, and underdosing of drugs, medicaments, and biological substances |
| T51-T65 | Toxic effects of substances chiefly nonmedicinal as to source |
| T66-T78 | Other and unspecified effects of external causes |
ICD-10-CM creates a distinction between burns and corrosions. Burns codes are for thermal injuries (except for sunburns), and corrosions identify burns that are due to chemicals. Many of the code categories in this chapter have seventh character values that are applicable. If a code is fewer than six characters and requires a seventh character value, a placeholder x is used to fill in the empty character value(s). There are a number of instructional notes throughout this chapter.
There are ICD-10-CM codes that can be used to identify underdosing. These would be used to code situations when a patient takes less of a medication than is prescribed or less than the manufacturer’s instructions, with a negative effect on health.
Burns and Corrosions (T20-T32) and Frostbite (T33-T34)
It may be necessary to transport burn victims to a hospital that has a specialized unit for care of the burn patient. Plastic surgeons, anesthesiologists, nurses, dietitians, and physical and occupational therapists assist the burn patient through the acute and recovery phases of their injury. As a result, many facilities only stabilize the burn patient in the emergency room and then transport to a burn unit, or only less critical burn patients are admitted for care.
According to the ICD-10-CM guidelines, the burn codes are assigned for thermal burns, except for sunburns, that come from a heat source such as a fire or hot appliance. Corrosion is a burn that is due to a chemical. The guidelines are the same for both types of burns. As with other injuries, it is necessary to assign separate codes for each burn site. Codes are available for multiple sites, but these should be used only if the documentation is insufficient to allow assignment of more specific burn codes.
Burn severity is classified by degrees (Figure 24-2):
First-degree burn: erythema or redness of the skin
Second-degree burn: formation of blisters with epidermal loss
Third-degree burn: full-thickness skin loss
Fourth-degree burn: deep necrosis of underlying tissues or deep third-degree burn
The guidelines instruct the coder to sequence the code that reflects the highest degree of burn first.
Often, a burn will be described as having different degrees at the same site. It is only necessary to assign the code that identifies the highest degree of burn.
Although the physician did not state first- or second-degree burn, by the description, this burn is a first- (erythema) and second-degree (blister) burn, so it would be coded to the most severe burn, which is second-degree.
For a variety of reasons, a burn may not heal quickly, or it may become infected. A nonhealing burn is coded as an acute burn. It is possible to have burns that occurred at the same time, and some may have healed completely while others have not yet healed. If the burn contains necrotic tissue, it is coded as an acute burn. It is possible to have late effects (e.g., scar, contracture) of a burn along with a nonhealing burn. Sometimes, late effects remain after the burn has healed, and these still require treatment.
T31 and T32 categories are provided to identify the extent of body surface that is involved by burns and to indicate the percentage of body surface that has third-degree burns. According to the classic “rule of nines,” in estimating involved body surface, head and neck are assigned 9%, each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, and genitalia 1%. These percentage assignments may change as necessary to accommodate infants and children who have proportionately larger heads than adults and patients who have large buttocks, thighs, or abdomen that involve burns (Figure 24-3). The percentages of body surface involvement must be documented by a healthcare professional for code assignment. Percentages should not be calculated by the coder.
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