CATEGORY	SECTION TITLES
E800-E807	Railway Accidents
E810-E819	Motor Vehicle Traffic Accidents
E820-E825	Motor Vehicle Nontraffic Accidents
E826-E829	Other Road Vehicle Accidents
E830-E838	Water Transport Accidents
E840-E845	Air and Space Transport Accidents
E846-E848	Vehicle Accidents, Not Elsewhere Classifiable
E849	Place of Occurrence
E850-E858	Accidental Poisoning by Drugs, Medicinal Substances, and Biologicals
E860-E869	Accidental Poisoning by Other Solid and Liquid Substances, Gases, and Vapors
E870-E876	Misadventures of Patients During Surgical and Medical Care
E878-E879	Surgical and Medical Procedure as the Cause of Abnormal Reaction of Patient or Later Complication, Without Mention of Misadventure at the Time of Procedure
E880-E888	Accidental Falls
E890-E899	Accidents Caused by Fire and Flames
E900-E909	Accidents Due to Natural and Environmental Factors
E910-E915	Accidents Caused by Submersion, Suffocation, and Foreign Bodies
E916-E928	Other Accidents
E929	Late Effects of Accidental Injury
E930-E949	Drugs, Medicinal and Biological Substances Causing Adverse Effects in Therapeutic Use
E950-E959	Suicide and Self-inflicted Injury
E960-E969	Homicide and Injury Purposely Inflicted by Other Persons
E970-E978	Legal Intervention
E980-E989	Injury Undetermined Whether Accidentally or Purposely Inflicted
E990-E999	Injury Resulting from Operations of War

a. General E Code Coding Guidelines

1) Used with any code in the range of 001-V91

An E code from categories E800-E999 may be used with any code in the range of 001-V91, which indicates an injury, poisoning, or adverse effect due to an external cause.

An activity E code (categories E001-E030) may be used with any code in the range of 001-V91 that indicates an injury, or other health condition that resulted from an activity, or the activity contributed to a condition.

2) Assign the appropriate E code for all initial treatments

Assign the appropriate E code for the initial encounter of an injury, poisoning, or adverse effect of drugs, not for subsequent treatment.

External cause of injury codes (E-codes) may be assigned while the acute fracture codes are still applicable.

See Section 1.C.17.b.1 for coding of acute fractures.

Example

Injury of left knee due to twisting movement while playing basketball at the YMCA gym, 959.7, E927.0, E849.4, E007.6, E000.8 (S89.92xA, Y93.67, Y92.310, Y99.8).

3) Use the full range of E codes

Use the full range of E codes (E800-E999) to completely describe the cause, the intent and the place of occurrence, if applicable, for all injuries, poisonings, and adverse effects of drugs.

See a.1.), j.), and k.) in this section for information on the use of status and activity E codes.

Example

Injury of left wrist and dislocation of right elbow from fall on escalator in public building. Dislocation was reduced, 832.00, 959.3, E880.0, E849.6, 79.72 (S53.104A, S69.92xA, W10.0xxA, Y92.29, 0RSLXZZ).

4) Assign as many E codes as necessary

Assign as many E codes as necessary to fully explain each cause. If only one E code can be recorded, assign the E code most related to the principal diagnosis.

5) The selection of the appropriate E code

The selection of the appropriate E code is guided by the Index to External Causes, which is located after the alphabetical index to diseases and by Inclusion and Exclusion notes in the Tabular List.

6) E code can never be a principal diagnosis

An E code can never be a principal (first listed) diagnosis.

Usually, E codes are reported in a specific designated area within a computer system or on an abstracting form. A limited number of fields may be available for reporting of E codes. When this occurs, the coder will need to refer to these guidelines to aid in the selection of the most important E codes. Facility policy may also provide instruction.

7) External cause code(s) with systemic inflammatory response syndrome (SIRS)

An external cause code is not appropriate with a code from subcategory 995.9, unless the patient also has another condition for which an E code would be appropriate (such as an injury, poisoning, or adverse effect of drugs.

8) Multiple Cause E Code Coding Guidelines

More than one E-code is required to fully describe the external cause of an illness, injury or poisoning. The assignment of E-codes should be sequenced in the following priority:

If two or more events cause separate injuries, an E code should be assigned for each cause. The first listed E code will be selected in the following order:

E codes for child and adult abuse take priority over all other E codes.

See Section I.C.19.e., Child and Adult abuse guidelines.

E codes for terrorism events take priority over all other E codes except child and adult abuse.

E codes for cataclysmic events take priority over all other E codes except child and adult abuse and terrorism.

E codes for transport accidents take priority over all other E codes except cataclysmic events, child and adult abuse and terrorism.

Activity and external cause status codes are assigned following all causal (intent) E codes.

The first-listed E code should correspond to the cause of the most serious diagnosis due to an assault, accident, or self-harm, following the order of hierarchy listed above.

9) If the reporting format limits the number of E codes

If the reporting format limits the number of E codes that can be used in reporting clinical data, report the code for the cause/intent most related to the principal diagnosis. If the format permits capture of additional E codes, the cause/intent, including medical misadventures, of the additional events should be reported rather than the codes for place, activity or external status.

b. Place of Occurrence Guideline

Use an additional code from category E849 to indicate the Place of Occurrence for injuries and poisonings. The Place of Occurrence describes the place where the event occurred and not the patient’s activity at the time of the event.

Do not use E849.9 if the place of occurrence is not stated.

Example

Injury to the left wrist occurred on the playground at the public park. Patient fell off slide, 959.3, E884.0, E849.4, E006.9, E000.8 (S69.92xA, W09.0xxA, Y92.830, Y93.59, Y99.8).

e. Unknown or Suspected Intent Guideline

1) If the intent (accident, self-harm, assault) of the cause of an injury or poisoning is unknown

If the intent (accident, self-harm, assault) of the cause of an injury or poisoning is unknown or unspecified, code the intent as undetermined E980-E989.

Example

Laceration of left wrist from sharp glass, intent unknown, 881.02, E986 (S61.512A, Y28.0xxA).

2) If the intent (accident, self-harm, assault) of the cause of an injury or poisoning is questionable

If the intent (accident, self-harm, assault) of the cause of an injury or poisoning is questionable, probable or suspected, code the intent as undetermined E980-E989.

Example

Laceration of left wrist from sharp glass, suspected suicide attempt, 881.02, E986 (S61.512A, Y28.0xxA).

f. Undetermined Cause

When the intent of an injury or poisoning is known, but the cause is unknown, use codes: E928.9, Unspecified accident, E958.9, Suicide and self-inflicted injury by unspecified means, and E968.9, Assault by unspecified means.

These E codes should rarely be used, as the documentation in the medical record, in both the inpatient outpatient and other settings, should normally provide sufficient detail to determine the cause of the injury.

g. Late Effects of External Cause Guidelines

1) Late effect E codes

Late effect E codes exist for injuries and poisonings but not for adverse effects of drugs, misadventures and surgical complications.

2) Late effect E codes (E929, E959, E969, E977, E989, or E999.1)

A late effect E code (E929, E959, E969, E977, E989, or E999.1) should be used with any report of a late effect or sequela resulting from a previous injury or poisoning (905-909).

Example

Left wrist with keloid scar due to previous burns from fire (accidental), 701.4, 906.6, E929.4 (L91.0, T23.072S, X08.8xxS).

3) Late effect E code with a related current injury

A late effect E code should never be used with a related current nature of injury code.

4) Use of late effect E codes for subsequent visits

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. Do not use a late effect E code for subsequent visits for follow-up care (e.g., to assess healing, to receive rehabilitative therapy) of the injury or poisoning when no late effect of the injury has been documented.

Example

Subsequent encounter for malunion fracture of right tibia from motor vehicle accident, 733.81, 905.4, E929.0 (S82.201P, V89.2xxS).

i. Terrorism Guidelines

1) Cause of injury identified by the Federal Government (FBI) as terrorism

When the cause of an injury is identified by the Federal Government (FBI) as terrorism, the first-listed E-code should be a code from category E979, Terrorism. The definition of terrorism employed by the FBI is found at the inclusion note at E979. The terrorism E-code is the only E-code that should be assigned. Additional E codes from the assault categories should not be assigned.

Example

The patient (civilian) had a head injury due to a terrorist explosion, 959.01, E979.2, E000.8 (S09.90xA, Y38.2x2A, Y99.8).

2) Cause of an injury is suspected to be the result of terrorism

When the cause of an injury is suspected to be the result of terrorism a code from category E979 should not be assigned. Assign a code in the range of E codes based circumstances on the documentation of intent and mechanism.

3) Code E979.9, Terrorism, secondary effects

Assign code E979.9, Terrorism, secondary effects, for conditions occurring subsequent to the terrorist event. This code should not be assigned for conditions that are due to the initial terrorist act.

Example

The patient (civilian) has chronic posttraumatic stress syndrome following a terrorist attack, subsequent encounter, 309.81, E979.9 (F43.12, Y38.9x2S).

4) Statistical tabulation of terrorism codes

For statistical purposes these codes will be tabulated within the category for assault, expanding the current category from E960-E969 to include E979 and E999.1.

j. Activity Code Guidelines

Assign a code from category E001-E030 to describe the activity that caused or contributed to the injury or other health condition.

Unlike other E codes, activity E codes may be assigned to indicate a health condition (not just injuries) resulted from an activity, or the activity contributed to the condition.

The activity codes are not applicable to poisonings, adverse effects, misadventures or late effects.

Do not assign E030, Unspecified activity, if the activity is not stated.

k. External cause status

A code from category E000, External cause status, should be assigned whenever any other E code is assigned for an encounter, including an Activity E code, except for the events noted below. Assign a code from category E000, External cause status, to indicate the work status of the person at the time the event occurred. The status code indicates whether the event occurred during military activity, whether a non-military person was at work, whether an individual including a student or volunteer was involved in a non-work activity at the time of the causal event.

A code from E000, External cause status, should be assigned, when applicable, with other external cause codes, such as transport accidents and falls. The external cause status codes are not applicable to poisonings, adverse effects, misadventures or late effects.

Do not assign a code from category E000 if no other E codes (cause, activity) are applicable for the encounter.

Do not assign code E000.9, Unspecified external cause status, if the status is not stated.

Remember that E codes identify how an injury occurred and the intent. E codes also identify the place that an injury occurred and describe the activity that caused the injury or other health condition. At the beginning of Chapter 17 in the ICD-9-CM code book, special instructions state, “Use E code(s) to identify the cause and intent of the injury or poisoning (E800-E999)” (Figure 23-1).

Figure 23-1 Instructional note regarding the use of E code(s) to identify the cause and intent of the injury or poisoning (E800-E999).

Apply the General Coding Guidelines as found in Chapter 5 and the Procedural Guidelines as found in Chapter 6.

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)

a. Application of 7^th Characters in Chapter 19

Most categories in chapter 19 have a 7^th character requirement for each applicable code. Most categories in this chapter have three 7^th character values (with the exception of fractures): A, initial encounter, D, subsequent encounter and S, sequela. Categories for traumatic fractures have additional 7^th character values.

7^th character “A,” initial encounter, is used while the patient is receiving active treatment for the condition. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.

7^th character “D,” subsequent encounter, is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Examples of subsequent care are: cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow-up visits following treatment of the injury or condition.

The aftercare Z codes should not be used for aftercare for conditions such as injuries or poisonings, where 7th characters are provided to identify subsequent care. For example, for aftercare of an injury, assign the acute injury code with the 7th character “D” (subsequent encounter).

7^th character “S,” sequela, is for use for complications or conditions that arise as a direct result of a condition, such as scar formation after a burn. The scars are sequelae of the burn. When using 7^th character “S,” it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The “S” is added only to the injury code, not the sequela code. The 7^th character “S” identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code.

b. Coding of Injuries

When coding injuries, assign separate codes for each injury unless a combination code is provided, in which case the combination code is assigned. Code T07, Unspecified multiple injuries, should not be assigned in the inpatient setting unless information for a more specific code is not available.

The code for the most serious injury, as determined by the provider and the focus of treatment, is sequenced first.

1) Superficial injuries

Superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site.

2) Primary injury with damage to nerves/blood vessels

When a primary injury results in minor damage to peripheral nerves or blood vessels, the primary injury is sequenced first with additional code(s) for injuries to nerves and spinal cord (such as category S04), and/or injury to blood vessels (such as category S15). When the primary injury is to the blood vessels or nerves, that injury should be sequenced first.

c. Coding of Traumatic Fractures

The principles of multiple coding of injuries should be followed in coding fractures. Fractures of specified sites are coded individually by site in accordance with both the provisions within categories S02, S12, S22, S32, S42, S49, S52, S59, S62, S72, S79, S82, S89, S92 and the level of detail furnished by medical record content.

A fracture not indicated as open or closed should be coded to closed. A fracture not indicated whether displaced or not displaced should be coded to displaced.

More specific guidelines are as follows:

1) Initial vs. Subsequent Encounter for Fractures

Traumatic fractures are coded using the appropriate 7th character extension for initial encounter (A, B, C) while the patient is receiving active treatment for the fracture. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.

The appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion.

Fractures are coded using the appropriate 7th character extension for subsequent care for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase. Examples of fracture aftercare are: cast change or removal, removal of external or internal fixation device, medication adjustment, and follow-up visits following fracture treatment.

Care for complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication codes.

Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7th character extensions for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R).

A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone.

See Section I.C.13. Osteoporosis.

The aftercare Z codes should not be used for aftercare for traumatic fractures. For aftercare of a traumatic fracture, assign the acute fracture code with the appropriate 7th character.

2) Multiple fractures sequencing

Multiple fractures are sequenced in accordance with the severity of the fracture.

20. Chapter 20: External Causes of Morbidity (V01-Y99)

Introduction: These guidelines are provided for the reporting of external causes of morbidity codes in order that there will be standardization in the process. These codes are secondary codes for use in any health care setting.

External cause codes are intended to provide data for injury research and evaluation of injury prevention strategies. These codes capture how the injury or health condition happened (cause), 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 (e.g., civilian, military).

a. General External Cause Coding Guidelines

1) Used with any code in the range of A00.0-T88.9, Z00-Z99

An external cause code may be used with any code in the range of A00.0-T88.9, Z00-Z99, classification that is a health condition due to an external cause. Though they are most applicable to injuries, they are also valid for use with such things as infections or diseases due to an external source, and other health conditions, such as a heart attack that occurs during strenuous physical activity.

2) External cause code used for length of treatment

Assign the external cause code, with the appropriate 7th character (initial encounter, subsequent encounter or sequela) for each encounter for which the injury or condition is being treated.

3) Use the full range of external cause codes

Use the full range of external cause codes to completely describe the cause, the intent, the place of occurrence, and if applicable, the activity of the patient at the time of the event, and the patient’s status, for all injuries, and other health conditions due to an external cause.

4) Assign as many external cause codes as necessary

Assign as many external cause codes as necessary to fully explain each cause. If only one external code can be recorded, assign the code most related to the principal diagnosis.

5) The selection of the appropriate external cause code

The selection of the appropriate external cause code is guided by the Alphabetic Index of External Causes and by Inclusion and Exclusion notes in the Tabular List.

6) External cause code can never be a principal diagnosis

An external cause code can never be a principal (first-listed) diagnosis.

7) Combination external cause codes

Certain of the external cause codes are combination codes that identify sequential events that result in an injury, such as a fall which results in striking against an object. The injury may be due to either event or both. The combination external cause code used should correspond to the sequence of events regardless of which caused the most serious injury.

8) No external cause code needed in certain circumstances

No external cause code from Chapter 20 is needed if the external cause and intent are included in a code from another chapter (e.g. T36.0×1- Poisoning by penicillins, accidental (unintentional)).