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TBT: Watch out for uninvited turkeys

Don't use Thanksgiving as a time to talk turkey. Count your blessings. Be thankful. Use compassion for those less fortunate who surround you.

Don’t use Thanksgiving as a time to talk turkey. Count your blessings. Be thankful.

Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you most likely wish had been left unpublished. We’ve picked up the theme going back into our archives to highlight some salient tid-bit. Today, in honor of Thanksgiving we’ve pillaged the archives over at the ICD-10 Trainer for this pearl pulled from the New York City headlines.

A feral flock of wild turkeys has invaded New York City. Seriously. And with them, they bring all sorts of code-ready diseases and mishaps. But what happens when a turkey tries to cross Broadway? Well, if the bird is unlucky, it will get run over. New Yorkers stop for no fowl.

However, if the birds are smart enough to cross en masse, they could cause some serious traffic disruptions and possibly some traffic accidents. We’ll leave the specific injuries (contusions, lacerations, broken bones, etc.) out of the equation for the moment and look at the External Causes codes associated with traffic accidents.

ICD-10-CM includes multiple code possibilities for transport accidents in sections V00-V99. The introductory note for the section states:

This section is structured in 12 groups. Those relating to land transport accidents (V01-V89) reflect the victim’s mode of transport and are subdivided to identify the victim’s ‘counterpart’ or the type of event. The vehicle of which the injured person is an occupant is identified in the first two characters since it is seen as the most important factor to identify for prevention purposes. A transport accident is one in which the vehicle involved must be moving or running or in use for transport purposes at the time of the accident.

If the turkeys on the Great White Way caused an accident, we would likely head to V40 (car occupant injured in collision with pedestrian or animal). Our choices include:

  • V40.0, car driver injured in collision with pedestrian or animal in nontraffic accident
  • V40.1, car passenger injured in collision with pedestrian or animal in nontraffic accident
  • V40.2, person on outside of car injured in collision with pedestrian or animal in nontraffic accident
  • V40.3, unspecified car occupant injured in collision with pedestrian or animal in nontraffic accident
  • V40.4, person boarding or alighting a car injured in collision with pedestrian or animal
  • V40.5, car driver injured in collision with pedestrian or animal in traffic accident
  • V40.6, car passenger injured in collision with pedestrian or animal in traffic accident
  • V40.7, person on outside of car injured in collision with pedestrian or animal in traffic accident
  • V40.9, unspecified car occupant injured in collision with pedestrian or animal in traffic accident

All of these codes require a seventh character to indicate the encounter type, so you’ll also need two placeholder Xs so the seventh character ends up in the seventh spot.

So if you’re flocking to New York for the holidays, watch out for those wild birds.

Boot Camp News: California, here we come!

dont miss itThe ICD-10 for CDI Boot Camp heads to sunny San Diego, California, December 8-10. The documentation issues that exist with ICD-9 will continue in ICD-10. The ICD-10 for CDI Boot Camp provides strategies that can be implemented immediately to improve documentation and facilitate a smooth transition to ICD-10-CM. ACDIS’ ICD-10 for CDI Boot Camp is the only training developed with CDI specialists in mind. Our instructors have in-the-field CDI experience and know exactly what CDI specialists need to know about the new coding system. You will get a CDI perspective on how to:

  • Evaluate, revise, and focus physician educational efforts and queries to meet documentation requirements for ICD-10-CM
  • Determine the impact ICD-10-PCS will have on the organization and whether CDI specialists should query for surgical procedures
  • Highlight changes from the ICD-9-CM to ICD-10-CM Official Coding Guidelines so that CDI specialists can get coders the specificity needed
  • Recognize how ICD-10-CM documentation requirements will affect principal diagnosis selection, additional diagnosis reporting, and diagnosis sequencing
  • Identify solutions that will maximize efficiency and limit productivity losses during and after the transition

We’ll be in San Diego in December, Las Vegas in February, and Orlando in March. Won’t you join us? Click here to learn more about the ICD-10 for CDI Boot Camp or call us at 800-650-6787.

Haunted Coding: The tell-tale chart

The month marked the 165th anniversary of Edgar Allan Poe’s death. We’re still not sure of the cause of Poe’s demise but there are have plenty of theories.


No more poor Poe.

First is the popular “he drank himself to death” theory that many people have heard. Poe was found “in great distress” outside of a polling place in Baltimore and died four days later. If Poe, who couldn’t really hold his liquor, did succumb to alcohol poisoning, how would we code it? First, we head to the Table of Drugs and Chemicals, then find alcohol and its 28 related entries. Apparently you can be poisoned by a lot of different types of alcohol.

In Poe’s case, it was probably ethanol (T51.0X-). In fact, 13 of the terms under alcohol in the Table of Drugs direct you to T51.0X-.

Now we need the intent behind the poisoning. We have specific codes for:

  • Accidental (unintentional)
  • Intentional self-harm
  • Assault
  • Undetermined

We also need a seventh character to denote the encounter. We have three choices:

  • A, initial encounter
  • D, subsequent encounter
  • S, sequela

Most likely, the alcohol poisoning (if that’s what put an end to the poet) was accidental, so we would report T51.0X1A.

However, we are faced with a more sinister possibility. Some have speculated that Poe was actually the victim of cooping, a method of voter fraud practiced by gangs in the 19th century. The gangs would kidnap people and take them around to various polling places so they could vote multiple times. After each successful casting of the ballot, the gang would reward their victim with alcohol.

You might be able to make a case for this being an assault, although that is probably a tough sell. You could also make a case for undetermined.

You’ll also find the following note under T51.01X-:


  • Acute alcohol intoxication or ‘hangover’ effects (F10.129, F10.229, F10.929)
  • Drunkenness (F10.129, F10.229, F10.929)
  • Pathological alcohol intoxication (F10.129, F10.229, F10.929)

An Excludes2 note tells us that the conditions listed are not part of T50.1X-, but a patient could be suffering from one of these conditions as well. So if Poe’s doctor documented pathological alcohol intoxication, we would code it in addition to the alcohol poisoning.

Sadly Poe’s medical records have gone missing and shall be seen nevermore.

Editor’s Note: This article originally published on the ICD-10 Trainer Blog.

Halloween Extra: A play on Poe, “Nevermore a Delay”

Once upon a midnight dreary, as I labored on a query

monter under bedTo send to the doc whose documentation was a source of constant woe

As I nodded, nearly napping (that darn G47.411 again)

Suddenly there came a tapping

As of someone gently rapping, rapping at my cubicle wall

Tis just my manager, I muttered, coming for the query

Only this and nothing more


The silken, sad, muffled rustling of each chart that I sat shuffling

Thrilled me—filled me with fantastic terrors never felt before (oh wait, that’s just F41.1);

So that now, to still the beating of my heart, I stood repeating,

“Tis just my manager coming for the query

Just my manager looking for the query”

This it is and nothing more.


Presently my soul grew stronger; hesitating then no longer,

“Jill,” said I, “or Shannon, truly your forgiveness I implore;

But you know my lack of hearing (H90.0) caused by this incessant ringing (H93.13)

Left me thinking there was no one tapping at my cubicle door,

I scarce was sure I heard you”—here I opened wide the door—

Darkness there and nothing more.


Deep into that darkness peering, long I stood there wondering, fearing (more F41.1),

Doubting, dreaming dreams no mortal ever dared to dream before;

But the silence was unbroken (or am I just suffering H91.23?), and the stillness gave no token,

Until I heard this one word spoken—ICD-10

This I whispered and an echo murmured back—ICD-10

Merely this and nothing more.

Back into the chamber turning, all my soul within me burning (maybe it’s really R12 and not my soul),

Soon again I heard a tapping somewhat louder than before.

Open here I flung the door, to see a Raven of the days of yore;

Perched above the neighboring cubicle door

Perched contently above my next-door neighbor’s cubicle door

Then he spoke—ICD-10—and nothing more.


Wonderful, I muttered, now I’m seeing birds, I shuttered

I’ve started hallucinating a creepy bird of yore (R44.1, too bad it doesn’t specify what I’m seeing)

I really want to write this query

So I can code this record, I am weary (R53.83)

Weary of worrying when ICD-10 will be implemented

Quoth the raven, 2015

This he said and nothing more.


Listen bird, I said with feeling, please don’t let me be dreaming

Please tell me that ICD-10 is really coming soon

Currently our codes are lacking

We can’t even tell what’s catching

We don’t know what diseases we’re not tracking

Quoth the raven, 2015

This he said and nothing more.


“Be that word our sign of parting, bird my friend!” I grinned, upstarting—

“Get thee back into the tempest and spread the word to every coder!

Leave one black plume as a token of that joy thy beak hath spoken!

Leave my hopefulness unbroken!—quit the perch above my neighbors door!

Take thy beak from out my heart (S26.19, W61.99XA), and take thy form from off my neighbor’s door!”

Quoth the raven, 2015

This he said and nothing more.

Editor’s Note: This article originally published on the ICD-10 Trainer Blog

Reveal the fact(s) behind the funny

Don't delay!

Don’t delay!

If I hear one more person poke fun at ICD-10-CM code V97.33XD (sucked into a jet engine, subsequent encounter), I am going to develop a very strong case of R45.850. (That’s homicidal ideation in case you don’t have your code book handy.)

First of all, most of the people making fun of this code don’t actually understand what the code is conveying. See the New York Times, an Alabama physicians group, Healthcare Dive, The Boston Globe, and on and on and on.

The subsequent encounter part is not saying the person was sucked into a jet engine twice (what are the odds of that?). It’s telling us that the person is being seen for a subsequent encounter for injuries suffered when he or she was sucked into the jet engine. (And you can indeed survive being sucked into a jet engine as long as you are not on that television show Lost.)

The seventh character is one of the main new concepts in ICD-10-CM. Maybe we need to do a better job of explaining what it means.

In most cases the seventh character indicates the episode of care. If the patient is receiving active treatment, you use seventh character A in most cases.

If the patient is being seen for routine follow up, the seventh character becomes D, again in most cases.

When the patient develops a complication or a condition that arises as a direct result of a condition, that’s a sequela reported with seventh character S (always).

Fracture codes have some additional seventh characters for nonunions, malunions, delayed healing, and open fractures. Most injury codes only give you three choices: A, D, and S.

Do the physicians at your organization know what the seventh character actually means? If not, here’s a perfect example you can use to explain it. V97.33XD doesn’t mean sucked into a jet engine twice. It means the patient is actually recovering from injuries sustained by his or her sole encounter with a jet engine.


New Guidelines include information on sequelae, sepsis, fracture coding

We’re still living under a code freeze as we (eagerly) await ICD-10 implementation. However, the four Cooperating Parties are still tweaking the ICD-10-CM Official Guidelines for Coding and Reporting. Both the Centers for Disease Control and Prevention and CMS posted the new guidelines on their websites last week. You can also download PDFs of the codes and indexes as well.


CDC released new ICD-10 Guidelines

The Guidelines don’t contain major changes, but CDI and coding professionals should download and read through them. New for 2015 are examples of sequelae, information about sepsis and severe sepsis, and additional information on fracture coding.

The specific examples of sequelae include:

  • Scar formation resulting from a burn
  • Deviated septum due to a nasal fracture
  • Infertility due to tubal occlusion from old tuberculosis

The updated the Guidelines for sepsis, focused on postprocedural infection and postprocedural septic shock. When the patient develops a postprocedural infection and severe sepsis, first report the code for the precipitating complication, such as code T81.4 (infection following a procedure). You should also report R65.20 (severe sepsis without septic shock) and a code for the systemic infection. If the postprocedural infection leads to septic shock, you still code the precipitating complication first, but now report code T81.12- (postprocedural septic shock) and a code for the systemic infection.

ICD-10-CM now includes additional information on the seventh character for pathologic fractures. The seventh character denotes the episode of care. Use seventh character A when the patient is undergoing active treatment, which now includes evaluation and continuing treatment by the same or a different physician.

The Guidelines further state:

While the patient may be seen by a new or different provider over the course of treatment for a pathological fracture, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time.

You’ll find the same information under the Guidelines for Chapter 19, Injury, Poisoning, and Certain Other Consequences of External Causes. You’ll also see some additional information on complications:

  • For complication codes, active treatment refers to treatment for the condition described by the code, even though it may be related to an earlier precipitating problem.
  • The guidelines further clarify that seventh character D is used when the patient has an x-ray to check the healing status of a fracture.
  • When it comes to external cause codes, the guidelines now specify that the seventh character for external cause should be the same as the one for the code assigned for the associated injury or condition for the encounter.

You probably know that you only assign a place of occurrence code once. Well, most of the time. ICD-10-CM now specifics that when the patient suffers a new injury during hospitalization (which should be rare), you can assign an additional place of occurrence code.

Editor’s Note: This article was originally published on the ICD-10 Trainer Blog.