To be prepared for the certified coding specialist (CCS) and physician-based (CCS-P) exams, coders should be aware of the latest ICD-9-CM code changes. There were a total of 313 new, 45 revised and 23 deleted diagnoses codes that went into effect on Oct. 1, 2009. Because of the very significant changes to the Supplementary Classification of External Causes of Injury and Poisoning chapter, this column focuses on E codes and related guideline revisions. More than 160 new E codes have been created. Many of these additions are related to two new categories of E codes: external cause status and activity codes.

External Cause Status Codes
Codes from category E000, External cause status, are to be used with other E codes to indicate the status of the person at the time the event occurred. Four codes have been created to report the status as follows:

E000.0 Civilian activity done for income or pay
E000.1 Military activity
E000.8 Other external cause status
E000.9 Unspecified external cause status

E000.8 will most likely be the most frequently assign status code because it is used to report an event that occurred during a non-work related activity such as leisure, sport, student, off-duty military, volunteer, while pursuing a hobby and during activities not elsewhere classified. Other codes are assigned for events that occur during active military duty, E000.1, or are work related, E000.0. Do not assign code E000.9, Unspecified external cause status, if the status is not stated.

Coding guideline state that a status code should be assigned whenever another E code is assigned for an encounter, such as transport accidents and falls. However, status codes should not be used when assigning codes for poisonings, adverse effects, misadventures or late effects.

Activity Codes
Currently, there is no way to code the activity in which a person is engaged in that result in a health condition or injury. Collection of this information is an essential process to enable epidemiologists and injury prevention specialists to work toward prevention strategies to reduce the negative health consequences associated with specific activities.

A new section was added to the E code chapter that includes 21 new categories, E001 through E030, and more than 100 new codes. These codes are used to indicate the activity the person was engaged in when the injury or other health condition occurred. The following categories have been added:

E001 Activities involving walking and running
E002 Activities involving water and water craft
E003 Activities involving ice and snow
E004 Activities involving climbing, rappelling and jumping off
E005 Activities involving dancing and other rhythmic movement
E006 Activities involving other sports and athletics played individually
E007 Activities involving other sports and athletics played as a team or group
E008 Activities involving other specified sports and athletics
E009 Activities involving other cardiorespiratory exercise
E010 Activities involving other muscle strengthening exercises
E011 Activities involving computer technology and electronic devices
E012 Activities involving arts and handcrafts
E013 Activities involving personal hygiene and household maintenance
E014 Activities involving person providing caregiving
E015 Activities involving food preparation, cooking and grilling
E016 Activities involving property and land maintenance, building and construction
E017 Activities involving roller coasters and other types of external motion
E018 Activities involving playing musical instrument
E019 Activities involving animal care
E029 Other activity
E030 Unspecified activity

These new activity codes should be used in conjunction with other E codes including status (E000) and place of occurrence (E849) if they provide additional information regarding the circumstances of the injury or condition. Unlike other E codes, these new activity codes may be assigned to indicate a health condition, not just injuries, that resulted from or was contributed by an activity. For example, if a patient had a syncopal episode while performing Pilates, code E010.3, Activity involving other muscle strengthening exercises, Pilates, is assigned.

Like the new status codes, the activity codes are not used when reporting poisonings, adverse effects, misadventures or late effects. Activity and external cause status codes are sequenced following all causal (intent) E codes.

Wrong Surgery
Adverse surgical events including procedures performed on the wrong body site and wrong patient are among the list of 28 Serious Reportable Events endorsed by the National Quality Forum (NQF). The Centers for Medicare and Medicaid Services (CMS) requested that codes be created to better identify and track wrong surgical events. Two codes were added and one was revised to report the occurrence of wrong surgeries as follows:

E876.5 Performance of wrong operation (procedure) correct patient (revised code)
E876.6 Performance of operation (procedure) on a patient not scheduled for surgery
E876.7 Performance of operation (procedure) on wrong side/body part

An example on the use of these codes is as follows: Code E876.6 would be assigned if a hip replacement was performed on Patient A when this procedure should have been performed on Patient B. Unlike other E codes, CMS requires these wrong surgery E codes be reported on the claim when an event occurs.

External Cause Codes for Military Operations
At the request of the Department of Defense, more than 50 new E codes were created to better identify the causes of injury among military personnel. A comprehensive expansion of categories E990-E999, Injuries resulting from operations of war, was made and now includes codes that identify specific causes of war injuries. For example, there are now 10 codes to report injuries due to explosions and 6 codes to report injuries due to destruction of aircraft. This expansion also includes injuries resulting from peacekeeping missions.

To review all new and revised E codes and related coding guidelines refer to the ICD-9-CM Official Guidelines for Coding and Reporting (Section C.19) and the E code tabular addenda at http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm. After reviewing this information, test your knowledge with the quiz below.

1. A patient falls and fractures a hip while walking at a park. What E codes would you assign for this case?

a. E888.8, E849.4, E001.0, E000.8

b. E888.8, E001.0, E000.8

c. E885.9, E849.4, E001.0, E000.9

d. E888.8, E849.4

2. A patient presents to the ED after his wife noticed that he was extremely drowsy after taking his Valium that night, as prescribed. The patient had three beers earlier that evening at home. Which of the following would be the appropriate code selection for this case?

a. 780.09, E938.4, 980.0, E860.0, E00.8, E849.0

b. 780.09, E939.4

c. 969.4, 980.0, 780.09, E860.0, E853.2, E849.0

d. 969.4, 980.0, 780.09, E860.0, E853.2, E000.8, E849.0


This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, facility solutions, Ingenix, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix (www.ingenix.com).

CPT is a registered trademark of the American Medical Association.

Answers:

1. a: Four E codes are assigned. One for the fall (E888.8), one for place of occurrence (E849.4), one for the activity (E001.0), and one for the status (E000.8).

2. c: Codes 969.4, 980.0, 780.09, E860.0, E853.2, and E849.0 are assigned for this case. When a reaction results from the interaction of a drug and alcohol, use the poisoning and E codes for both. Do not assign status code E000.8 because status codes are not assigned with poisoning E codes.