When a person has an accident, such as a fall while sleeping, and there are no injuries, the encounter following an accident and its external causes needs to be reported.
** This post has been updated to reflect FY 2020 coding guidelines. **
Have you ever been injured while sleeping?
I asked myself that question.
Sure, yes, I have slept in an awkward position and sometimes the pillow I was using would cause neck pain. And I have slept on my stomach and it put stress on my back. I have also slept on a poor mattress before that has caused some back pain.
Upon further reflection, I recall a time when my son, only about 9 months old at the time, fell off a sofa and hurt himself. Can you imagine the concern if it were your child?
It really scared me, and I worried that he could have broken his nose or suffered a concussion. Thankfully, though, he was fine.
Outpatient Coding Scenario
Let’s look at the following documentation:
A 9-month old child rolled off the sofa and onto the floor while sleeping at a relative’s home. The mom stated she was sitting next to her child on the sofa, and while she was looking away, the incident occurred. The mom was very concerned about possible injury and brought the child to the office. The pediatrician examined the child for any outward signs of injury or sustained trauma and found no injuries. The encounter was for observation; suspected injury after fall was ruled out. The mom was instructed to look for any signs that may develop.
First of all, the patient presented to the pediatrician’s office after having an accident (fall), but no symptoms or injuries were diagnosed or documented.
In outpatient reporting, if the patient displays no signs or symptoms, we must report a code from categories Z03, Z04, or Z05 to show observation for suspected conditions, according to ICD-10-CM Official Guidelines for Coding and Reporting.
These codes are used when a patient is seen because the parent thinks the child has a condition, but after careful review, the condition does not exist.
Z04.3 – Encounter for examination and observation following other accident.
The note at Z04 indicates that this category is also used for administrative and legal observation status. Be sure to read all the instructional notes before assigning this code.
We can also assign the external cause codes based on the documentation. Chapter 20 codes (External Causes of Morbidity), include categories V00-Y99.
These codes are secondary codes used to identify the cause, intent, place where the patient was when injured, patient’s status, and activity being performed at the time. These codes are never reported alone.
The child fell from a sofa while visiting a relative’s home, and the activity was sleeping.
External cause: W08.XXXA – Fall from other furniture, initial encounter. The 7th character “A” indicates that patient is receiving active treatment.
Place of occurrence: Y92.018 – Other place in single-family (private) house as the place of occurrence of the external cause
Activity: Y93.84 – Activity, sleeping
In summary, when a patient presents for a suspicious condition after an accident, and there are no signs and symptoms and no diagnosis, we need to code for the encounter following the accident.
We also need to assign the external cause codes based on the documentation.
And hopefully, you will take my advice and get your child checked out after a fall like this just to be on the safe side.
This post has been updated to reflect FY 2020 coding guidelines.
Need more help coding for external causes? See…
- Taking the Pain Out of Gunshot Wounds in ICD-10
- External Cause Codes and the Bite From the Angry Dog
- Coding For Pectoralis Major Muscle Tears In ICD-10