Taking the Pain Out of Gunshot Wounds in ICD-10

Coding for gunshot wounds in ICD-10 begins with knowing that a gunshot wound is more than an “open wound.”

What is a Gunshot Wound?

Basically, a gunshot wound is physical trauma caused by a firearm. The National Institutes of Health (NIH) defines a firearm-related injury as “a gunshot wound or penetrating injury from a weapon that uses a powder charge to fire a projectile.” These gunshot injuries stem from handguns, rifles, and shotguns. 

Air-powered, gas-powered, pellet and BB guns are not included in this definition and are not considered firearm-related injuries. Nor are non-penetrating injuries related to firearms, such as pistol-whipping.    

The NIH goes on to state, “Firearm-related injuries are a major public health problem in the United States, contributing significantly each year to premature death, illness, and impairment.”  Furthermore, they state, “More than 32,000 persons die and over 67,000 persons are injured by firearms each year.”

This number may have increased since the date of the report put out by the NIH. Nevertheless, this is no inconsequential matter.

Apart from the physical problems that result from a gunshot injury, there are also traumatic emotional scars that can be caused by such a devastating event. 

Entrance and Exit Wounds

Entrance and exit wounds are often caused by an individual being shot by someone with a firearm. A bullet enters the body and then exits through another area of the body, leaving entrance and exit wounds.

According to Explore Forensics, in some cases, the entrance and exit wounds are clean, and the bullet travels through the body and causes only superficial damage. However, the overall wounding pattern is often based on how close the assailant is to the victim, the type of weapon, and the number of rounds fired from the weapon.

If the bullet hits a bone, the bone may break into pieces, or the bullet may ricochet and take a different path, according to the National Institutes of Health.

Entrance Wounds

Entrance wounds typically include the following characteristics:

• Smaller and more regular in form than exit wounds
• Ringed with gunpowder and cordite residue that comes from the bullet
• Abrasion ring with an imprint of the gun barrel if shot at close range
• Discoloration such as a black or grey ring caused by the burning of gunpowder as it touches the skin
• Tattooing of the skin caused by gunpowder spraying around the area of the wound and burning the skin

Exit Wounds

Exit wounds typically include the following characteristics:

• Larger and looks more destructive in appearance than entrance wounds due to the bullet slowing down and requiring more force to push through the skin
• Ragged with damage to skin, tissue, muscle, and bone sometimes
• Without the presence of burning or tattooing
• Bleeds in great amounts usually

The Damage It Causes

Gunshot wounds are penetrating wounds that can cause significant injury, according to the U.S. National Library of Medicine. Possible injuries include:

• Damage to vital organs, major blood vessels, and nerves
• Severe bleeding
• Broken bones
• Wound infections
• Paralysis

ICD-10-CM Coding Guidelines

An “open wound” is a very broad term that can refer to many types of wounds, such as abrasions, lacerations, incisions, punctures, and penetrating wounds. Each of these types of wounds has a different ICD-10-CM code.

Therefore, the term “open wound” should be avoided when reporting a diagnosis.  

A gunshot wound is a penetrating wound or a puncture wound. It is also a traumatic wound.

Penetrating wounds are caused by any object or force that breaks through or punctures the skin to the underlying organs or tissue. These wounds vary in size, shape, and presentation, depending on the cause.

Open wounds in ICD-10-CM are categorized according to the following:

• Site. This refers to the anatomic location. The information needed to report the appropriate diagnosis code varies based on the site. Some laceration and puncture wound codes are classified by “with foreign body” and “without foreign body.”
• Laterality. The right or left side of the body.
• Encounter. The 7th character extender, being initial, subsequent, or sequela.

• • Initial encounter is a visit to determine what treatment is required to repair the wound. 
  • Subsequent involves aftercare treatment.
  • Sequela is a complication or condition that occurs as a result of the wound.

Coding Example

A 27-year-old patient was brought to the hospital with a gunshot wound to the right thigh. Further details of the event were not provided, and the intent could not be determined. Assign the correct ICD-10-CM code(s).

Before we discuss how to locate and verify the appropriate codes, remember:

A gunshot wound is a penetrating wound or a puncture wound. It is also a traumatic wound.

This is a traumatic injury. According to ICD-10-CM Coding Guidelines, traumatic injury codes (S00-T14.9) should not be used for normal, healing surgical wounds or to identify complications of surgical wounds.

Puncture Wound – Locate and Verify

Look in the ICD-10-CM coding manual Index under Puncture, or start by looking under Penetrating wound, which refers you to Puncture. Puncture is broken down by body site, then laterality, and with and without foreign body.

There is nothing in the documentation to indicate a bullet or bullet fragments have been been found upon examination, so we can only assume that it entered and then exited the body. Therefore, we need to go to Puncture, thigh, right S71.131.

When verifying S71.131 in the Tabular, S71.131 refers to Puncture wound without foreign body, right thigh.

There is also a note at S71 that indicates we need a 7th character to show whether it is an initial encounter, subsequent encounter, or sequela. This is an initial encounter and the patient is receiving active treatment; hence, we need to add ‘A’ to S71.131, making it: 

S71.131A, Puncture wound without foreign body, right thigh, initial encounter

Be sure to read all parenthetical notes at S71 as to ‘Code also’ and ‘Excludes1’ and ‘Excludes 2’ notes for any additional coding instructions before making your final code selection.

Are we done? No, we have only told part of the story. We still need to code for the external cause of morbidity.

External cause codes describe the cause of the injury, the intent (unintentional or accidental; or intentional, such as suicide or assault), place of occurrence, the activity of the patient at the time of the event, and the person’s status (e.g., civilian or military). The number of reportable external cause codes is based on the documentation provided.

A gunshot wound may be accidental, self-inflicted, or due to assault.

As the ICD-10-CM Coding Guidelines state:

“If the intent (accident, self-harm, assault) of the cause of an injury or other condition is unknown or unspecified, code the intent as accidental intent.”

“External cause codes for events of undetermined intent are only for use if the documentation in the record specifies that the intent cannot be determined.”

External cause codes are never sequenced as a first-listed or principal diagnosis.

Based on the documentation provided in the above coding example, we know a gunshot wound was the cause of the injury, but we don’t know the specific type of firearm used.

We also don’t know if the gunshot wound was accidental, self-inflicted, or due to assault. The documentation indicates the intent of the gunshot wound could not be determined. Therefore, we need to use an ‘unspecified’ code.

External Cause – Locate and Verify

In the External Cause of Injuries Index, look up Discharge, firearm, stated as undetermined whether accidental or intentional Y24.9. Verified in the Tabular, Y24.9 refers to Unspecified firearm discharge, undetermined intent.

There is a note at Y24 that indicates a 7th character is needed for the episode of care. Therefore, Y24.9XXA is the correct code to show it is an initial encounter.

Y24.9XXA, Unspecified firearm discharge, undetermined intent, initial encounter

There are many other possible external cause codes related to firearm-related injuries. (see below)

External Cause Codes Associated With Firearm-Related injuries

According to the ICD-10-CM coding manual, there are many external cause codes to choose from when reporting for firearm-related injuries. These codes include:

• Intentional Assault (gun homicide, attempted or completed):
  • X93.-  Assault by handgun discharge
  • X94.-  Assault by rifle, shotgun, and larger firearm discharge
  • X95.-  Assault by other & unspecified firearm discharge (includes airguns, BB guns, and flare guns)
• Intentional Self-harm (gun suicide, attempted or completed):
  • X72.-  Intentional self-harm by handgun discharge
  • X73.-  Intentional self-harm by rifle, shotgun, and larger firearm discharge
  • X74.-  Intentional self-harm by other and unspecified firearm and gun discharge
• Accidental Unintentional (unintentional shooting, fatal or non-fatal):
  • W32.-  Accidental handgun discharge and malfunction
  • W33.-  Accidental rifle, shotgun, and larger discharge and malfunction
  • W34.-  Accidental discharge and malfunction from other and unspecified firearms and guns
• Undetermined Intent (unknown cause, fatal or non-fatal):
  • Y22.-  Handgun discharge, undetermined intent
  • Y23.-  Rifle, shotgun, and larger firearm discharge, undetermined intent
  • Y24.- Other and unspecified firearm discharge, undetermined intent
• Firearm Injury: Legal intervention, operations of war, military operations, and terrorism, fatal or non-fatal):
  • Y35.0 –  Legal intervention involving firearm discharge
• Firearm Injury: Terrorism (gun terrorism, fatal or non-fatal):
  • U01.4 –  Terrorism involving firearms (homicide, completed or attempted). A rarely used, provisional category.

Conclusion

With over 67,000 persons being injured by firearms each year, it is likely that you will come across a patient encounter of this type in your day-to-day coding. Therefore, it is imperative that you understand how to code for firearm-related injuries and their external causes and know that a gunshot wound is a penetrating wound that occurs when a bullet punctures the skin to the organs or tissue. Knowing your guidelines is critical.

This post was reviewed on 10/28/20 and reflects the current ICD-10-CM Coding Guidelines for FY 2021.

 

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