Are you coding for the whole picture?

November 27, 2023

We’ve had our first taste of winter in many parts of the country. And with winter come accidents caused by snow, icy surfaces, and outdoor activities—and injured patients whose encounters you’ll need to code fully and accurately to receive reimbursement.

Accidents with winter conditions as a contributing factor provide a good opportunity to reinforce a message that applies to all times of year: Coders and providers must provide as complete and specific a picture as possible for payors. We must code not only for the type of injury but for the location and circumstances of that injury. You might be surprised at how often we have talked to providers who experienced payment delays or even denials simply because they did not “code for the whole picture.”

Here’s an example of what I mean…

Let’s say you and your family go to a hockey game. A flying puck sails over the glass and strikes you in the right eye, briefly knocking you unconscious. How should a provider code this incident? First, they must apply S05.91XA (Unspecified injury of right eye and right orbit). To that they would add R55 (loss of consciousness).

So far, so good—but it’s not enough. Next, the provider would need to add a code describing how the injury happened (W21.220A—Struck by a puck). Then there would need to be a code for the location (Y92.330—Ice rink).

Another example: A patient suffers a heart attack and develops frostbite while shoveling snow. Again, you will need to start with the code(s) for the specific injury: I46.9—Cardiac arrest and T33.61XA—Superficial frostbite of right hip and thigh. Then you have to include a code for the context: Y93.2—Snow shoveling. And finally, you need to code for the location: Y92.014—Private driveway to a single-family (private) house.

Here are some of the other descriptors that should be included with injuries that occur due to winter conditions or winter sports:

Fall from steps – due to ice/snow W00.1XXA
Slip on ice/snow (with Skates) W00.0XXA
Struck by hockey puck W21.220A
Struck by hockey stick W21.210A
Fall down hill W17.81XA
Fall down ramp W10.2XXA
Fall down stairs W10.9XXA
Due to ice/snow W10.9XXA
Snow shoveling Y93.2

FORCES OF NATURE

Blizzard X37.2XXA
Cold X31.XXXA

PLACE OF OCCURRENCE

Ice rink Y92.330
Figure skate (pairs) Y93.21
Hockey Y93.22

SPORT

Cross-country skiing Y93.24
Sledding V00.228A
Hitting stationary object V00.222A
Skiing Y93.17
Skis V00.328A
Hitting stationary object Hitting stationary object
Snowboarding V00.318A
Tubing /snowboarding, sledding, tobogganing Y93.23
Other activity involving ice and snow Y93.29

 

People sometimes ask me why this degree of specificity is necessary. It has to do with payors and liability. Depending on the circumstances, the party responsible for covering the patient’s care may differ.

If the injury resulted from an automobile accident on a snowy road, then the obligation to pay falls on the patient’s automobile insurance provider, not their primary healthcare insurance provider. If the patient fell while walking across an icy parking lot at work, rather than on an icy driveway at home, the case would be covered under Worker’s Comp. To make such determinations, payors need the complete picture. And if you don’t provide these specifics, it will only delay payment and create more work for you later.

I’ve often used the mantra, “If it’s not documented, it didn’t happen.” To that I’ll add: “If you don’t provide the whole picture, you may not get paid.” And that’s true for any season of the year.

 

Got a question about E/M coding? We’d love to hear from you.

Submit your questions by emailing us at coders@calmwatersai.com

 

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Michelle Sergei-Casiano
Michelle Sergei-Casiano
Michelle Sergei-Casiano
CPC, CFPC, CEMC Senior Manager, Regulatory and Coding Compliance coders@calmwatersai.com

 

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