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Background information on ICD-10-CM, the differences between it and ICD-9-CM, and a proposed framework for presenting injury morbidity data based on ICD-10-CM codes. It includes discussions on external cause codes, their placement in the framework, and major issues identified during the construction process.
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U.S. Department of Health and Human Services Centers for Disease Control and Prevention
0 500 1000 1500 2000 00–04 yrs 05–09 yrs 10–14 yrs AGE GROUP NONFATAL UNINTENTIONAL MOTOR VEHICLE-TRAFFIC OCCUPANTINJURY RATES, UNITED STATES, 2012 MALE FEMALE RATE PER 100,000 POPULATION 15–19 yrs 20–24 yrs
Proposed Framework for Presenting Injury Data using ICD-10-CM External Cause of Injury Codes is a publication of The National Center for Injury Prevention and Control and the National Center for Health Statistics within the Centers for Disease Control and Prevention. Centers for Disease Control and Prevention Thomas R. Frieden, MD, MPH, Director National Center for Injury Prevention and Control Daniel M. Sosin, MD, MPH, FACP, Acting Director National Center for Health Statistics Charles J. Rothwell, MBA, MS, Director Suggested citation: Annest, J., Hedegaard, H., Chen, L., Warner, M., and Small, E. (2014). Proposed Framework for Presenting Injury Data using ICD-10-CM External Cause of Injury Codes. Atlanta, GA: National Center for Injury Prevention and Control, National Center for Health Statistics, Centers for Disease Control and Prevention.
IMPROVING INJURY DATA Executive Summary External cause of injury frameworks based on the International Classification of Diseases (ICD) have served the injury field in providing standards for presenting and analyzing state, national and international injury mortality and morbidity data. The external cause of injury framework, commonly called the external cause matrix, categorizes ICD codes into major mechanism (e.g., motor vehicle- traffic, cut/pierce, drowning, fall, firearm, fire/burn, natural/environmental, poisoning) by intent of injury (i.e., unintentional, self-harm, assault, legal intervention/war, undetermined) categories. In the United States, morbidity coding is currently based on ICD-9-CM, and is proposed to transition to ICD-10-CM on October 1, 2014. In preparation for the use of ICD-10-CM-coded morbidity data for injury surveillance and analytic research, the National Center for Injury Prevention and Control and the National Center for Health Statistics at the Centers for Disease Control and Prevention (CDC) have proposed an ICD-10-CM External Cause of Injury Framework or Matrix. This report provides background information on ICD-10-CM, a comparison between ICD-9-CM and ICD-10-CM external cause code sets, an overview of the proposed framework and the guiding principles used to construct it, and a list of major issues and recommended resolutions based on feedback from CDC’s health information specialists and subject matter experts in injury data and surveillance systems.
PROPOSED EXTERNAL CAUSE FRAMEWORK I. Introduction Since the early 1990s, the National Center for Injury Prevention and Control (NCIPC) and the National Center for Health Statistics (NCHS) at the Centers for Disease Control and Prevention (CDC) have worked together with colleagues from the International Collaborative Effort (ICE) on Injury Statistics and the American Public Health Association (APHA)-Injury Control and Emergency Health Services (ICEHS) Section to improve the analysis and use of fatal and nonfatal injury data in the United States and internationally. One aspect of this collaboration has been the development of frameworks, or matrices, based on standard groupings of International Classification of Diseases (ICD) codes for presenting fatal and nonfatal injury data by external causes of injury (mechanism and intent of injury) and by injury diagnosis (body region and nature of injury). Since 1979, the Clinical Modification to the 9th^ Revision of ICD (ICD-9-CM) has been used in the United States to code morbidity data; and since 1999, the 10th^ Revision of ICD (ICD-10) has been used in the United States for coding mortality data.^1 Frameworks have been developed for injury mortality data based on ICD- 9 and ICD-10 codes and for injury morbidity data based on ICD-9-CM codes.2-4^ These frameworks are used extensively to generate county, state, regional, national, and international comparisons of fatal and nonfatal injury data by external causes of injury and by injury diagnoses (e.g., WISQARS, CDC WONDER, CDC Injury Indicators Project, and ICE on Injury Statistics).5- The Clinical Modification of ICD-10 (ICD-10-CM), similar to ICD-9-CM, was developed by NCHS for use in morbidity coding in the United States. The ICD-10-CM coding structure, based on ICD- 10 published by the World Health Organization,^9 has been in the public domain for more than a decade. Proposed changes are evaluated each year through the Coordination and Maintenance Committee headed by NCHS and the Centers for Medicare and Medicaid Services (CMS). Compared to the ICD-9-CM, the ICD-10-CM is greatly expanded, including nearly five times the number of codes (approximately 70,000 codes in ICD-10-CM compared to 14,000 codes in ICD-9-CM).^10 ICD- 10-CM codes provide much more detail about the injury diagnosis and external cause of injury than ICD-9-CM codes, making this classification system useful for capturing extensive information for documenting clinical care, billing, and public health surveillance and practice. More specifically, the updated medical terminology and classification of diseases, injuries, and procedures in ICD-10- CM can potentially provide better data for measuring quality of care provided to patients, tracking injuries and health conditions, conducting epidemiologic research, and assessing the economic costs of diseases and injuries. Recently, the Department of Health and Human Services released a ruling that ICD-10-CM will replace ICD-9-CM in the United States for coding of morbidity data beginning on October 1, 2014. On that date, the transition to ICD-10-CM will be effective for all Medicare and Medicaid claims by hospitals and other health care providers covered by the Health Insurance Portability and Accountability Act (HIPAA).^11 Shortly thereafter, injury morbidity data coded using ICD-10-CM will be available in state-based hospital discharge and emergency department data systems for injury surveillance and prevention program planning. This report describes a proposed framework for presenting injury morbidity data by external causes of injury based on ICD-10-CM codes, and includes a discussion of differences between ICD-9-CM and ICD-10-CM classification systems, methods used to construct the proposed framework, the framework structure, major issues regarding placement of codes in the framework, and next steps for pilot testing and ultimate release. The final ICD-10-CM external cause framework will facilitate injury surveillance and epidemiologic
PROPOSED EXTERNAL CAUSE FRAMEWORK
IMPROVING INJURY DATA codes were evaluated using SAS computer programs to compare the codes in the spreadsheet with independent files of all ICD-9-CM and ICD-10-CM external cause codes and selected T codes to check for any missing codes in either direction. Finally, ICD-10-CM codes were reviewed individually for each major mechanism by intent category to determine comparability with codes in the ICD-9-CM external cause matrix as well as with codes in the ICD-10 external cause matrix. Because ICD-10-CM contains codes not found in either ICD-9-CM or ICD-10, a set of Guiding Principles was developed to determine where an individual code should be placed in the ICD-10- CM matrix (Appendix A). These Guiding Principles took into consideration the differences between ICD-10-CM codes and ICD-9-CM and ICD-10 codes. Using the Guiding Principles, NCIPC and NCHS staff independently reviewed and assigned the codes to major mechanism by intent categories, then discussed discrepancies to reach consensus on placement of the codes. In many instances, compatibility with the ICD-10 matrix took precedence over that for the ICD-9-CM matrix (e.g., transportation-related incidents) because of the importance in using ICD-10 and ICD-10-CM for international comparisons of trends in fatal and nonfatal injury rates. While most codes were placed using these methods, some codes needed further review and discussion by the injury surveillance community. Therefore, the proposed ICD-10-CM External Cause Matrix was shared with injury surveillance, data, and subject matter experts from the American Public Health Association’s Injury Control and Emergency Health Services Section (APHA-ICEHS), NCIPC’s State Grantees, the Safe States Alliance (Safe States), the Council of State and Territorial Epidemiologists (CSTE), the Society for Advancement of Violence and Injury Research (SAVIR), and the International Collaborative Effort (ICE) on Injury Statistics. Based on their feedback, final decisions were made for placement of codes in the matrix. IV. Results: ICD-10-CM External Cause Matrix Structure and Code Sets The proposed ICD-10-CM External Cause Matrix is structured by major mechanism and intent categories similar to those in the ICD-9-CM External Cause Matrix,^4 with modifications to adjust for the changes in coding structures and current and future data needs for national and state-based injury surveillance and prevention program planning activities (Table 2). Compared to the ICD- 9-CM External Cause Matrix, the ICD-10-CM External Cause Matrix has ten additional mechanism categories (All Transportation; Motor Vehicle – Traffic (MVT)-Other; Motor Vehicle (MV) – Non-traffic; Other Land Transport; Bites and Stings, nonvenomous; Bites and Stings, venomous; Drug Poisoning; Non-drug Poisoning; Other Specified, Child and Adult Abuse; and Other Specified, Foreign Body), and two changes in the names of intent categories (Self-inflicted and Other categories in the ICD-9- CM External Cause Matrix have been changed to Intentional Self-harm and Legal Intervention/War, respectively. War includes all War Operations codes). The proposed ICD-10-CM External Cause Matrix code sets are provided in two parts in the accompanying EXCEL files ( http://www.cdc.gov/injury/wisqars/dataandstats.html ). One EXCEL file includes all external cause codes other than those related to poisonings and most toxic effects (referred to as the proposed ICD-10-CM External Cause Matrix for Causes other than Poisoning ). The other EXCEL file includes codes for poisoning and most toxic effects (referred to as the proposed ICD-10-CM External Cause Matrix for Poisoning ). Each of these files includes five spreadsheets, one for each of the following intent categories: (1) Unintentional, (2) Intentional Self-harm,
IMPROVING INJURY DATA V. Tabulation/Code Placement: Issues and Proposed Resolutions While working on placement of codes and code sets in the ICD-10-CM External Cause Matrix, a number of major issues were identified for further examination and review by the injury research and practice community. Based on that input, preliminary resolutions have been incorporated into the proposed ICD-10-CM External Cause Matrix. Additional assessment and pilot testing using ICD-10-CM external cause-coded data from state and national morbidity data systems are needed before decisions can be finalized. Issue 1. Tabulation of Data on Injury-related Hospitalizations and Emergency Department Visits Background: Most ICD-10-CM external cause-related codes (V, W, X, Y, and T) have a 7th^ character that indicates whether the code is associated with the initial encounter (A), subsequent encounter (D), or a sequela (S). The initial encounter character (A) is used while the patient is receiving active treatment (e.g., emergency department encounter, surgery, evaluation and treatment by a new physician) for the condition. The subsequent encounter character (D) is used for encounters after the patient has received active treatment for the condition and is receiving routine care for the injury during the healing or recovery phase. The sequela character (S) is used with any report of a late effect or sequela resulting from a previous injury. Question: In tabulating morbidity data for hospitalizations and emergency department visits using state-based administrative data, should counts and rates be based on the initial encounter codes only or on the initial encounter and subsequent encounter codes? Proposed resolution: Tabulations using the ICD-10-CM External Cause Matrix will be based on the initial encounter (e.g., initial emergency department visit or initial hospitalization) for an injury incident. If the ICD-10-CM external cause code is unspecified for type of encounter, the case will default to initial encounter. Issue 2. Tabulation of Injury-related Data using Sequela Codes Background: In the ICD-9-CM External Cause Matrix, the few non-specific late effects codes (E929.0–.5, .8, .9) were placed in the Other Specified—Classifiable, Other Specified—Not Elsewhere Classifiable (NEC), and Unspecified categories rather than in the major mechanism-specific categories. In the ICD-10 External Cause Matrix, there were only a few late effects codes (Y85-Y87, Y89). Y85.0 was specific to motor-vehicle crash and was placed in Other Specified—Classifiable. The other late effects codes were nonspecific and were placed in Other Specified—NEC or Unspecified. In contrast, ICD-10-CM sequela (late effects) codes are numerous since most ICD-10-CM external cause codes have an associated sequela code, identified by an “S” in the 7th^ character of the code.
PROPOSED EXTERNAL CAUSE FRAMEWORK Question: Should the ICD-10-CM sequela codes be: (1) included in mechanism-specific categories of the ICD-10-CM External Cause Matrix; (2) placed in the Other Specified and Unspecified mechanism categories to be consistent with the ICD-9-CM and ICD-10 Matrices; or (3) excluded from the Matrix and tabulated separately? Proposed resolution: Sequela codes will not be included in the proposed ICD-10-CM External Cause Matrix or in routine tabulations of injury-related hospitalizations and emergency department visits, but should be tabulated and analyzed separately. Issue 3. Placement of ICD-10-CM W16 and W22 Drowning/Submersion Codes Background: In ICD-10, W16 Diving or Jumping into Water Causing Injury other than Drowning or Submersion consists of a single code and is placed in Unintentional Fall in the ICD-10 External Cause Matrix. In ICD-10-CM, W16 includes multiple codes for falling, jumping or diving into a swimming pool or natural body of water, with separate codes that specify drowning/submersion or other injuries. Similarly, in ICD-10, W22 Striking against or Struck by Other Objects consists of a single code and is placed in Unintentional Struck by/against in the ICD-10 External Cause Matrix. In ICD-10-CM, W22 includes multiple codes for striking against or struck by other objects, including two codes specific to striking against the wall of swimming pool causing drowning and submersion (W22.041) and other injury (W22.042). Questions: Should the ICD-10-CM W16 codes associated with drowning and submersion be placed in Unintentional Drowning/Submersion, or should they remain with the other W codes and placed in Unintentional Fall in the ICD-10-CM Matrix? Similarly, should the ICD-10-CM W22.041 code associated with drowning and submersion be placed in Unintentional Drowning/Submersion, or should it remain with the other W22 codes and placed in Unintentional Struck by/against in the ICD-10-CM Matrix? Proposed resolution: ICD-10-CM W16 and W22 codes that specify drowning/submersion will be placed in Drowning/Submersion in the ICD-10-CM External Cause Matrix. Issue 4. Placement of Transportation-related Codes involving Watercraft Background: In ICD-10, transportation codes involving watercraft that resulted in drowning/ submersion or other causes of injury (burn, crush, fall, struck by/against, other) are placed in Unintentional Other Transport in the ICD-10 External Cause Matrix. Question: Should ICD-10-CM transportation codes (V90.xxx-V94.xxx) involving watercraft that result in drowning/submersion and other injuries be placed in Unintentional Other Transport in the ICD-10-CM External Cause Matrix (for consistency with the ICD-10 External Cause Matrix), or should they be placed with their respective mechanisms (Unintentional Drowning/Submersion, Unintentional Fall, Unintentional Struck by/against, etc.)? Proposed resolution: Transportation codes involving watercraft that result in drowning/ submersion or other mechanisms of injury (e.g., fire/burn, crush, fall, struck by/against) will be placed in Unintentional, Other Transport in the ICD-10-CM External Cause Matrix.
PROPOSED EXTERNAL CAUSE FRAMEWORK Question: Should Foreign Body codes (T15.xxx-T19.xxx) be added to the matrix as a separate Unintentional mechanism category (i.e., Other Specified—Foreign Body) , or should Foreign Body codes be placed in Unintentional—Other Specified, Classifiable in the ICD-10-CM External Cause Matrix? Proposed resolution: Foreign Body codes (T15.xxx-T19.xxx) will be placed in a separate Unintentional mechanism category called Other Specified—Foreign Body in the ICD-10-CM External Cause Matrix for Causes other than Poisoning. Issue 8. Placement of the Suicide Attempt Code Background: In ICD-10-CM, there is a T code (T14.91) specifically for suicide attempt. The ICD-10-CM coding guidelines indicate that this code is only to be used when the nature and body region of injury and the mechanism of injury are unknown (e.g., the medical record only says “suicide attempt” with no additional information). Question: Should the suicide attempt T code (T14.91) be placed in the matrix as Unspecified Self-harm, or should it be excluded from the matrix? Proposed resolution: The suicide attempt (T14.91) code will be placed in the Unspecified Self-harm category in the ICD-10-CM External Cause Matrix for Causes other than Poisoning. Issue 9. Placement of Adult and Child Abuse/Neglect/Other Maltreatment Codes Background: Adult and child abuse/neglect/other maltreatment codes were not included in a separate Assault category in the ICD-9-CM or ICD-10 External Cause Matrices. ICD-10-CM provides the opportunity to consider adding a separate Child/Adult Abuse category because of its enhanced specificity and detailed coding guidelines. In ICD-10-CM, Abuse codes (T74 (confirmed) and T (suspected)) can be used to classify adult and child abuse, neglect, and other maltreatment. T74.xx and T76.xx sub-codes specify neglect/abandonment, physical abuse, sexual abuse, psychological abuse, Shaken Infant Syndrome, and unspecified maltreatment. According to the ICD-10-CM child and adult abuse coding guidelines, if documentation in the medical record states abuse or neglect, the case is coded as confirmed (T74.xx). If documentation in the medical record states suspected abuse or neglect, the case is coded as suspected (T76.xx). The coding guidelines also indicate that adult and child abuse, neglect and maltreatment are classified as assault. For confirmed cases of abuse, neglect, and other maltreatment, an external cause code from the Assault section (X92-Y08) should be assigned to identify the cause of any physical injuries; also, a perpetrator code (Y07) should be assigned when the perpetrator of the abuse is known. For suspected cases of abuse, neglect and other maltreatment, the guidelines specify that external cause and perpetrator codes are not assigned.
IMPROVING INJURY DATA Questions: a. Should the T74 (confirmed) and T76 (suspected) codes for adult and child abuse, neglect and other maltreatment be placed in a separate mechanism category in the matrix? b. Should both confirmed and suspected cases of abuse, neglect and other maltreatment be counted? Proposed resolution: Confirmed (T74) and suspected (T76) Child/Adult Abuse codes will be placed in their own Assault category in the ICD-10-CM External Cause Matrix for Causes other than Poisoning. Both confirmed and suspected cases will be used to count abuse, neglect and other maltreatment. This should be pilot tested when ICD-10-CM coded data become available. Issue 10. Recording of Poisoning/Toxic Effects and Asphyxiation Codes in Administrative Databases Background: In ICD-10-CM, there are no external cause codes for Poisoning/Toxic Effects of substances and Asphyxiation (suffocation). Poisoning/Toxic Effects and Asphyxiation are classified using T codes with a character to designate intent of injury. These T codes are included in the ICD-10-CM External Cause Matrix. Questions: a. How should T codes for Poisoning/Toxic Effects and Asphyxiation be recorded in administrative databases (e.g., state-based emergency department and hospital discharge data sets)? b. Should some or all of these T codes be captured only as diagnosis codes or should they be captured as both diagnosis and external cause of injury codes? Proposed resolution: How ICD-10-CM combination codes will be recorded in administrative databases is currently under discussion by NCHS and CMS. Guidelines will be provided prior to October 1, 2014.
IMPROVING INJURY DATA
General Equivalence Mappings (GEM) ICD-9-CM as source file General Equivalence Mappings (GEM) ICD-10-CM as source file Spreadsheet with the major categories of mechanism and intent of injury NCIPC and NCHS staff used SAS programs to compare the codes in the spreadsheet with independent files of all ICD-9-CM and ICD-10-CM external code causes (and selected T codes) to check for any missing codes in either direction. NCIPC and NCHS staff independently reviewed and assigned ICD-10-CM codes to major mechanism by intent of injury categories using a set of Guiding Principles (Appendix A). NCIPC and NCHS staff discussed discrepancies and reached consensus on final placement of codes. NCIPC and NCHS staff considered feedback from injury coding, data, and surveillance experts to arrive at recommended resolutions for major issues in the proposed ICD-10-CM external cause framework. The proposed framework will be pilot tested when ICD-10-CM data become available.
PROPOSED EXTERNAL CAUSE FRAMEWORK
Item ICD-9-CM ICD-10-CM
