External Cause Codes and Their Many Uses in Utah

External Cause Codes and Their Many Uses in Utah

Cristy Sneddon, RHIT

Utah Department of Health

Objectives

• External Cause of Injury Codes (E Codes)

• Mandates and Administrative Code

• Data and the Violence and Injury Prevention Program (VIPP)

• Opiate/Opioid Overdose Project

• Unspecified Elderly Falls Project

• ED Concussion Data

• ICD-10 External Cause Codes

External Cause of Injury Codes

• E Codes help us:– Describe the magnitude of injury morbidity by

cause of injury– Identify population subgroups at high risk for a

particular cause of injury• Bicycle related injuries in children 5 – 14 years

– Identify the place of occurrence for specific types of injuries/populations

• Elderly falls 65 and older


• Develop prevention strategies targeting specific causes of injury and specific population groups at risk• Helmet give-away and educational programs

to school-aged children• Exercise programs for elderly adults at risk

for falls


• Evaluate the effectiveness of the intervention programs• Cost-effectiveness of helmet programs and

education in reducing bicycle-related injuries in school-aged children

• Monitor elderly fall injury trends to see if rates are decreasing

Source: Public Health Data Standards Consortium. The Importance of Understanding External Cause of Injury Codes Tutorial, 2006.

Historical Perspective

• In 1991, the National Committee on Vital and Health Statistics (NCVHS) recommended that external cause of injury codes (E Codes) be included in hospital discharge (HDD) data sets• At that time only 5 states had HDD systems

which collected E Codes

Utah Mandates

• Utah passed legislation requiring the routine collection of E Codes statewide:

• In 1995 for Hospital Discharge Data (HDD)

• In 1996, for Hospital Emergency Department Data (HEDD)

Utah Administrative Code

• Rule 428-10• Health Data Authority Hospital Inpatient

Reporting Rule• HDD Code

• Rule 386-703• Injury Reporting Rule

• Injury Reporting Rule

A Snapshot of 2011

• 11,571 Utahns were hospitalized due to an injury or violent act

• 31 people hospitalized every day

• 154,047 Utahns were treated in an ED

• Enough people to fill Energy Solutions Arena 8 times

Source: Violence and Injury Prevention Program website, http://www.health.utah.gov/vipp/index.html; and Utah’s Indicator Based Information System for Public Health (IBIS-PH), 2011 data [cited 2013 August]

VIPP Background

• The Violence and Injury Prevention Program (VIPP) has been gathering Injury data and providing prevention resources for 30 years.

• Majority of programs are Federally funded from the Centers for Disease Control and Prevention (CDC)

VIPP Background

• Prevention Programs include:– Traumatic Brain Injury– Spinal Cord Injury– Falls Among Older Adults– Prescription Drug Overdose– Rape and Sexual Assault– Student Injury– Infant Sleep Death

VIPP Background

• Prevention Programs include:– Teen Driving– Safe Kids– Child Abuse and Maltreatment– Dating and Domestic Violence– Motor Vehicle Crashes– Violent Death (Homicide, Suicide,

Undetermined)

Current Projects

• Opiate/Opioid Overdose Hospitalization Project

• Unspecified Elderly Falls Project

• Traumatic Brain Injury (TBI) Surveillance, Emergency Department Concussion Data

Current Projects

Opiate/Opioid Overdose Hospitalizations

Surveillance Quality Improvement (SQI)

• In 2011, Utah was one of four states to receive Surveillance Quality Improvement (SQI) Grant– UT, CO, NC, MA– 5 year grant cycle

• Every year the multi-state group, including CDC, decides on a project pertinent to emerging public health conditions


• Year 2 Multi-State Project– Accidental Opiate/Opioid Overdose– ED or Inpatient (Utah chose inpatient)

• Year 2 Individual State Project– Suicide and Undetermined intent

– Determine the complete inpatient overdose picture

Criteria

• Report from the Injury Surveillance Workgroup on Poisoning (ISW-7) for National and State Poisoning Surveillance

• ISW-7

• The Safe States Alliance is a national non-profit 501(c)(3) organization and professional association whose mission is to strengthen the practice of injury and violence prevention

Criteria

• Standardized code set for ICD-9-CM opiate/opioid poisoning and associated E Codes

– 965.00, 965.01, 965.02, 965.09– Accidental; E850.0, E850.1, E850.2– Suicide; E950.0, E950.4, E950.5– Undetermined; E980.0, E980.4, E980.5

Criteria

– Determine PPV (Positive Predictive Value) for both sets of codes

– Documentation of one or more of the following clinical signs to verify Opioid Analgesic Overdose:– Respiratory depression– Miosis– Stupor– Rhabdomyolysis– Myoglobinuric Renal Failure– Compartment Syndrome

Criteria

– Use of Naloxone as treatment for overdose either given in the hospital or prior to arrival

– Medical record documentation to support coded intention

Clinical Signs Source: The New England Journal of Medicine, Management of Opioid Analgesic Overdose, July 12, 2012

Opiate/Opioid Overdose

• Pulled code criteria from 2011 data year

• Total of 842 inpatient hospitalizations for record review– Accidental – 346– Suicide – 224– Undetermined – 77– Cases with ICD-9 poison code, but no E code

for intent - 195


• PPV Results for ICD-9 Poison codes

Positive Predictive Value

Intent PPV

Accident 99.6

Therapeutic 100.0 (only 1 case)

Suicide 93.5

Assault 0 (no cases)

Undetermined 95.2


• PPV for E Codes and intent of injury

Sensitivity: actual positive cases which are correctly identified as such

2011 E Code Sensitivity E code PPV E Code

E850087% 96%

E850193% 100%

E850297% 100%

E950098% 94%

E980097% 95%

Uses for Opiate/Opioid Data

• Information shared with the Prescription Drug Task Force

• Multi-state Special Emphasis Report – Drug Overdose Morbidity

• Naloxone study

• Naloxone study results presented at the Safe States Alliance Conference

• Naloxone poster presented at the Council of State and Territorial Epidemiologist (CSTE)


• Naloxone Study– Medical record review process included

administration of Naloxone– 57% of hospitalizations given Naloxone– Findings: Early administration of drug

associated with discharge to home instead of other location or death

– Helped inform legislators and supports new Naloxone law passed last session


• H.B. 119 – Opiate Overdose Emergency Treatment– Permits administration of Naloxone to

someone experiencing overdose– Immunity for good faith– Doctors can prescribe Naloxone to:

• Person at risk of opiate-related overdose• Family member, friend or other person in a position

to assist someone who is a user of pain killers or Heroin

Findings

• 842 cases reviewed, 2 cases found to be false positive (FP) – First FP case coded - 965.09, Other opiate

(Codeine, Morphine Meperidine); E850.2, Accidental Other opiate and related narcotic; E850.4, Accidental Aromatic analgesics

– On review, case was found to be accidental Methamphetamine overdose (969.2, E854.2)

Findings

– Second FP case coded - 965.09, Other opiate (Codeine, Morphine Meperidine); E950.0, Suicide and self-inflicted Analgesics, Antipyretics and Antirheumatics

– On review, patient admitted for suicidal ideation – No mention of overdose – No medication mentioned – All lab results negative

Findings

• Total positive cases - 840– Found documentation to ‘revise’ 42 cases

No Reason to be Alarmed

Please remember and don’t panic

When talking about ‘revising’ or ‘being able to revise’ E Codes we don’t remove or change original coding

We add additional variables for surveillance coding comparison

Findings

• Total positive cases - 840– Found documentation to ‘revise’ 42 cases

• 5 with correct poison code, no E codes listed• 2 coded as accidental, but documentation stated

suicide intent• 1 case had both suicide and undetermined intent

codes listed• 2 cases had correct poison, but listed E858.8 other

specified drug– One case had diagnosis of Opiates and Benzodiazipines

NOS (E850.2, E853.2)– One case had diagnosis of Opiates NOS (E850.2)

Findings

• Most alarming– Found 15 cases coded as Suicide

• 35.7% of total cases ‘revised’• Documentation found stated Accidental• Verified with individual hospital coding supervisors

– Wanted to make double sure we didn’t miss anything– Determined to be confusion and coding training issue

– On a larger scale…• Total of 224 inpatient suicide overdose cases• 15 cases represents 6.7% which has potential to

affect (skew) our percentage and rates nationally

Findings

• ICD-9 poisoning codes– Several cases had missing or incorrect codes

• Had Opiate code, missed Methadone • Had Heroin coded as 965.00 instead of 965.01• Had Heroin listed on diagnosis, not coded

• 965.00 vs. 965.09 – Found multiple cases where original code was

965.00– On case review felt should be coded as

965.09 as there was a ‘named’ drug

Discussion

• 965.00 vs. 965.09– Under the impression that a drug that is NOS

or generic is coded 965.00– Named drugs, such as Oxycodone would be

coded as 965.09

Current Projects

Unspecified Elderly Fall Hospitalizations


• Year 3 Individual SQI State Project

• Elderly falls is an emerging public health condition

• Project focused in this area

Standard Definitions

• Standard Definitions– Fall:

• An event which results in a person coming to rest on the ground or other lower level precipitated by a misstep such as a slip, trip, stumble; from loss of grip or balance; from jumping; or from being pushed, bumped, or moved by another person, animal or inanimate object or force

– Fall-Related Injury:• An injury precipitated by a fall (as defined above)

and caused by striking an injury-producing surface

Criteria

• National Report from the Injury Surveillance Workgroup on Falls (ISW-4)

• ISW-4– Specific set of fall related E Codes

• E880-E886, E888, E957, E968.1, E987• Also included Utah identified codes; E917.8, Striking against

other stationary object with fall; and E917.7 Striking against furniture with fall

Criteria

• Utah specific Criteria– Utah resident– 65 and older– Acute care inpatient hospitalization

Unspecified Falls Project

• Data taken from 2012 HDD

• Total of 4,369 cases met criteria

• Significant issue to explore– 1,682 identified cases had an Unspecified Fall

E Code (E888.9)– 38.5% of total fall cases


• Random Sample of 350 cases (20.8%)– Determine if documentation available for more

specific E Code

• Identified 137 cases with documentation for more specific code (39.1%)– Utah refers to ‘revise’– Don’t remove or change original coding, add

additional variables for surveillance coding comparison


• Graph showing 137 cases before


• Referring to the previous graph what kind of information can you get?

• In terms of fall prevention, what information can you get?– What type of falls are happening?


• Graph showing 137 cases before


• Now using ‘revised’ codes……..

Uses for Unspecified Falls Data

• Information shared with Utah Falls Prevention Coalition

• Fact Sheets to share data with local health departments and other partners

• Multi-state Special Emphasis Report on Elderly Falls

• Show need for programs such as Stepping On and Matter of Balance• Scientifically tested and proven interventions

Current Projects

Traumatic Brain Injury

Surveillance

Traumatic Brain Injury (TBI)

• Previous presentations looked at Inpatient hospital data• Focus on E Codes from reviewed cases• Specifically looking at coding differences and

findings

TBI ED Data

• Standard case definition for TBI Surveillance taken from the Center for Disease Control and Prevention (CDC) – Same code set as Inpatient– Code sets for both Morbidity and Mortality

(our focus for this presentation is Morbidity)

Criteria

• Opiate/Opioid project used both ICD-9-CM and E Codes to determine injury

• Unspecified Elderly Falls Project used only E Codes to determine injury

• TBI data for both inpatient and ED is pulled strictly by ICD-9-CM diagnosis codes

Criteria

• ICD-9-CM codes to Identify TBI include:• 800.0 – 801.9 (Fracture of the vault or base of the

skull)• 803.0 – 804.9 (Other and unqualified and multiple

fractures of the skull)• 850.0 – 854.1 (Intracranial injury, including

concussion, contusion, laceration, and hemorrhage)• 950.1 – 950.3 (Injury to the optic chiasm, optic

pathways and visual cortex)• 959.01 (Head injury, unspecified)• 995.55 (Shaken Infant Syndrome)



• Snapshot of 2011 ED data specific to Concussion • Code set 850.0-850.9• Emerging public health condition• Not chart reviewed• Information based solely on E Codes

received from HEDD

TBI ED Data

• Total of 19,968 TBI visits in the Emergency Department – Determine by entire code set criteria

• Total of 6,228 Concussion Only– 850.0 - 850.9

ED Concussion Data

• Total 6,228 cases – 188 no E Code to identify external cause (3%)

• Discharge Status– 6,088 to home– 87 admitted for additional treatment

• Total Cost for Concussion – $19,042,148.68– Median (average) cost $2,434.59– Highest cost $53,930.36

ED Concussion Data

• Rely on E Codes to determine cause of injury – Some give good information– Some are fairly vague

ED Concussion Data

• Transport Related E Codes (E800-E829)– Motor Vehicle Crashes

– Driver, Passenger, Pedestrian related

– Traffic or off-road related

– Bicycle crashes related

– Horseback Riding related

• Easy to pull code sets for data– Crashes (all positions), pedestrians, bikes

ED Concussion Data

N = 817

ED Concussion Data

• Looking at the data from a public health standpoint………………

• Could we determine the age group or groups at the highest risk for motor vehicle injury by rate?

ED Concussion Data

N = 817

ED Concussion Data

• Sports-Related E Codes – Diving or Swimming (E883.0)– Roller Skating (E885.1)– Scooter - Non-motorized (E885.0)– Skiing (E885.3)– Skateboarding (E885.2)– Snowboarding (E885.4)

ED Concussion Data

ED Concussion Data

• Put your public health surveillance glasses on again….

ED Concussion Data

What snow sport has the highest injury count?

ED Concussion Data

• Would roller skating be considered a top 5 priority for injury prevention?

ED Concussion Data

• When coding, most E Codes can be very informative and describe the injury well

• BUT when it comes to injury surveillance, some codes can be a bit vague

Enough Information?

• E884.9 Other fall from one level to another

• E885.9 Other fall from slipping, tripping or stumbling

• E886.0 Fall on the same level from collision, pushing, shoving by or with another person, In sports

Enough Information?

• E917 Striking against or struck accidentally by objects or persons– E917.0 In sports without fall– E917.5 Object in sports with fall– E917.9 Other striking against with or without

fall

ED Concussion Data

Scenario

A football player for the University of Utah received a hard tackle and was taken out of the game due to severe concussion. The story was carried by several local news stations.

Now…..

A news reporter is calling wanting to know how many concussions occur in football and how many people were diagnosed with a concussion in 2011.

ED Concussion Data

• Of the 2,109 injuries represented on the previous chart could you determine how many were:– Football related

ED Concussion Data

Number of Football-related injury? Soccer-related injury? La Crosse/Field Hockey-related injury?

Importance of Activity Codes

• Using a combination of E Codes and Activity codes for the same 2,109 cases from the previous chart


• How many football related concussion occurred?


• Activity Code Guidelines– Assign a code from category E001-E030 to

describe the activity that caused or contributed to the injury or other heath condition

– Appropriate for use if identifying the activity provides additional information on the event

– Not applicable with poisoning, adverse effects, misadventures or late effects


• How many La Crosse/Field Hockey related concussion occurred?


• What sport had the highest number of injuries for water or snow related injuries?


• Able to identify individual sport-related injury

Uses for TBI Surveillance Data

• Brain Injury Alliance of Utah (BIAU)

• Local health departments to show injury rates by age for focused prevention efforts

• Non-profit agencies to show need for funding for patient care and rehabilitation

• UDOH Small Area Report

• Data to submit to CDC for inclusion in national rates (WISQARS)

• IBIS-PH (Utah’s Public Health Data Resource)

Projects on the Horizon

• Upcoming Year 4 SQI Projects

• ‘No E Code’ Project– Over 2,000 cases that have an injury code,

but no external cause coding– Determine if codes are available in record

• Elderly Falls with ICD-10 Project– Review records for elderly falls– Assign ICD-10 External Cause Codes– Determine if compatible and complete– Give better more accurate detail of injury

Current Projects

ICD-10-CM

External Cause Codes

External Cause ICD-10-CM

• Codes range from V00 – Y99– Greatly expanded– 7th digit encounter codes

– (A) Initial Encounter– (D) Subsequent Encounter– (S) Sequela

– Late Effect Codes now Sequela– Means more codes to use rather than

general category codes


• Transport Accidents– ICD-9-CM was categorized by type of injury– ICD-10-CM by who was injured how– More classifications of transport vehicles

– Heavy Transport Vehicle (Semi-truck or Bus)– Pedestrians on roller skates

ICD-9 vs. ICD-10

Motorcycle driver collided with a semi-truck on the freeway

ICD-9

E812.2 - Other motor vehicle traffic accident involving collision with motor vehicle; Motorcyclist

E849.5 - Street or Highway

ICD-10

V24.4xxA - Motorcycle driver injured in collision with heavy transport vehicle or bus in traffic accident

Y92.411 – Interstate highway


• Place of Occurrence (Location) Codes– Y92 codes– Much more detail and classifications– Only list for initial encounter– Should only be 1 Place of Occurrence code

ICD-9 Codes

ICD-9 Place of Occurrence

E849.0 – Home (includes apartment, house, farm house, driveway, garden, garage yard etc.)

E849.6 – Public Building (includes bank, airport, courthouse, church, theater, store etc.)

E849.4 – Place for recreation or sport (includes baseball field, golf course, skate rink, vacation resort, etc.)

ICD-10 Codes

ICD-10 Place of Occurrence

Home

Y92.012 – Bathroom of single family house

Y92.027 – Garden or yard of mobile home

Public Building

Y92.253 – Opera House

Y92.240 – Courthouse

Recreation or Sport

Y92.312 – Tennis Court

Y92.322 – Soccer Field

ICD-9 vs. ICD-10


• Poisoning Codes– Drug combination codes include intent

• Additional intent code– Accidental (Unintentional)– Self-Harm (Intentional)– Assault– Undetermined– Adverse Effect– Underdosing


• Combination codes for poisoning and intent

• ICD-9– Accidental Heroin overdose– 965.01, E850.0

• ICD-10– Accidental Heroin overdose, initial encounter– T40.1x1A

ICD-10-CM Activity Codes

• Y93

• Similar to ICD-9-CM

Remember….

External cause codes (E Codes) capture the “who, what, why, where and how” an injury occurs

Activity codes are used to help provide additional information when applicable

So remember….

When grandma gets on her mobility scooter and goes wheeling around the art gallery while she is knitting a sweater for Aunt Jane and crashes into a statue…

There’s a Code for That….

V00.832A – Motorized mobility scooter colliding with stationary object

Y92.250 – Art Gallery

Y93.D1 – Activity, Knitting and Crocheting

In Summary

• E Codes are required by Utah law

• Given a picture of how external cause codes are used for surveillance in Utah

• Why they are important

• Why good documentation

• Leads to good coding

• Leads to good surveillance data

• Accurate prevention focus

In Summary

• Good documentation is an issue

• Can only code what is available in the record

• What can we do?

• Education of physicians on importance of E Codes

• Show need for better documentation

In Summary

• ICD-10-CM is coming and everyone is preparing

• We are good at using E Codes

• Now is a good time to get better and in a good routine of using external cause codes

• Get familiar with Activity Codes

In Summary

Soap Box

Okay, hopping off my E Code

Web Links

• http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/Injury/ISW7.pdf

• http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/Injury/isw4.pdf

• http://www.rules.utah.gov/publicat/code/r428/r428-010.htm

• http://www.rules.utah.gov/publicat/code/r386/r386-703.htm

• http://www.health.utah.gov/vipp/

• http://ibis.health.utah.gov/

• http://www.cdc.gov/injury/wisqars/index.html

Contact Information

Cristy Sneddon, RHITData Abstraction Lead

Violence and Injury Prevention ProgramUtah department of Health

Office phone: 801-538-6550Fax: 801-538-9134

http://health.utah.gov/vipp/

Documents

External Cause Codes and Their Many Uses in Utah