Winter injuries: Documenting to tell the story

Jan. 25, 2019 / By Karla VonEschen, MS, CPC, CPMA

Welcome 2019! For me, this time of year means mostly freezing temperatures and snow, but I have Scandinavian blood and remind myself it’s the life I choose. I live in Minnesota and I remember getting a call from my dad last year around the middle of winter. He told me that, while out walking the dog, he had slipped on a patch of ice and fell on his back side. Being a medical coder, I informed him there was an ICD-10 code for that and asked if he was all right. He said he was fine, but sore with a little lower back pain, although he thought the fall may have actually adjusted his back. Not all of us are so lucky. 

For those of us who live in cold weather states where some snow and ice are inevitable, winter injuries are all too common. This past summer I wrote a blog about heat-related illnesses, so I thought it was time to move to the opposite end of the weather spectrum and talk about winter-related injuries and documentation.

Winter weather diehards can experience anything from frostbite to traumatic head injuries this time of year. We love our skiing, skating, sledding and snowmobiling and hate shoveling, plowing snow and driving on black ice. The more common injuries seen by physicians this time of year include frostbite, sprains and broken bones from falling on ice, muscle strains from shoveling and injuries due to motor vehicle collisions on icy roads. Remember, you may not be required to submit an external cause code with your claim, but the ICD-10 codes assigned to your claims should tell the story of what happened to the patient. It’s vital for physicians to document fully and with appropriate detail; at the very least, documentation should include:

• Indication:
  • Signs and symptoms
    • Anatomical or organ site
    • Laterality if appropriate
  • What type of accident occurred
  • Where did the accident happened
  • When did the accident take place
• Impression
  • Specific injury such as fracture, bone bruise, concussion, etc.
  • Initial, subsequent, sequela encounter if appropriate

When looking at the ICD-10 code book, the options seem endless, especially when coding for fractures or external causes. Reporting of external cause codes is not mandatory, but that does not mean clear and complete documentation in the patient chart isn’t necessary. Any healthcare provider who picks up a patient chart should be able to clearly tell, for example, the patient had been seen for a left wrist sprain from falling on an icy sidewalk while shoveling snow at home. A simple and to the point statement tells the story.

As for my dad, he now chooses his walking paths with the dog more carefully to avoid M54.5 due to W00.0XXA while Y93.K1.

Karla Voneschen is a coding analyst at 3M Health Information Systems.