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Real World Examples of ICD-10 Coding

This page contains scenarios of documentation enhancement examples needed to support ICD-10 specificity requirements.

Swimming into ICD-10 waters

Summertime means beach time and unfortunately for some, Fix 'Em Up Clinic time.  Click the links below to view how each case is handled with ICD-10.


First Patient

First into the clinic today is Eric. After swimming in the ocean yesterday, Eric developed a pruritic, erythematous, papular rash on his trunk, axillae and groin. Today, he experienced malaise, chills and a sore throat.

What could be wrong with Eric? His symptoms are vague and could point to a lot of different ailments.

After further questioning by Dr. C. Shore, Eric revealed that he saw jellyfish in the area where he was swimming. He thinks he may have come into contact with one. Dr. Shore diagnoses the toxic effects of contact with a jellyfish.

Not surprisingly, ICD-10-CM includes a code for that. Actually, it includes eight codes that each require a seventh character. You'll find the codes in the T63.6 (toxic effect of contact with other venomous marine animals) series and you need to choose between:

  • Toxic effect of contact with Portuguese Man-o-war (T63.61) Toxic effect of contact with other jellyfish (T63.62)

Eric is certain he was not stung by a Portuguese Man-o-war, so we know we're in the T63.62 series. We still have four choices:

  • T63.621, toxic effect of contact with other jellyfish, accidental (unintentional)
  • T63.622, toxic effect of contact with other jellyfish, intentional self-harm
  • T63.623, toxic effect of contact with other jellyfish, assault
  • T63.624, toxic effect of contact with other jellyfish, undetermined

Based on Eric's statement that he accidentally swam into the jellyfish, we'll go with T63.621A. The seventh character denotes the encounter. This is Eric's first visit for treatment, so we add A for initial encounter.

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Second Patient

Samantha, 14, apparently thought a crab on the beach was dead, so she poked it—repeatedly. The crab was not pleased and tried to take off the offending digit. The crab was only partially successful, although it did succeed in sending Samantha screaming back to her mother.

In order to code this encounter, we need to know:

  • Partial or complete amputation
  •  Which hand
  • Which specific finger
  • Encounter type (initial, subsequent, sequela)

Dr. Shore documents an initial encounter for a partial amputation of the right index finger, which leads us to S68.120A (partial traumatic metacarpophalangeal amputation of right index finger, initial encounter).

We can also add these External Causes codes for Samantha's injury:

  • W56.81xA, bitten by other nonvenomous marine animals, initial encounter Y92.832, beach as the place of occurrence of the external cause Y99.8, other external cause status (leisure activity)

ICD-10-CM does not include codes for poking a crab or examining a presumed dead animal, so we can't add an activity code without more information.

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Third Patient

The last patient of the day also suffered a marine animal mishap, but this time, a seagull was indirectly to blame.

Bob was out scavenging for seashells and sea glass for his artwork when he spotted a group of seagulls having clams for lunch. The gulls would take off, drop the clams on the rocks to break them, then swoop in and consume the exposed inner clam.

Not all of the seagulls were on target and not all of the clams simply broke open. Bob had the misfortune of stepping on a sliver of clam shell, which sliced open the bottom of his bare foot. Of course, Bob was forced to flee the beach, picking up plenty of sand and other debris along the way.

We know Bob suffered a laceration to the bottom of his foot. Were his toes involved? If yes, we'll need to add a code or codes for those injuries. Luckily for Bob, he only lacerated his foot. However, some of the sand remained in the cut, and Dr. Shore had to remove it.

We also need to know which foot Bob injured and the encounter type. In Dr. Shore's notes, he documented an initial visit for a 3 cm laceration of the left foot with foreign material.

That gives us code S91.322A (laceration with foreign body, left foot, initial encounter).

Be aware that the codes will vary by location on the body Laterality Type of wound With or without foreign body. We can also report some external cause codes for Bob, including:

  • W22.8xxA, striking against or struck by other objects, initial encounter Y92.832, beach as the place of occurrence of the external cause Y93.01, activity, walking, marching and hiking Y99.0, civilian activity done for income or pay

A quick word about the first and last codes on this list. When you look up stepping on an object in the Alphabetic Index, you are directed to W22.8. That's the code we'll use even though the definition doesn't seem exactly correct.

The Y99.0 code is open to debate a little, too. Bob said he was looking for material for his artwork. We would report Y99.0 if he sells his artwork because scavenging shells could be considered a work activity. If he creates art for art's sake, we would use Y99.8 (other external cause status).

Just remember the next time you're at the beach: avoid the jellyfish, don't poke the marine life, and stay away from seagulls.

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