ED Coding and Reimbursement Alert

From lacerations to ulcers, determine how you’d fare in these scenarios.

On any given day, emergency departments can see a wide range of diagnoses, from pediatric contusions to massive trauma. Coding these situations requires a vast knowledge of ICD-10 conventions, and with the new year quickly approaching, now’s a good time for emergency department coders to test their skills in this area.

Check out the following three scenarios to determine if you can select the right ICD-10 codes for these ED encounters.

Check This Inexplicable Bruise Case

Question 1: Your ED physician saw a 9-year-old patient who had a contusion on her left foot. However, the note did not indicate whether the bruise was caused by a trauma. How should you code this?

Solution 1: While it is unusual for someone to bruise without an identifiable cause, it is certainly possible. Some medical conditions and medications can thin the blood to the point where an individual bruises easily, even to the point of bruising without a known trauma.

If this is indeed the case, you should report R23.3 (Spontaneous ecchymoses). You can use this for bruises larger than 1 centimeter; you can also use this code for bruises less than 3 millimeters (called petechiae). However, contusions less than 1 centimeter but larger than 3 millimeters are known as purpura and are coded to D69.- (Purpura and other hemorrhagic conditions).

If this does not describe your case and your ED physician does confirm that the contusion was caused by a trauma, then you would look to S90.32- (Contusion of left foot), using the placeholder X and seventh character A, D, or S to describe whether the encounter was initial, subsequent, or sequela. You should also follow this code with an external cause code from Chapter 20 to describe how the injury occurred.

Query: This is one of those times when you will definitely need to connect with your ED physician to determine the most specific code for the diagnosis.

Code These Mouth Ulcers

Question 2: The ED physician diagnosed a patient with Bednar’s aphthae. Which diagnosis code applies?

Solution 2: Your first step is understanding what’s involved in Bednar’s aphthae. In this condition, which primarily affects younger people, the patient has multiple recurrent ulcers in their mouth. Knowing that information, you’ll look to K12.0 (Recurrent oral aphthae) to report the visit.

When your ED physician suspects a diagnosis of recurrent aphthous ulcer, they will evaluate the patient to understand the frequency of ulcer formation and the size of the lesions. They will also check the patient’s history to understand if there is any family history for the condition, or personal medical history to determine if the patient is suffering from any kind of allergies or vitamin deficiencies. They might also evaluate whether any trauma or medications caused the issue.

In cases where the physician identifies an external cause, you can add a secondary ICD-10 code to describe that. However, one is not required to report K12.0 — the code can stand on its own if necessary. Recurrent aphthous ulcers are fairly common in patients with ulcerative colitis or Crohn’s disease, for example, says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a physician and former CPT^® Editorial Panel member in Pasadena, California.

Check This Laceration Scenario

Question 3: A diabetic patient came to the ED noting that she had dropped a dirty kitchen knife on her right lesser toe, cutting the top of her toe two days prior to her ED visit. The ED provider evaluated her swollen, red, and painful toe, which had a yellow discharge coming from it. The patient did not sustain damage to her toenail, and there was no foreign body in the wound. The ED physician took a culture of the laceration, and the result from the lab came back as a staph infection. Which ICD-10 codes should you report on this claim?

Solution 3: You should report S91.114A (Laceration without foreign body of right lesser toe(s) without damage to nail, initial encounter) for the laceration along with the proper ICD-10 code such as B95.8 (Unspecified staphylococcus as the cause of diseases classified elsewhere) for the staph infection. You should also report W26.0XXA (Contact with knife, initial encounter) as the external cause code.