Wiki Y99.9 ICD-10 code

[jschauer]

I have a general question regarding the use of Y99.9.

If we have a patient that comes into our Trauma center and the only information we receive from the ER states TRAUMA. We read the report for a 1V chest, 4V knee, etc and there is no findings, everything is normal. We are getting T14.90XA as the admitting diagnosis along with the words Trauma.

Can we use T14.90XA and Y99.9 since we do not know the external cause of the patient's injury?

Or is there another way we should be coding these?

We are coding for the physicians, so we can only look at the clinical information, impression and the order (or requisition).

Any direction you can give us would be appreciated.

 

[Pathos]

While Unspecified codes definitely have their place in Coding, CMS generally doesn't like them:

"Question 27: (new 08/18/2016)
Will unspecified codes be allowed once ICD-10 flexibilities expire?
Answer 27:
Yes. In ICD-10-CM, unspecified codes have acceptable, even necessary, uses. Information about unspecified codes, including an MLN Matters article and videos, can be found on the CMS website. While you should report specific diagnosis codes when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, in some instances signs/symptoms or unspecified codes are the best choice to accurately reflect the health care encounter. You should code each health care encounter to the level of certainty known for that encounter. When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (for example, a diagnosis of pneumonia has been determined but the specific type has not been determined).
For ICD-10 coding resources, visit the Provider Resources section of the CMS ICD-10 website."

I would query the provider(s) and explore the option for a more specified documentation, which would support a more specified ICD-10 code. Perhaps a more specified injury code, and if still unknown the cause (Y99.9) could still be unspecified. The provider would want to learn the external cause at some point though, which could affect future billing for this provider.