ICD-10-CM Coding for Injury Resulting from Terrorism

By Karen Kostick, RHIT, CCS, CCS-P

On October 1, 2015, the ICD-10-CM coding classification was implemented in the United States. This article provides a coding update on how to report injuries resulting from terrorism, which is now classifiable under ICD-10-CM. In the US, ICD-10 (mortality coding) and ICD-10-CM (morbidity coding) are the standardized classification systems to identify deaths (ICD-10) and non-fatal injuries (ICD-10-CM) resulting from terrorism.

The purpose of reporting terrorism codes is to capture the terrorist element responsible for a person’s death or injury. If these codes are not reported, a person’s death or injury cannot be formally tracked in the coding data as being associated with a terrorist-related incident. Unfortunately, this is what occurred following the September 11, 2001 (9/11) terrorist attacks. According to the Centers for Disease Control and Prevention (CDC), “The events of September 11 have had many repercussions especially in the health area... For health data, the September 11 events present challenges, in particular, the urgent need for a classification that can be used to characterize and statistically classify, report, and analyze injuries, sequelae of injuries, and deaths associated with those events.”

In response to the ICD-10 and ICD-9-CM coding classification limitation, the National Center for Health Statistics (NCHS) formed the Ad Hoc Workgroup on the Classification of Death and Injury Resulting from Terrorism. The workgroup developed a set of new codes within ICD-10 and ICD-9-CM that allowed the identification of death and injury due to terrorism. The implementation of the codes developed for morbidity first became effective October 1, 2002.

ICD-10-CM Y38 Terrorism codes are classified by the type of terrorist attack and then further classifiable by the type of person injured during the attack, specified as a public safety official, civilian, or terrorist. The Y38 Terrorism codes also require a seventh character extension to indicate whether the episode of care being identified is the initial (A), subsequent (D), or sequela (S). As illustrated in the table on page 47, the post-9/11 ad-hoc workgroup has positioned US healthcare facilities and providers with the ability to report the patient’s full incident in relation to an injury associated with terrorism. ICD-9-CM terrorism classification legacy data is present in ICD-10-CM in addition to new ICD-10-CM subcategory specificity.

The ICD-10-CM Y38 Terrorism codes are classified in Chapter 20, External causes of morbidity (V00-Y99), which permits the classification of environmental events and circumstances as the cause of injury, and other adverse effects. ICD-10-CM Chapter 20 External cause codes are intended to capture how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event, and the person’s status (i.e., civilian or military).

The ICD-10-CM Official Guidelines for Coding and Reporting state that in order for the terrorism codes to be used for the classification of injuries, the incident in question must be designated as a terrorist act by the US Federal Bureau of Investigation (FBI), which has jurisdiction over the investigation and tracking of terrorism in the US. The definition of terrorism-related injury employed by the FBI is found at the inclusion note at the beginning of ICD-10-CM Terrorism Category Y38, which states: “Terrorism codes are for use to identify injuries resulting from the unlawful use of force or violence against persons or property to intimidate or coerce a Government, the civilian population, or any segment thereof, in furtherance of political or social objective.”

The ICD-10-CM Official Guidelines for Coding and Reporting specify that there is no national requirement for mandatory Chapter 20 external cause code reporting. Unless a provider is subject to a state-based external cause code reporting mandate or these codes are required by a particular payer, reporting of ICD-10-CM codes in Chapter 20, External Causes of Morbidity is not required. In the absence of a mandatory reporting requirement, providers are encouraged to voluntarily report external cause codes, as they provide valuable data for injury research and evaluation of injury prevention strategies.

The following ICD-10-CM chapter-specific coding guidelines apply for terrorism-related incidents:

• Y38 Terrorism codes are not to be sequenced as the first-listed or principal diagnosis as they are intended to be used secondary to a code from another chapter of the classification indicating the nature of the condition. For terrorism incidents, the nature of the condition will usually be classifiable to Chapter 19, Injury, poisoning and certain other consequences of external causes (S00-T88).
• More than one code from Category Y38 may be assigned if the injury is the result of more than one mechanism of terrorism.
• Assign an additional code for place of occurrence (Y92.-). Codes from category Y92, Place of occurrence of the external cause, are secondary codes for use after other external cause codes to identify the location of the patient at the time of injury or other condition.
• When the cause of an injury is suspected to be the result of terrorism, a code from category Y38 should not be assigned. Suspected cases should be classified as assault.
• Assign code Y38.9, Terrorism, secondary effects, for conditions occurring subsequent to the terrorist event. This code should not be assigned for conditions that are due to the initial terrorist act.
• It is acceptable to assign code Y38.9 with another code from Y38 if there is an injury due to the initial terrorist event and an injury that is a subsequent result of the terrorist event.

Steps for Coding Terrorism

The following steps are recommended in order to apply accurate, complete, and consistent coding practices for ICD-10-CM terrorism coding.

1. Specify the requirement for the assignment of terrorism codes

It is imperative for health information management (HIM) ICD-10-CM facility-specific coding guidelines and coding compliance programs to specify the requirement to report Y38 Terrorism codes in the event of an injury associated with terrorism. This will ensure the person’s injury is specified as an injury associated with a terrorist-related incident. The facility-specific coding guideline is required due to the absence of national ICD-10-CM Chapter 20 codes reporting requirements and inconsistent state level reporting requirements.

2. Define acceptable documentation for terrorism coding

ICD-10-CM facility-specific coding guidelines should define acceptable provider and non-provider documentation types for terrorism coding. The process for obtaining FBI approval to report the terrorism codes should be specified in the facility-specific coding guidelines. The 2014 first quarter Coding Clinic from the American Hospital Association states that documentation is not limited to the face sheet, discharge summary, progress notes, history and physical, or other report designed to capture diagnostic information. This advice refers only to inpatient coding. In addition, this issue of Coding Clinic states if the physician doesn’t document the external cause information, coding professionals may use available nonphysician documentation.

3. Provide terrorism coding education and raise awareness

HIM coding professionals should provide coding education to clinicians on the ICD-10-CM specificity documentation requirements necessary to assign accurate Y38 Terrorism codes. Also, coding professionals should raise awareness of the importance to report the terrorism codes to local, state, and federal data systems such as the hospital discharge data systems and hospital emergency department data systems so that this critical data is collected and available for analysis as needed.

References

American Hospital Association. AHA Coding Clinic for ICD-10-CM and PCS 1, no. 1 (First quarter, 2014): 12, 19.

Castro, Anne B. ICD-10-CM Code Book, 2016. Chicago, IL: AHIMA Press, 2015.

Centers for Disease Control and Prevention. “Classification of Death and Injury Resulting from Terrorism.” September 1, 2009.

Centers for Disease Control and Prevention. “Notice to Readers: New Classification for Deaths and Injuries Involving Terrorism.” Morbidity and Mortality Weekly Report 51 (Special Issue, September 11, 2002): 18-19. 

Centers for Medicare and Medicaid Services. “ICD-10-CM Official Guidelines for Coding and Reporting: FY 2016.”

Karen Kostick (karen.kostick@nuance.com) is senior technical business analyst, clinical documentation, at Nuance Communications, Inc.