Health Care Facility/Provider - Coding - ICD10-Ca

There is often more than one code that might be suitable for the problem that you are managing. Select the code that, in the opinion of the health provider, is most appropriate.

Examples

Single Injuries

Most single physical injuries will fall under Chapter XIX of the ICD 10-Ca: Injury, poisoning and certain other consequences of external causes

Why? Generally, injuries from auto collision are not diseases or illnesses that originate from internal or systemic origins
However, in some circumstances, there are sequelae from the physical injury that result in the patient’s need for health services and other types of codes may be required

Multiple physical injuries

Can be captured using a sub-section of Chapter XIX of the ICD10-Ca: Injuries involving multiple body regions

Do not enter bilateral injuries twice. Use a T code instead.

Example: Bilateral fractures lower limb = T02.5 (fractures involving multiple regions of both lower limbs)

Example 1: Spinal cord injury and home accessibility assessment

Patient's injury/problem/circumstances	Claimant sustained complete paraplegis following collision Home is not WC accessible Health professional (HP) received approval to conduct home accessibility assessment
Primary problem responsible for health goods &/or services	Patient unable to access home environment
Locate appropriate code	Z59 - Problems related to housing
Coding Breakdown Chapter Block Category	Chapter Z - Factors influencing health status and contact with health services Block 59 - problems related to housing & economic circumstances Optional - may also code category .1 (e.g. Z59.1) to express "inadequate housing"

Example 2: Same client with SCI being treated by psychologist for depression

Patient's injury/problem/circumstances	Claimant sustained complete paraplegis following collision Reports lowering of mood, reduction of energy, and decrease in activity. Capacity for enjoyment, interest, and concentration is reduced, and marked tiredness after even minimum Referred by GP to psychologist for assessment and treatment OCF 18 being prepared by psychological practice
Primary problem responsible for health goods &/or services	Moderate depressive episode
Locate appropriate code	F32 - Depressive episode
Coding Breakdown Chapter Block Category	Chapter F - Mental and behavioural disorders Block 32 - Depressive episode Optional - may also code category .1 (e.g. F32.1) to express moderate depressive episode