By Abby Hansen, MHA, RHIA, CCS, CCS-P
The Centers for Disease Control and Prevention (CDC) reports that suicide rates have increased by more than 30 percent since 1999. In 2014, suicides accounted for 42,773 deaths in the United States; 2015 saw 44,193 suicides, and suicides increased to 44,965 in 2016. Suicide has consistently remained in the top 10 leading causes of death for all age groups. It is the second leading cause of death for 10- to 34-year-olds and the fourth leading cause of death for 35- to 54-year-olds.
This is not just a mental health problem, but a public health crisis. Therefore, accurate coding is vital for reporting purposes. Why is this important? The data collected through reported ICD-10-CM codes is used for research, treatment development, and clinical decision-making. It is also used to establish suicide prevention programs. The data obtained through ICD-10-CM codes is also used to analyze outcomes and costs. Coding professionals are on the frontline for collecting this important information.
Cause of Injury and Coding Structure
In 2016, the three most common methods of suicide were by firearms, suffocation, and poisoning. Suicides are coded by the cause of injury. These codes are in Chapter 19 of the ICD-10-CM Code Book. The coding structure for poisoning and suffocation are very similar and include the method as well as the associated intent of the injury. Suicide by firearm is coded as a puncture wound to the organ affected. For injuries by firearm, it will be important to reference the specific subcategory notes in the Tabular List of the ICD-10-CM Code Book for instructional guidelines for any additional injuries that should be coded. For example, a gunshot wound to the chest with penetration to the heart and a retained bullet would be coded as a puncture wound with foreign body of thorax with penetration into thoracic cavity. This would be followed by a code for the injury to the heart. Since the puncture wound does not include an intent or cause, an external cause code from Chapter 20 would be added to include the intent of self-harm and method by gun. The Chapter 20 codes for external causes of morbidity are of great importance for suicide reporting. External cause codes in the range of X71-X83 signify injuries with an intent of self-harm.
The conversion from ICD-9 to ICD-10 saw a vast improvement in data capture. ICD-10-CM brought a more complete description of coding scenarios, allowing coding professionals to fully capture a patient’s condition. For example, a code for poisoning consists of one combination code including the drug taken and the intent—whether intentional, accidental, assault, or undetermined. This is not only important for the coding professional, but also for those who study the data derived from ICD-10-CM codes. Since many of these codes can be captured with combination codes, it makes it much simpler to abstract data for those who need it.
Accidental, Intentional Self-harm, Assault, or Undetermined
When the documentation does not signify the intent of a poisoning, it should be coded as accidental. Some coding professionals will be tempted to use “undetermined” when the documentation is lacking the intent. However, “undetermined” is reserved only for use when the documentation specifically states the intent is undetermined or unknown. A poisoning or strangulation that is coded with an intent of “undetermined” will still fall into the mortality data for the National Vital Health Statistics (NVHS) for reported suicides, while an intent of “accidental” will not be reported for suicide mortalities. Incorrect coding leads to inaccurate data if some of the “undetermined” cases are really accidents or the “accidents” are intended as self-harm. It is important for coding professionals to thoroughly review the documentation for accurate reporting of the intent. The intent can often be found in the emergency department (ED) documentation as this may be the patient’s first encounter at the hospital.
Coding for Poisoning
Poisonings are a more common method of suicide for females than males, accounting for one-third of all female suicide deaths in 2014. The CDC has estimated that suicides from opioid poisonings virtually doubled between 1999 and 2014. While the US is currently in a state of “opioid crisis,” it is difficult to differentiate between poisonings that occur by accident versus those that occur intentionally. However, data from a 2014 survey indicated that people addicted to prescribed opioids have a 40 to 60 percent higher risk for suicidal ideation. Additionally, perpetual users of opioids are twice as likely to attempt suicide as individuals who do not use them.
As a reminder, a poisoning occurs when there is an improper use of a medication. An error is made either in prescribing the medication or by administering the drug by the provider, patient, or other person. This includes accidentally taking too much of a medication, overdosing on a drug intentionally taken, or taking a nonprescribed drug with a correctly prescribed and administered drug, resulting in drug toxicity. A poisoning would also be coded when there is an interaction between the use of a medication and alcohol. The poisoning is listed first, followed by the manifestation.
Consider the following coding scenario: A 47-year-old female is found with no pulse after an intentional overdose of her prescribed opioids. The ICD-10-CM code would be T40.2X2A, Poisoning by other opioids, intentional self-harm. The sixth character of “2” indicates the poisoning was intentional.
Coding for Suffocation
Suicide by suffocation has increased since 1999 for both men and women in the US. This includes hanging and strangulation. Hanging is a form of asphyxia caused by suspension of the body by a ligature that encircles the neck. Death occurs when the airway becomes blocked due to the compression of the larynx and trachea. A suicide carried out by suffocation is indexed in the ICD-10-CM Code Book under the term “asphyxiation.”
Consider the following coding scenario: A 34-year-old male is found in his hotel bathroom unresponsive after having hung himself by a rope. The ICD-10-CM code would be T71.162A, Asphyxiation due to hanging, intentional self-harm, initial encounter.
Coding for Firearms
In 2016, the most common method of suicide was due to the use of firearms and accounted for more than half of all suicide deaths. This includes both males and females.
Consider the following coding scenario: A 52-year-old male is brought to the ED after sustaining a self-inflicted gunshot wound of the brain, using his own handgun. He is unconscious and expires an hour after arrival to the hospital. The ICD-10-CM codes used would be S01.83XA, Puncture wound without foreign body of other part of head, initial encounter; S06.893A, Other specified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes; and X72.XXXA, Intentional self-harm by handgun discharge.
For this example, the cause of injury is the puncture wound of the head. Subcategory “S01” of the ICD-10 Tabular List gives the instruction to also code any intracranial injury which includes the injury to the brain with a loss of consciousness. Since this injury does not include an intent, a code from Chapter 20 is added to signify the intent of self-harm and the method by handgun.
The Importance of Accurate Data
The importance of accurate coding for suicides can often be overlooked. Coded data is the source that identifies the frequency of poisonings, suffocations, and fatal gunshot wounds. As suicide rates climb, the accuracy of the data becomes even more important. These data are studied and interpreted by researchers in determining the need for suicide prevention programs. It is essential to maintain a high quality of coding accuracy and integrity.
American Foundation for Suicide Prevention. www.afsp.org.
Centers for Disease Control and Prevention. ICD-10-CM Official Guidelines for Coding and Reporting FY 2017. www.cdc.gov/nchs/data/icd/10cmguidelines_2017_Final.pdf.
Curtin, Sally C., Margaret Warner, and Holly Hedegaard. “Increase in Suicide in the United States, 1999-2014.” NCHS Data Brief no. 241 (April 2016). www.cdc.gov/nchs/products/databriefs/db241.htm.
Hedegaard, Holly, Sally C. Curtin, and Margaret Warner. “Suicide Rates in the United States Continue to Increase.” NCHS Data Brief no. 309 (June 2018). www.cdc.gov/nchs/data/databriefs/db309.pdf.
Nutt, Amy Ellis. “Suicide rates rise sharply across the United States, new report shows.” Washington Post. June 7, 2018. www.washingtonpost.com/news/to-your-health/wp/2018/06/07/u-s-suicide-rates-rise-sharply-across-the-country-new-report-shows/?noredirect=on&utm_term=.b20996cb4f59.
Abby Hansen (firstname.lastname@example.org) is a coding compliance specialist at UASI and is an adjunct instructor at Johnson County Community College in Overland Park, KS.
Hansen, Abby. “Coding’s Impact on Suicide Prevention” Journal of AHIMA 89, no. 8 (September 2018): 68–69.