ICD-9-CM Coding Advice for Healthcare Encounters
in the Hurricane Aftermath

Introduction
This document is intended to be used as a guide to help coding professionals when coding healthcare encounters of those individuals affected by the hurricane. This coding advice has been approved by the four Cooperating Parties – American Health Information Management Association, American Hospital Association, Centers for Medicare & Medicaid Services, and National Center for Health Statistics.

Use of E Codes
An External Cause code (E code) should be assigned to identify the cause of an injury(ies) incurred as a result of the hurricane. The use of E codes is supplemental to the application of ICD-9-CM diagnosis codes. E codes are never to be recorded as principal diagnoses (first-listed in non-inpatient setting). The appropriate injury code should be sequenced before any E codes.

The use of E codes is limited to injuries, adverse effects, and poisonings. They should not be assigned for encounters to treat hurricane victims’ medical conditions when no injury, adverse effect, or poisoning is involved.

E codes should be assigned for each encounter for care and treatment of the injury. Note that this advice is an exception to the ICD-9-CM Official Guidelines for Coding and Reporting and applies only to healthcare encounters resulting from the hurricane. E codes may be assigned in all healthcare settings. For the purpose of capturing complete and accurate ICD-9-CM data in the aftermath of the hurricane, a healthcare setting should be considered any location where medical care is provided by licensed healthcare professionals.

Sequencing of E Codes
Cataclysmic events, such as hurricanes, take priority over all other E codes except child and adult abuse and terrorism and should be sequenced before other E codes. Assign as many E codes as necessary to fully explain each cause. For example, if an injury occurs as a result of a building collapsing during the hurricane, E codes for both the hurricane and the building collapse should be assigned with the E code for hurricane being sequenced as the first E code.

For injuries incurred as a direct result of the hurricane, assign the appropriate code(s) for the injuries, followed by code E908.0, Hurricane, and any other applicable E codes. Code E908.0 should be assigned when an injury is incurred as a result of flooding caused by a levee breaking. Code E909.3, Collapse of dam or man-made structure, should not be assigned when the cause is a hurricane. Code E909.3 is limited to collapses of man-made structures due to earth surface movements, and tidal surges caused by storm action are excluded from category E909.

Other E Code Issues
For injuries that are not a direct result of the hurricane, such as an evacuee that has incurred an injury as a result of a motor vehicle accident or a police officer being injured while attempting to stop looting, assign the appropriate E code(s) to describe the cause of the injury, but do not assign code E908.0. If it is not clear whether the injury was a direct result of the hurricane, assume the injury is due to the hurricane and assign code E908.0, as well as any other applicable E codes.

In addition to code E908.0, other possible applicable E codes include:

• E900.0 Excessive heat due to weather conditions
• E904.0 Abandonment or neglect of infant and helpless persons
• E904.1 Lack of food
• E904.2 Lack of water
• E906.0 Dog bite

Use of V Codes
V codes may be assigned as appropriate to further explain the reasons for presenting for healthcare services, including transfers between healthcare facilities. The ICD-9-CM Official Guidelines for Coding and Reporting identify which codes may be assigned as principal or first-listed diagnosis only, secondary diagnoses only, or principal/first-listed or secondary (depending on the circumstances). Possible applicable V codes include:

• V20.1, Other healthy infant or child receiving care
• V46.12, Encounter for respirator dependence during power failure
• V60.0 Lack of housing
• V60.1, Inadequate housing
• V60.2, Inadequate material resources
• V62.89, Other psychological or physical stress NEC
• V63.2, Person awaiting admission to adequate facility elsewhere
• V63.8 Other specified reasons for unavailability of medical facilities

The E and V codes listed above are not an all inclusive list. Other codes may be applicable to the encounter based upon the documentation. Assign as many codes as necessary to fully explain each healthcare encounter. Since patient history information may be very limited, use any available documentation to assign the appropriate E and V codes.

See the ICD-9-CM Official Guidelines for Coding and Reporting for further guidance regarding the use of ICD-9-CM diagnosis codes, including E and V codes. This document can be accessed at the following link: www.cdc.gov/nchs/data/icd9/icdguide.pdf.

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Hurricane Relief Update: NUBC Approves New Codes

The National Uniform Billing Committee (NUBC), in response to an emergency request from CMS, has approved a series of new codes to help facilitate medical billing for services rendered to victims of Hurricane Katrina. While the details and definitions have not yet been fully developed, the NUBC intends that the new codes will help track the cost of providing medical care to victims.

The new condition code, “DR,” is intended to help CMS and other health plans identify claims for which the admission is related to a disaster. In addition, CMS has said that long-term care hospitals caring for Katrina evacuees will be excluded from the calculated statistics intended to ensure the average long-term care stay is 25 or more days. There could be other uses for this new claim identifier, but these uses will be further developed as CMS reviews and finalizes future disaster policies.

Other new codes approved by NUBC, but currently acting only as placeholders until implementation, are a new Occurrence Code, “DR,” and Occurrence Span Code, “MR.” The Occurrence Code could, for example, capture the date of a declared disaster, like Katrina, while the Occurrence Span Code could capture a date range - when a disaster was declared and when the disaster officially ended. These codes also could reflect the date that FEMA declared an area to be a disaster area.

In addition to these codes, a new Value Code, “DR,” is intended to record a specific numeric or monetary amount pertaining to the disaster. It also is a placeholder for now.

NUBC plans to have this and additional information on its Web site at www.nubc.org, soon. Hospital billing personnel dealing with evacuees are urged by NUBC to check the site periodically for additional changes and updates.

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