Injury, poisoning and certain other consequences of external causes
This chapter includes traumatic injuries such as fractures, dislocations, sprains, burns, lacerations, and internal injuries. It also covers poisonings, toxic effects of substances, and complications of medical or surgical care. Codes are highly specific and typically require details about anatomical location, laterality, type of injury, and encounter type (initial encounter, subsequent encounter, or sequela). Burns are classified by depth and extent of body surface area involved.
Poisoning codes differentiate between accidental exposure, intentional self-harm, assault, or undetermined intent. This chapter is central to emergency medicine and trauma care documentation. Accurate injury coding supports clinical management, legal reporting, insurance claims, and public health injury surveillance.
Clinical & Coding Guidelines
Chapter Notes
- Use secondary code(s) from Chapter 20, External causes of morbidity, to indicate cause of injury. Codes within the T section that include the external cause do not require an additional external cause code
- The chapter uses the S-section for coding different types of injuries related to single body regions and the T-section to cover injuries to unspecified body regions as well as poisoning and certain other consequences of external causes.
Excludes2 (Partial exclusion)
- birth trauma (P10-P15)
- obstetric trauma (O70-O71)