Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | ICDCount | ICD Count | ||
Form 1 | Mod1ICDold | 3490 | Please Enter All Abstracted ICDs | 2014-04-01 - Variable Added |
INJURY COMORBIDITIES
ICD DIAGNOSIS
Definition
ICD-10 Diagnosis Codes assigned by acute hospital(s) on discharge.
Form
[X] Form 1
[ ] Form 2
Source
Abstraction (acute record)
Details
These codes should be assigned by medical records and recorded on the chart at acute discharge. Numbers should be coded just as they appear on the record and not padded with zeros.
This variable should include all ICD-CM codes from any system acute care hospitalization irrespective of relatedness to TBI. If there are multiple acute stays, ICD-CM codes should be taken from all acute stays.
Do NOT include V, W, X or Y codes, as these are “External Causes of Morbidity” codes which should only be coded under the ICD External Cause of Injury Codes variables.
If you suspect errors in ICD-CM coding and can verify correct codes, please use corrected codes.
Do not assign ICD codes for a diagnosis found on acute admit or discharge note that was not included on the center’s medical record ICD list.
It is recommended by the Data Committee that only ICD codes reported in the medical record should be used.
If there is a “Problem List” in the acute medical record that has word-for-word code descriptions without the ICD code associated with the description, a data collector can enter the description in the ICD database and search to identify the appropriate code.
Links
Characteristics
ICD 9 CM Related: (moved to collecting ICD-10-codes only in 2017)
V-codes are to be included when using ICD-9-CM. The ‘99999. Unknown’ code used in this syllabus should not be confused with the ICD-9-CM code for ‘99999. Other Unspecified Complication.’
Variables
Codes and Values
No codes found for the given group IDs.
History
Date | Description |
|---|---|
2021-08-06 | Added NOTE : If there is a "Problem List" in the acute medical record that has word-for-word code descriptions but not the ICD code associated with the description, a data collector can enter the description in the ICD database and search to identify the appropriate code. |
2024-11-05 | Added Note: "Do NOT include V, W, X or Y codes, as these are "External Causes of Morbidity" codes which should only be coded under the ICD External Cause of Injury Codes variables." This is not a change in procedure. Just adding clarification to the DD. |
ICD DIAGNOSIS - CALCULATED
Variables
Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | ICDs | 7644 | Indicator of ICD Codes Entered |
Codes and Values
ID | Code | Description |
|---|---|---|
7644 | 0 | No |
7644 | 1 | Yes |
History
No history found for the Domain.