ICD-10 Coding for History of Gunshot Wound(Z87.818, Z18.01)
Complete ICD-10-CM coding and documentation guide for History of Gunshot Wound. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Gunshot Wound
Z87.81-Z87.89Primary Range
Personal history of other specified conditions
This range includes codes for personal history of injuries, including gunshot wounds, which are no longer active but have potential long-term effects.
Retained foreign body fragments
This range is used when there are retained bullet fragments from a gunshot wound.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Z87.818 | Personal history of other specified injuries | Use when documenting a past gunshot wound that no longer requires active treatment. |
|
| Z18.01 | Retained metal fragments | Use when there are retained bullet fragments from a past gunshot wound. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for history of gunshot wound
Essential facts and insights about History of Gunshot Wound
Primary ICD-10-CM Codes for history of gunshot wound
Decision Criteria
clinical Criteria
- No active treatment required for the gunshot wound.
Applicable To
- History of gunshot wound
Excludes
- Current injury or active treatment
Clinical Validation Requirements
- Documented history of a gunshot wound
- No active treatment required for the wound
Code-Specific Risks
- Misclassification as an active injury
Coding Notes
- Ensure documentation specifies the gunshot wound is historical and not currently treated.
Z18.01 - Retained metal fragments
Use when there are retained bullet fragments from a past gunshot wound.
Applicable To
- Retained bullet fragments
Excludes
- Fragments causing active symptoms
Clinical Validation Requirements
- Imaging showing retained metal fragments
Coding Notes
Ensure imaging confirms the presence of retained fragments.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Retained metal fragments
Z18.01Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting History of Gunshot Wound to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z87.818.
Impact
Clinical: May affect understanding of potential complications., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims if intent affects treatment.
Mitigation Strategy
Include intent in initial documentation, Review police or forensic reports if available
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate patient history records.
Mitigation Strategy
Use Z87.818 for historical gunshot wounds.
Impact
Using active injury codes for historical injuries.
Mitigation Strategy
Regular training on ICD-10 coding updates.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for History of Gunshot Wound, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Gunshot Wound
Use these documentation templates to ensure complete and accurate documentation for History of Gunshot Wound. These templates include all required elements for proper coding and billing.
Follow-up for historical gunshot wound
Specialty: Primary CareRequired Elements
- Date of original injury
- Current status of the wound
- Presence of any retained fragments
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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