Chapter 20.

External Causes of
Morbidity (V00–Y99)

Chapter-specific Guidelines with

Coding Examples
The chapter-specific guidelines from the ICD-10-CM Official
Guidelines for Coding and Reporting have been provided
below. Along with these guidelines are coding examples,
contained in the shaded boxes, that have been developed to
help illustrate the coding and/or sequencing guidance found
in these guidelines.
The external causes of morbidity codes should never be
sequenced as the first-listed or principal diagnosis.
External cause codes are intended to provide data for injury
research and evaluation of injury prevention strategies.
These codes capture how the injury or health condition
happened (cause), the intent (unintentional or accidental; or
intentional, such as suicide or assault), the place where the
event occurred the activity of the patient at the time of the
event, and the person’s status (e.g., civilian, military).
There is no national requirement for mandatory ICD-10-CM
external cause code reporting. Unless a provider is subject
to a state-based external cause code reporting mandate or
these codes are required by a particular payer, reporting of
ICD-10-CM codes in Chapter 20, External Causes of
Morbidity, is not required. In the absence of a mandatory
reporting requirement, providers are encouraged to
voluntarily report external cause codes, as they provide
valuable data for injury research and evaluation of injury
prevention strategies.

a. General external cause coding guidelines

1) Used with any code in the range of A00.0–T88.9,
Z00–Z99
An external cause code may be used with any code in
the range of A00.0-T88.9, Z00-Z99, classification that
represents a health condition due to an external cause.
Though they are most applicable to injuries, they are
also valid for use with such things as infections or
diseases due to an external source, and other health
conditions, such as a heart attack that occurs during
strenuous physical activity.
Actinic reticuloid due to tanning bed use
L57.1 Actinic reticuloid
W89.1XXA Exposure to tanning bed, initial
encounter
Explanation: An external cause code may be used
with any code in the range of A00.0–T88.9, Z00–Z99,
classifications that describe health conditions due to
an external cause. Code W89.1 Exposure to tanning
bed requires a seventh character of A to report this
initial encounter, with a placeholder X for the fifth
and sixth characters.
2) External cause code used for length of
treatment
Assign the external cause code, with the appropriate
7th character (initial encounter, subsequent encounter
or sequela) for each encounter for which the injury or
condition is being treated.
 Most categories in chapter 20 have a 7th character
requirement for each applicable code. Most categories
in this chapter have three 7th character values: A,
initial encounter, D, subsequent encounter and S,
sequela. While the patient may be seen by a new or
different provider over the course of treatment for an
injury or condition, assignment of the 7th character for
external cause should match the 7th character of the
code assigned for the associated injury or condition for
the encounter.
3) Use the full range of external cause codes
Use the full range of external cause codes to
completely describe the cause, the intent, the place of
occurrence, and if applicable, the activity of the patient
at the time of the event, and the patient’s status, for all
injuries, and other health conditions due to an external
cause.
4) Assign as many external cause codes as
necessary
Assign as many external cause codes as necessary to
fully explain each cause. If only one external code can
be recorded, assign the code most related to the
principal diagnosis.
5) The selection of the appropriate external cause
code
The selection of the appropriate external cause code is
guided by the Alphabetic Index of External Causes and
by Inclusion and Exclusion notes in the Tabular List.
6) External cause code can never be a principal
diagnosis
An external cause code can never be a principal (first-
listed) diagnosis.
7) Combination external cause codes
 Certain of the external cause codes are combination
codes that identify sequential events that result in an
injury, such as a fall which results in striking against an
object. The injury may be due to either event or both.
The combination external cause code used should
correspond to the sequence of events regardless of
which caused the most serious injury.
Toddler tripped and fell while walking and struck his
head on an end table, sustaining a scalp contusion
S00.03XA Contusion of scalp, initial
encounter
W01.190A Fall on same level from slipping,
tripping and stumbling with
subsequent striking against
furniture, initial encounter
Explanation: Combination external cause codes
identify sequential events that result in an injury,
such as a fall resulting in striking against an object.
The injury may be due to either or both events.
8) No external cause code needed in certain
circumstances
No external cause code from Chapter 20 is needed if
the external cause and intent are included in a code
from another chapter (e.g. T36.0X1-, Poisoning by
penicillins, accidental (unintentional)).

b. Place of occurrence guideline

Codes from category Y92, Place of occurrence of the
external cause, are secondary codes for use after other
external cause codes to identify the location of the
patient at the time of injury or other condition.
Generally, a place of occurrence code is assigned only
once, at the initial encounter for treatment. However, in
 the rare instance that a new injury occurs during
hospitalization, an additional place of occurrence code
may be assigned. No 7th characters are used for Y92.
Do not use place of occurrence code Y92.9 if the place is
not stated or is not applicable.
A farmer was working in his barn and sustained a foot
contusion when the horse stepped on his left foot
S90.32XA Contusion of left foot, initial
encounter
W55.19XA Other contact with horse, initial
encounter
Y92.71 Barn as the place of occurrence of
the external cause
Explanation: A place-of-occurrence code from category
Y92 is assigned at the initial encounter to identify the
location of the patient at the time the injury occurred.

c. Activity code
Assign a code from category Y93, Activity code, to
describe the activity of the patient at the time the injury
or other health condition occurred.
An activity code is used only once, at the initial encounter
for treatment. Only one code from Y93 should be
recorded on a medical record.
The activity codes are not applicable to poisonings,
adverse effects, misadventures or sequela.
Do not assign Y93.9, Unspecified activity, if the activity is
not stated.
A code from category Y93 is appropriate for use with
external cause and intent codes if identifying the activity
provides additional information about the event.
 Ranch hand who was grooming a horse sustained a foot
contusion when the horse stepped on his left foot
S90.32XA Contusion of left foot, initial
encounter
W55.19XA Other contact with horse, initial
encounter
Y93.K3 Activity, grooming and shearing an
animal
Explanation: One activity code from category Y93 is
assigned at the initial encounter only to describe the
activity of the patient at the time the injury occurred.

d. Place of occurrence, activity, and status codes

used with other external cause code
When applicable, place of occurrence, activity, and
external cause status codes are sequenced after the main
external cause code(s). Regardless of the number of
external cause codes assigned, generally there should be
only one place of occurrence code, one activity code, and
one external cause status code assigned to an encounter.
However, in the rare instance that a new injury occurs
during hospitalization, an additional place of occurrence
code may be assigned.

e. If the reporting format limits the number of

external cause codes
If the reporting format limits the number of external
cause codes that can be used in reporting clinical data,
report the code for the cause/intent most related to the
principal diagnosis. If the format permits capture of
additional external cause codes, the cause/intent,
including medical misadventures, of the additional events
should be reported rather than the codes for place,
activity, or external status.
f. Multiple external cause coding guidelines
More than one external cause code is required to fully
describe the external cause of an illness or injury. The
assignment of external cause codes should be sequenced
in the following priority:
If two or more events cause separate injuries, an external
cause code should be assigned for each cause. The first-
listed external cause code will be selected in the following
order:
External codes for child and adult abuse take priority over
all other external cause codes.
See Section I.C.19., Child and Adult abuse guidelines.
External cause codes for terrorism events take priority
over all other external cause codes except child and adult
abuse.
External cause codes for cataclysmic events take priority
over all other external cause codes except child and adult
abuse and terrorism.
External cause codes for transport accidents take priority
over all other external cause codes except cataclysmic
events, child and adult abuse and terrorism.
Activity and external cause status codes are assigned
following all causal (intent) external cause codes.
The first-listed external cause code should correspond to
the cause of the most serious diagnosis due to an assault,
accident, or self-harm, following the order of hierarchy
listed above.
30-year-old man accidentally discharged his hunting
rifle, sustaining an open gunshot wound, with no
retained bullet fragments, to the right thigh, which
caused him to fall down the stairs, resulting in closed
displaced comminuted fracture of his left radial shaft
S71.131A Puncture wound without foreign
 body, right thigh, initial encounter
W33.02XA Accidental discharge of hunting rifle,
initial encounter
S52.352A Displaced comminuted fracture of
shaft of radius, left arm, initial
encounter for closed fracture
W10.9XXA Fall (on) (from) unspecified stairs and
steps, initial encounter
Explanation: If two or more events cause separate
injuries, an external cause code should be assigned for
each cause.

g. Child and adult abuse guideline

Adult and child abuse, neglect and maltreatment are
classified as assault. Any of the assault codes may be
used to indicate the external cause of any injury resulting
from the confirmed abuse.
For confirmed cases of abuse, neglect and maltreatment,
when the perpetrator is known, a code from Y07,
Perpetrator of maltreatment and neglect, should
accompany any other assault codes.
See Section I.C.19. Adult and child abuse, neglect and
other maltreatment
h. Unknown or undetermined intent guideline
If the intent (accident, self-harm, assault) of the cause of
an injury or other condition is unknown or unspecified,
code the intent as accidental intent. All transport accident
categories assume accidental intent.
1) Use of undetermined intent
External cause codes for events of undetermined intent
are only for use if the documentation in the record
specifies that the intent cannot be determined.
i. Sequelae (late effects) of external cause guidelines
1) Sequelae external cause codes
Sequela are reported using the external cause code
with the 7th character “S” for sequela. These codes
should be used with any report of a late effect or
sequela resulting from a previous injury.
See Section I.B.10 Sequela (Late Effects)
2) Sequela external cause code with a related
current injury
A sequela external cause code should never be used
with a related current nature of injury code.
3) Use of sequela external cause codes for
subsequent visits
Use a late effect external cause code for subsequent
visits when a late effect of the initial injury is being
treated. Do not use a late effect external cause code
for subsequent visits for follow-up care (e.g., to assess
healing, to receive rehabilitative therapy) of the injury
when no late effect of the injury has been documented.

j. Terrorism guidelines
1) Cause of injury identified by the Federal
Government (FBI) as terrorism
When the cause of an injury is identified by the Federal
Government (FBI) as terrorism, the first-listed external
cause code should be a code from category Y38,
Terrorism. The definition of terrorism employed by the
FBI is found at the inclusion note at the beginning of
category Y38. Use additional code for place of
occurrence (Y92.-). More than one Y38 code may be
assigned if the injury is the result of more than one
mechanism of terrorism.
2) Cause of an injury is suspected to be the result
of terrorism
 When the cause of an injury is suspected to be the
result of terrorism a code from category Y38 should not
be assigned. Suspected cases should be classified as
assault.
3) Code Y38.9, Terrorism, secondary effects
Assign code Y38.9, Terrorism, secondary effects, for
conditions occurring subsequent to the terrorist event.
This code should not be assigned for conditions that
are due to the initial terrorist act.
It is acceptable to assign code Y38.9 with another code
from Y38 if there is an injury due to the initial terrorist
event and an injury that is a subsequent result of the
terrorist event.

k. External cause status

A code from category Y99, External cause status, should
be assigned whenever any other external cause code is
assigned for an encounter, including an Activity code,
except for the events noted below. Assign a code from
category Y99, External cause status, to indicate the work
status of the person at the time the event occurred. The
status code indicates whether the event occurred during
military activity, whether a non-military person was at
work, whether an individual including a student or
volunteer was involved in a non-work activity at the time
of the causal event.
A code from Y99, External cause status, should be
assigned, when applicable, with other external cause
codes, such as transport accidents and falls. The external
cause status codes are not applicable to poisonings,
adverse effects, misadventures or late effects.
Do not assign a code from category Y99 if no other
external cause codes (cause, activity) are applicable for
the encounter.
An external cause status code is used only once, at the
initial encounter for treatment. Only one code from Y99
should be recorded on a medical record.
Do not assign code Y99.9, Unspecified external cause
status, if the status is not stated.