ICD-10 Coding for Motor Vehicle Accident Follow-Up Visit
For a patient presenting several days after a motor vehicle accident, use V89.2 (Person injured in unspecified motor-vehicle accident, traffic) as the primary external cause code, combined with specific injury codes based on clinical findings and the seventh character "D" to indicate subsequent encounter.
Primary Coding Structure
The appropriate ICD-10 coding requires a two-part approach:
- External cause code: V89.2 (Person injured in unspecified motor-vehicle accident, traffic) serves as the baseline when specific vehicle type and patient role are unknown 1
- Injury-specific codes: Document all identified injuries with appropriate seventh character "D" for subsequent encounter (follow-up visit after initial treatment)
Refining the External Cause Code
If additional details about the accident are available, use more specific V-codes:
- Driver of car: V49.9XXD (Car occupant injured in unspecified traffic accident, subsequent encounter)
- Passenger in car: V49.6XXD (Car passenger injured in unspecified traffic accident, subsequent encounter)
- Pedestrian struck by vehicle: V09.9XXD (Pedestrian injured in unspecified traffic accident, subsequent encounter) 2
- Motorcyclist: V29.9XXD (Motorcycle rider injured in unspecified traffic accident, subsequent encounter) 1
Injury-Specific Coding
Based on clinical examination findings, add codes for documented injuries with seventh character "D":
- Soft tissue injuries: S13.4XXD (Sprain of ligaments of cervical spine, subsequent encounter) for whiplash-type injuries
- Contusions: Code by body region (e.g., S00-S09 for head, S20-S29 for thorax)
- Fractures: Use appropriate fracture codes with "D" for routine healing or "G" for delayed healing 3
- Traumatic brain injury: S06.XXD series if documented 3
Special Considerations for Delayed Presentation
Patients presenting days after the accident require careful evaluation for occult injuries that may not have been immediately apparent 4, 3:
- Document mechanism of injury details (frontal impact, side impact, ejection, entrapment) as these correlate with specific injury patterns 3
- Side-impact crashes are associated with higher injury severity and multiple injuries 3
- Frontal impacts carry higher risk of traumatic brain injury 3
- Entrapment correlates with significantly higher injury severity 3
Common Coding Pitfalls
Avoid using unspecified codes when clinical documentation provides specific details 4:
- If the patient describes being the driver, use driver-specific codes rather than V89.2
- Document all identified injuries separately rather than using a single "multiple injuries" code
- Always include the seventh character "D" for subsequent encounters—this is critical for proper reimbursement
Do not assume initial evaluation was complete—studies show that while initial emergency room evaluations are generally thorough, patients may develop symptoms from injuries not initially apparent 4. However, code only documented findings from the current encounter.
Additional Codes to Consider
- Z codes for encounter circumstances: Z04.1 (Encounter for examination and observation following transport accident) if still under observation
- Symptom codes: R51 (Headache), M79.1 (Myalgia), R52 (Pain, unspecified) when specific injury cannot be identified but symptoms persist 5
- Psychological sequelae: F43.10 (Post-traumatic stress disorder, unspecified) if emotional distress is documented 5