September 30, 2025
CDI Tip: Reporting Firearm Injury Intent from Other Clinicians’ Documentation
What’s New in FY 2026?
- CMS and ICD-10-CM guidelines now allow documentation by clinicians other than the patient’s provider (e.g., nurses, social workers, trauma team) to be used for assigning external cause codes, including firearm injury intent.
- This change supports more accurate public health reporting and injury surveillance
Key Actions for CDI Specialists
- Review All Clinical Notes
- Check ED notes, nursing assessments, social work documentation, and EMS reports for statements about firearm injury intent (e.g., accidental, assault, self-harm, undetermined).
- Apply the New Intent Hierarchy
- If intent is clearly documented by any clinician, code accordingly:
- Accidental: W34 series
- Assault: X93–X95 series
- Self-harm: X72–X74 series
- Undetermined: Y22–Y24 series
- If no intent is documented, follow the updated guideline: default to undetermined intent for firearm injuries (Y24.9), unless otherwise specified.
- Query When Needed
- If conflicting documentation exists (e.g., ED note states “possible assault,” nursing note says “accidental”), query the provider for clarification.
- Document Source
- When coding based on another clinician’s note, ensure the documentation is clearly attributed in the record.
Pro Tip: Incorporate firearm injury intent review into your trauma and ED CDI workflows. Educate providers that intent matters for coding, quality metrics, and injury prevention programs.
Example Clinical Scenario with Query:
Setting: ED, trauma bay
Patient: 28-year-old male with a through and through gunshot wound of the left thigh; hemodynamically stable.
Documentation in record:
- ED triage RN note: “Pt states he was shot by someone outside a bar.”
- EMS run sheet: “Bystanders report drive by shooting; single GSW to L thigh.”
- ED SW note: “Patient reports unknown assailant; denies self-harm.”
- ED provider note: “GSW L thigh; hemorrhage controlled; analgesia given.” Intent not specified in provider note or discharge summary
Query:
Documentation in the medical record shows that the patient was injured by a firearm. Please clarify the intent of the firearm injury for this encounter, based on your clinical judgment and the medical record.
- Assault (injury inflicted by another person)
- Accidental/unintentional
- Intentional self-harm
- Undetermined (unable to determine intent from available information)
- Other (please specify): _______________________
Alyce Reavis, RN, MSN, CCDS, CCS
Senior CDI Educator, Consulting Services at UASI
Drawing on clinical experience in adult, pediatric, and neonatal acute care, Alyce brings valuable insight to CDI education and documentation improvement. She holds an MSN in Leadership/Education along with CCDS, CCS, and AHIMA’s outpatient CDI micro credential, supporting health systems in strengthening documentation accuracy, quality reporting, and reimbursement integrity. Passionate about truthful, clinically aligned health records, she helps organizations ensure documentation reflects true patient acuity. She is a past presenter for the ACDIS National Convention, Local chapter meetings, and the ACDIS Virtual Best Practices conference.
Works Cited
Centers for Medicare & Medicaid Services. (2025). ICD-10-CM Official Guidelines for Coding and Reporting, FY 2026.
Available at https://www.cms.gov/files/document/fy-2026-icd-10-cm-coding-guidelines.pdf
Centers for Medicare & Medicaid Services. (2023). Improving the collection of social determinants of health data with ICD-10-CM “Z” codes. Available at https://www.cms.gov/files/document/cms-2023-omh-z-code-resource.pdf
