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Coding Corner: “Initial” vs. “subsequent” vs. “sequela” in ICD-10-CM coding

December 01, 2015
Area(s) of Interest: Payor Issues and Reimbursement Practice Management 


CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.   


Many codes in Chapter 19 of ICD-10-CM (Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88)) require a 7th character to identify the episode of care. With the exception of the fracture codes, most Chapter 19 codes have three 7th character values.


Example 1: An initial encounter (character “A”) describes an episode of care during which the patient is receiving active treatment for the condition. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician.


Although it’s counter-intuitive, “initial encounter” does not necessarily mean “initial visit.” A patient may receive active treatment for a condition beyond the initial visit. The ICD-10-CM Chapter 19 Guidelines confirm: “While the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time” (emphasis added).


Assuming the provider is providing active care, a seventh character of “A” is appropriate, regardless of how many times the provider saw the patient previously.


Example 2: A subsequent encounter (character “D”) describes an episode of care during which the patient receives routine care for her or his condition during the healing or recovery phase. Examples include cast change or removal, medication adjustment, and other follow-up visits following treatment of the injury or condition.


Note that ICD-10-CM guidelines do not definitively establish when “active treatment” becomes “routine care.” This is a clinical decision based on the individual’s course of treatment. As Rhonda Buckholtz, AAPC Vice President of Strategic Development, explains, “When the doctor sees the patient and develops his plan of care—that is active treatment. When the patient is following the plan—that is subsequent. If the doctor needs to adjust the plan of care—for example, if the patient has a setback or must returns to the OR—the care becomes active, again.”


A seventh character “D” is appropriate during the recovery phase, no matter how many times he has seen the provider for this problem previously.


Example 3: A sequela character (“S”) is applied for complications or conditions that arise as a direct result of a condition or injury (in ICD-9, these were known as “late effects”). Examples may include joint contracture after a tendon injury, hemiplegia after a stroke or scar formation following a burn.


A late effect can occur only after the acute phase of the injury or illness has passed; therefore, you cannot report a code for the acute illness and a code for the late effect at the same encounter, for the same patient. The only exception occurs if both conditions exist (for example, the patient has a current cerebrovascular condition and deficits from an old cerebrovascular condition).


When reporting sequela(e), you usually will need to report two codes. The first describes the condition or nature of the sequela(e) and the second describes the sequela(e) or “late effect.” For example, you may report M81.8 Other osteoporosis without current pathological fracture with E64.8 Sequelae of other nutritional deficiencies (calcium deficiency).


If a late effect code describes all of the relevant details, you should report that one code, only (e.g., I69.191 Dysphagia following nontraumatic intracerebral hemorrhage). 

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