Initial, Subsequent, or Sequela Encounter?

Take the patient’s perspective when appending the

seventh character in ICD-10-CM.

By Debra Mitchell, MSPH, CPC-H

A diagnosis is meant to describe the patient at a particular encounter. That may sound obvious, but it’s a fact with important implications. As we move toward ICD-10 implementation, remember that the new code set requires us to append a seventh character for injuries and most external cause reporting.

The seventh character indicates:

A – Initial encounter

D – Subsequent encounter

S – Sequela

Put Yourself in the Patient’s Shoes

A, D, and S usually represent the diagnosis from the patient’s perspective. If the visit is a patient’s initial encounter for active treatment of the injury, it’s always an initial encounter. Has the patient previously received active treatment for this condition? If so, it may be a subsequent encounter—with exceptions, discussed below.

“Initial” Is a Subtle Concept in ICD-10

There is a wrinkle: The ICD-10-CM definition of initial is more complicated than the usual understanding of the word. Specifically, guidelines state that a seventh character A is “used for the initial encounter for the injury or condition while the patient is receiving active treatment for the injury. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.”

The statement “evaluation and treatment by a new physician” can be a source of confusion, but you will code correctly if you are able to answer the basic question, “Has the patient previously received active treatment for this condition in any setting or by any provider?”

For example: The patient is evaluated in the emergency room (ER) for a displaced transverse fracture of the left ulna that cannot be managed at this time. The ER applies immobilization and ice and instructs the patient to follow up with orthopedics in the morning. This would be reported using S52.222A Displaced transverse fracture of the left ulna, initial encounter for closed fracture.

When the orthopedist rechecks the patient and reduces the fracture the next day, the patient is receiving initial active treatment for this fracture. That is, this is the first encounter at which the patient receives definitive care (the ER was able to apply comfort care only). Per ICD-10 guidelines, you would again report S52.222A for an initial encounter.

Now, let’s change the scenario: The patient has a greenstick fracture of the shaft of the left ulna, which is definitively managed in the ER with a cast or splint. You would report this with S52.212A Greenstick fracture of the shaft of left ulna, initial encounter for closed fracture.

At a later date, the same orthopedist who provided care in the ER rechecks the injury in her office. This is a subsequent encounter because the provider cared for the same condition, previously.

Subsequent Is Simple

ICD-10-CM defines subsequent encounters as “encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase. Examples of subsequent care are: cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following injury treatment.”

Continuing with our example: If the fracture is healing as it should at the subsequent visit, the orthopedic office would report S52.212D Greenstick fracture of the shaft of left ulna, subsequent encounter for fracture with routine healing.

What Is Sequela?

ICD-10-CM says the seventh character S is “for use for complications or conditions that arise as a direct result of an injury, such as scar formation after a burn. The scars are sequelae of the burn.” In other words, sequela are the late effects of an injury.

Perhaps the most common sequela is pain. Many patients receive treatment long after an injury has healed as a result of pain. Some patients might never have been treated for the injury at all. As time passes, the pain becomes intolerable and the patient seeks a pain remedy.

For example: A patient suffers a low back injury that heals on its own. The patient isn’t seeking intervention for the initial injury, but for the pain that persists long after. The chronic pain is sequela of the injury. Such a visit may be reported as G89.21 Chronic pain due to trauma and S39.002S Unspecified injury of muscle, fascia and tendon of lower back, sequela.

The bottom line: With ICD-10 CM, it’s important to stay focused on the patient’s diagnoses and code only from that perspective.


Debra Mitchell, MSPH, CPC-H, is a coding and compliance consultant and auditor, as well as a professional instructor in coding, billing, and medical terminology. She has developed several courses for adult education programs in medical coding and billing, and has contributed to the development of a coding certification program. Mitchell was recently named to the Biltmore’s Who’s Who in America’s Professional Women. She is a member of the Colombia, Mo., local chapter.

25 Responses to “Initial, Subsequent, or Sequela Encounter?”

  1. Erika says:

    Hi Debra,

    When the aftercare visit documents: “healed fracture” what code should I assign? There’s controversial information I found on this article that point to two possibilities:

    1. Code the fracture with the 7th character S (This is Tim’s example on the 3rd visit, after 6 monts)
    2. Code the fracture with the 7th character D

  2. Heiner says:

    Dolly was a bottlenose dpoihln, Tursiops truncatus. The dpoihlns affected by tuna fishing are Pacific spotted and spinner dpoihlns, different species. Under the Marine Mammal Protection Act, U.S. tuna fishermen must use various types of gear and procedures to minimize dpoihln by-catch; those dpoihlns that were caught never became part of the human food chain. Other nations, however, are still not constrained from dpoihln by-catch. Please look for the “dolphin safe” label on chunk light tuna before you buy it. Albacore tuna is caught by hook and line, and dpoihlns are not harmed in the process.

  3. gina says:

    I’m assuming you’ve corrected this somewhere? – according to everything I’m reading -coding as “subsequent” is WRONG! (ie, patient seen in ER- then referred to our orthopaedic dr (not associated with ER) sees pt for 1st time -it’s “initial” for both the ER doctor AND for us.

  4. Mary says:

    Hello! I work in a nursing home facility, and one of our residents do have a non-healing full-thickness burn on his back due to a radiation treatment from 2009. My question is what seventh character should I use? A or D? Thanks.

  5. Patti Helton says:

    I have a questions. I work for ER doctors for a children’s hospital. Mosy all my visits will be “A” Initial encounter, but if they go somewhere first – (see example)

    (hx of depression who presents to the ED accompanied by mother and aunt for intentional ingestion of 8 Klonodine at 0000. She informed her mother she took the pills approximately 10 minutes after taking them. She was taken to Upper Valley Medical Center where she was given Charcoal, Zofran, and an NS IV Bolus. The pt had informed the physician at Upper Valley she took Klonodine to kill herself, however, now she says she took it to go to sleep. Brother is a sick contact at home. No recent illnesses. Immunizations are UTD. NKDA. There are no other complaints or modifying factors at this time.)

    Patient was taken to outside “Upper Valley Hopsital” and then sent here “Children’s ER hospital”


    A – Initial encounter

    D – Subsequent encounter

    Thanks for the help.

  6. Mary says:

    I have 2 questions.

    1.Do you put the M in from of all Orthopaedic referrals/
    2.What is the code for evaluate and treat?

    Thank you

  7. David huang says:

    Whose perspective?
    D of H?
    You will get a different answer each time.
    As far as I am concerned a bunch of non health care providers got together to dream up this idiocy .

  8. Cheryl Tribley says:

    What if at the follow up visit the patient has a new issue and the doctor gives a new diagnosis for this new condition? Is this still coded with a “D” as the 7th character as this is a subsequent follow up visit?

  9. Helen Pinkard says:

    Patient is seen in ICU by a pulmonologist. Patient has 6 rib fractures on the left sustained in an automobile
    accident 4 days prior to us being consulted. Is our encounter initial, subsequent or Sequela?

  10. Kellie says:

    I understand what initial, subsequent and sequella mean but tell me the “code” that needs to be attached with it. I’m trying to understand ., Help me. Does it mean additional letters or numbers are added to the cpt code?
    Thanks for you help.

  11. Kelly says:

    Patient see’s physician for knee pain. Sends patient for MRI. Next visit patient comes in to discuss MRI findings which include a meniscus tear. Surgery is scheduled in future. For this second visit do I code A or S??? I was thinking A since this is still active and patient is having surgery??

  12. Carol Ann Tomko says:

    I have patients come to our ER after being at another ER. Is that an initial or subsequent encounter?

  13. Megan says:

    So, my question is, if the patient is seen at the ER and then by the orthopod, then they see their PCP, how does the PCP code it? And what if the patient is seen by a different provider at their primary care office?

  14. Michael Bince says:

    thanks very helpful

  15. Stephen R Kerr MD says:

    I am an inpatient surgeon. I have a patient with rib and sternal fractures. I saw and admitted him from the ER, easy initial encounter. now, I round on him every day, are these visits still part of the initial encounter, or are they then subsequent encounters?

  16. Elena says:

    Hello Debra
    If an uninsured patient was seen at any particular ER for a fracture, then is referred to a community clinic with no affiliation to the ER can I use the Subsequent code?

  17. Kelly says:

    We have a medicare contractor that is rejecting therapy claims that have the “D” after them, requiring us to enter S.
    It is Palmetto GBA
    Has anyone else had this issue

  18. Karla says:

    What if the patient is an inpatient? They have been treated in the ER and on admit, but this is the third day in inpatient hospital setting due to this accident. Is this still the initial because we are inpatient and have not yet been discharged from “this encounter stay”? or is it subsequent?

  19. Kim P says:

    I have a patient that went to ER due to fracture. The ER Dr. put her in a splint and told her to follow-up with Ortho Dr. She came in for the initial visit for fracture care. We reviewed the x-rays, and the ER plan. Dr. told her to stay with the plan from the ER and to follow-up with him in 3 weeks. Should we bill the fracture care for this visit?

  20. nell says:

    patient receiving home infusion antibiotics due to an infected hardware of right knee, would that be initial

  21. Tim says:

    Not sure if any of these questions are being answered but here goes…I work at a physical rehabilitation hospital. When a patient is coming in for care after being paralyzed how would I code that? While he’s an inpatient, I would use and A. What would I use for outpatient followups? D? It’s routine care following a paralyzing injury. Confused.

  22. mary says:

    If a family physician is activity treating a patient for keen injury without facture and has a follow up visit with another physician in the same practice would the dx code be A for activity treatment for the active car of this patient?

  23. A.J. says:

    I bill for an independent laboratory and am getting ready to send some CA work comp bills and several of the ICD codes we received from the doctors office have a seventh character. Is that a requirement for labs who don’t physically see the patient?

  24. Florissa says:

    Question: Can Sequelae of poliomyelitis be primary diagnosis?

  25. Jen says:

    I was wondering what is considered active treatment? If a patient came in on Monday for initial visit for S91.302A, this would be initial. Then the patient comes in every other day to get wound care such as remove packing, debride necrotic tissue and redress. Would this S91.302A or S91.302D subsequent. I always get this messed up.

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