When Is an Injury Initial, Subsequent, or Sequela?

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  • April 1, 2014
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When Is an Injury Initial, Subsequent, or Sequela?

Identify the episode of care for external cause codes.

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

A – Initial encounter
D – Subsequent encounter
S – Sequela

“Initial” Isn’t as Simple as It May Seem

“Initial encounter” does not mean 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. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.”

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 is reported 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.

Subsequent Encounter Meaning

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.”

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

Note that ICD-10-CM guidelines do not definitively establish when “active treatment” becomes “routine care.” Active treatment occurs when the provider sees the patient and develops a plan of care. When the patient is following the plan, that is subsequent. If the provider 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.

Defining 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.

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 second 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).

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.

Orthopaedic Surgery COSC

Medical coding books

No Responses to “When Is an Injury Initial, Subsequent, or Sequela?”

  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 http://www.icd10hub.com/blog/index.php/2011/07/icd-10-brush-up-on-ap-when-coding-fractures/) 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:

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  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.

  26. Jean Marsicek says:

    I am still confused – my orthopaedic surgeon is called in to consult on an INPATIENT – newly admitted to the burn unit from another facility. Patient has had a 1 year history of a dislocated shoulder that could not be treated due to comorbidities – but was transferred for continuing care of those other issues and potentially re evaluate the treatment of the dislocation. Initial (A) because she is a new consult to facility and MD, Subsequent (D) because it is a year old or sequela (S) due to ongoing pain as a result of > 1year dislocated?

  27. Angie says:

    I work for an OB/Gyn practice and we get patients referred to us for ongoing vaginal infections. My understanding is because we have not seen the patient for this issue and she is being seen in our clinic for the first time for the issue the visit would be coded as “initial”. Am I correct that because she is coming to us for the first time even though it would be “subsequent” with her primary that we bill with “initial”? Also if the patient then follows up with us for continuing care for the same thing it becomes “subsequent” after the first visit? or does it stay “initial” until treatment is complete?
    What I am reading here and online vs what I was trained is confusing me. Thank you for your help

  28. Rose Kolvek says:

    I struggled with this, as well. I researched it and this is what I found.
    You code by the patient’s illness, not the number of times he sees the provider. Ex. If the patient is seen in E.R. for neck pain caused by MVA, this is the initial. Patient goes one week later to his primary care provider complaining of the neck pain caused by MVA, this is subsequent. Notice, his first time seeing his primary care provider, but his 2nd encounter for presenting illness. A third visit would be sequela.

  29. Debbie says:

    Clarification: Just because an ER physician RECHECKS a fracture in his/her office does not mean the injury is coded as a subsequent encounter. If the patient is receiving ACTIVE TREATMENT it is coded as INITIAL encounter.

  30. Rose Kolvek says:

    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.

  31. Brian Berube says:

    my take on this is, that the injury will always be Initial, until there is workup or treatment done on it. Once the treatment has finished, then it would be considered subsequent no matter who sees them. Sequela is for any long-term affects left over from the injury, after it has healed.
    For example a patient comes has a torn ACl ligament in their knee. This will remain as an A or initial no matter how many times he sees the same providers or different providers, until work or treatment has been done on it and completed.

  32. Cindy Tevis says:

    An injury occurs. Patient goes to the ER – Initial. Then they go to the Dr for a follow up on the injury – Initial. Lets say the injury becomes infected during this time. It would be Initial (for the infection, which is a new problem). Patient goes to a wound clinic for treatment of the infection – Initial, follow up visits at the wound clinic are also initial as long as they are receiving treatment (for example – antibiotic therapy). Once they are in the recovery phase (treatment is discontinued) it is considered subsequent. Dressing changes and wound checks at this point would be subsequent. Am I correct?