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.