Have a Coding Quandary? Ask John

Have a Coding Quandary? Ask John

ICD-10-CM Sequela

Q: I have a question regarding the seventh character extensions in ICD-10. Are there specific rules to follow when classifying a visit as active treatment?

As I understand it, if the patient is still receiving medication refills, activity restrictions, physical therapy without significant improvement, etc., the patient is receiving active treatment. 

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We billed S33.5XXA Sprain of ligaments of lumbar spine; initial encounter for a patient unable to work due to the severity of the injury. We took the severity of the injury and current activity restrictions as active treatment for the injury. Is this appropriate, or is this “subsequent” treatment because the patient has been seen for this injury previously?

A: Chapter 19 codes have a seventh character that identifies the episode of care. With the exception of the fracture codes, most categories in chapter 19 have three seventh character values. Per the ICD-10-CM Official Guidelines for Coding and Reporting:

  • 7th character A, initial encounter, is used while 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.
  • 7th character D, subsequent encounter, is used for encounters after the patient has received active treatment, and is receiving routine care for the condition during the healing or recovery phase. Examples of subsequent care are: cast change or removal, an X-ray to check healing status of fracture, removal of external or internal fixation device, medication adjustment, other aftercare and follow-up visits following treatment of the injury or condition.
  • 7th character S, sequela, is for use for complications or conditions that arise as a direct result of a condition or injury [in ICD-9, these were known as "late effects”], such as scar formation following a burn. The scars are sequelae of the burn.

Note that 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 Official Guidelines for Coding and Reporting confirm, “While the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the seventh character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time.”

The guidelines do not definitively establish when active treatment becomes routine care. This is a clinical decision based on the individual’s course of treatment.

AAPC Vice President of Strategic Development Rhonda Buckholtz, CPC, CPCI, CPMA, CRC, CHPSE, CENTC, CGSC, CPEDC, COBGYN, explains it this way: “When the doctor sees the patient and develops his ‘game plan,’ that is active treatment. When the patient is following the game plan that is subsequent. If the doctor needs to adjust the game plan, it’s active (for example, patient setbacks, returns to the OR, etc.).”

The information provided in this case makes it difficult to determine if active care is still being provided for the patient’s lumbar sprain, or whether he is in the recovery phase. Assuming the qualified healthcare professional is providing active care, seventh character A is appropriate, regardless of how many times the provider saw the patient previously. Likewise, seventh character D is appropriate during the recovery phase, no matter how many times the patient has seen the provider for this problem.

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 404 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

5 Responses to “Have a Coding Quandary? Ask John”

  1. Donna Porcelli says:

    If a patient presents to the ED with traumatic injury, fx ulna is treated and released. Patient returns 2 days later for an unrelated issue that had nothing to with the initial injury and gets admitted for medical reasons. would that injury then be coded as the initial encounter ?

    Also patient comes to ED with traumatic injury, fx ulna, admitted to hospital, has nonsurgical management and is discharged, Returns 2 weeks later for definitive surgical treatment. Is this injury coded as the initial encounter or subsequent encounter.

  2. ASaiz says:

    Thank you for your comment. You’ll find a lot of suggestions and better answers to your question in the Member Forums.

  3. Anita Odum says:

    Hospital consult then follow by follow up visits in the hospital the consult has an A for the Initial encounter and the encounter if for infection status post total knee replacement first time seen the MD, so would the next day follow up in the hospital still inpatient be an D for subsequent for the icd-10 code

    Please help second guessing my self and others

  4. Kimberley Markovich says:

    If a resident is in a SNF, has a fall, fractures 2 ribs but is not treated outside of the facility is his fracture coded as initial encounter or subsequent encounter?

  5. Brad Ericson says:

    Initial.

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