Fracture Diagnosis Coding: Initial Visit vs. Subsequent Visit
These familiar terms have new meaning in ICD-10-CM.
Fracture coding can be a challenge for both physicians and coders, but its effect on hierarchical condition code (HCC) funding in Medicare Advantage, as well as health plan Star ratings, leaves little room for speculation. Knowing how ICD-10 delineates initial and subsequent visits is key.
Initial Means Active Treatment
Although the terms initial and subsequent, relating to fracture care, were used in ICD-9-CM, they have new meaning in ICD-10-CM. Basically, neither term has little to do with whether a provider has previously seen or treated the patient for the condition.
Initial does not equate to a first visit — although, it may be the first time the provider has seen the patient for the fracture. Initial is interpreted as active treatment. When the visit is for the purpose of deciding what treatment is required to repair the fracture, it is an initial encounter. Likewise, when the visit results in a changed active plan of care, it is an initial encounter.
Initial visit examples:
- The provider follows up with a patient for an ankle fracture that is not healing, and makes the decision to surgically repair the fracture. This decision is considered active care, and is an initial encounter.
- The provider decides the patient may need additional treatment and refers the patient to another provider for a consult. Both the treating physician and the consulting physician have provided active care, and both visits are initial encounters.
Neither prescribing medicine, nor referral to a physical therapist, is considered active care for fracture coding.
Subsequent Means Aftercare
Subsequent equates to aftercare treatment, and may be appropriate to code even when it’s the provider’s first time seeing the patient. For example, if the first time a provider sees the patient for the fracture is to continue post-treatment care, the initial visit is a subsequent fracture encounter.
Subsequent visit examples:
- The patient received a fracture diagnosis and surgical repair three weeks ago while he was out of town. This is the first time the patient has visited his provider since returning home. The provider orders and reviews an X-ray to determine the healing status, and recommends continuing the same plan of care. This is a subsequent encounter for fracture aftercare.
- The doctor who is treating the patient for fracture care is out of town. The patient is having a lot of pain and comes to your office for pain medication. A prescription is written for pain medication and the patient is told to follow up with his physician. This is a subsequent encounter because treatment was not directed at the fracture.
Explore More Cases for Clarity
Ongoing scenarios provide additional examples of when initial and subsequent visits are used.
Scenario 1: The patient was seen in the emergency department (ED) for radial fracture. The ED physician splints the fracture and advises the patient to follow up with an orthopedic specialist for continued treatment. An ortho appointment is scheduled for three days later. In the meantime, the patient attends his previously scheduled health risk assessment (HRA) appointment with his primary care physician (PCP), who reminds the patient of an upcoming orthopedic appointment.
The orthopedic specialist sees the patient, orders an additional X-ray, and decides to keep the patient in the same splint. A follow up with the orthopedic specialist is scheduled for two weeks later. The patient is in continuous pain, and returns to the PCP for a pain medication refill.
- ED codes an initial fracture encounter. Active treatment was provided.
- PCP codes a subsequent encounter. No active treatment was provided.
- Orthopedic specialist codes an initial fracture encounter. Active treatment was provided.
- PCP codes a subsequent fracture encounter. A refill or prescription for pain medication is not considered active fracture treatment for diagnosis coding.
Scenario 2: The patient fell at home and hurt her ankle. She makes an appointment with her PCP. The PCP orders X-rays and determines the ankle is broken. The PCP wraps the ankle, prescribes pain medication, and refers the patient to an orthopedic specialist.
The orthopedic specialist places a splint and wants to see the patient in two weeks. After one week, the patient is complaining of severe pain. The orthopedic specialist sees the patient and orders an additional X-ray. The X-ray shows a misaligned fracture, and surgery is scheduled. The orthopedic specialist sees the patient two weeks post-surgery for follow-up.
- PCP codes an initial fracture encounter. Initial Fracture Diagnosis = Active Treatment
- First orthopedic office visit codes an initial visit. Initial Fracture Care = Active Treatment
- Second orthopedic office visit codes an initial visit. Decision for Surgery = Active Treatment
- Surgical orthopedic visit codes an initial visit. Surgery = Active Treatment
- Post-surgical orthopedic office visit codes a subsequent visit. Follow Up = Aftercare
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