Select the Right Episode of Care Every Time
Timing is everything when defining and capturing the 7th character in an ICD-10-CM code.
ICD-10-CM brought about new concepts for diagnosis coding, with some being straightforward and others being a bit confusing when interpreting the guidelines. One concept that is often debated is how to select the correct seventh character, representing the episode of care.
The term episode of care is applicable to most injuries, poisonings, and other external causes. The alphabetic seventh character represents the timing of the encounter: initial, subsequent, or sequela.
Injuries typically require codes from the “S” and “T” categories and external cause codes falling in the V – Y categories; however, depending on the circumstances, codes from other categories may apply.
Definitions of the seventh character are described in the ICD-10-CM Official Guidelines for Coding and Reporting.
A – Initial encounter: Use “A” for each encounter where the patient is receiving active treatment.
The term initial encounter used by ICD-10 causes confusion. In the United States, unlike other countries, we use CPT® codes to report a face-to-face service. Many of the evaluation and management (E/M) codes are determined by initial or subsequent encounters. This same approach cannot be applied with diagnosis coding. A more simplistic way to think about initial treatment is to consider it active treatment.
The place of service — whether it be urgent care, primary care, emergency department, or even a specialist’s office — does not impact diagnosis coding. The key to correct coding is to use “A” for active treatment. Active treatment might be applicable to several encounters, from the first visit to multiple encounters by different providers.
Example: Patient presents to the emergency department (ED) with an injury and is instructed to follow up with his primary care physician (PCP). At the PCP visit, the patient is evaluated and then referred to a specialist for advanced care. All three visits — ED, PCP, and specialist — are coded as active treatment.
Active treatment encompasses encounters for the active care of a condition. Once active treatment is completed, the patient converts to subsequent status.
D – Subsequent encounter: The seventh character “D” describes patients who receive routine care for the condition during the healing or recovery phase.
Example: Patient was seen in the ED and diagnosed with a concussion. Told to monitor at home and follow up with PCP in 10 days. No other treatment needed at this time. When the patient sees their PCP, in the office 10 days later, there is no active/ongoing treatment, so the office visit is coded with “D” for subsequent.
S – Sequela: This seventh character is used for complications or conditions that arise as a direct result of a condition, such as scarring from a burn or paralysis from a spinal cord injury. Previously, under ICD-9, these were referred to as “late effects.”
Sequela is a residual effect that occurs after the acute phase of an illness or injury has passed, and now a complication of the original illness/injury brings the patient back for further/ongoing care.
Example: A patient had burns to an extremity. The burns are healed but scarring is preventing the patient from having full mobility. The sequela (scarring) is sequenced first, with the injury (the burn, because it’s responsible for the sequela) sequenced second. The “S” is only applicable to the injury (burn) and not the sequela code (scarring).
Fractures have their own expanded list of seventh characters. Note that documentation should specify the location and laterality of the injury. Many payers have front-end edits that will prevent a claim from processing when it has non-specific diagnosis codes.
Initial vs. Subsequent Encounter for Fractures
Code traumatic fractures using the appropriate seventh character for the initial encounter. This also holds true for a patient who may have delayed seeking treatment for a fracture or nonunion.
Initial Fracture Care
A = Initial encounter for closed fracture
B = Initial encounter for open fracture type I or II
Initial encounter for open fracture NOS
C = Initial encounter for open fracture type IIIA, IIIB, or IIIC
The subsequent fracture codes are based on open or closed fracture and further defined by the healing state (routine, delayed, nonunion, or malunion).
Subsequent Fracture Care
D = Subsequent encounter for closed fracture with routine healing
E = Subsequent encounter for open fracture type I or II with routine healing
F = Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing
G = Subsequent encounter for closed fracture with delayed healing
H = Subsequent encounter for open fracture type I or II with delayed healing
J = Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing
K = Subsequent encounter for closed fracture with nonunion
M = Subsequent encounter for open fracture type I or II with nonunion
N = Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion
P = Subsequent encounter for closed fracture with malunion
Q = Subsequent encounter for open fracture type I or II with malunion
R = Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion
S = Sequela
Specificity is the key to telling the complete story of injuries. Details should include when the injury or accident occurred, the nature of the injury, and the healing status (active, subsequent, sequela).
Certain diagnosis codes from musculoskeletal, pregnancy, childbirth, and puerperium chapters may also need a seventh character to indicate the episode of care.
Always consult the most current version of ICD-10-CM Official Guidelines for Coding and Reporting for all changes or updates to codes and guidelines.