EM Coding Alert

Longer Dx codes might require this ‘placeholder’ character.

If you’re still getting used to the ICD-10 diagnosis system, you’re not alone.

Many medical practices are having growing pains while adopting this huge new diagnosis coding system. Getting your ICD-10 codes as accurate as possible, however, is the best way to prove medical necessity for your patients’ E/M services.

Two issues: Some ICD-10 codes extend to a seventh character, while others do not. Also, several ICD-10 codes include the letter X, which could flummox a coder that doesn’t know what it’s there for.

We picked the brains of a couple of ICD-10 masters for the lowdown on these important diagnosis coding topics. Here’s what they had to say.

Character 7 Keeps Count of Encounters

If you encounter a code that has a seventh character, it means that to complete the ICD-10 code, you have to know how many times the patient has reported to your practice for that particular problem.

“ICD-10 uses the seventh-character extensions to provide additional information about the characteristic of the encounter for episode of care for obstetrics, injuries and external causes of injuries,” reported Marvel Hammer, RN, CPC, CCS-P, ACS-PM, CPCO, owner of MJH Consulting in Denver, Co. during the session “ICD-10 Coding for Pain Management.”

Consider the seventh character in these three ICD-10 codes:

• S43.422A, Sprain of left rotator cuff capsule, initial encounter
• S43.422D, Sprain of left rotator cuff capsule, subsequent encounter
• S43.422S, Sprain of left rotator cuff capsule, sequela.

For this diagnosis, the seventh character indicates if the patient is still having active treatment for the sprain, if the patient is in the healing phase of the sprain and having routine care, or if the patient has a complication as a result of the rotator cuff sprain. 

The initial encounter is the first encounter with that provider for this problem and thus the subsequent encounters are the follow-up visits. A sequela event is when the patient had the problem some time ago and has noticed the issue is again bothersome, symptomatic or has not completely healed.

Example: Your physician performs a level-three E/M service for an established patient who has a sprained left rotator cuff capsule. The initial encounter occurred three weeks ago, and the patient is reporting for routine follow-up care. In this instance, you’d report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity) with S43.422D appended to prove medical necessity. If, however, this established patient is receiving her first treatment for the shoulder injury, you’d use S43.422S instead.

If the seventh character is there in the ICD-10 book for a diagnosis code, you must include one.  For example, S43.422 would be considered a truncated or non-valid ICD-10 code. One of the three seventh characters for the S43 category must be reported.

ICD-10 Uses ‘X Factor’ In ‘Short’ Codes

If you see an X in an ICD-10 code, it means that the diagnosis code requires a seventh character—but the ICD-10 code is not six digits in length already. In these cases, you must use X to fill in the empty characters, Hammer explained. The X is not optional. Leaving it out of the code will result in a truncated code and a rejection of the claim.

For example, consider these ICD-10 codes containing X:

• M80.08XD, Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with routine healing
• S33.6XXA, Sprain of sacroiliac joint, initial encounter
• W14.XXXS, Fall from tree, sequela.

Example: An established patient reports to the practice for treatment of a pathological vertebra fracture with age-related osteoporosis. The patient has received care for the injury already, and is reporting for routine follow-up care. Notes indicate a level-two E/M service. For this encounter, you’d append M80.08XD to 99212 (… a problem focused history; a problem focused examination; straightforward medical decision making) when reporting the E/M.