Code This Slippery Subsequent Scenario
Question: A patient came to our office after visiting the emergency department (ED) where they had been diagnosed with a nondisplaced fracture of the fifth metatarsal. They said they slipped and fell while shoveling the driveway and they were still having trouble walking. The patient was limping and experiencing significant foot pain with swelling and bruising. Can you help us determine which ICD-10-CM codes to use? Also, should we use initial or subsequent encounter 7th character codes for this visit? Wisconsin Subscriber Answer: In this encounter, it’s essential to use several ICD-10-CM codes. Pay close attention to the application of the 7th character and ensure the codes are arranged according to the sequencing guidelines of ICD-10-CM. Code signs and symptoms first: Despite the fact you have a definitive diagnosis from the ED visit for your patient, it’s still necessary to document the patient's signs and symptoms. These are the basis for the encounter and the conditions that your provider will be addressing. So, in this scenario, you would report: Code the Dx next: For a metatarsal fracture, you would look to S92.354- (Nondisplaced fracture of fifth metatarsal bone, right foot). To determine the correct 7th character to add to the code, you’ll need to consult Chapter 19 guidelines, which tell you that “while the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time.” Simply put, choosing the right character isn’t about who diagnoses the condition initially, like the ED attending; but rather it’s about whether the encounter is intended for treating the patient’s condition. So, in this encounter, as your provider’s role is to treat the patient, you would add character “A” (Initial encounter for closed fracture) as the 7th character to S92.354-. External cause is coded last: Technically, “there is no national requirement for mandatory ICD-10-CM external cause code reporting,” according to the guidelines, “unless a provider is subject to a state-based external cause code reporting mandate, or these codes are required by a particular payer.” But reporting the cause, intent, or location of an injury yields useful data that in the words of the ICD-10-CM guidelines, helps “injury research and evaluation of injury prevention strategies.” Regardless of whether it’s required or a personal choice to report the external cause of injury, the code should appear last in the coding sequence. Your external cause code in this case would be Y93.H1 (Activity, snow shoveling). Again, ICD-10-CM guidelines come into play, as they specify that “the external causes of morbidity codes should never be sequenced as the first listed or principal diagnosis.” Compile your list of codes: With all this in mind, your final documentation should look like this: Lindsey Bush, BA, MA, CPC, Development Editor, AAPC
