clarify the Inital or subsequent encounter

bharathiT

Guru
Messages
102
Location
Salem, Tamil Nadu
Best answers
0
Assessment
1. Infected abrasion of hand (S60.519A,L08.9)
2. Contusion of hand, left (S60.222A)

Plan
Medications
1. Start: Sulfamethoxazole-Trimethoprim 800-160 MG Oral Tablet; TAKE 1 TABLET TWICE
DAILY UNTIL FINISHED

3. XR HAND-LEFT; Status:Complete

1-Wound debrided, cleaned and bandaged during visit. Rocephin shot during visit. Start oral antibiotics right away.
2- Tylenol for pain. Elevate at rest. Activity restrict
Follow up in 2 days for recheck. Seek more immediate attention if symptoms worsen or change.


Chief Complaint*:
pt complains of L hand injury, pt stated was in tuesday, pt went to ER, and had some stitches and pt think is infected
Patient rates their health as: good.


HPI: the patient denies abdominal pain. no fever no headache no neck pain no weakness
Pt crashed on bike 5 days ago-treated at ER for hand laceration. Past 24 h-despite taking keflex-increased redness. Left hand painful and states -no x-ray.
Redness extending into forearm-left side.


ICD -infected abrasion of hand (S60.519) coded as Initial or subsequent encounter?
 

mitchellde

True Blue
Messages
13,430
Location
Columbia, MO
Best answers
1
This would be subsequent regardless of whether is is the same or different provider. These are patient diagnosis codes not provider encounter codes. Read the guidelines. Initial refers to the encounter for initial active treatment of the injury it does not matter if this is the first encounter with your provider. The ER provided the initial active treatment, the visit with the next provider is the patient’s subsequent encounter for treatment.
 

twizzle

True Blue
Messages
1,182
Location
Sarasota FL
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0
Although it's difficult to tell whether this is another ER visit or a follow-up visit with the patient's own provider, it makes no difference in this scenario. 7th character A would be appropriate.
According to the official coding guidelines, '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'.
This patient is receiving active treatment.
 
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