Wiki Icd 10

[GSBSA2016]

My doctor does Trauma call at one of the hospital's. When he does trauma rounds, patient already admitted, what ICD 10 do I use? With the A, D, or S at the end? To him it is the initial encounter, but patient has been in hospital for a few days so does it change to subsequent encounter? Any help is greatly appreciated!

 

[CodingKing]

If patient is inpatient still they are likely in active treatment. If they were in the routine healing phase they would have have likely been transferred to a lower level of care such as Rehab, SNF, Home care.

from the ICD-10-CM guidelines

7th character “A”, initial encounter is used for each encounter wherethe patient is receiving active treatment for the condition.

7th character “D” subsequent encounter is used for encounters after thepatient has completed active treatment of the condition and is receivingroutine care for the condition during the healing or recovery phase.

7th character “S”, sequela, is for use for complications or conditions thatarise as a direct result of a condition, such as scar formation after aburn. The scars are sequelae of the burn. When using 7th character “S”,it is necessary to use both the injury code that precipitated the sequelaand the code for the sequela itself. The “S” is added only to the injurycode, not the sequela code. The 7th character “S” identifies the injuryresponsible for the sequela. The specific type of sequela (e.g. scar) issequenced first, followed by the injury code.