16 Nov 0
Since ICD-10 implementation there have been quite a few changes in the world of coding and documenting. One in particular would be the usage of Initial, Subsequent, and Sequela, requiring us to append a seventh character for injuries and most external causes reported.
The seventh character indicates “A” for initial encounter, “D” for subsequent encounter, and “S” for sequela of an encounter. You may ask yourself “What do these terms mean and how do I apply them?”
“Initial” and the concept in ICD-10
In ICD-10 the definition of initial seems to be more complicated than the usual understanding of it. The guidelines state that the seventh character “A” is used for the initial encounter for an injury or condition while the patient is receiving active treatment. For example:
The patient is evaluated in the emergency room (ER) for a stress fracture of the, right hip and cannot be managed at this time. The ER applies immobilization and ice and instructs the patient to follow up with orthopedics in the morning. The code to be reported would be M84.351A Stress fracture, right femur, initial encounter for fracture. When the orthopedist checks the patient the next day, and the decision is made for surgical repair, the patient is receiving initial active treatment for this fracture. That is, this is the first encounter at which the patient receives definitive care (the ER was able to apply comfort care only). Per ICD-10 guidelines, you would again report M84.351A Stress fracture, right femur, initial encounter for fracture.
If we change the scenario: The patient has a closed fracture of the right hip, which is definitively managed in the ER with surgical repair. You would report this with S72.001A Fracture of unspecified part of neck of right femur, initial encounter for closed fracture.
At a later date, the same orthopedist who provided care in the ER rechecks the injury in the office. This is a subsequent encounter because the provider cared for the same condition, previously.
Subsequent is a much simpler term to follow. In ICD-10 it is defined as “encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase. For example:
Continuing with our previous example: If the fracture is healing as it should at the subsequent visit, the orthopedic office would report S72.001D Fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing.
What is Sequela? ICD-10 states that the seventh character “S” is used for complications or conditions that arise as a direct result of an injury or condition. In other words, sequela is the late effect of an injury or condition.
To recap, it is important to stay focused on the patient’s diagnosis and only code from that perspective. Remember to always double check the coding guidelines, this will help lead you to deciphering the correct code and don’t be afraid to query the provider if the documentation is not clear.