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INITIAL, SUBSEQUENT, SEQUELA…

Embracing new coding concepts and guideline changes can sometimes overshadow established policies that we use daily, prompting a need to revisit.  Recently, while researching a concept I felt was clear to me, I realized that depending on the circumstance, the clarity may not be so apparent.  All of us are vulnerable to being lulled into a false sense of coding satisfaction.  Take for instance the 7th character assignment of injuries and conditions.  Many of us learned this coding concept from the very beginning of ICD-10-CM training.

  • Initial = A “used for the initial encounter for the injury or condition while the patient is receiving active treatment for the injury”

A patient presenting to the point of care for the very first time to be examined and/or treated for a condition or injury that just occurred; assigning the seventh character “A” is a straightforward coding decision.

Example:  Forty-seven year-old male presented with a 10 cm. laceration of the right forearm following a chain saw accident in his yard, trimming his tree.  The laceration required layer closure in the Emergency Department. (S51.811A)(W29.3XXA)(Y93.H2)(Y92.017)(Y99.8)

Example:  Patient is admitted for acute care treatment for overdose of Advil, trazodone, lithium. (T43.212A, T43.592A, T39.312A (and the external cause codes)).

It is following the patient throughout the treatment process that can be puzzling.  One thing that helps me is to ask myself this question:

  • Has the patient previously received any active treatment for this particular injury or condition in any other setting (ED, provider office, hospital, clinic, etc.) or by any provider of care?

If the answer is no, then you have no question that the seventh character is “A” initial.  If the answer is yes, we have a decision to make and it helps to understand our choices.

  • Subsequent = D “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”

Seems simple doesn’t it, and for injuries and conditions that follow the “routine course of healing” coders should have no problem with this concept.  It is when the “routine” is interrupted with an infection, or dehiscence or complication that causes the injury or condition to be readdressed that a true understanding of the seventh character assignment is required.  Anytime an injury or condition that was in the ‘routine’ healing phase requires attention, the seventh character “A” is reinitiated.  A new treatment plan is developed, the patient is no longer in the ‘healing’ phase, but rather is on a new “initial” phase.

Example:  Forty-seven year-old male presented following repair of a 10 cm. laceration of the right forearm following a chain saw accident in his yard, trimming his tree.  The laceration was closed and seemed to be healing well until the patient was changing the car tire in his home garage and the wound opened.  Upon presentation to the provider, a decision was made to admit the patient to the hospital for debridement, washout and closure of the wound dehiscence.  (T81.33XA)(X50.0XXA)(Y93.89)(Y92.015)(Y99.8)

Example:  Patient is accepted to the Psychiatric Center follow treatment for an overdose with Advil, Trazodone and lithium for evaluate and treatment of the major depressive disorder and post-traumatic stress disorder. (MDD and PTSD are PDX/sec dx, with (T43.212D. T43.592D. T39.312D).

Same wound, but requiring a new care plan; the seventh character is appropriately assigned “A” initial.  This is not aftercare; this is a new problem impacting a previous injury.

Following the phase of injury and/or condition healing is the state of healed/recovered.  When a late effect occurs directly resultant from the previous injury or condition, the following seventh character should be assigned:

  • Sequela = S “for use for complications or conditions that arise as a direct result of an injury, such as scar formation after a burn.  The scars are sequelae of the burn”

Example:  Chronic pain due to low back injury

(G89.21) chronic pain due to trauma (S39.002S) unspecified injury of muscle, fascia, and tendon of lower back, sequela

Coders need to use caution when coding fractures as there are more choices:

  • A – initial encounter for closed fracture
  • B – initial encounter for open fracture
  • D – subsequent encounter for fracture with routine healing
  • G – subsequent encounter for fracture with delayed healing
  • K – subsequent encounter for fracture with nonunion
  • P – subsequent encounter for fracture with mal-union
  • S – sequela

Coders may be tempted to assign the nonunion and mal-union fractures to acute as the treatment plan has changed to require additional treatment.  However following the initial treatment the fracture, during the healing phase, develop unique conditions.  In mal-union, the bony healing is occurring but the fracture fragments are in poor position.   In nonunion, healing is also taking place, but there remains a gap between the bony structures at the fracture site.  In these cases, the appropriate seventh digit for subsequent encounter is assigned (K/P).

Applying the guidelines to daily coding can be difficult; I’m hopeful this information will provide you with clarity regarding the characters representing initial, subsequent and sequela.


About the Author

Marie Thomas holds a Masters Healthcare Administration from Pfeiffer University, Charlotte, NC, and a Bachelor of Science in Healthcare Administration from Pfeiffer University. Marie has furthered her career education by becoming an AHIMA-Approved ICD-10-CM/PCS Trainer and Ambassador as well as earning the RHIT, CCS, CCDS, and CPC-H credentials. For more information please email us at contact@eclathealth.com


What’s up “with” Diabetic Coding?

Responding to coder questions has always been one of my great joys.  The challenge of searching for the underlying cause or the analysis of a detailed operative note is second only to a Dr. Seuss favorite with my Grands.  Lately, diabetic coding has been a frequent topic for clarification.

According to the American Diabetes Association,“29.1 million Americans have been diagnosed with diabetes with another 86 million identified with pre-diabetes.”  The manifestations and associated conditions are staggering, as this disease impacts many body systems.  In ICD-9-CM code assignment with the designation of primary or secondary whether type I or II, controlled, uncontrolled and with a documented association of manifestations common to diabetes was the guidance. ICD-10-CM implementation eliminated the controlled and uncontrolled designation, opting for a more robust manifestation instruction.

The American Hospital Association (AHA) Coding Clinic publications for first quarter 2016, again second quarter 2016 reiterate the ICD-10-CM Official Guidelines for Coding and Reporting FY 2017 I.A.15 which says:

“With”  the word “with” should be interpreted to mean “associated with” or “due to” when it appears in the code title, the Alphabetic Index, or an instructional note in the Tabular List.  The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List.  These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must like the conditions in order to code them as related. The word “with” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order.”

As coders plunge into their daily coding process, there remain areas of concern in complying with the instruction that as written seems so clear.  In the setting of a type II diabetic patient presenting with nausea and vomiting, gastric emptying studies support the diagnosis of gastroparesis the diagnosis code assigned would be E11.43.  The proximity of the documentation in the record of the two conditions (diabetes type II) and (Gastroparesis) have no bearing on the expectation to assign one code, assuming the relationship between the diabetes type II and the gastroparesis.

The same is true for CKD, foot ulcer, gangrene, and the list goes on as the coder references the Index “Diabetes, diabetic (Mellitus)(sugar) “with” or enters the key word “diabetes” in the encoder.  Recent coder questions include the diagnosis of cataract.  When the provider has not documented the type of cataract, (nuclear sclerosis, age-related, etc.) the coder is instructed to assume a link between the diabetes and cataract, reporting as diabetic cataract.  This may be an area of concern for some facilities as their statistical analysis will shift from an “H” diagnosis in Chapter 5 diseases of the eye to an “E” diagnosis in Chapter 4 endocrine diseases.  In talking with a local ophthalmologist, this raised awareness for him as he shared he has many diabetic patients that he may perform cataract surgery that have no relationship between the two conditions.  It is important to inform the providers as guidelines change that may impact their patient population data so they understand the need for the appropriate level of specificity documentation.

Osteomyelitis is also causing some eyebrow rising among coders.  The coding book Index, Diabetes “with” includes osteomyelitis “E11.69”.  In the coding book Index, Diabetes Type I or Type II “with” does not include osteomyelitis.  So, what’s a coder to do?  The answer was provided today in the AHIMA October 15, 2016 Conference.  Everywhere in the ICD-10 CM index that “with” is a part of the indexed condition, the link between the condition referenced by the index and the “with” condition is to be made unless the provider has documented the referenced condition is not due to the “with” condition or is due to another condition.  That includes osteomyelitis in a diabetic patient.  Just to be sure we are clear, additional examples including osteomyelitis will be included in the Coding Clinic 4th Quarter 2016.

As we continue to work with providers with regard to their documentation it is important to share with them how their patient is reflected in coding as many of them are unaware of coding guidelines.  Documentation matters now more than ever.


About the Author

Marie Thomas holds a Masters Healthcare Administration from Pfeiffer University, Charlotte, NC, and a Bachelor of Science in Healthcare Administration from Pfeiffer University. Marie has furthered her career education by becoming an AHIMA-Approved ICD-10-CM/PCS Trainer and Ambassador as well as earning the RHIT, CCS, CCDS, and CPC-H credentials. For more information please email us at contact@eclathealth.com