While the implementation of ICD-10 has gone “so far so good,” according to ICD-10 Monitor, some small coding issues have begun to arise, including the 7th character selections for injury, poisonings, and other trauma.
According to Laurie Johnson, director of health information management at Panacea Healthcare Solutions, coding questions about that 7th digit were brought up in an August 27 national provider call and continue to swirl around the AHIMA (American Health Information Management Association) listserv.
The 7th character is used to indicate the episode of care. Generally, the following three options are available as 7th character extensions:
- A, initial encounter
- D, subsequent encounter
- S, sequela (complications or conditions resulting from an injury)
For fracture care, the options are a little more extensive:
- 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 malunion
- S, sequela
And choosing the 7th character extension for some open fractures becomes more complicated still, adding the type of fracture into the mix with episode of care.
Generally, the confusion in choosing 7th character extensions for injuries and poisonings arises from the definition of “encounter.”
For instance, an encounter is not an indicator of how many times the patient has received the same injury. “It’s perhaps too common for someone to read that ‘subsequent encounter’ part of the diagnosis and wonder how many times a patient could run into a lamppost, get sucked into a jet engine or get bit by a macaw,” writes Carl Natale at ICD-10 Watch. “So it’s worth reminding everyone that the encounter describes the patient seeing a clinician not a second injury.”
But encounter also does not mean simply how many times a patient sees the doctor. According to Johnson, when choosing the 7th character, “the coder should not focus on the number of times the patient has visited, but on the type of treatment that the examining physician is providing.”
An article at Implement HIT offers an example: “a patient may be seen in the Emergency Department for a fractured ankle, then referred to their family physician for follow up, and then subsequently referred to an orthopedic surgeon for treatment and ultimately, surgery. All three providers would code the ankle fracture using the 7th character ‘A’ because the patient is still receiving active treatment for the fracture.”
On the other hand, an example from the ICD-10 Trainer blog shows a patient who fractured his ankle while on vacation and was treated in the Emergency Department (and coded with a 7th character extension of “A” for that initial encounter). When that same patient followed up with another doctor back in his hometown three weeks later and that doctor confirmed that everything was healing up just right, the coder would choose 7th character extension “D.”
Remember 7th character extensions also are required for some pregnancy complication codes. In that case, the 7th character indicates which fetus is affected.
For more information and examples for choosing 7th character extensions, check out these informative articles:
- Get to know the 7th character in an ICD-10 code by Carl Natale at ICD-10 Watch
- Nonunion, malunion, or delayed healing? by Michelle A. Leppert at ICD-10 Trainer
- Injuries and the 7th Character in ICD-10-CM by Kathy Devault at Implement HIT
- ICD-10 Coding for Pregnancy Complications by Lori Becks at Contemporary OB/GYN
— Compiled and written by Charity Singleton Craig for CIPROMS. All rights reserved. For use or reprint in your blog, website, or publication, please contact us firstname.lastname@example.org. Photo by Andrew Magill via Flickr used with permission under the Creative Commons License.