Monday, August 15, 2016

Coding for Initial Encounter; Subsequent Encounter; Sequela: ICD-10 documentation Challenges

Coding for Initial Encounter; Subsequent Encounter; Sequela:  ICD-10 documentation Challenges 

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP
Originally Published: May 15, 2016

A bit of Background

ICD-10cm has been fully implemented, however the struggle is still very “real” to both inpatient and outpatient coders that spend the majority of the work day performing diagnosis coding.  The issue at hand is trying to gain perspective regarding whether the encounter should be considered “initial”  “subsequent” or “sequela” when coding from ICD10cm chapters 19 and 20.   These chapters contain the codes for injuries, poisonings, and other external causes. 

Unfortunately, physician and mid-level care providers also struggle with the clinical  documentation required for accurate coding within this code set.  One area in particular, is documentation to support, or to define the “initial”, “subsequent” or “sequela” for care provided.    Upon review of medical care provided, physician providers are very good at documenting when the issue is “initial”  or “subsequent”, however the “sequela” or late effect documentation remains an issue of concern.  

In ICD-10cm, the diagnosis is meant to describe the complete reason(s) why a patient is seeking care during a specific encounter with a provider or facility.  This may be a simplistic observation, however, with the onset of the new ICD-10cm codes and its implementation on October 1, 2015; the usage of the term(s) initial, subsequent and sequela have not only taken on a specific meaning in relation to the code set but requires coders  to append the seventh character for injuries, poisoning and other consequences regarding the diagnosis and patient care for injuries, burns and fracture care.  

As we have learned, the seventh character indicates coders to use the letters: A – Initial encounter; D – Subsequent encounter and S – Sequela.    A, D, and S usually represent the diagnosis from the patient’s perspective, however, in the ICD-10cm guidelines note that if the visit/encounter  is a patient’s initial encounter for active treatment of the injury, it’s to be considered and coded as an initial encounter. The patient may be seen by a new or different provider over the course of treatment for an injury.   Again, the 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.

Understanding Critical Verbiage

As a coder, it is imperative that we understand the differences and are able to discern if the care being provided is considered “active treatment” care, or if the care provided is considered a subsequent treatment care phase.  The usage of the 7th character “A” requires definitive clinical documentation and clarity of the care being performed.  In addition, clarity regarding the term “active care” needs to be well documented within the medical record and is paramount to successfully coding “active treatment” correctly. 

Examples of active treatment are:
·         surgical treatment
·         Emergency department encounter
·         Evaluation and continuing management treatment by the same or a different physician

The 7th character “D” subsequent encounter,  is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.

Examples of subsequent care are:
·         Cast change or removal
·         An x-ray to check healing status of fracture
·         Removal of external or internal fixation device
·         Medication adjustment,
·         Other aftercare and/or  follow up visits following treatment of the injury or condition

The 7th Character of “S” is to be used to denote a sequela , late effect, complication or condition that arises due to the direct result of an injury or complication of care.  Sequela is defined by the ICD-10 guidelines as “…the residual effect (condition produced) after the acute phase of an illness or injury has terminated.” There is no time limit on when a sequela code can be used. The residual complication or “sequela” may be apparent soon after subsequent care has been completed,  or it may occur months or even years later.

Examples of Sequela include
·         scar formation resulting from a burn
·         deviated septum due to a nasal fracture
·         chronic pain from previous back injury

When using 7th character “S”, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The “S” is added only to the injury code, not the sequela code.  The 7th character “S” identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code.

Procedure Documentation Scenario:

Scenario for “A” Initial Encounter

An adult patient is evaluated in the emergency department (ED ) for a traumatic rupture of the right ear drum. The ED provider informs the patient that the ENT physician is unavailable at this time, and provides the patient with painkillers.  The patient is then instructed by the ED to present to the ENT office directly upon discharge from the Emergency department care.  Coding for the care in the ED would be reported with ICD10cm code S09.21A  Traumatic rupture of right ear drum.

The patient then presents to the ENT office, and the provider  rechecks the patient and applies a paper patch to the eardrum in the ENT office.  At this time, the patient is receiving  active treatment for this injury.

In summation; this is the first encounter at which the patient receives definitive care (the ED was able to apply comfort care only and referred on to the ENT). Per ICD-10 guidelines, you would again report S09.21A for an initial encounter at the ENT office. 

Scenario for “D”  Subsequent Encounter

An adult patient is evaluated in the emergency department (ED ) for a traumatic rupture of the right ear drum. The ED provider informs the patient that the ENT physician is unavailable at this time.  The ED provider applies a paper patch to the eardrum while the patient is still in the ED per request of the ENT physician, and provides the patient with painkillers upon discharge from the ED.  .  The patient is then instructed by the ED to present to the ENT office directly upon discharge from the Emergency department care.  Coding for the care in the ED would be reported with ICD10cm code S09.21A  Traumatic rupture of right ear drum, initial encounter. 

The patient was instructed upon discharge from the ED to follow up with the ENT in one week to ensure healing of the eardrum.  One week later the ENT provider rechecks the ear-drum injury in the office.  As per ICD-10cm guidelines, this care would be considered  a subsequent encounter, and would be reported as S09.21D traumatic rupture of right ear drum subsequent encounter.  

 The rationale for the subsequent encounter code,  is the ENT provider cared for the same condition, but was not performing “active care”  but “follow up” care for the injury.  

Scenario for “S”  Sequela

Scenario 1:
A patient is admitted to a longterm acute care facility for chronic respiratory failure and ventilator dependency after an acute admission for treatment of an accidental drug overdose.

 – Assign code J96.10, Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, as the principal diagnosis

 – Assign secondary codes – T50.901S, Poisoning by unspecified drugs, medicaments and biological substances, accidental (unintentional), sequela

– Z99.11, Dependence on respiratory [ventilator] status

Scenario 2:
A patient presents for release of skin contracture due to third degree burns of the right hand that occurred due to a house fire five years ago.
Assign code(s)
         L90.5, Scar conditions and fibrosis of skin, as the principal diagnosis.
         T23.301S, Burn of third degree of right hand, unspecified site, sequela
         X00.0XXS, Exposure to flames in uncontrolled fire in building or structure, sequela
A 29 year old female patient has presented to the Internal Medicine specialty clinic to establish care.  She is a complete paraplegic due to a tramatic L3 vertebral fracture 8 years ago due to a motor vehicle accident.  In her intake, she does not have any other current problems.  
Assign code(s)
         G82.21 paraplegia complete
         S32.029S Fracture traumatic vertebra, lumbar, second.

Clinical documentation:   a look to the future….

Good clinical documentation for accurate coding of the 7th placeholder in ICD-10cm is necessary not only for the claims process, but to ensure transparency and clarity for the medical record.  Fracture and burn documentation have additional requirements for coders to clearly code care that is rendered.  The Clinical documentation needs to include:

**Documentation for a current encounter:
– Diagnoses current and relevant
         Clearly denotes;  “active”  treatment; “subsequent” treatment or “sequela” .

**Clinical Documentation for Fractures need to include:
• Cause:
- Traumatic
- Stress
- Pathologic
• Location:
- Which bone?
- Which part of the bone?
- Laterality (right, left, or bilateral)
• Type:
- Non-displaced
- Displaced
- Open (Gustilo classification where applicable)
- Closed (Greenstick, spiral, etc.)
- Salter-Harris (specify type)
• Encounter:
- Initial
- Subsequent
° For routine healing
° For delayed healing
° For non-union
° For malunion
- Sequela (such as bone shortening)

• Include the external cause of the fracture, such as fall while skiing, motor
vehicle accident, tackle in sports, etc.

• Document any associated diagnoses/conditions

**Clinical documentation for burns need to include:
• Type:
- Corrosion
- Thermal
• Site:
- Specify body part
- Include laterality
• Degree:
- First
- Second
- Third

• Document total body surface area (TBSA) burned (percentage)

• Specify the percentage of third degree burns

• Include the external cause of the burn, such as house fire, stove, acid, etc.

• Document any associated diagnoses/conditions

Final thoughts – wrap it up neatly

As a coder, when coding these difficult treatment scenarios, always read the ICD-10cm guidelines thoroughly and pay close attention to any includes or excludes statements, present on admission, primary, secondary and all pertinent diagnoses. 

If the medical record documentation is not clear to you, or you are uncertain regarding “initial, subsequent, or sequela” query the provider or ask for clarification regarding the scope and definition of care that has been provided to the patient.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at or you can also find current coding information on her blog site:   

No comments:

Post a Comment