# Initial encounter vs subsequent



## gracz

We are diagnostic radiology. If patient sent to us from primary care for an X-Ray to rule out fracture will than the fracture get "A" or "D"? Also if it is considered "initial" than do we need to add all the External Cause codes too? 
thanks


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## nancyenos

*Active Care vs Subsequent Care 7th character*

Seventh character A is for use as long as the patient is receiving active treatment for the fracture. Examples of active treatment are:  surgical treatment, emergency department encounter, evaluation and treatment by a new physician. Seventh character D is to be used for encounters after the patient has completed active treatment. The other seventh characters, listed under each subcategory in the Tabular List, are to be used for subsequent encounters for treatment of problems associated with the healing, such as malunions and delayed unions or sequela.

Note: Look in your tabular list at Block S89 and review the 7th character extensions. These are based on the episode of care, as well as the type of fracture. 

Nancy Enos, FACMPE, CPC-I, CPMA, CEMC CMC
AAPC Approved ICD-10 Instructor
www.enosmedicalcoding.com


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## Pam Brooks

If it's your provider's first encounter, then code A.  If it's an injury, you'll need to code the external causes, whether or not it's an A, D or S.  If it's a fracture, you also have to consider G, K and P, but you would also code the external causes.


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## mitchellde

Pam Brooks said:


> If it's your provider's first encounter, then code A.  If it's an injury, you'll need to code the external causes, whether or not it's an A, D or S.  If it's a fracture, you also have to consider G, K and P, but you would also code the external causes.



If I can make one correction... It is not if this is the providers first encounter for the injury .. the A is for if this is the patient's first encounter for treatment of the injury.  The diagnosis code describes the patient not the provider.  IF the injury has been treated previous whether by your provider or other then it ios not an initial encounter for the patient to receive treatment.
From a radiology perspective.. if this is an acute injury seeking diagnosis of fx or not then it is initial and yes the external cause codes.  If this is a return encounter to check on the fx status .. even if this is the first time your radiologist has seen this patient then it is subsequent encounter with the external cause codes also.


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## mitchellde

I understand that someone disagrees with me, however you must remember this dx represents the patient diagnosis not the providers.
If the patient's injury has been treated prior to the encounter with your provider then this is a subsequent encounter for the patient for treatment of the injury.  However there are times with on initial presentation the provider is unable to treat the injury, the patient is then stabilized and sent to another provider for definitive treatment.  In this case the patient is still seeking initial treatment of the injury.
However if the first provider did provide definitive treatment and sends the patient on to other provider for follow up then the patient is seeking subsequent treatment for the injury.
If you follow the flawed logic that it is always an initial encounter if this is the first time your physician sees the patient then when a patient comes to your office for suture removal for a laceration repaired in the ER then that would be an initial encounter as well... and clearly it is not it is a subsequent encounter
for the patient even though initial for the provider.  Code the dx code from the patient perspective. 
If other webnars etc atre teaching this differently, then that is truely unfortunate.


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## Pam Brooks

I stand corrected, Deb, and appreciate your explanation.  I don't disagree with you, and I certainly do see my "flawed logic" based on the wording of my post.   I was interpreting from my understanding of the concept through a presentation I attended at the NH MGMA last year.  The speaker's slides instructed on assigning the A from an "encounter type" perspective, but didn't go on to reference the active treatment concept, and I didn't research it further.  I am glad that you provided clear guidance, and thank you.   

This board is designed for us to help each other, after all.


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## CBC

*fracture care 7th digit clarification*

I'm a little confused after reading these posts and reading the ICD-10 guidelines.  Our discussion was - a patient was treated by an orthopedic in a group for a fracture (casted, xray) - then the patient came back 2wks later for follow up eval.  Another orthopedic in the "same group" examined and re-xrayed the patient.  The guideline states eval & trmt by a new physician falls in the description of active care.  Would the visit be subsequent?  Also, what if the patient went to a different orthopedic in a different group for follow up care - would that then be considered initial or still subsequent?

Thank you for advice!!
Deb


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## mitchellde

the guideline states evaluation and TREATMENT by new physician.  When the patient is seen in follow up by a different (new) provider the injury has already had the active treatment, even if the cast is changed and a new on applied, this is not active treatment as the first provider determined the course of treatment and applied the definitive therapy at that visit.  If you look at the description of subsequent it explains that subsequent treatment includes cast changes.  
the only time the encounter for a fx will be initial as a secondary encounter is when the initial treating provider could not render treatment to the injured area.  Such as a displaced fracture with a lot of swelling is evaluated in the ER.  They ice it and immobilize it but cannot treat the injury.  Now from the patient perspective when they are then evaluated by the ortho doc the next day this is still for initial treatment of the injury by a new provider.  If the injury could be successfully treated in the ER and they are sent to ortho for follow up then the patient is here for subsequent treatment of their injury as the ER has already performed initial treatment.  
Pam-- No problem, these forums are an excellent tool to exchange ideas and learn from.  I think the biggest problem by far is having coders see the diagnosis from the patient view.  These are a disease classification system not an encounter classification.  Always code the diagnosis code from the perspective of the one that has the diagnosis.


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## erjones147

Always use 'A' if the patient is receiving Active treatment for the condition; it doesn't matter if it's the 56th encounter or the first.

Stop thinking about it as "initial" and "subsequent"


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## dyorkovich

What if the patient goes to the orthopaedic doctor for a fracture and has to have surgery three days later for internal fixation by the same doctor.  Is the surgical visit coded as initial or subsequent?


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## mitchellde

It just depends on if the fracture was initially treated with active treatment or if treatment was delayed for some reason.... or if the initial treatment is proving ineffective and you have a delayed healing, nonunion or malunion.  You must look at this from the patient's fx perspective not from the providers treatment perspective.


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## CBC

It would seem to me to fall under active treatment as described in the guidelines: Examples of Active treatment are surgical treatment, emergency dept encounter & evaluation and treatment by new physician.  I would think "A" for active treatment.  Any other advice welcome.

Deb


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## erjones147

Stop thinking of 'A' as "initial"; think of it as "active treatment"

A patient could be seen 57 times for the same fracture by the same provider if it hasn't healed yet, and the 7th digit would still be 'A'


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## lorrpb

Surgical treatment of a fracture is given as an example of active treatment/initial encounter in OGCR I.C.19.c.1).

With all due respect I disagree with the previous post. This same OGCR specifically defines "initial encounter" as "the patient is receiving active treatment for the fracture." "Subsequent encounter" is defined as "the patient has completed active treatment of the fracture is and is receiving routine care for the fracture during the healing or recovery phase."


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## mitchellde

erjones147 said:


> Stop thinking of 'A' as "initial"; think of it as "active treatment"
> 
> A patient could be seen 57 times for the same fracture by the same provider if it hasn't healed yet, and the 7th digit would still be 'A'



Initial is from the patient diagnosis perspective, has the patient received initial active treatment, after that it is subsequent.  If the fx has not healed yet then the question is, is it healing as it should.. then it is subsequent with routine healing, is it delayed-then it is subsequent with delayed healing, Is it a non union- then it is subsequent with delayed healing, or is it a mal union- then it is subsequent with mal union, it is a non union - then it is subsequent with non union.  You would not have 57 initial encounters unless the patient has some condition that prohibits the treatment of the fracture.
A provider following up after the fx has been appropriately treated is seeing a patient for a subsequent encounter, regardless of which provider performed the patient's initial active treatment.


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## YoseJenn

*Not clear about initial vs subsequent*

After reading the posts I am more confused as well. At our clinic we often are the first care a patient receives for a fracture. We x-ray and splint etc... Obviously, we are the initial treatment for that fracture. But if they are referred to a specialist, say for more definitive treatment are they to bill under the A too? (I see this very much the same question as the original post about radiology). Also A does not stand for Active, it represents initial.


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## lorrpb

The "name" of A is 'Initial' but when you read the OGCR for ch 19, you see that the "definition" of A is for Active treatment. So active treatment by the specialist would still be billed as A.


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## mitchellde

Again this comes down to whether the INJURY was treated at the first encounter.  If the injury could not be effectively treated due to some mitigating factor such as excessive swelling, or a patient is on coumadin, then when the injury is treated it is still initial.  If the first provider that sees the injury does provide active treatment for the injury then this is initial, and visits following this are subsequent.  The World Health Organization that created the ICD codes defines these as patient diagnosis codes.  These are not to be used to reflect the providers side of the encounter, they reflect the patient's perspective only.  It is possible to have more than one initial encounter but it will be due to other factors that prevent treatment of the injury.


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