# Initial vs subsequent vs sequela



## wynonna (Feb 7, 2018)

If a patient was treated in a nearby ER or Hospital for a bone fracture, and then comes to an internal medicine office as an established patient to be treated for the bone fracture, is the fracture treatment/evaluation considered an initial or subsequent visit to the internal medicine office?  In other words, is it initial or subsequent if it is the first time patient is in the office for the bone fracture that was diagnosed and evaluated at the nearby ER?
Sequela is late effects so how many months/years need to go by when a subsequent visit/illness becomes a sequela?
thank you


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## daedolos (Feb 7, 2018)

If you are billing for the specialist visit AND it's the first time the patient is there for the current fracture AND the doctor (or any doctor from the same specialty group) has NOT seen the patient before for the current fracture (example: hospital consult), then you would code the fracture with the 7th digit designation A for initial treatment in the office visit.

Peace
@_*
Hope that helps.


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## mitchellde (Feb 7, 2018)

The use of the initial vs subsequent vs sequela is not based on the encounter being the first encounter with the provider.  It is based on the status of the injury.
If the fracture was appropriately and definitively treated in the ER and your provider is following up on that care then you use the 7th character for subsequent even if this is a new patient encounter or you are seeing the patient for the first time for this injury, since active treatment was already rendered in the ER.  If the ER was unable to provide definitive fracture treatment due to issues such as excessive swelling, so they only stabilized the injury and deferred definitive treatment to your provider, then you would code with the 7th character for initial as this would be the initial encounter for active treatment.
Sequela has no time restrictions, it is dependent on documentation.  The provider must document that the current condition is due to the injury.  It could occur immediately after healing or years later.


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## daedolos (Feb 8, 2018)

mitchellde said:


> The use of the initial vs subsequent vs sequela is not based on the encounter being the first encounter with the provider.  It is based on the status of the injury.
> If the fracture was appropriately and definitively treated in the ER and your provider is following up on that care then you use the 7th character for subsequent even if this is a new patient encounter or you are seeing the patient for the first time for this injury, since active treatment was already rendered in the ER.  If the ER was unable to provide definitive fracture treatment due to issues such as excessive swelling, so they only stabilized the injury and deferred definitive treatment to your provider, then you would code with the 7th character for initial as this would be the initial encounter for active treatment.
> Sequela has no time restrictions, it is dependent on documentation.  The provider must document that the current condition is due to the injury.  It could occur immediately after healing or years later.



Thanks for that clarification.  You're right.  All the cases that we see that are coded as 7th letter A were from ER visits where the fracture was stabilized and deferred to an ortho specialist.

Peace
@_*


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## wynonna (Feb 14, 2018)

I understand the rationale, but it seems time consuming for the MD and coder to research ER records every time patient presents with an injury to see when active treatment began, which may be a clinical decision and not a coder's.
Maybe if we ask is this the first visit for the injury, (ie fracture)  from the patient's point of view, that clarifies.  However, we have to trust patient is a good historian and understands principle of active treatment.


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## ellzeycoding (Feb 14, 2018)

Just to be clear, the instructions for initial vs. subsequent were updated/modified for 2017 (in October 2016).

A= initial is appended to ICD-10 for the initial encounter and all other encounters where active treatment is occurring (not just the first encoutner)
S= subsequent is appended to the appropriate ICD-10 after active treatment has concluded and the patient is healing or in recovery.


Here is the exact wording from the Office 2017 ICD-10 Guidelines, Chapter 19, (page 64).   The bolded section were the changes made starting October 2016.

_"7th character “A”, initial encounter is used *for each encounter where* the patient is receiving active treatment for the condition.

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


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## mitchellde (Feb 15, 2018)

wynonna said:


> I understand the rationale, but it seems time consuming for the MD and coder to research ER records every time patient presents with an injury to see when active treatment began, which may be a clinical decision and not a coder's.
> Maybe if we ask is this the first visit for the injury, (ie fracture)  from the patient's point of view, that clarifies.  However, we have to trust patient is a good historian and understands principle of active treatment.



The MD will, in the majority of cases, know by examination whether the patient has received active treatment by another provider or if the injury has only received preliminary care or stabilization. 
example is a case where the patient was documented as having a fracture or the wrist and the provider indicated the patient had a splint previously applied.  Now this visit could have been initial or subsequent depending on what the provider does.  The chief complaint was pain.
in this case the provider did not remove the splint, nor x-ray the limb.  the care was minimal.  However they had tried to code this as initial.  Clearly this was subsequent care, even though this was the providers initial encounter with the patient, it was the patient's subsequent encounter for treatment since no active treatment was offered or rendered. 
even if the splint had been removed, unless there is further manipulation/reduction needed, or internal fixation, then no further active treatment has been applied.
perhaps it is best if we quit looking at the A as meaning initial encounter and start looking at A as indicating Active treatment


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