# ICD-10 Qualifiers for Injury codes



## kelas (Jun 1, 2015)

Hello Fellow Coders!  I am needing some clarification on when we should use the A Qualifer vs the D Qualifer.  Example would be *S06.890A vs. S06.890D*[/U][/B].  The facility I work for does long term residential care for TBI injury patients and all patients have been extensively treated by the time they come to to us.  I feel we should be using the "D" qualifier but I am having a hard time convincing our Software provider that it should NOT be "A".  Any clarification or reference to documentation I can provide will be greatly appreciated!


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## mitchellde (Jun 1, 2015)

If you look in the guidelines for 2015 you will see that they added a clarification for initial,  initial is when the patient is seeking initial active treatment for the injury, and just because they are seeing you for the first time.  I think sometimes you may use the D and other times the S.  The difference is the D is used for aftercare encounters while the injury is still healing.  The S is used when the injury itself does not require treatment but the residuals that remain due to the injury are being treated.  So an admission to rehab following a TBI could be the residual condition first followed by the injury code with the 7th character S.


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## BenCrocker (Jun 2, 2015)

Unless they get treatment during the healing stage then it would be D.


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## Lynda Wetter (Jun 3, 2015)

mitchellde said:


> If you look in the guidelines for 2015 you will see that they added a clarification for initial,  initial is when the patient is seeking initial active treatment for the injury, and just because they are seeing you for the first time.  I think sometimes you may use the D and other times the S.  The difference is the D is used for aftercare encounters while the injury is still healing.  The S is used when the injury itself does not require treatment but the residuals that remain due to the injury are being treated.  So an admission to rehab following a TBI could be the residual condition first followed by the injury code with the 7th character S.



Debra, How would the 7th digit be assigned if the patient returns for a dressing change or because of pain or things in that nature?
Would this still be considered "active treatment" 
I assume when the patient returns on a routine follow up that is when we assign the D, correct?


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## mitchellde (Jun 3, 2015)

Dressing changes are a D also.. If it was code able in ICD-9 with a V code for aftercare like suturecremoval or fitting and adjustment, or dressing changes, etc.. It is now coded as the injury code with a D.  Keeping in mind that many coders coded this incorrectly in ICD-9 by continuing to use injury codes.  
Active treatment would be like a grisly contaminated wound that the provider did not close due to risk of infection.  Instead it was cleansed and packed.  Then for several days the wound is unpacked, debrided, and re packed.  Each day this is active wound treatment and gets an A.  Once the wound is closed and the payient returns to be checked and the dressings changed, this is aftercare and will get the D.  Once it has healed, and a scar remains, the scar is sequela.
Once any injury goes into pain control mode, the pain is usually sequela.


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## Lynda Wetter (Jun 3, 2015)

So with these statements 

*7th character "A", initial encounter is used while the patient is receiving active treatment for the condition. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician.

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 follow up visits following treatment of the injury or condition.
*
You would consider a complication not part of the "Active" treatment but part of a healing/recovery phase. So basically the A would be assigned only once per wound/fracture?
Wouldn't it be considered "continuing treatment"
If not, do you have an example of continuing treatment?

Thanks for your help in trying to make sense of this!


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## mitchellde (Jun 3, 2015)

Continuing active treatment is like I suggested in my post , continued wound packing and debridement of a wound that has not been closed.  The would is still open and the treatment is a continuation of the active wound treatment.  You get this with third degree burns as well active treatment can go on for days.  The A initial character can be assigned multiple visits not just once.  However for most it will be just the one time
It will be initial for a fracture until fracture treatment is rendered to align the bone and apply a traction device.
It will be initial for a laceration until it is closed
It is initial for sprain until it is immobilized.
Once the injury is successfully treated and it enters into the healing state then it goes yo subsequent.
A complication might be subsequent or might be sequela the documentation will be key for this.


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