# 7th digits A, D, and S



## Bierle (Apr 1, 2015)

I have been getting ready to take the proficiency exam and came across an article from April 2014 in Healthcare Business Monthly that states that if a provider takes care of an injury initially it is an A but if another provider in another office takes care of it following that definitive treatment that provider would use the D even though it is the first time that provider is seeing him.  Now in Boot Camp I was told that the second provider would also be an A because it is the first visit for that injury.  Which is the correct way to bill for the second provider A or D?


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## mitchellde (Apr 1, 2015)

The 2015 guidelines have clarified this.  The assignment of the 7th character is dependent on whether the patient is receiving active initial treatment of the injury and not whether the provider is seeing the patient for the first time.  These are patient diagnosis codes not provider encounter codes.  So if the injury has already been treated and the patient is in for follow up care then the visit is subsequent for the patient.  If the injury still requires initial active treatment then it is still an initial encounter for the payient to receive active treatment.  For instance if a fracture cannot be treated at this first encounter due to swelling, so the patient is referred to a specialist the next day.  The patient presents to the specialist and then has the fracture reduction performed. Then that visit is also initial for the patient to receive active fracture treatment.  However if the fracture were successfully treated by the first provider and they are sent to a different provider for follow up, then when the patient sees the second provider, although a new patient, that is (for the patient) a subsequent encounter.   
Now imagine an open wound that is badly contaminated.  Provider A flushes the wound and packs it, this is initial.  The patient is told to continue the treatment with provider B.  The patient then goes to provider B who unpacks the wound, performs debridement, re packs the wound and tells the patient to return in two days, this visit is initial to the patient.  The patient returns and the same treatment is applied, this visit is also initial.  It will stay initial as long as the provider is performing initial active treatment to the wound.  When the wound is closed and the patient presents for follow up then it will subsequent.


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## pediatrics (Apr 2, 2015)

*7th digits A, D and S*

Great info. This has been the most confusing to me. I understood that if a patient comes through our trauma unit and is admitted, that you would use the "A" during that entire admission. If the patient is discharged and returns 3 days later for a complication and is readmitted, would you use the "S" for that different admission? I don't know how physician's are going to keep this straight. And what is defined as "active treatment"? Once a cast is applied, hardware, medication? Any feedback would be appreciated.


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## mitchellde (Apr 2, 2015)

Active is when you are still treating the injury with active treatment, not a cast change or a dressing change.  The hospital would use the A for the admission butnthensurgeon would use the A until after the surgery then it will be a D.  As far as complications got, it will depend on the complication.  If the complication code is in the T section of the book and the patient comes in for that, the T code for complication gets an A, the code it will get an A ffor theninitial treatment of the complication, the injury gets a D..  However if it is not coded with a T such as a hematoma, then you code the injury with a D followed by the L code for the hematoma.
Sequela is for the residual conditions after the injury is considered healed.


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## mtimson (Apr 22, 2015)

*7th digits A,D and S*

Hello, i was wondering if i could get clarification on the initial vs. subsequent.
Lets say the patient has been seen for hip pain without a definitive diagnosis.  After a couple visits the doctor orders an MRI, with a definitive diagnosis of a labral tear.  Now that i have a definitive dx does this get documented as the initial encounter?  And if so, at what point does this become subsequent, if the patient dosen't require surgery but does P.T. and pain manegement etc.


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## erjones147 (Apr 22, 2015)

@mtimson - in the scenario you describe, you would still be looking at an A/initial because you are still "A"ssessing the "A"ctive stage of the disease/problem

At my Boot Camp, Susan Ward explained it this way (paraphrasing here): don't think of A as "initial encounter" like it says in the little pink boxes - think of A as initial _stage of the disease process_. Only use D/subsequent when you are checking the healing status

In your scenario, I would code D/subsequent when the disease/problem reaches the PT/pain management stage etc., because treatment has begun


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## mtimson (Apr 23, 2015)

THank you so very much, this is excellent advice!  I really appreciate your feedback!


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## monica03 (Apr 24, 2015)

erjones147 said:


> you would still be looking at an A/initial because you are still "A"ssessing the "A"ctive stage of the disease/problem



I like this!


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## JLRees (Jun 13, 2019)

mitchellde said:


> Active is when you are still treating the injury with active treatment, not a cast change or a dressing change.  The hospital would use the A for the admission butnthensurgeon would use the A until after the surgery then it will be a D.  As far as complications got, it will depend on the complication.  If the complication code is in the T section of the book and the patient comes in for that, the T code for complication gets an A, the code it will get an A ffor theninitial treatment of the complication, the injury gets a D..  However if it is not coded with a T such as a hematoma, then you code the injury with a D followed by the L code for the hematoma.
> Sequela is for the residual conditions after the injury is considered healed.


Specific to this statement: _The hospital would use the A for the admission but then the surgeon would use the A until *after the surgery then it will be a D*_
What if this scenario happens during a hospital stay where a patient is admitted through ER due to a fall where a fracture is discovered?  For example:   Patient is admitted by MD (7th digit for fracture code is A) next day surgery is done by ortho surgeon (7th digit is still A) and then the patient is seen POD#2 by admitting physician.  Does the 7th digit change to D because the "active treatment" has been completed?  Or is *post op* hospital stay considered part of the initial treatment?  It seems like the digit should change to D since surgery has been completed, however, since its all happening within the same admission and the patient hasn't been cleared and D/C'd by a doctor confirming the active treatment process is successful/complete, it also makes sense that the 7th digit should remain A for the duration of the hospital stay.  Which is correct.  I have looked through the guidelines for fractures/7th digits but am not finding anything specific to inpatient hospital admissions.


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## mcdream (Jun 13, 2019)

mitchellde said:


> Active is when you are still treating the injury with active treatment, not a cast change or a dressing change.  The hospital would use the A for the admission butnthensurgeon would use the A until after the surgery then it will be a D.  As far as complications got, it will depend on the complication.  If the complication code is in the T section of the book and the patient comes in for that, the T code for complication gets an A, the code it will get an A ffor theninitial treatment of the complication, the injury gets a D..  However if it is not coded with a T such as a hematoma, then you code the injury with a D followed by the L code for the hematoma.
> Sequela is for the residual conditions after the injury is considered healed.


Debra- What about the Osteoporosis with current pathological fracture codes (M80.-XA/D) that require 7th character? 
I code for an endocrinologist who assigns M80.-XA because he is seeing the patient for the osteoporosis (prescribes &/or monitors bone medication, or assesses osteoporosis w/o bone meds) not for treatment of the fracture. Is M80.-XA for initial encounter correct or should these encounters be M80.-XD for subsequent encounter?
Thank you for your help


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## mitchellde (Jun 17, 2019)

If your provider is not treating the fracture then it would seem that the fracture is being managed by other provider so I would assume the 7th character of D is correct, however without actually seeing the documentation for each encounter, this is just a guess.


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## Caren Balanza (Oct 21, 2019)

I have a question.  The patient is being seen for shoulder pain initially.  the doctor recommended x-ray and pain meds.  Then on follow up, x-ray result came out with normal findings but the patient still has shoulder pain. doctor recommended to continue pain meds.  would the second visit still be A or  S?


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## mitchellde (Oct 21, 2019)

Shoulder pain codes are in the M25 category and do not get assigned A,D,or S characters.


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## Caren Balanza (Oct 22, 2019)

Sorry, diagnosis is left shoulder strain


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## mitchellde (Oct 22, 2019)

It really depends on the documentation if the strain has already been treated with immobilization and that is all that is to be done then it goes to a D


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