# Initial & Subsequent Visit



## rhart@wabashgeneral.com (Aug 10, 2015)

I have a documentation question. My coders and I need some clarification regarding the initial and subsequent visit. I have been requesting feedback from my coders on the providers they code for and their consistent feedback is that the providers need to state if the visit is initial or subsequent using that exact wording. When I go to the charts, key phrases like ?presents for? lets me know this is a initial visit. Phrases like ?returns for? and ?follow up for? lets me know this is a subsequent visit. My coders disagree. They state the documentation must state Initial or subsequent visit. Are they being too literal? Is there any documentation to support either side? We are all CPC certified, so I would like your opinions please.


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## mitchellde (Aug 10, 2015)

The provider does not need to state initial or subsequent.  The determining factor in whether it is initial or subsequent is the status of the injury and the treatment.  It is not dependent on if the are seeing your provider for the first time or returning to your provider.  Think of the word initial more in terms of active treatment.  If you are still treating an active injury with active treatment it is still initial.  Such as an active contaminated wound which cannot be closed yet due to infection risk.  Each visit where the payient returns to have packing removed and possible debridements is active(initial) encounter.  Once the wound is closed and now in a healing status the return visit to check the dressing or remove sutures are subsequent.  You will need to read the note to know exactly what the status of the injury is and what exactly is being performed to know whether this encounter us the patient's initial encounter (for active or continued active treatment) or subsequent (follow up or aftercare)


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## kathymoon (Dec 22, 2015)

Debra,

This is probably the best explanation I have found for initial vs. subsequent.  I have a patient with blisters/wounds and three visits so far for "treatment" as it is not healing well.  I needed verification of the coding.  This helped a lot.

Thank you.


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## Cheezum51 (Dec 23, 2015)

From what I've read and heard at various lectures regarding initial and subsequent visits, I have to disagree with what Debra says above. Every speaker I've heard has said that the first time a patient presents for a specific problem, usually an injury, it is the "A" (initial) visit. Every time you see them in follow up, whether the problem is resolved or not, it is a "D" (subsequent) visit. Therefore, you can only have one "A" visit for a problem but you may have several "D" visits as you go through the treatment for that problem.

Thomas Cheezum, O.D., CPC


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## mitchellde (Dec 23, 2015)

I am sorry to disagree with other speakers, but what they have stated is not correct per the definition in the guidelines. From the chapter 19 guidelines:
 While the patient may be seen by a new or different provider over the course of treatment for an injury, 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.
For complication codes, active treatment refers to treatment for the condition described by the code, even though it may be related to an earlier precipitating problem. For example, code T84.50XA, Infection and inflammatory reaction due to unspecified internal joint prosthesis , initial encounter, is used when active treatment is provided for the infection, even though the condition relates to the prosthetic device, implant or graft that was placed at a previous encounter.
Initial- used for the initial encounter for the injury or condition while the patient is receiving active treatment for the injury. Examples of active treatment are: surgical treatment, emergency department encounter, and continuing active treatment by the same or different physician.


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## Cheezum51 (Dec 23, 2015)

Since the majority of the lectures I've attended recently have to do with optometry/ophthalmology, here is the consistent thing I've heard from multiple speakers.
Example: Pt is hit in the eye while working with a workbench tool at home and sustains a scratch/abrasion on the eye. The first time the patient is seen by the eye doctor, the diagnosis for the abrasion is coded with an A and you also code the activity and location codes. When the patient is seen back to evaluate the effectiveness of the treatment prescribed at the first visit and to also evaluate how well the eye is healing, that is a D visit. You don't have to code again for the activity and location. Until the abrasion is healed and the patient is dismissed from care for that injury, any subsequent visits are also D visits. 
If the patient returns at a later time and say a corneal scar has developed in the area of the abrasion, that would be a Sequela of the past injury and that visit would be coded with an S.
Thomas Cheezum, O.D., CPC


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## mitchellde (Dec 23, 2015)

For that scenario yes you are correct.  However let's say there was a foreign object removed in the ER and then sent to Opthalmogy for further treatment, the Ophthalmologist then needs to be for several ablations that the ER could not do, this is continued active treatment of the injury caused by the foreign object so they are billed with the A as well.  Just don't confuse the A with a first encounter, there can be multiple A encounters.  On a weekend I had a direct hard hit to my eye causing instant blindness, the ER could not properly evaluate the injury and so administered drops and a patch, that is an A.  I was seen urgently Monday morning in the office and examined this is also an A.  I was in surgery the next day for treatment of a detached retina, this is also an A.
PS 
I don't think you ever came to one of my lectures.  (Just a bit of humor)


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## akoschoff (Dec 23, 2015)

Do the A and D encounter types for external cause codes follow the same guidelines as those for the injury chapter?


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## Cheezum51 (Dec 29, 2015)

Debra, thanks for the clarification for the different scenarios. Much appreciated.

When is your next lecture?


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## mitchellde (Dec 29, 2015)

I go out the week of Jan 10 to the Atlanta area.  I travel to all states.  
Yes the external cause codes follow the same rules for 7th characters.


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