General Surgery Coding Alert

Question: Our surgeon removed sutures from a patient new to our practice who had a right-thigh laceration (no foreign body) treated in an emergency room by a different physician. Should we use the ICD-10-CM seventh character that indicates this is an initial encounter?

Codify Subscriber

Answer: Although this patient is new to your practice, the diagnosis code should reflect that this is a subsequent encounter.

The confusion over the way to apply seventh characters A (Initial encounter), D (Subsequent encounter), or S (Sequela) to a code from the Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88) chapter of ICD-10-CM stems from the belief that the characters apply to the encounter itself. If that were the case, you would be tempted to use the seventh character “A,” in this case.

But that would be incorrect. ICD-10 guideline C.19.a states, “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.”

Tip: Think of the initial-encounter seventh character “A” as an abbreviation for “Active.”

The fact that the patient is reporting to your surgeon to have sutures removed indicates that the patient is no longer undergoing active treatment, because the injury has healed. This encounter would meet the ICD-10 criteria for a subsequent encounter, which is defined as an encounter “after the patient has completed active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.” In the case of lacerations, this would include suture removal, so you should code the encounter as S71.111D (Laceration without foreign body, right thigh, subsequent encounter).

More: As for the seventh character S, guideline C.19.a notes that this character is “for use for complications or conditions that arise as a direct result of the condition, such as a scar formation after a burn.” So, if your patient returned sometime after the encounter to be treated for pain from the scar contracting and thickening, you would code the injury with S71.111S (Laceration without foreign body, right thigh, sequela), sequencing a code such as L90.5 (Scar conditions and fibrosis of skin) first for the encounter.