ICD 10 Coding Alert

Question: A patient came to our office after visiting the emergency department (ED) where she had been diagnosed with a nondisplaced fracture of the fifth metatarsal. She was still experiencing difficulty walking; she was limping and experiencing significant foot pain with swelling and bruising. What ICD-10-CM codes do we use, and do we use initial or subsequent encounter 7th character codes for this visit?

Colorado Subscriber

Answer: You’ll need to use multiple ICD-10-CM codes in this encounter, and not only will you need to be careful with 7th character use, but you’ll also need to make sure you get the codes in the correct order per the ICD-10-CM guidelines for sequencing.

Signs and symptoms first: Even though the ED visit provided a definitive diagnosis for your patient, you will still need to record the patient’s signs and symptoms, as they are the reason for the encounter and the conditions that your provider will be treating.

So, in this scenario, you would report:

• R26.2 (Difficulty in walking, not elsewhere classified)
• M79.671 (Pain in right foot)
• M25.474 (Effusion, right foot)

Dx comes next: For a metatarsal fracture, you would look to S92.354- (Nondisplaced fracture of fifth metatarsal bone, right foot). To determine the correct 7th character to add to the code, you’ll need to consult Chapter 19 guidelines, which tell you that “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.”

In other words, determining the correct character has nothing to do with the provider who diagnoses the condition at the initial encounter — in this case, the ED attending — but whether the encounter is for the purpose of treating the patient’s condition. So, in this encounter, as your provider’s role is to treat the patient, you would add character “A” (Initial encounter for closed fracture) as the 7th character to S92.354-.

Code the external cause last: Technically, “there is no national requirement for mandatory ICD-10-CM external cause code reporting,” according to the guidelines, “unless a provider is subject to a state-based external cause code reporting mandate or these codes are required by a particular payer.” But reporting the cause, intent, or location of an injury yields useful data that in the words of the ICD-10-CM guidelines, helps “injury research and evaluation of injury prevention strategies.”

So, whether you are mandated, or if you choose to report the external cause of injury (which, in this case, would be Y93.41 [Activity, dancing]), the code should appear at the end of the coding sequence. Again, ICD-10-CM guidelines come into play, as they specify that “the external causes of morbidity codes should never be sequenced as the first listed or principal diagnosis.”

Putting it all together: With all this in mind, your final documentation should look like this:

• R26.2
• M79.671
• M25.474
• S92.354A
• Y93.41.