Eli's Rehab Report

Key: Choose carefully between 7^th characters ‘A’ and ‘D.’

A patient visits urgent care with a suspected fracture after rolling her foot during ballet class. X-rays reveal a spiral oblique distal shaft fracture of the right 5^th metatarsal. The physician determines a non-displaced fracture but instructs the patient to follow-up with a foot and ankle specialist and sends her home in an ace bandage and a boot. The patient sees the foot and ankle specialist one week later, who confirms a non-displaced “dancer’s fracture,” determines she won’t need surgery, and instructs her on home care.

The patient is, however, experiencing significant foot pain. She also is limping and has minor swelling and bruising. She is coming to your office to see if PT could return her to high-performance foot usage at a faster rate in hopes that she can return to dance as soon as possible.

The question: How would you code for this patient’s case with ICD-10 coding?

1) Determine what physical therapy will be treating. In this case, you would not be treating the fracture itself, but the symptoms the patient is experiencing. Thus, “you would code first for difficulty walking, pain in the foot, and effusion of the foot,” says Rick Gawenda, PT, president of Gawenda Seminars & Consulting. The codes would be as follows:

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

2) Select the appropriate fracture code. Unlike ICD-9, where the correct fracture code is 825.25 (Closed fracture of metatarsal bone(s)), in ICD-10, you need a more specific code that indicates laterality, as well as the affected digit, etc.

“The fracture ICD-10 code would be S92.354 (Non-displaced fracture of the fifth metatarsal bone, right foot),” Gawenda says. But you’re not finished just yet. “You then need to add the appropriate 7^th character to the fracture code,” he says. “Remember, all S and T codes need a 7^th character.”

In this case, the correct 7^th character would be “D,” so you’d code S92.354D (… subsequent encounter for fracture with routine healing). “You would choose D because the physical therapy is follow-up care after the injury,” Gawenda says. “The patient has already received the active care, x-rays, etc. from the physicians.”

Exception: In the rare case that the PT did the initial diagnosis and treatment (ace bandaging, wrapping, x-rays, home care, etc.), then the correct 7^th character would be A (initial encounter).

Good to know: The 7^th character, “A,” is not only for the first visit to urgent care. In this case, both the visit to urgent care and the foot and ankle specialist would use “A.”

According in the 2015 ICD-10-CM Official Guidelines for Coding and Reporting, “While the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the 7^th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time” (emphasis added).

Per the Guidelines, examples of active treatment include: surgical treatment, the emergency department visit, evaluation and continuing treatment by the same or a different physician.

“7^th 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,” the Guidelines state. This is where PT would come in.

Other examples of subsequent care include: cast change or removal, an x-ray to check the 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, the Guidelines say.

3) Put your codes in the right order. In this foot fracture case example, for the physical therapist, the symptom codes that are the result of the fracture go first, followed by the fracture code (with 7^th character D), then the activity code, Gawenda says:

• R26.2
• M79.671
• M25.474
• S92.354D 
• Y93.41 (Activities involving dancing and other rhythmic movement).