Podiatry Coding & Billing Alert

Question: Can a coder refer to a previous encounter to determine whether this is the initial or subsequent encounter for a particular injury, for the purpose of selecting the seventh character? How about for the purpose of determining the specific injury?

– Doubtful About Descriptors, Green Bay, WI

Answer: No, documentation for the current encounter should clearly reflect those diagnoses that are current and relevant for that specific encounter. Previous encounters may not be used to determine the seventh character for an injury because the key to appropriate code selection is based on whether active treatment is being provided during the current encounter.

“Initial encounter” in this case refers to the injury, not the physician-patient first meeting. The specific injury should also be reflected in the documentation for the current encounter. It’s important to stay focused on the patient’s diagnoses and code only from that perspective.