Primary Care Coding Alert

Question: If a patient comes to us following a visit to the emergency department (ED) for a foot injury, and our provider sees the patient for the first time and reviews the plan of care but does not actively treat the patient, which seventh character — A or D — do I apply to the ICD-10 code for the injury?

AAPC Forum Participant

Answer: ICD-10 guideline 1.C.19.a tells you to apply seventh character A (Initial encounter) or D (Subsequent encounter) “based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time.”

In this particular encounter, you say your provider has reviewed the plan of care but is not actively treating the patient. However, even if your provider simply approves the plan and is not going to alter it in any way, you can still apply seventh character A to indicate that the patient’s treatment is currently active under your provider.

Remember: Any encounter related to the patient’s injury following completion of active treatment of the condition for which the patient is receiving routine care during the condition’s healing or recovery phase will be indicated by applying seventh character D.