Primary Care Coding Alert

Question: Is the condition of an injury in its healed state ever considered a sequela, or does sequela only relate to further issues with the original injury? Can sequelae ever be reported as primary?

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Answer: Yes, the condition of an injury in its healed state can be considered a sequela. A sequela, known also as a late effect, is defined in ICD-10 Official Guidelines, Section I.B.10 as “the residual effect (condition produced) after the acute phase of an illness or injury has terminated … [which] may occur months or years later, such as that due to a previous injury.”

For example, a patient comes in complaining that a scar on the back of her left hand has recently become painful. The provider notes that five years ago, she suffered a third-degree burn to that location and notes that the scar is a sequela to the burn. In this situation, the injury (the burn) has healed, and the patient is experiencing no further issues from the injury itself. However, the injury has created a scar, which is a sequela of the injury and the reason for the encounter.

In this case, you would code both the scar and the injury that caused it, using the 7th character, S, for the injury code like this:

• L90.5 (Scar conditions and fibrosis of skin)
• T23.362S (Burn of third degree of back of left hand, sequela)

As the primary issue at this encounter is the painful scar, even though it’s technically a sequela, you will follow ICD-10 guideline I.B.10, which states, “the condition or nature of the sequela is sequenced first. The sequela code is sequenced second.” Guideline I.C.19.a explains that in situations such as this, “the specific type of sequela (e.g. scar) is sequenced first, followed by the injury code.” In other words, in this example, the sequela of the injury, the scar, is reported as the first-listed, or primary, condition.