Wiki Coding Sequela

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Radcoder86

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I'm confused on how to code an encounter where a patients is experiencing upper back pain as a result from a fall with residual muscle soreness. The fall happened in July and I think the note makes it clear that the patient is not in the acute phase. I'm having a hard time finding sequela codes that really fit what the patient is being seen for. The patient stated pain in scapular area, but the doctor noted upper back pain. There's no code for injury to upper back, but there is one for shoulder area. Would coding it - other dorsalgia, other injuries of R shoulder, then the fall code be correct?
Thanks!
 
If the original encounter was for back pain due to a fall, and no sprain, starin, dislocation, contusion is noted, then it was just back pain due to a fall. Now in ICD-10 CM that would be coded with the M code for the back pain and the external cause code for the fall with an A. Now the patient returns with what is documented as residual muscle soreness due to the previous fall. Code the M code for the muscle soreness and the external cause code with the S.
 
Sequela

Just a thought...don't forget that, if the original problem is an injury code, you would code the sequela, then the injury code with S suffix, followed by external cause code with S suffix.

Thanks!
Amy Meyers, CPC
 
A sequala is another condition or injury that was the result of a previous condition or injury. For example a scar that is a result of frostbite. The scar is the new condition and is coded FIRST as primary. The frostbite is the coded with an S to indicate the causing injury for the sequela condition

Add an "A" any code that requires a 7th character where active treatment is occurring. There was a clarification for 2016/2017. It's not just the initial visit, but any other visit where active treatment is occuring. In the above example, if frostbite occurs, you code the first visit with a 7th character of A and any other visits afterwards where treatment for the frostbite is occuring also with a 7th character of A.

A subsequent or follow-up visit is code for any visit for this frostbite AFTER ACTIVE TREATMENT has concluded. So if there is an E/M visit, or another visit after the postop but no active treatment is occcuring, this is a SUBSEQUENT visit for the frostbite and is coded with a D for the 7th character.
 
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