Wiki ICD 10 Pathological Fracture 7th Charactor A

[janicelane]

Good morning,

Need help in determning what is meant by "active treatment" in a patholocigal fracture to use 7th character A.

CAse scenerio:
Patient is in for a f/u with PCP and has vertebral pathological frature diagnosised 1 year prior due to Osteoporosis and is currently on pain meds to control the pain.

In this scenerio would I use 7th character A for "Inital encounter/Active Treatment" or would I use D "subsequent encounter for fracture with routine healing or S "sequela"

I cannot get clear direction for the above scenerio. need to know what is considered "active treatment"????

 

[mitchellde]

I doubt this would be initial since fx diagnosed a year ago probably received some type of treatment, either a brace or surgery. The question is what is the status of the fx at this encounter. For that you will need more clear documentation. Such as it is still healing, routinely (D), delayed (G), with nonunion (k), or malunion (P). Or is the fx considered as healed with the residual effect (S) of the pain. From what you have provided there is no way to tell.