rbright1@hmc.psu.edu
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If an ortho resident sees a patient in the ED for a distal radius fracture and the patient returns 2 weeks later and sees an orthopaedic surgeon, in ICD10 world, what is the 7th character?
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Wiki ICD10 Fracture Coding
- Thread starter rbright1@hmc.psu.edu
- Start date
Pam Warren
True Blue
If the patient is still receiving active treatment, then it's A. It's hard to say without knowing why the surgeon is seeing the patient. If it's to evaluate whether or not surgery is appropriate, then use A, because the patient is not yet in the healing phase. From Decision Health:
Initial encounter. Initial encounter is defined as the period when the patient is receiving active treatment for the injury, poisoning, or other consequences of an external cause. An A may be assigned on more than one claim. For example, if a patient is seen in the emergency department (ED) for a head injury that is first evaluated by the ED physician who requests a CT scan that is read by a radiologist and a consultation by a neurologist, the 7th character A is used by all three physicians and also reported on the ED claim. If the patient required admission to an acute care hospital, the 7th character A would be reported for the entire acute care hospital stay because the 7th character extension A is used for the entire period that the patient receives active treatment for the injury.
Subsequent encounter. This is an encounter after the active phase of treatment and when the patient is receiving routine care for the injury during the period of healing or recovery. For example a patient with an ankle sprain may return to the office to have joint stability re-evaluated to ensure that the injury is healing properly. In this case, the 7th character D would be assigned.
Sequela. The 7th character extension S is assigned for complications or conditions that arise as a direct result of an injury. An example of a sequela is a scar resulting from a burn.
Initial encounter. Initial encounter is defined as the period when the patient is receiving active treatment for the injury, poisoning, or other consequences of an external cause. An A may be assigned on more than one claim. For example, if a patient is seen in the emergency department (ED) for a head injury that is first evaluated by the ED physician who requests a CT scan that is read by a radiologist and a consultation by a neurologist, the 7th character A is used by all three physicians and also reported on the ED claim. If the patient required admission to an acute care hospital, the 7th character A would be reported for the entire acute care hospital stay because the 7th character extension A is used for the entire period that the patient receives active treatment for the injury.
Subsequent encounter. This is an encounter after the active phase of treatment and when the patient is receiving routine care for the injury during the period of healing or recovery. For example a patient with an ankle sprain may return to the office to have joint stability re-evaluated to ensure that the injury is healing properly. In this case, the 7th character D would be assigned.
Sequela. The 7th character extension S is assigned for complications or conditions that arise as a direct result of an injury. An example of a sequela is a scar resulting from a burn.