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Home Health Coding and OASIS Expert

Diagnosis Coding:

Master 7th Character Selection Injuries and Complications

Don’t look to aftercare Z codes when caring for an injury.

Knowing which seventh character to select is one of ICD-10’s trickiest aspects for home health coders. Keep in mind the code set’s definition for “active treatment” to guide your choice.

Old way: As home health agencies ramped up for the ICD-10 transition, most training advised never assigning seventh character “A” for initial encounter. Originally, home health coding experts believed that seventh character “A” would never be appropriate in home health because these patients had already been seen for treatment in another setting.

New way: But as early as Aug. 2015, the National Association for Home Care & Hospice (NAHC) reported that the organizations responsible for the official ICD-10 coding guidance had issued a clarification requiring home health agencies to indicate an “A” (initial encounter) in the seventh character for some ICD-10 codes.

“An ‘A’ in the seventh character should be used for any encounter where the patient is still receiving active treatment for the clinical condition, including home health. While in many cases this would not apply to home health, there are times where it could, such as antibiotic treatment for a postop infection,” NAHC said in the Aug. 21 NAHC Report member newsletter.

Since that statement, the ICD-10 transition date has come and gone and the Home Health PPS grouper has been updated to accept seventh character “A” for certain diagnosis codes. But for many coders, knowing exactly when to report seventh character “A” is still a challenge.

Read the Guidelines

Seventh characters are required in only a handful of chapters in your ICD-10 manual. Expect to report these characters when you’re coding for musculoskeletal and obstetric diagnoses as well as when you’re reporting complications, injuries, or external causes.

Most, but not all categories in Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes require a seventh character, says Lisa Selman-Holman, JD, BSN, RN, COS-C, HCS-D, HCS-O, AHIMA Approved ICD-10-CM Trainer/Ambassador of Selman-Holman & Associates, LLC, CoDR — Coding Done Right and Code Pro University in Denton, Texas.

When your patient is recovering from an injury, you won’t report an aftercare code in ICD-10. Instead, you’ll continue to report the injury code, selecting the appropriate seventh character depending on whether the patient is receiving active treatment, routine care, or is experiencing sequelae of the original condition.

Your seventh character options for conditions other than fractures found in Chapter 19 include:

A — Initial encounter: If you hope to select the correct seventh character, you’ll need to get over a wording quirk in ICD-10. “Disregard the word ‘initial’” in the description for seventh character “A,” said Nelly Leon-Chisen, RHIA, Director of Coding and Classification with the American Hospital Association (AHA).

Seventh character “A” can be used “for multiple healthcare encounters as long as the patient is still receiving active treatment for the condition described in the code,” Leon-Chisen said during an AHA-sponsored webinar on Chapter 19.

“While the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time,” according to the ICD-10 official coding guidelines for Chapter 19.

Example: The guidelines offer several scenarios for active treatment, including “surgical treatment, [an] emergency department encounter, and evaluation and continuing treatment by the same or a different physician.” But for home health coders, seventh character “A” will see most use with infections and other complications.

Don’t miss: If your agency is providing wound VAC treatment for wound dehiscence, you would also report seventh character “A,” Leon-Chisen said.

Coding example: Your patient has a deep right lower quadrant stab wound of the abdomen extending into the peritoneal cavity. You will be providing wound VAC dressing changes. List S31.613A (Laceration without foreign body of abdominal wall, right lower quadrant with penetration into peritoneal cavity, initial encounter) for this patient, said Leon-Chisen. Wound VAC treatment requires specialized training and is considered active treatment.

Caution: Do not report a Z code for the wound VAC, Selman-Holman says. There are a couple of reasons why this isn’t appropriate coding. First, the wound VAC is considered active treatment, and second, it’s not appropriate to list a Z code for complicated wounds, she says.

Additionally, there is no specific code for a wound VAC, Selman-Holman notes. So, you’ll just continue to report the appropriate code for the wound with seventh character “A” in these cases.

“For complication codes, active treatment refers to treatment described by the code, even though it may be related to an earlier precipitating problem. For example, code T84.50XA, Infection and inflammatory reaction due to unspecified internal joint prosthesis, initial encounter, is used when active treatment is provided for the infection, even though the condition relates to the prosthetic device, implant or graft that was placed at a previous encounter.”

D — Subsequent encounter: You’ll report seventh character “D” when your patient has already received active treatment for the condition and you are providing routine care during the healing or recovery phase. Seventh character “D” will likely be the most common in home health.

Tip: “Think ‘D’ for default,” Selman-Holman says. “I think it helps to think of ‘D’ as aftercare for a resolving or healing condition. So if everything is progressing, then choose D.”

The examples of subsequent encounters listed in the official coding guidelines include cast change or removal, medication adjustment, other aftercare, “And follow up visits following treatment of the injury or condition.”

Coding example: Your patient’s right great toe was cut off when mowing the lawn with his powered lawnmower. The wound is healing well without any current complications. You’d report S98.111D (Complete traumatic amputation of great toe; subsequent encounter) and W28.xxxD (Contact with powered lawnmower) for this patient, says Selman-Holman. There’s no need to list Z89.411 (Acquired absence of right great toe) for this patient because the traumatic amputation code provides this information, she says.

Don’t use the aftercare Z codes when you’re providing aftercare for “conditions such as injuries or poisonings, where 7th characters are provided to identify subsequent care,” the guidelines advise. In these cases, assign the acute injury code with seventh character “D.”

S — Sequela: You’ll use seventh character “S” when your patient has a residual effect that arises as a direct result of an acute condition. For example, skin contractures due to a previous burn.

Key: Use a sequela code when the original injury no longer requires treatment, but there are residuals left after the healing that still require treatment, Selman-Holman says.

Coding example: Your patient has a burn on the back of her hand that hasn’t healed. Another burn on her wrist has healed, but there is a skin contracture present. Your agency will provide skilled nursing for wound care to the burn, and occupational therapy for work on the contracture. List T23.361D (Burn of third degree of back of right hand; subsequent encounter), L90.5 (Scar conditions and fibrosis of skin), and T23.371S (Burn of third degree of right wrist; sequela) for this patient, Selman-Holman says.

Remember, when coding for a sequela, you’ll generally sequence what you see first, followed by the sequela code, Selman-Holman says. In this case, you’ll list the skin contracture first, followed by the code for the burn, with “S” as the seventh character to indicate you’re treating a sequela of the original acute injury.

Note: Download the AHA webinar here: