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Charlene Posted Wed 07th of March, 2018 13:06:13 PM
Since ICD-10 we are on the fence as to the correct way to code an acute injury, when the surgical treatment is delayed until much later. Example: Patient slipped and tore rotator cuff, biceps tendon and SLAP in September but delayed surgery until March the following year. Prior to ICD-10 the thought was if the injury was 3 months or older, the condition was now chronic. Does this guideline still hold true or would, for instance, the RT SLAP tear ICD-10 be S43.431A due to active treatment (surgery) or M24.111?
SuperCoder Answered Thu 08th of March, 2018 05:54:43 AM

If it was planned to delay the surgery for the long time and physician already treated the patient, then ICD S43.431A is not to be coded for the current visit because it will not be considered as Initial Encounter, hence use ICD for Subsequent Encounter or Sequela, i.e. S43.431D or S43.431S respectively accordingly to the condition of the patient. On the other hand, if the patient is treated first time with the surgery, then ICD S43.431A is more appropriate than M24.111. Whereas, ICD S43.431A or M24.111 does not suggest for the acute or chronic condition. In medical coding patter, most of the injury codes are not defined as acute or chronic. So, code the direct injury code wherever applicable.

Charlene Posted Tue 13th of March, 2018 11:35:57 AM
I'm still confused. I thought the guideline stated surgical treatment is considered "initial treatment", therefore, A as the 7th digit. One of the many things that make ICD-10 confusing is the term "initial". Another more descriptive wording could have been used.
SuperCoder Answered Wed 14th of March, 2018 04:51:50 AM

The ICD-10-CM definition of initial visit is little complicated than the usual understanding of the word. Specifically, guidelines state that a seventh character A is “used for the initial encounter for the injury or condition while the patient is receiving ACTIVE TREATMENT for the injury. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment. so, as described earlier, you will be coding ICD S43.431A to support surgery procedure code instead of M24.111 in described situation.


For example: The patient is evaluated for injury that cannot be managed at this time. The physician applies immobilization and ice and instructs the patient to follow up with orthopedics. This would be reported using Initial Encounter for injury.

When the orthopedist rechecks and treat the patient, the patient is receiving initial active treatment for this injury. This is the first encounter at which the patient receives definitive care (initial treatment was comfort care only). Per ICD-10 guidelines, you would again report for an initial encounter.

To clarify, let's take another example: The patient has a greenstick fracture, which is definitively managed with a cast or splint. You would report this with greenstick fracture, initial encounter for closed fracture. Later, the same orthopedist who provided care in the beginning, rechecks the injury in the office. This is a subsequent encounter because the provider cared for the same condition, previously.


Subsequent Encounter is little simple, as encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase.

For examples: cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following injury treatment.


Whereas, Sequela Encounter is for use for complications that arise as a direct result of an injury, such as scar formation after a burn. The scars are sequelae of the burn, as the the late effects of an injury.


Perhaps the most common sequela is pain. Many patients receive treatment long after an injury has healed as a result of pain. These kinds of visits may be reported as G89.21 chronic pain due to trauma and sequela encounter code of the injury.


Hope this clears your doubts!

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