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Here are answers to your musculoskeletal ICD-10 coding questions

The following questions were answered by Ruby O’Brochta Woodward, BSN, CPC, CPMA, COSC, CSFAC, during the Nov. 10 webinar, Get answers to your ICD-10-CM musculoskeletal coding questions to boost productivity, reduce denials.

Seventh character coding for injury

Question: We saw a patient last week for injury to right knee and added a seventh character “A” for initial encounter and ordered an MRI. The patient returned this week and the diagnosis is an ACL tear based on the MRI. We now have a definitive diagnosis of S83.511-. Would we code this diagnosis with seventh character of “A” or “D”?

Answer: Until a treatment plan has been created and active treatment — such as surgery — completed, visits would be reported with seventh character “A.” Once the patient enters the healing stage, follow-up visits would be coded with “D.”

Sequela following injury

Question: Can you give some examples for sequela posting using ICD-10 codes?

Answer: Here are two examples. Notice that in each case, the problem being addressed is listed first, followed by the fracture code with seventh character “S”:

Example 1: Post-traumatic degenerative joint disorder resulting from a displaced pilon fracture of left ankle:
  • M19.172 (Post-traumatic osteoarthritis, left ankle and foot) and
  • S92.872S (Displaced pilon fracture).
Example 2: Contracture of the proximal interphalangeal joint of the right index finger due to an open intra-articular fracture of the middle phalanx with laceration of the profundus tendon:
  • M24.541 (Contracture, right hand) for the PIP contracture with
  • S62.620S (Displaced fracture of medial phalanx of right index finger) and
  • S66.120S (Laceration of flexor muscle, fascia and tendon of right index finger at wrist and hand level) for the original profundus tendon injury.

  • Determine when a seventh character is needed

    Question: Doctor has treated the patient for three months. The patient is now scheduled for surgery. Do you code the seventh character as initial or subsequent?

    Answer: First, we need to know whether the presenting problem is a fracture or other injury or a complication. In other words, verify that a seventh character is required. Remember, you would include a seventh character only with an injury code from Chapter 19 (S and T codes) and with pathologic, stress or osteoporotic fracture codes in Chapter 13 (M codes).

    If the patient’s condition does require a seventh character, you may need to include a character for subsequent encounter for a complication (e.g., non-union, malunion or delayed healing), depending on the requirements of the specific code category.

    Alternately, if the patient’s condition is chronic, such as degenerative joint disease, and the surgeon is scheduling the patient for a major joint replacement, no seventh character would be reported.

    Seventh character for surgery

    Question: A consultant told us that each time a patient goes to surgery, the seventh character is coded as “A,” initial encounter. That makes sense to me because the surgery is active treatment, but I was wondering if you had any other insight.

    Answer: It’s not quite that simple. Seventh character reporting applies only for codes in Chapter 19 and the nontraumatic fracture codes in Chapter 13 (see answer above for more details).

    In addition, seventh character “A” could apply for other encounters. The ICD-10-CM Official Guidelines state: “Seventh character ‘A,’ initial encounter, is used while the patient is receiving active treatment for the condition. Examples of active treatment are: surgical treatment, emergency department encounter and evaluation and treatment by the same or a different physician” (C.19.a).

    There may also be times when the patient is returned to surgery to address a fracture complication, such as a malunion, non-union or a delayed healing. In those cases, you’d report the relevant subsequent encounter seventh character.

    Here’s when to report ‘D’ for subsequent encounter

    Question: Patient had rotator cuff repair surgery on 10/15/2015 (we used ICD-10 code S46.011A) and returns to the office on 11/02/2015 for a follow-up visit. Is the visit on 11/02/2015 considered an initial or subsequent encounter? Should the follow up visit on 11/02/2015 be coded S46.011A or S46.011D?

    Answer: The follow-up visit would be coded as S46.011D because it would fall under the ICD-10 definition of a subsequent encounter:
    “Seventh character ‘D’ subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Examples of subsequent care are: cast change or removal, an X-ray to check healing status of fracture, removal of external or internal fixation device, medication adjustment, other aftercare and follow-up visits following treatment of the injury or condition” (ICD-10-CM Official Guidelines, C. 19, a.).

    Selecting seventh characters for open fractures

    Question: When there is an open fracture, we use a seventh character “B” for initial encounter, but when we code “D” for subsequent visit, the description states closed fracture. So many different circumstances, so hard to figure out correct coding. With ICD-9, we used the acute code and the V codes for each visit after.

    Answer: Different fracture S-code categories require different sets of seventh characters, so you must make sure you are referring to the correct seventh character list when coding a subsequent encounter. For example, category S42 (Fracture of shoulder and upper arm) instructs you to report seventh character “B” for initial encounter for open fracture, but for your subsequent encounter, you’ll be reporting based on whether healing is routine (“D”), delayed (“G”), non-union (“K”) or malunion (“P”).

    However, some fracture categories require you to select a seventh character based on the Gustilo open fracture classification. For these, you have a much longer list of initial and subsequent encounter seventh characters. For example, Category S82 (Fracture of lower leg, including ankle) requires you to select from this list for the initial encounter:
    • A – Initial encounter for closed fracture,
    • B – Initial encounter for open fracture type I or II/ initial encounter for open fracture NOS and
    • C – Initial encounter for open fracture type IIIA, IIIB or IIIC.
    And this list for the subsequent encounter:
    • D – Subsequent encounter for closed fracture with routine healing,
    • E – Subsequent encounter for open fracture type I or II with routine healing,
    • F – Subsequent encounter for open fracture type IIIA, IIIB or IIIC with routine healing,
    • G – Subsequent encounter for closed fracture with delayed healing
    • H – Subsequent encounter for open fracture type I or II with delayed healing
    • J – Subsequent encounter for open fracture type IIIA, IIIB or IIIC with delayed healing,
    • K – Subsequent encounter for closed fracture with non-union
    • M – Subsequent encounter for open fracture type I or II with non-union
    • N – Subsequent encounter for open fracture type IIIA, IIIB or IIIC with non-union,
    • P – Subsequent encounter for closed fracture with malunion,
    • Q – Subsequent encounter for open fracture type I or II with malunion or
    • R – Subsequent encounter for open fracture type IIIA, IIIB or IIIC with malunion.

    As you can see, for open fractures in Category S82, you must select the subsequent encounter seventh character based on two factors:
    1. The Gustilo open fracture type for the original code and
    2. The surgeon’s documentation of how the fracture is healing. For example, if you have an open fracture that you coded to initial character “B” (open fracture type I or II/ initial encounter for open fracture NOS) and the orthopedist documents routine healing, you’d code the subsequent encounter as “E” (Subsequent encounter for open fracture type I or II with routine healing).

    However, if the surgeon states that that same patient has a non-union, you’d add seventh character “M” (Subsequent encounter for open fracture type I or II with nonunion).

    Tip: If you use ICD-10 coding software, make sure it is displaying the correct seventh character options for the category you are coding. Share these Gustilo open fracture classification sites with your surgeons: www.orthopaedicsone.com/display/Main/Gustilo+open+fracture+classification and www.orthobullets.com/trauma/1003/gustilo-classification.