ICD-10-CM diagnosis codes are composed of codes with 3, 4, 5, 6 or 7 characters. A three-character code is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable. The 7th character meaning or value will depend on the chapter it is being used in.
- Chapter 13: Diseases of the Musculoskeletal System – Encounter (Coding pathological fractures)
- Chapter 15: Pregnancy, Childbirth and the Puerperium – Fetus identification
- Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified – Comma scale
- Chapter 19: Injury, Poisoning, and Certain Other Consequences of External Causes – Encounter
- Chapter 20: External Causes of Morbidity – Encounter
- Chapter 21: Factors influencing Health Status and Contact with Health Services – Encounter
The “Encounter” is the most common value of the 7th character. The most common “encounter” values are designated as “A” initial encounter, “D” subsequent encounter, and “S” sequela; however, it is important to reference the tabular index for appropriate characters for each category (i.e., categories for traumatic fractures have additional 7th character values).
To understand the definition of these encounter designations additional instruction was added to the current ICD-10-CM coding guidelines, “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.”1
“7th 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 continuing treatment by the same or a different physician.”2
“7th 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.”3
“7th character “S,” sequela, is for use for complications or conditions that arise as a direct result of a condition, such as scar formation after a burn. The scars are sequelae of the burn. When using 7th character “S,” it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The “S” is added only to the injury code, not the sequela code. The 7th character “S” identifies the injury responsible for the sequela. The specific type of sequela (e.g., scar) is sequenced first, followed by the injury code.”4
In summary, “A,” initial encounter, is reported when the patient is receiving active treatment of the condition. “D,” subsequent encounter, is reported after the active treatment is completed and the patient is receiving routine care during the healing or recovery phase (i.e., routine follow-up or aftercare). “S,” sequela, is used for complications or conditions that arise as a direct result of a condition.
Keeping these basics in mind will assist when confronted with expanded 7th character values, as indicated in the following examples.
To provide additional specificity, the fracture extensions for Category S42 (Fracture of shoulder and upper arm):
- A: Initial encounter for closed fracture
- B: Initial encounter for open fracture
- D: Subsequent encounter for fracture with routine healing
- G: Subsequent encounter for fracture with delayed healing
- K: Subsequent encounter for fracture with nonunion
- P: Subsequent encounter for fracture with malunion
- S: Sequela
The extensions available for Category S52 (Fracture of the forearm), S72 (Fracture of Femur) and S82 (Fracture of Lower Leg) are based on the Gustilo open fracture classification for extremities:
- B: Initial encounter for open fracture type I or II
- C: Initial encounter for open fracture type IIIA, IIIB, or IIIC
- 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
- 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
- M: Subsequent encounter for open fracture type I or II with nonunion
- N: Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion
- Q: Subsequent encounter for open fracture type I or II with malunion
- R: Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion
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