What does subsequent encounter for fracture mean?

From the time ICD 10 codes have been implemented, coders are facing lot of issues with new diagnosis codes. Injury codes in ICD 10 are still creating problems for coders. For non-traumatic or pathological fractures, we have discussed previously. But for traumatic fracture coding, medical coders are still having lot of confusion. The initial, subsequent and sequela encounters of injuries codes have made coding little complicated. But, today I will try to clear your doubt in this article about coding fractures and the different types of fractures used in medical coding.

Traumatic fractures are coded using the appropriate 7th character for initial encounter (A, B, C) for each encounter where the patient is receiving active treatment for the fracture. The appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion.

But, when should be the subsequent encounters be coded in injury coding. When the patient has completed active treatment of the fracture and is receiving routine care during the healing or recovery phase, subsequent encounters are coded using the appropriate 7th character for subsequent care of fractures. Also the care for complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication codes. Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7th character for subsequent care with nonunion (K, M, N) or subsequent care with malunion (P, Q, R).

Read also: Difference between Excludes I and Excludes 2 in ICD 10 

Difference between a Closed and Open Fracture

Medical coders are mostly confused with coding closed and open fracture or the fracture is traumatic or pathological. So, always remember a fracture not indicated as open or closed should be coded to “closed.” If you are not aware of Open and closed fracture definition, just read the below description.

Closed or simple fracture—In this type of fracture, the bone is broken, but the skin is not lacerated.

Open or compound fracture— In open fracture, the skin may be pierced by the bone or by a blow that breaks the skin at the time of the fracture. The bone may or may not be visible in the wound.

The step of the coder is to find out whether the fracture is displaced or nondisplaced along with the site of fracture. A fracture not indicated as “displaced” or “not displaced” should be coded to displaced. Also, do remember for fracture in upper or lower extremity should be coded with specific laterality (RT, LT, Bilateral) in ICD 10 coding. There are many different types of fracture you may come across while coding injury reports. Below is a list of common types of fracture in detail found in ICD 10 CM coding.

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Burst: Compression of vertebral body due to a fracture

Comminuted: Fracture has broken bones into several small pieces

Depressed: Fracture is a piece of bone that is depressed, more common in the skull

Elevated: Fracture is a piece of bone that is elevated, more common in the skull

Fissure: Incomplete fracture of the outer portion of a bone that is nondisplaced

Greenstick: Incomplete fracture with bending of the bone, more common in children

Impacted: The ends of the fractured bone are pushed into each other

Linear: Fracture that runs parallel along the length of the bone

Missile: Open fracture caused by an outside force with a projectile

Puncture: Open fracture that perforates the skin

Salter-Harris (I-IV): Fractures through the growth plate of a bone in children

Spiral: Fracture due to a twisting force that results in a spiral break along the bone

Torus: Similar to a greenstick fracture with buckling on one side of the break

Wedge : Compression fracture that occurs in the lateral or anterior part of the thoracic spine

Read also: Coding tips for Heart failure ICD 10 Codes

Complications during Healing phase of Fracture

Once the fracture is under the treatment phase or healing phase, there may be few complications with fracture. There are three common complication which you can see during the healing phase of fracture, delayed union, Nonunion and Malunion. Below is the exact definition of these complications.

Delayed union—a delay in normal fracture healing; not necessarily a pathological process

Nonunion—failure of healing of a fracture or osteotomy; with continued motion through a nonunion, a pseudarthrosis will form

Malunion—healing of a fracture in an unacceptable position

In ICD 9, we have straight codes for injuries or external cause of injuries. However, ICD 10 has different set of codes for injuries. Here the injuries are divided into initial, subsequent and sequela encounter with the physician. Hence, the codes are very specific for the treatment of the injuries. Now in injuries we do not have to code for aftercare codes when the fracture is into healing phase, you just need to select the appropriate ‘7th’ character to coding the condition. This is one of the reason we have so many ICD 10 codes. Therefore, injuries in ICD 10 are very different compared to ICD 9. In ICD 10 the seventh character will give the information about the initial, subsequent or sequel encounter for injuries. The seventh character used for the injuries are

A – Initial Encounter

D- Subsequent Encounter

S – Sequela  

Read also: Difference between Excludes 1 and Excludes 2 in ICD 10

The seventh character ‘A‘ is used when an “active treatment is given to patient for the injury in the initial encounter”. Example for active treatment can be a surgical treatment, emergency treatment and evaluation and management by a new physician. The word “active” treatment should be understood very clearly before assigned initial encounter for the injuries.

For example, if the patient is treated for a fracture by an ER physician and again reduced by an orthopedician next day, both are considered as an active treatment and the injuries will be coded as initial encounter by the seventh character ‘A‘ only. Here both ER physician and Orthopedician worked on the same diagnosis and provided active treatment.

Now, in same scenario if the patient comes with a ER physician with fracture and the fracture is treated with placing a splint and then the patient goes for a follow-up visit with the orthopedician for the same diagnosis, where the orthopedician only recheck the fracture without giving any active treatment. In such case, the second encounter with orthopedician is a subsequent encounter with seventh character D for the injury.

Read also: When to use Z codes in ICD 10

When to code Subsequent Encounter

There are many cases where the patient revisits to his physician. The few examples are for refilling his medicine, for rechecking his healing fracture or follow-up visit for treatment of any injury. Most of the case includes the removal or change of cast and removal of external or internal fixation device. Hence, the cases for subsequent encounter are assigned with the seventh character ‘D‘ for the injury codes.

Subsequent encounter codes are used to avoid using multiple codes. Earlier, in ICD we used to use mutliple codes for coding Status post fracture, for frature screw fixation, for routine healing ( callus formation) exams. V codes like V54.09, V54.89 or V54.01 are used as primary primary codes in ICD 9 followed by fracture code.

But, in ICD 10 we have to code only one diagnosis for these scenarios by just changing the 7th character as “D“.

If the fracture is under routine healing, we can directly use ” D” as 7th character.

You can differentiate between the use A and D by the use of active treatment or not.

Read also: New coding Guidelines for Z3A category for diagnosis coding

When the patient go to different physicians for same diagnosis

If the patient has a fracture and goes to a physician, it is a first and active treatment (A).  And when the patient again after few days goes to another physician for same diagnosis, then also it is considered as active treatment by the physician. Since. Patient encounter was first or initial for each physician, the reported diagnosis will be coded as initial encounter (A)

When the patient visits the same physician for same diagnosis treatment.

Here, the patient goes to the same physician for initial or subsequent encounter. In such case, the first or intial encounter will be coded as active treatment. All the subsequent encounters, will be reported as “D” as 7th character.

In short, all aftercare or follow-up visit to check the status  of injuries will be coded as subsequent encounter for same physician.

Read also: Difference between Followup and Aftercare Z Codes

When to code Sequela

Seventh character ‘S’ is used for coding “complication or condition that arise for the direct result of the injury such as scar formation after a burn”. The scars are sequela of the burn. Sequelas are late effects of an injury. For example, when the patient has an injury and does not seek any intervention for the initial injury, but the pain persists for long time. This chronic pain is a late effect for the untreated injury of the past. Such chronic pain due to injury are coded for the patient visit to the physician followed by the injury code with seventh character ‘S’ denoting sequel or late effect.