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The Importance of the 7th Character in ICD-10-CM

By:  Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Published:  July 27th, 2017

There is still confusion on the use of the seventh character. Let's clarify a few common areas.

  • The 7th character represents the physicians encounter, but not the number of visits.
  • Reporting the phase of treatment the patient is seeing the provider for, but not the number of injuries or number of visits.

The most common seventh character extension is used to capture information about the phase of treatment.

A- Initial Encounter: Active treatment or initial encounter for an injury, poisoning, or other consequences of and external cause.  The initial encounter can occur more than once and can be used any time during active treatment of the same encounter.  For example; if the practitioner sends the patient to the Emergency room, then is seen by a radiologist, all three treating providers would code the injury with "A" Initial Encounter.  

DSubsequent Encounter: Used during the healing phase after the active phase; this may be seen to ensure the patient is healing correctly. 

S- Sequela: Complications or conditions as a direct result of a previous injury; for exapmle, a scar from a burn. 

Category S42 requires more specifics on the state of the fracture (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

When coding extremities, fractures are based on Gustilo open fracture classifications. For example, this would apply when reporting codes for fractures in Category S52 (Fracture of the forearm), S72 (Fracture of Femur) and S82 (Fracture of Lower Leg). 

The following extensions are to be used to ensure a complete code:

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

To provide additional specificity, the fracture extensions require the following seventh character. Coding the encounter and the phase of treatment are combined in this group of characters used for fractures: 

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

Using the "X" place holder

Each chapter may have different requirements or may not have a seventh character at all, however; if there is a seventh character required, the code is considered invalid or incomplete if there are not seven characters in the code.  

If a code requires the reporting of a seventh character and there is no fifth or sixth character option, the use of the "X" placeholder may be required.  For example, when using the following code, there are no options for the fifth or sixth character:

S02.2XXK Fracture of nasal bones, subsequent encounter for fracture with nonunion

The next code has a fifth character but not a sixth, therefore the "X" place holder should be used. 

S02.30XG Fracture of orbital floor, unspecified side, subsequent encounter for fracture with delayed healing


References:

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