Q. Will you please help me understand initial visit, subsequent visit, and sequelae related to fracture care? If the patient is treated elsewhere for a fracture and the provider just stabilizes the fracture and instructs the patient to then come to my office for reduction, is this a subsequent visit or an initial visit?
A. International Classification of Diseases 10th Revision, ClinicalModification (ICD-10-CM) 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 (ED) encounter
- Evaluation and treatment by a new physician
Evaluation and treatment by a new physician is sometimes misunderstood by health-care providers and coders alike. You must determine whether the patient has previously received active treatment for this condition in any setting or by any provider.
For example, the patient is evaluated in an ED for a closed fracture of the distal phalanx of the right index finger. The ED provides comfort care by icing and immobilizing the finger, and then instructs the patient to follow up with an urgent care center in the morning. The ED’s billing department reports ICD-10-CM code S62.630A because this is the patient’s initial visit.
When the urgent care center rechecks the patient and reduces the fracture the next day, the patient is receiving initial active treatment for this fracture. The Current Procedural Terminology (CPT) code to bill is 26755, “closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each.” Per the ICD-10-CM guidelines, you would again report ICD-10- CM code S62.630A because this is the first time the patient is receiving active treatment from the urgent care center.
Subsequent care is defined in the ICD-10-CM guidelines 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,” and it is assigned using the injury code with the seventh character D, “subsequent encounter for fracture with routine healing.” Examples of subsequent care are:
- Cast change or removal
- Removal of external or internal fixation device
- Medication adjustment
- Other aftercare
- Follow-up visits after injury treatment
In the example of the patient with the phalanx fracture, if the fracture is healing as it should at the subsequent visit to the urgent care center, the center’s office would report S62.630D, “displaced fracture of distal phalanx of right index finger, subsequent encounter with routine healing.” CPT code 99024, “postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for . . . reason(s) related to the original procedure,” could also be included on the claim at no cost to represent the evaluation and management (E/M) portion of the visit.
Sequelae are the late effects of an injury and thus are assigned using the injury code with the seventh character S, “for use for complications or conditions that arise as a direct result of an injury, such as a scar formation after a burn. The scars are sequelae of the burn,” according to ICD-10-CM guidelines.
DAVID STERN, MD (Practice Velocity)