Description for ICD Trauma: “Initial” Isn’t as Simple as It May Seem 

“Initial encounter” does not necessarily mean “initial visit.” A patient may receive active treatment for a condition beyond the initial visit. The ICD-10-CM Chapter 19 Guidelines confirm, “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” [emphasis added]. 

Assuming the provider is providing active care, a seventh character of “A” is appropriate, regardless of how many times the provider saw the patient previously. Examples of active treatment are surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.” 

For example: The patient is evaluated in the emergency room (ER), and they then refer the patient to an oral physician for treatment. Example: patient fall hitting face breaking her nose and fracturing teeth has been looked at by the physician. The treatment completed at hospital is dealing with her nose fracture, bleeding and cuts cleaned with antibiotic cleaners and pain medication for the trauma has been prescribed. She is then referred to her oral physician who administers only emergency treatment for pain and appoints the patient to come back after the swelling and nose is healed, if possible, not to cause more pain.  

When the patient has a visit next day for her oral cavity reduces the fracture the next day, the patient is receiving initial active treatment for this fracture. That is, this is the first encounter at which the patient receives definitive care (the ER was able to apply comfort care only). Per ICD-10 guidelines, you would again report S52.222A for an initial encounter. 

Subsequent Encounter Meaning 

ICD-10-CM defines subsequent encounters 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. Examples of subsequent care are cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following injury treatment.” 

A seventh character “D” is appropriate during the recovery phase, no matter how many times he has seen the provider for this problem, previously. 

Note that ICD-10-CM guidelines do not definitively establish when “active treatment” becomes “routine care.” Active treatment occurs when the provider sees the patient and develops a plan of care. When the patient is following the plan, that is subsequent. If the provider needs to adjust the plan of care—for example, if the patient has a setback or must return to the OR—the care becomes active, again. 

Defining Sequela  

ICD-10-CM says the seventh character S is “for use for complications or conditions that arise as a direct result of an injury, such as scar formation after a burn. The scars are sequelae of the cuts.” In other words, sequela are the late effects of an injury. 

The most common sequela is pain. Many patients receive treatment long after an injury has healed because of pain. Some patients might never have been treated for the injury at all. As time passes, the pain becomes intolerable, and the patient seeks a pain remedy. 

A late effect can occur only after the acute phase of the injury or illness has passed; therefore, you cannot report a code for the acute illness and a code for the late effect at the same encounter, for the same patient.  

When reporting sequela(e), you usually will need to report two codes. The first describes the condition or nature of the sequela(e) and the second describes the sequela(e) or “late effect.” For example, you may report M81.8 Other osteoporosis without current pathological fracture with E64.8 Sequelae of other nutritional deficiencies (calcium deficiency). For example: A patient suffers an injury that heals on its own. The patient isn’t seeking intervention for the initial injury, but for the pain that persists long after. The chronic pain is sequela of the injury. Such a visit may be reported as G89.21 Chronic pain due to trauma and S39.002S Unspecified injury of muscle, fascia and tendon of lower back, sequela.