October 9, 2012

ICD-10-CM Seventh-Character Coding May Require Internal Policies and Procedures

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A seventh character has been added to some chapters of ICD-10-CM. The meanings of the seventh character vary across chapters and categories, though. The language of each applicable ICD-10-CM category will identify the necessity to use a seventh character. The applicable seventh character is required for all codes within certain categories, or as the notes in the tabular lists instruct. A code that has an applicable seventh character is considered invalid without the seventh character. Such characters also always must be the seventh characters in the data field, and if the code is not of sufficient length, a placeholder of “x” is required to fill empty characters.

 

Below is an excerpt from the 2012 ICD-10-CM Tabular List, in which a seventh character is required for all codes within category S06. For example, S06.0X0 is invalid without a seventh character of A, D, or S (i.e., S06.0X0A, S06.0X0D, and S06.0x0S are valid codes).

S06   Intracranial injury

Includes: Traumatic brain injury

Code also Any associated:

open wound of head (S01.-)

skull fracture (S02.-)

Excludes: Head injury NOS (S09.90)

The appropriate seventh character is to be added to each code from category S06

A - Initial encounter

D - Subsequent encounter

S - Sequela

S06.0  Concussion

Commotio cerebri

Excludes: Concussion with other intracranial injuries classified in category S06 (code to

specified intracranial injury)

S06.0X    Concussion

S06.0X0     Concussion without loss of consciousness

S06.0X1     Concussion with loss of consciousness of 30 minutes or less

S06.0X2     Concussion with loss of consciousness of 31 minutes to 59 minutes

S06.0X3     Concussion with loss of consciousness of 1 hour to 5 hours 59 minutes

S06.0X4     Concussion with loss of consciousness of 6 hours to 24 hours

S06.0X5     Concussion with loss of consciousness greater than 24 hours with return to

preexisting conscious level

S06.0X6     Concussion with loss of consciousness greater than 24 hours without return to

preexisting conscious level with patient surviving

S06.0X7      Concussion with loss of consciousness of any duration with death due to brain

injury prior to regaining consciousness

S06.0X8      Concussion with loss of consciousness of any duration with death due to other

cause prior to regaining consciousness

S06.0X9      Concussion with loss of consciousness of unspecified duration

Concussion NOS

There are numerous seventh-character coding requirements in ICD-10-CM Chapter 19 (Injury, poisoning and certain other consequences of external causes S00-T88). The good news is that the first healthcare facility where a patient receives care for an injury or poisoning is likely to have the most comprehensive documentation needed for coding. For example:

First Visit for Concussion: In the USA Medical Center emergency room (ER) record, the ER physician documents that a “22-year-old intoxicated man was admitted to the ER with a concussion,” and that “his friends report that he was unconscious for two minutes.”

 


 

First Visit ICD-10-CM Concussion Code: The hospital’s coding specialist now has sufficient documentation to code the concussion as S06.0X1A (concussion with loss of consciousness of 30 minutes or less, initial encounter).

Assigning specific injury and poisoning codes for which seventh characters are required may be problematic, however, when the patient is seen for subsequent additional care (such as for aftercare or complications). For example:

Second Visit for Concussion: Three days after suffering the concussion, the 22-year-old man goes to University Hospital’s Walk-In Medical Clinic because he needs a follow-up visit and a doctor’s note before he can return to his job. Due to his intoxication at the time of the concussion, the man tells the clinic doctor that he can’t remember the duration of his unconsciousness. The clinic doctor simply documents “follow-up visit for concussion with loss of consciousness.” University Hospital’s coding specialist has no other documentation about the concussion, so she queries the clinic physician, who tells her that he has no other information about the patient’s concussion (and that the patient initially was seen in another hospital’s ER after his injury).

Second Visit ICD-10-CM Concussion Code: The coding specialist assigns code S06.0X9D (concussion with loss of consciousness of unspecified duration, subsequent encounter).

This scenario will not be uncommon when a coding specialist is coding a case for a patient whose original injury or poisoning initially was treated in another facility. For that matter, the reporting of seventh-character codes itself can be time-consuming even if the patient initially was seen in the same facility, because the coding specialist may need to locate and access the previous medical record for the initial injury or poisoning.

In the absence of a regional electronic health information exchange (HIE) that includes all healthcare providers and patients, this issue clearly will require coding managers to develop policies and procedures for the seventh-character coding of injuries and poisonings.

A sample policy and procedure is provided below – however, this should not be implemented in any facility without proper approval by authorized staff (i.e. a coding director or coding manager).

POLICY: Seventh-Character Coding when Unspecific Documentation is Provided

 

EFFECTIVE DATE: 10/1/14

PROCEDURE:

 

When a seventh character is required for ICD-10-CM coding and an unspecified code is the tentative code assignment because the level of detail needed for a specific code is not provided, please follow the procedures below.

 

I.     If the patient’s first visit for the injury or poisoning occurred at another facility:

  • Query the attending physician for the specific clinical information needed.
  • If the attending physician doesn’t have the specific clinical information, use the Health Information Exchange (HIE) platform if the patient’s original provider is documented in the chart and is also a member of the HIE (NOTE: there may be a separate policy and procedure for coding using the HIE platform).
  • Use the unspecified ICD-10-CM code with the appropriate seventh character if the query and HIE do not provide the level of detail needed for a more specific code assignment.

II.    If the patient’s first visit for the injury or poisoning occurred at this facility:

 

  • Search the previous electronic health records (EHRs) for this patient and locate the visit for the first episode of care associated with this injury or poisoning.
  • In the previous EHR, locate the specific document or form that provides the specificity needed to code the current visit for this patient (i.e. the history and physical, radiology report, etc.).
  • Copy and paste the specific document or form into the current EHR for this patient. This information is needed to support the coding for the current visit.
  • Assign the specific ICD-10-CM code with the appropriate seventh character.

Please understand that this is just one example of a policy to address this issue – the key is to address it now so you’ll be ready and compliant on Oct. 1, 2014.

 

Read 31 times Updated on March 16, 2016
Lolita M. Jones, RHIA, CCS

Lolita M. Jones, RHIA, CCS, is the principal of Lolita M. Jones Consulting Services (LMJCS), founded in October 1998 in Fort Washington, MD. Ms. Jones has over 25 years of experience in coding and consulting. She started preparing for the implementation of ICD-10-CM/PCS by going back to school. On September 12, 2010, Ms. Jones became an AHIMA-approved ICD-10-CM/PCS trainer.