EDITOR’S NOTE: The following is the final installment of a two-part series dealing with early signs of challenges facing physicians in their adoption of ICD-10.

Many physicians are confused as to when to report the seventh-character extension. Physicians are confusing CPT® guidelines with ICD-10 guidelines. CPT and ICD-10 are two different code sets. We report a CPT code to identify the service or procedure performed and the ICD-10-CM code to report all diagnoses affecting the patient encounter to support medical necessity.


So, when does the physician report a seventh-character extension? The most common seventh characters are “A,” “D,” and “S.” The seventh character is required to report accidents, injuries, and fracture care, as well as poisonings. Many physicians now are beginning to understand that not all categories will require a seventh character. But for those diagnoses that do, when do you report initial encounter versus subsequent encounters?

Report the seventh character for the initial encounter for active treatment, which may or may not include the first visit. The subsequent seventhcharacter is reported for the healing phase or follow-up phase of treatment. The ICD-10 Official Guidelines for Coding and Reporting states: 

“The seventh character ‘A,’ initial encounter, is used while the patient is receiving active treatment for the condition. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician.

The seventh character ‘D,’ subsequent encounter, is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Examples of subsequent care are: cast change or removal, an X-ray to check healing status of fracture, removal of external or internal fixation device, medication adjustment, other aftercare, and follow up visits following treatment of the injury

The seventh character ‘S,’ sequela, is used when there is a residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used.

The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Examples of sequela include: scar formation resulting from a burn, deviated septum due to a nasal fracture, and infertility due to tubal occlusion from old tuberculosis.Coding of sequela generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is sequenced second.

An exception to the above guidelines are those instances where the code for the sequela is followed by a manifestation code identified in the tabular list and title, or the sequela code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect or condition.”

I think that when physicians and coders use the ICD-10 codes on a daily basis, it will eventually become easier.

The goal during this transition period is to stay calm, and to keep a keen eye on coding, documentation, and revenue. If you don’t have a clinical documentation improvement (CDI) process in place, incorporate CDI into your organization quickly. Stay alert and resolve all issues as they arise immediately.

Remember that we are all in this together: hospitals, physicians, healthcare facilities, payers, vendors, and others. The next few months may be challenging, but with diligence and focus, we all will be up to the challenge.


Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner

Deborah Grider has 34 years of industry experience and is a recognized national speaker, consultant, and American Medical Association (AMA) author who has been working with ICD-10 since 1990. She is the author of “Preparing for ICD-10, Making the Transition Manageable,” “Principles of ICD-10,” and the ICD-10 Workbook, among many other publications written for the AMA. She has assisted hospital systems and physician practices in transitioning and understanding ICD-10 for many years. She is a senior healthcare consultant with Karen Zupko & Associates and a clinical documentation improvement practitioner helping physicians improve clinical documentation among all specialties.

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