October 31, 2011

It’s All in a Word (or Words): Documentation Impacts Accurate ICD-10 Coding


Famed writer and socialite Truman Capote once wrote: “To me, the greatest pleasure of writing is not what it’s about, but the music the words make.” In terms of medical record (MR) documentation, however, with a growing nexus of rules and regulations and all of the governmental “do’s and don’ts” of compliance spun tightly around every single documented phrase, “the music the words make” is quite likely to sound like the jarring cacophony of a tree full of magpies.

Perhaps it is more apropos – in relation to MR documentation – to state as one anonymous writer once did, “Be careful of the words you say, keep them short and sweet; you never know from day to day which ones you’ll have to eat!”

Words are important in ICD-10-CM; in fact they are critical to accurate code assignment. Take the word “sequela,” for example. The concept of sequela (or sequelae, plural) – meaning a condition or disease arising from an initial or previous condition, disease or trauma at any time following that initial condition – is coded accurately in ICD-10-CM either by assigning the sequela-inherent diagnosis code or a second code representing the original condition from which the sequela arose. These codes generally involve musculoskeletal diseases (Chapter 13, M00-M99), injuries and poisonings (Chapter 19, S00-T88), or in some instances, diseases of the circulatory system. There are examples of sequelae codes in numerous other chapters as well.

Rarely will the actual term “sequela” appear in MR documentation. Instead a coder might see terminology such as “secondary to,” “as a result of” or “due to” in diagnostic statements (for example, “hypertrophic scar secondary to third-degree burn”). These phrases denote the current condition being diagnosed, further indicating that the sequela is a result of an initial or previous condition, disease or trauma. In this case, the hypertrophic scar is a direct result of the third-degree burn.

Often sequela will be documented and/or coded as a late effect. As a matter of semantics as well as a general nuance in clinical medicine, a late effect typically is seen as a condition developing after an initial condition, disease or trauma has run its course, arising secondary to that condition or indirectly from the treatment of that condition and often occurring much later than the original condition, disease or trauma first appeared.

Often in contrast, a diagnosis termed a “sequela” generally is viewed as a condition (often a complication, and sometimes chronic) arising out of an initial or prior acute condition. The difference is subtle. In fact, sequelae and conditions classified as late effects are interchangeable in ICD-10-CM.  When a coder searches for “late effect” in the ICD-10-CM Index, he or she is redirected to “sequela.” This is a change from ICD-9-CM, for which late effects currently are itemized extensively in the index.

A patient encounter occasioned by the sequela of another condition is represented in many ICD-10-CM codes by the seventh character extension “S.” There are clear ICD-10-CM guidelines for coding these patient encounters. In the ICD-10-CM Official Guidelines for Coding and Reporting (2011), Section C, Chapter-Specific Coding Guidelines, 19.a, the guideline explicitly states:

“Extension ‘S,’ sequela, 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 burn. When using extension ‘S,’ it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The ‘S’ is added to the injury code, not the sequela code. The ‘S’ extension identifies the injury responsible for the sequela. The specific type of sequela (e.g., scar) is sequenced first, followed by the injury code.”

For example, MR documentation stating “cervicalgia secondary to prior stress fracture of C7” is assigned to ICD-10-CM codes and sequenced as such: 1) M54.2 Cervicalgia (for the sequela) and 2) M48.42xS Fatigue fracture of vertebra, cervical region, sequela of fracture (for the original injury/condition, with the “S” extension denoting the patient encounter type).



Providers must be aware that their MR documentation is critical to coders, and coders must be aware of the typical language used by providers. As a general rule, providers will not be adjusting their standard language employed during the documenting of patient care (though the quality and economics of that documentation might be addressed in CDI efforts), but it still is a good idea to make providers aware of the challenges such MR documentation can pose to coders.

Walking a provider through a few coding examples and tracing the steps from MR documentation reading (and frequently deciphering) to the translation of the documentation into ICD-10-CM codes often is an enlightening experience. Obviously, patently two-way communication and a healthy query process are tantamount to success.

Not unlike protocols for ICD-9-CM diagnosis coding, ICD-10-CM protocols arise from and depend on complete, concise and informative MR documentation. However, ICD-10-CM promises to provide more concise and succinct individual codes than ICD-9-CM, and the updated codes are comprised of much more detailed information.  Data reflective of laterality, condensed code information (i.e. combination codes) and patient encounter types are just some examples of how more patient data can be found in ICD-10-CM codes in contrast to most current ICD-9-CM codes. And often, the correct code assignment can hinge on a single word.

About the Author

Michael G. Calahan, PA, MBA, is the director of physician services at KForce Healthcare, Inc. Michael has more than 25 years of experience in health care, beginning as a physician assistant with the USN. He has served as an administrator for several physician practices and has enjoyed a varied career in healthcare consulting, being affiliated with Ingenix, CGI, Navigant, PWC and Parente-Randolph. He has authored numerous industry publications and articles in physician, IP/OP/ASC, DMEPOS, ESRD, HHA, ambulance, HIPAA and in Medicare Parts C & D for Medicare Advantage.

Contact the Author

Read 165 times Updated on September 23, 2013
Michael Calahan, PA, MBA

Michael G. Calahan, PA, MBA, is the vice president of hospital and physician compliance for HealthCare Consulting Solutions (HCS). Michael lives and works in the Washington, D.C. metro area, specializing in compliance, revenue cycle management, CDI, and coding/billing in the facility inpatient/outpatient and physician arenas.