November 13, 2011

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Understanding ICD-10-CM Episode of Care Seventh-Character Extensions

Written By Laui Gray, RHIT, CPC

To begin, let’s look at similarities and differences between the format and structure of ICD-9-CM and ICD-10-CM.


ICD-9-CM

ICD-10-CM

Three digit categories

Three character categories

Four digit subcategories

Four or five character subcategories

Five digit subclassifications

No subclassifications

Three-, four- or five-digit codes

Three, four, five, six or seven character codes

One significant difference between ICD-9-CM and ICD-10-CM is the need to assign a seventh character (also called a seventh-character extension) to codes in certain ICD-10-CM categories. These seventh characters are found predominantly in two chapters: Chapter 19 (Injury, Poisoning and Certain Other Consequences of External Causes) and Chapter 15 (Pregnancy, Childbirth and the Puerperium). The details captured with these extra characters are not details recorded under ICD-9-CM.


For injuries, poisonings and other external causes, the seventh character provides information about episodes of care; for pregnancy, childbirth and the puerperium, it provides information about the fetus. More specifically, the two types of seventh-character extensions provide information as follows:

  • Episode of care: designates the episode of care as initial, subsequent or a sequela for injuries, poisonings and certain other conditions; in some instances it also provides additional information about the diagnosis.
  • Fetus: used to identify certain complications of pregnancy with multiple gestation to denote which fetus(es) is(are) affected by the condition indicated by the code.

The seventh character typically is required for all codes in these categories, but instructions in each category should be reviewed for any exceptions. The seventh character always occupies the seventh-character data field, even for codes that have fewer than six characters. For codes of three to five characters, the placeholder “X” is used to fill in the empty character fields. In this article the seventh-character extensions that provide information about episode of care are reviewed.

Episode of Care

The episode-of-care seventh characters are used primarily for injuries, poisonings and other consequences of external causes; there are three seventh-character extensions for most of these conditions, with the exception of fractures. These include:

Initial encounter (“A”): initial encounter is defined as the period when a patient is receiving active treatment for an injury, poisoning or other consequences of an external cause. An “A” may be assigned on more than one claim. For example, consider a patient seen in the emergency department (ED) for a head injury that first is evaluated by an ED physician. If the ED physician requests a CT scan that subsequently is read by a radiologist and a neurologist, the seventh character “A” is used by all three physicians and also reported on the ED claim. If the patient required admission to an acute-care hospital, the seventh character would be reported for the entire acute-care hospital stay because “A” is used for the entire period when the patient receives active treatment.

Subsequent encounter (“D”): this is an encounter occurring after the active phase of treatment, when a patient is receiving routine care during a period of healing or recovery. For example, a patient with an ankle sprain may return to the office to have joint stability re-evaluated to ensure that the injury is healing properly. In this case, the seventh character “D” would be assigned.




Sequela (“S”): the seventh-character extension “S” is assigned for complications or conditions arising as a direct result of an injury. An example of a sequela is a scar resulting from a burn.

Episode of Care for Fractures

Assigning episode-of-care seventh characters for fractures is a bit more complicated than assignment for other injuries because the episode of care provides additional information about the fracture – including whether the fracture is open or closed and, during the healing phase, whether healing is routine or occurring with complications such as delays, nonunion or malunion. Just to complicate things a bit more, seventh-character extensions for some open fractures capture the Gustilo open fracture classification.

Gustilo Open Fracture Classification

The Gustilo open fracture classification groups open fractures into three main categories, designated as Type I, Type II and Type III (with Type III injuries being divided further into Type IIIA, Type IIIB and Type IIIC). The categories are defined by three characteristics, which include:

  • Mechanism of injury
  • Extent of soft tissue damage
  • Degree of bone injury or involvement

The specific characteristics for each type are as follows:

Type I

  • Wound less than one centimeter
  • Minimal soft tissue damage
  • Wound bed clean
  • Typically low-energy injury
  • Fracture type typically one of the following:
    • Simple transverse
    • Short oblique
    • Minimally comminuted

Type II

  • Wound greater than one centimeter
  • Moderate soft-tissue damage
  • Minimal or no wound bed contamination
  • Typically low-energy injury
  • Fracture type typically one of the following:
    • Simple transverse
    • Short oblique
    • Minimally comminuted

Type III

  • Wound greater than one centimeter
  • Extensive soft-tissue damage
  • Typically a high-energy injury
  • Highly unstable fractures, often with multiple bone fragments
  • Injury patterns resulting in fractures typically classified to this category include:
    • Open segmental fracture, regardless of wound size
    • Gunshot wounds with bone involvement
    • Open fractures with any type of neurovascular involvement
    • Severely contaminated open fractures
    • Traumatic amputations
    • Open fractures with delayed treatment (more than eight hours)

Type IIIA

  • Adequate soft tissue coverage of open wound
  • No local or distant flap coverage required
  • Fracture open segmental or severely comminuted and still classified as Type IIIA

Type IIIB

  • Extensive soft tissue loss
  • Local or distant flap coverage required
  • Wound bed contamination requiring serial irrigation and debridement to clean open fracture site

Type IIIC

  • Major arterial injury
  • Extensive repair, usually requiring skills of a vascular surgeon, required for limb salvage

Seventh-Character Extensions for Fractures

Examples of seventh-character extensions for fractures with and without Gustilo classifications are described below.

Category S42

Category S42, fracture of shoulder and upper arm, does not require Gustilo classifications, and the seventh-character extensions are as follows:

“A”     Initial encounter for closed fracture

“B”     Initial encounter for open fracture

“D”    Subsequent encounter for fracture with routine healing

“G”    Subsequent encounter for fracture with delayed healing




“K”     Subsequent encounter for fracture with nonunion

“P”     Subsequent encounter for fracture with malunion

“S”     Sequela

Example 1: Emergency-room evaluation (initial) and treatment of closed, non-displaced simple supracondylar fracture of the right humerus without intercondylar involvement

ICD-10-CM code:

S42.414A Non-displaced simple supracondylar fracture without intercondylar fracture of right humerus, initial encounter for closed fracture.

Example 2: Office visit for nonunion of displaced fracture of medial condyle of right humerus

ICD-10-CM code:

S42.461K Displaced fracture of medial condyle of right humerus, subsequent encounter for fracture with nonunion.

Category S52

Category S52, fracture of forearm, does use Gustilo classifications (except for fractures in this category documented as torus or greenstick), and the applicable seventh characters are as follows:

A       Initial encounter for closed fracture

B       Initial encounter for open fracture, type I or II

C       Initial encounter for open fracture, type IIIA, IIIB or IIIC

D       Subsequent encounter for closed fracture with routine healing

E       Subsequent encounter for open fracture, type I or II, with routine healing

F       Subsequent encounter for open fracture, type IIIA, IIIB or IIIC, with routine healing

G       Subsequent encounter for closed fracture with delayed healing

H       Subsequent encounter for open fracture, type I or II, with delayed healing

J        Subsequent encounter for open fracture, type IIIA, IIIB or IIIC, with delayed healing

K       Subsequent encounter for closed fracture with nonunion

M      Subsequent encounter for open fracture, type I or II, with nonunion

N       Subsequent encounter for open fracture, type IIIA, IIIB or IIIC, with nonunion

P       Subsequent encounter for closed fracture with malunion

Q       Subsequent encounter for open fracture, type I or II, with malunion

R       Subsequent encounter for open fracture, type IIIA, IIIB or IIIC, with malunion

S       Sequela

Example: Orthopedic surgical consultation for open displaced segmental left radial and ulnar shaft fractures with good soft tissue coverage




ICD-10-CM codes:

S52.362C Displaced segmental fracture of shaft of radius, left arm, initial encounter for open fracture type IIIA, IIIB or IIIC.

S52.262C Displaced segmental fracture of shaft of ulna, left arm, initial encounter for open fracture type IIIA, IIIB or IIIC.

Note: There are no combination codes for fractures involving both the radius and ulna, so each fracture is coded separately.

It should be noted that there is no seventh character for a “not otherwise specified” or unspecified episode of care. There also is not a “not otherwise specified” designation for open/closed fractures, or for the Gustilo classification when it is required. Guidelines state that if a fracture is not documented as open or closed, it automatically is coded to closed. However, failure to provide sufficient documentation with which to select the appropriate open/closed designation and/or Gustilo classification should be the exception rather than the rule.

Summary

So as you can see, injuries, poisonings and certain other conditions will require additional documentation in order to capture episode of care. This will require physician education as well as coder training, particularly for fractures.

About the Author

Lauri Gray, RHIT, CPC, is the clinical technical editor of coding and reimbursement print and electronic products for Contexo Media. She has worked in the health information management field for 30 years and began her career as a health records supervisor in a multi-specialty clinic. Following that she worked in the managed care industry as a contracting and coding specialist for a major HMO. Lauri has also taught medical coding at the College of Eastern Utah.  She is a member of the American Academy of Professional Coders (AAPC) and the American Health Information Management Association (AHIMA).

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