Health Information Management

A is for active treatment

HIM-HIPAA Insider, September 22, 2014

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CMS hosted an ICD-10 “Code-a-thon” Monday (a title which instantly brings to mind all of the PBS pledge drives I’ve unwittingly watched). One of the questions that has come up repeatedly is when to use A as the seventh character in an ICD-10-CM code.

I think part of the confusion comes from the quick definition of A: initial encounter. You will use seventh character A for more than the first time the patient sees a physician for treatment of an injury.
 
According to the ICD-10-CM Official Guidelines for Coding and Reporting, coders should use seventh character A when the patient is receiving active treatment, including:
  • Surgical treatment
  • ED encounter
  • Evaluation and treatment by a new physician
James comes into the ED after breaking his arm. Dr. Bones evaluates James and diagnoses a nondisplaced fracture of the neck of the right radius. Dr. Bones stabilizes the injury and sends James home with instructions to see an orthopedist.
 
ED coders would report S52.134A (A for the initial encounter).
 
The following day, James sees Dr. Stetter, an orthopedist. Dr. Setter determines that James does not require surgery on his arm and instead immobilizes it in a cast. Dr. Setter’s coder will report S52.134A, exactly the same code that the ED coder reported.
 
Instead of thinking A for initial encounter, think of it as A for active treatment. If the patient is being actively treated and is not in the healing phase, use seventh character A.
 
This article originally appeared on HCPro’s ICD-10 Trainer blog.



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