Physician Practice

Coding Clinic defines ICD-10-CM seventh character

Physician Practice Insider, August 25, 2015

by Sharme Brodie, RN, CCDS

We're months away from the implementation of ICD-10-CM/PCS, and the AHA Coding Clinic for ICD-10-CM/PCS is rolling right along with advice for the new code set.

Seventh character application
Starting off, Coding Clinic (pp. 3-21) devoted a lot of time to explaining the application of ICD-10-CM's seventh character used in:

  • Chapter 15, Pregnancy, Childbirth, and the Puerperium
  • Chapter 19, Injury, Poisoning, and Certain Other Consequences of External Causes
  • Chapter 20, External Causes of Morbidity

Coders and clinical documentation improvement (CDI) specialists need a clear understanding of how to use the seventh character to ensure all the information is present in the chart, so the coding staff can accurately apply the correct character when applicable.

In Chapter 15, the seventh character accounts for certain complications of multiple gestational pregnancies to indicate which fetus is affected by the condition.

In Chapter 19 and Chapter 20, the seventh character provides specific information about the episode of care (e.g., initial episode, subsequent episode, and sequelae).

When used with fracture codes, it provides additional details, such as whether the fracture is closed or open (with type), whether there is routine or delayed healing, and whether the fracture was a nonunion or malunion.

The Cooperating Parties (the four organizations in charge of the code set maintenance, including CMS, AHIMA, AHA, and the National Center for Health Statistics) revised the Official Guidelines for Coding and Reporting to clarify how the seventh character is used.

Most of the categories in Chapter 19 have a seventh character requirement—meaning that, in order for a code to be assigned, it must have a seventh character. Coders typically have three to choose from:

  • A, initial encounter: Used while the patient is receiving active treatment for the condition. Some examples include surgical treatment, ED encounter, and evaluation and continuing treatment by the same or a different physician.
  • D, subsequent encounter: Used after the patient received active treatment for the condition and is receiving routine care during the healing or recovery phase. Examples of subsequent care include cast change or removal, an x-ray to check healing status of a fracture, removal of external or internal fixation device, medication adjustment, and other aftercare and follow-up visits following treatment of the injury or condition.
  • S, sequelae: Used for complications or conditions that arise as a direct result of a condition, such as a scar formation caused by a burn.

Categories for traumatic fractures have more available options for the seventh character. While the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the seventh character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time, according to the Official Guidelines for Coding and Reporting.

Additionally, when deciding the seventh character for complication codes, the Official Guidelines for Coding and Reporting tell us that "active treatment refers to treatment for the condition described by the code, even though it may be related to an earlier precipitating problem."

The example given to help us better understand this guideline involves code T84.50XA (infection and inflammatory reaction due to unspecified internal joint prosthesis, initial encounter).

Coders would report T84.50XA when the physician is actively treating the infection, even though the condition relates to the prosthetic device, implant, or graft that was placed at a previous encounter.

Documenting dominance
New guidelines governing a patient's dominant versus nondominant side in diseases of the nervous system, such as a cerebrovascular accident, tell coders to assign ambidextrous and right-sided patients to dominant and left-sided patients to nondominant if the physician does not specify and there is no default code.

Providers should be educated to include the side of dominance for their patient in their patient assessments and history and physical documentation to avoid default code assignments.

Editor's note: Brodie is a CDI education specialist for HCPro, a division of BLR, in Danvers, Massachusetts. Contact her at Read the entire article in the May issue of CDI Journal.

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