Update to explanation for initial versus a subsequent encounter

This is an update and correction concerning the explanation for initial versus the subsequent office visit encounter (follow-up) for any injury.

In both the live and recorded course I used the new patient and existing patient guidelines to determine whether the visit was initial (XA) or subsequent (XD). While there are some grey areas in the official explanation I am revising my opinion on this matter based on additional information and feedback. The bold and italics below are mine.

This is per the AHA ICD-10 Coding Guidelines Manual Nov 2014 (Chapter 19: pgs 66-67) (full document link at the end of this article):

7th 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 treatment by a new physician.

It could be argued whether the list above means “and” or “or.” Is the new physician a requirement or does the active treatment by any new physician determine it’s initial?

7th 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, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition.

The aftercare Z codes should not be used for aftercare for conditions such as injuries or poisonings, where 7th characters are provided to identify subsequent care. For example, for aftercare of an injury, assign the acute injury code with the 7th character “D” (subsequent encounter).

Additional Notes are from the article below:

Per Guest Contributor, Debra Mitchell, MSPH, CPC-H, In Coding Edge April 1, 2014,  “Take the patient’s perspective when appending the seventh character in ICD-10-CM.”

The statement “evaluation and treatment by a new physician” can be a source of confusion, but you will code correctly if you are able to answer the basic question, “Has the patient previously received active treatment for this condition in any setting or by any provider?”

Per this article, her take is that if the patient saw another doctor in Florida or in the ER for a foreign body in their eye and are now seeing you as a follow-up , then it would be coded as subsequent, not initial based on new versus established patient guidelines.  This is different from my 2014/2015 ICD-10 classes and the recorded training. Based on this new information, I am revising my opinion on this pending any confirmation by Medicare or other official sources (AHA, AHIMA).

I was not able to get any additional confirmation or determine if other information was used to determine this interpretation.

However, per the article, if the patient did not receive active treatment (e.g., remove the foreign body) then this encounter would be the initial, not subsequent. So there is some grey area here. The key is to be consistent in your interpretation among doctors and staff.

The rest of the article explains active treatment:

For example: The patient is evaluated in the emergency room (ER) for a displaced transverse fracture of the left ulna that cannot be managed at this time. The ER applies immobilization and ice and instructs the patient to follow up with orthopedics in the morning. This would be reported using S52.222A Displaced transverse fracture of the left ulna, initial encounter for closed fracture.

When the orthopedist rechecks the patient and reduces the fracture the next day, the patient is receiving initial active treatment for this fracture. That is, this is the first encounter at which the patient receives definitive care (the ER was able to apply comfort care only). Per ICD-10 guidelines, you would again report S52.222A for an initial encounter.

Usage of XA or XD hinges on interpretations of “active treatment” and “definitive” care. If the ER doctor removed two FB from the patient’s eye  but on the subsequent visit to the OD, another FB particle is found and removed, is that an initial or subsequent visit? Based on the interpretation above, I would now code it as subsequent–the patient did receive a foreign body removal service. Think of subsequent as “aftercare” regardless of whether you continue with the treatment or simply monitor it.

For those who know me, I always defer to official sources and I  confirm whether what I am stating is based on my professional opinion or a specific source. Sometimes there is very little official documentation to follow.

I will continue to monitor the definitions and usage of “initial” versus “subsequent” and send my findings to all the EyeCodingForum ICD-10 clients. I will post findings to my website as well. The complete guidelines are below:


Jeffrey Restuccio, CPC, CPC

July 24 ICD-10 coding exercises for optometry and ophthalmology

July 24 2015: Every week the EyeCodingForum will be posting ICD-10 coding exercises for optometry and ophthalmology. These follow our comprehensive, six-hour ICD-10 training program and our 4-page ICD-10 code list (aka “cheat sheet). Click on the image below to print it full-size.

ICD-10 exer 1 July 27 2015 20 codes

The answer key and explanations will be supplied to all EyeCodingForum ICD-10 recorded training, 4-page ICD-10 code list and Site License customers. The EyeCodingForum staff has spent hundreds of hours preparing and educating thousands of Eyecare clinics nationwide. Let us worry about ICD-10 so you don’t have to. If you are not on our e-mail list enter your contact information here.

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ICD-10 coding exercises for optometry and ophthalmology.










Report viral conjunctivitis. Enter code in the boxes=>


Report DM type 1 controlled


Dry eye syndrome of both eyes


Report dry ARMD of the right eye:


Code POAG:


Report hyperopia of both eyes:


Code for amblyopia of the right eye:


The patient presents with pain in the right eye:


Code for essential (primary) hypertension


Code for tobacco use:


Code for a benign neoplasm of rt conjunctiva:


Code ptosis of the right upper eyelid:


Report unspecified keratitis of both eyes:


Code ocular HTN:


Code astigmatism:


Report presbyopia of both eyes


The patient has blurred vision of both eyes


The patient presents with red eyes


Code for a follow up visit for a FB in cornea, left eye


Code for pseudophakia

ICD-10 Implementation Plan for Eyecare

This free, three-page implementation is a succinct outline of an action plan for preparing for the October 1 ICD-10 deadline.

It is suitable for optometry and ophthalmology offices. It includes:

  1. Overview
  2. Action Items
  3. New to ICD-10 Concepts
  4. What to review starting now
  5. Data entry practice recomendations
  6. Basics
  7. ICD-10 concept review
  8. Reporting 2 codes when required (this is covered in detail in my ICD_10 training course)
  9. Documentation issues pertaining to specific diseases (covered in my online, recorded course)
  10. Injury coding
  11. Top 10 codes/code groups most clinics omit.
  12. List of six actual omitted codes
  13. 42 questions posted separately on the EyeCodingForum

Click on this link to enter  your information and download the free, three-page implementation form.

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Checking the Status of your ICD-10 Training for Eyecare

If you work in an optometry or ophthalmology office the following questions below will help you access your preparation status for the October 1, 2015 ICD-10 deadline.

The EyeCodingForum offers a six-hour, recorded video ICD-10 training course, a Site License offer (ICD-10 training plus over 36 Webinars) and a  comprehensive Top Ten Clinic service. The answers to the questions below are all in my comprehensive ICD-10 training course.

Please share these with everyone you know in Eyecare:

  1. Which eye conditions have 20 ICD-10 codes?
  2. Which eye conditions have 12 ICD-10 codes?
  3. What is an “abnormal finding” during a routine vision exam?
  4. Which category (anatomy) now has seven (7) codes for every condition?
  5. Does pseudophakia [Z96.1] support medical necessity?
  6. How do you report a dense cataract?
  7. Does blurred vision [H53.8] support medical necessity?
  8. How do you report a Drance Heme?
  9. Is degenerative myopia [H44.2*] paid on a medical claim?
  10. How do you report bacterial conjunctivitis?
  11. In ICD-10 you should no longer document wet or dry ARMD by eye (right or left) [True or False].
  12. Modifiers (LT for left, RT for right, and MOD-50 for bilateral) are no longer required after October 1 2015 [True or False].
  13. How do you report a nasal or temporal pterygium?
  14. Is refractive amblyopia [H53.02* ] paid on a  medical claim?
  15. Is internal ophthalmoplegia [ H52.51*] paid on a medical claim?
  16. Can a suture, stent, conjunctival concretion removal be coded as a foreign body removal?
  17. How do you report a rule-out of a blowout fracture?
  18. How do you report laterality for congenital conditions?
  19. How do you report “uncontrolled diabetes Type II” in ICD-10?
  20. How do you report laterality for tension, migraine, ocular, and retinal migraines?
  21. How do you determine which ICD-10 codes have laterality and which do not?
  22. Which codes do not have a bilateral (3) option?
  23. In which two categories would an unspecific condition code be considered reasonable?
  24. Which codes require a “2” for the right eyelid and a “9” for the left eyelid [exceptions]?
  25. How will reporting Lupus or Rheumatoid arthritis increase your medical billing?
  26. How do you report a skin tag on the eyelid?
  27. An ophthalmoplegic, ocular, and retinal migraine are all reported with the same ICD-10 code [ True or False?]
  28. The H54.** blindness codes now have laterality [True or False]
  29. What is the congenital code category letter in ICD-10?
  30. What are collagen vascular disorders and why should you care?
  31. How do you report malignant HTN versus benign in ICD-10?
  32. How many drugs/conditions can you name that are paid annual screenings?
  33. How do you sequence AIDS coding related to eyecare manifestations?
  34. How do you code a foreign body embedded in the external eyelid?
  35. How do you code a foreign body embedded in the internal portion of the eyelid?
  36. What code category is used to report accidentally splashing an alkaline substance in your eyes?
  37. What code category is used to report an injury by a paintball gun?
  38. What code category is used to report injuries from a lathe or grinding wheel?
  39. What code category is used to report common locations such as home, school, factory, or a public park?
  40. Z status codes can also have laterality [True or False].
  41. There are ICD-10 codes for a malingerer and noncompliance [True or False].
  42. There is a national requirement for injury activity and location codes [True or False].

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How to Get started with ICD-10 training for ophthalmology and optometry TODAY

With our recorded, video training, you can train all your doctors (up to 10), and your staff for one low, discounted price. You can watch the videos anytime and as often as you want until Oct 1 2015. Recorded training is per clinic so it’s a great deal at any price. To get started:

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After you purchase the course you will set up a User ID and password. Enter those on the subscription page and you should see a menu with all your training options and links. Click on the subscription link(s) on the left and enjoy the videos.

I have taught this ICD-10 class live over 100 times. I have 15-20 years experience as a coding instructor, and I’ve audited over 10,000 records. I specialize in eyecare. The training course is over seven hours and and covers over 100 diseases. No other course, and some are twice the price, comes close.

If you have any problems contact me at ecf@eyecodingforum.com or call me at (901) 517-1705. Be specific exactly what the problem is. Most problems are best fixed through emails but the links above should solve 95% of problems.

Jeffrey Restuccio, CPC, COC, MBA