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