ICD-10 contains 2 different code sets. They are International Classification of Diseases, 10th Revision: Clinical Modification (ICD-10-CM) and International Classification of Diseases, 10th Revision: Procedure Coding System (ICD-10-PCS). The PCS codes are not required for outpatient settings. All ICD-10 information that APTA provides is related to ICD-10-CM codes. Access all of APTA's ICD-10 resources.
Updates for ICD-10
Do I have to purchase a new ICD-10 book every year?
Providers must use the ICD-10 codes for the current Financial Year (FY). The correct FY codes should be used for inpatient discharges occurring from October 1, through September 30, and for outpatient encounters occurring from October 1, through September 30, CMS offers a webpage with links to the 2017 codes.
Unless there is a hold on updating ICD-10 codes, it is best practice to purchase a current ICD-10 book.
The updates typically includes the following:
- New codes
- Revised codes
- Deleted codes
- Changes in descriptions
- Index revision (more than just to new codes)
- Tabular revisions
- Includes notes
- Excludes notes
- Use additional code notes
Are there any updates to ICD-10 FY 2017 that will impact patients seen by me?
For 2017, there were 1,974 new codes added, 425 codes revised, and 311 codes deleted.
Below is a list of some changes that are likely to impact physical therapist.
- G56.03 Carpal tunnel syndrome, bilateral
- I16.- Hypertension codes
- I16.0 Hypertension Urgency
- I16.1 Hypertension Emergency
- I16.2 Hypertension Crisis, unspecified
- I69.- Sequela of cerebrovascular disease.
(Added subcategory, 6th character descriptions, for coding cognitive deficits)
- I69.01-, I69.11-, I69.21-, I69.31-, I69.81, I69.91-:
- 0 Attention and concentration deficit
- 1 Memory deficit
- 2 Visuospatial deficit and spatial neglect
- 3 Psychomotor deficits
- 4 Frontal lobe and executive function deficit
- 5 Cognitive social or emotional deficit
- 8 Other symptoms and signs involving cognitive function
- 9 Unspecified symptoms and signs involving cognitive function
- M21.6- Other acquired deformities of foot
- M21.61 Bunion
- M21.611 Bunion of right foot
- M21.612 Bunion of left foot
- M21.619 Bunion of unspecified foot
- M21.62 Bunionette
- M21.621 Bunionette of right foot
- M21.622 Bunionette of left foot
- M21.629 Bunionette of unspecified foot
- M25.54 Pain in joints of hand (previously indexed to M79.64-)
- M25.541 Pain in joint of right hand
- M25.542 Pain in joint of left hand
- M25.549 Pain in joint of unspecified hand
- M50.- Cervical disc disorders (Expanded each code in the mid-cervical disc range to specify each level separately (C4-C7)
- M50.02-, M50.12-, M50.22-, M50.32-, M50.82-, M50.92-:
- 0 Unspecified
- 1 C4-C5 level
- 2 C5-C6 level
- 3 C6-C7 level
- M62.84 Sarcopenia (Code first underlying disease, if applicable.)
- X50 Overexertion and strenuous or repetitive movements (New codes have been created for External causes of morbidity for Overexertion and strenuous or repetitive movements)
The appropriate 7th character is to be added to each code from category X50
A - initial encounter
D - subsequent encounter
S – sequela
Overexertion from strenuous movement or load
- Lifting heavy objects
- Lifting weights X50.1 Overexertion
from prolonged static or awkward postures
- Prolonged bending
- Prolonged kneeling
- Prolonged reaching
- Prolonged sitting
- Prolonged standing
- Prolonged twisting
- Static bending
- Static kneeling
- Static reaching
- Static sitting
- Static standing
- Static twisting
- X50.3 Overexertion from repetitive movements
- Use of hand as hammer
- Excludes2: Overuse from prolonged static or awkward postures (X50.1)
Other and unspecified overexertion or strenuous movements or postures
- Contact pressure
- Contact stress
- S06.0 Concussion (Has been revised and should not use concussion when intracranial injury is identified.)
- Excludes 1 Concussion with other intracranial injuries classified in subcategories S06.1- to S06.6-, S06.81- and S06.82- code to specified intracranial injury
- S06.0X Concussion (Deleted several 6 character codes. Now 3 codes are left.)
- S06.0X0- Concussion without LOC
- S06.0X1- Concussion with LOC less than 30 minutes
- S06.0X9- Concussion with LOC of unspecified duration
The Transition From ICD-9 to ICD-10
Do I have to transition from ICD-9 to ICD-10?
All entities covered by the Health Insurance Portability and Accountability Act (HIPAA) are required to change from ICD-9 to ICD-10. This includes Medicare, Medicaid, and most private insurance companies.
Who isn't required to switch to ICD-10?
Insurers such as workers' compensation and auto insurers are not subject to HIPAA and are not required to switch, but most will likely transition, anyway. This is because ICD-9 will no longer be maintained after ICD-10 is implemented, and so it will be in even a noncovered entity's best interest to use ICD-10. In addition, noncovered entities will find value in the increased detail in ICD-10, and the Centers for Medicare and Medicaid Services (CMS) will work with them to use it.
There have been public announcements that some worker's compensation programs will switch to ICD-10 on October 1. To be sure, check with each payer for details.
For information on the status of the adoption of ICD-10 by entities that are not required to do so, the Workgroup for Electronic Data Interchange hosts a Property and Casualty ICD-10 State Readiness Resource Center.
When do we have to start using ICD-10?
The switch to ICD-10 occurred on October 1, 2015, for services provided on that date and beyond. Your documentation for each visit, whether using ICD-9 or ICD-10, must support the code used.
- Institutional providers. The transition for institutional providers (eg, Medicare Part A services) is based on discharge date or through date.
Example 1: If a patient is discharged from the hospital on or before September 30, the claim would use ICD-9 codes. If a patient is admitted to the hospital any day prior to October 1 and discharged on or after October 1, the claim would use ICD-10 codes.
Example 2: If a skilled nursing facility or long-term care facility has a patient that was admitted on July 1, 2015, and the facility submits claims on the 30th of every month, then the claims for July, August, and September would use ICD-9 codes and the claim for October and any after date would use ICD-10 codes.
- Outpatient services. The transition for outpatient services is based on date the service is provided. It is not based on the date the claim is submitted.
Example 1: If a patient's episode of care starts September 29 and ends October 2, the claims submitted for September 29 and 30 would use ICD-9 codes. The claims submitted for October 1 and 2 would use ICD-10 codes. (*Note: Do not submit the claims for September 30 and October 1 on the same form. Any claim that contains both ICD-9 and ICD-10 codes will be rejected.)
Example 2: lf you submit a claim using ICD-9 codes on October 1 for a service that was provided on September 29 and the claim is rejected for any reason, when you resubmit the claim you still use the ICD-9 codes.
- CMS Resource: Institutional Services Split Claims Billing Instructions for Medicare Fee-For- Service (FFS) Claims that Span the International Classification of Diseases, 10th Edition (ICD-10) Implementation Date
If an episode of care begins before October 1 and continues after October 1, do I need a new referral or plan of care to switch to ICD-10?
No. There is no need to get a new referral or revise the plan of care based on the switch to ICD-10.
If I have a cash-based practice that is out-of-network with all insurances and I don't see patients who are eligible for Medicare, do I have to switch to ICD-10?
For cash-based services, provide what your patients need to submit to their payers. If you have been providing ICD-9 codes, it is likely you will need to begin using ICD-10 codes for processing your patients' out-of-network claims.
Why is there a transition from ICD-9 to ICD-10?
First, it is important to understand that this change was not optional. ICD-9 was developed in 1970 and is outdated, based on medicine and technology that is no longer in use. It lacks the detail needed to pay for today's treatments, and it has no space for new codes.
ICD-10 allows for greater detail by describing laterality, primary and subsequent encounters, external causes of injury, preventive health, and socioeconomic, family relationship, and lifestyle-related issues. ICD-10 has the capacity to accommodate evolving technology, and it supports exchange of health data with other countries. All other G-7 nations have transitioned to ICD-10 already.
How do I find the "official guidelines" for ICD-10?
ICD-10-CM was developed and is maintained by the World Health Organization (WHO) and the National Center for Health Statistics within the Centers for Disease Control and Prevention (CDC). As with ICD-9-CM, ICD-10-CM is supplemented by a set of official guidelines that are designated as part of the ICD-10-CM code set by the HIPAA "medical data code set" regulations (45 CFR 162.1002(C)(2)). The CDC updates these guidelines annually. You can find the 2016 guidelines at ICD-10-CM Official Guidelines for Coding and Reporting FY 2016. Use the codes and the guidelines that correspond with the year in which you provide the service.
For 2016, the guidelines include the following sections:
- Section I: Conventions, general coding guidelines, and chapter-specific guidelines
- Section II: Selection of principal diagnosis
- Section III: Reporting additional diagnoses
- Section IV: Diagnostic coding and reporting guidelines for outpatient services
Are there different coding guidelines for inpatient and outpatient settings?
The code sets apply to all nonoutpatient settings, such as acute care, short-term care, long-term care, and psychiatric hospitals; home health agencies; rehab facilities; and nursing homes.
An additional section in the guidelines addresses outpatient settings. The same rules apply for hospital-based outpatient settings and private outpatient settings. See the ICD-10-CM Official Guidelines for Coding and Reporting FY 2016, Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services.
What is the difference between ICD-10-CM codes and ICD-10-PCS codes, and which are used in outpatient setting?
ICD-10 contains 2 different code sets. They are International Classification of Diseases, 10th Revision: Clinical Modification (ICD-10-CM) and International Classification of Diseases, 10th Revision: Procedure Coding System (ICD-10-PCS). The PCS codes are not required for outpatient settings. All ICD-10 information that APTA provides is related to ICD-10-CM codes.
Where do I find a list of ICD-10 codes?
The ICD-10-CM and ICD-10-PCS code sets, as well as the official ICD-10-CM guidelines, are available free of charge on the 2016 ICD-10-CM and GEMs page of the CMS ICD-10 website the page links to, among other things, a ZIP file that contains the code table and index. Another link is to general equivalence mappings (GEM), which provide a crosswalk of sorts between ICD-9 and ICD-10. We say "of sorts" because the change from ICD-9 to ICD-10 doesn't allow for a 1-to-1 crosswalk, and if you only use this tool you will likely not use the fully specified code or even the correct codes.
Be sure that you are downloading the codes for the correct year that the services are provided. The page above is for 2016; If your services were provided in 201, you'll want to reference the 2015 ICD-10-CM and GEMS.
Do I have to provide external cause codes?
Similar to ICD-9, there is no national requirement to report the ICD-10 codes for "external causes for morbidity," which are found in Chapter 20 of the official guidelines. You may have to provide these codes if you are subject to a state-based external cause code reporting mandate or if a particular payer requires them. If you have not been reporting ICD-9 external cause codes, switching to ICD-10 in itself will not require you to report them. If your state or a private payer institutes such a requirement, it would be independent of ICD-10 implementation. Even without a reporting requirement, you are encouraged to voluntarily report external cause codes, as they provide valuable data for injury research and evaluation of injury-prevention strategies.
How do I purchase a hard copies of the code book? Is it best to get the current edition?
Most online booksellers carry printed version of ICD-10-CM for the current Financial Year. When Ordering, you should ensure that you are ordering a code book that is not in draft form.
You will need to use the 2015 codes for dates of service from October 1 to December 31, 2015, and then use the 2016 codes. You can purchase hard copy books, and you can also access the index and tabular lists online for both years at no charge. [See "Where do I find a list of ICD-10 codes?"]
Are any third-party payers providing support for the ICD-10 transition?
Most third-party payers provide information about transition to ICD-10 on their websites, including CMS and its Medicare administrative contractors. CMS also announced that it will provide support that includes setting up a communication and collaboration center to resolve issues; using an ICD-10 ombudsman to help receive and triage provider issues; and possibly make advanced payments available if Part B Medicare contractors are unable to process claims. Follow the links below for more details.
Does CMS have a list of ICD-10 codes that must be reported along with specific CPT codes for services to be considered medically necessary?
You will need to check with your local Medicare administrative contractor (MAC) to determine if you're required to report certain ICD-10 codes along with specific CPT codes for Medicare coverage.
General Coding Guidance
Who determines what ICD-10 code will be used in the claim?
This depends on whether or not the organization uses coders. If so, CMS provides the following guidance: A joint effort between the health care provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Medical record documentation from any provider involved in the care and treatment of the patient may be used to support the determination of whether a condition was present on admission or not. In the context of the official coding guidelines, the term "provider" means a physician or any qualified health care practitioner who is legally accountable for establishing the patient's diagnosis.
To ensure that you are using the best codes, communication with the coder and potentially the billing department is essential. Consider reviewing charts as a team so that you all can agree that the documentation is complete and proper codes are used for submission of the claim.
What should I know up front to be successful with coding?
- You should note that code construction and guidance can change from body system to body system, from condition to condition, and from inpatient setting to outpatient setting, to name a few examples. Always orient yourself when considering an unfamiliar code, to be sure you are selecting what's most appropriate. Find the code in the ICD-10 guidelines, and read the chapter's introductory information in addition to any headings and subheadings notes preceding the specific codes you are considering.
- For institutional settings (eg, acute care, short-term care, long-term care, and psychiatric hospitals; home health agencies; rehab facilities; nursing homes) the code or codes are determined for a single patient's claim; there are not separate codes for each provider within the institution who treats that patient.
For outpatient settings, there is additional specific guidance for both hospital-based on private outpatient clinics. See ICD-10-CM Official Guidelines for Coding and Reporting, FY 2016, Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services.
What are the basic steps to use in selecting the codes?
You will find this information at ICD-10-CM Official Guidelines for Coding and Reporting, FY 2016.
- Locate the term that best identifies the diagnosis or reason for visit in the Alphabetical Index. Always start you search with the Alphabetical Index to help ensure that you are looking up the correct code that most accurately reflects the condition.
- Verify the code to the greatest level of specificity in the Tabular Index. Once you have identified the appropriate 3-digit code in the alphabetical index, use that code to search in the Tabular Index.
- Make sure you understand the guidance from the ICD-10-CM Official Guidelines for Coding and Reporting, FY 2015. The guidelines note: "The most critical rule involves beginning the search for the correct code assignment through the Alphabetical Index. Never begin searching initially in the Tabular List as this will lead to coding errors."
You can download a ZIP file of the 2017 Alphabetical Index and Tabular index from CMS's website 2017 ICD-10-CM and GEMS. First download the "2017 Code Tables and Index [ZIP, 16MB]. The files are titled "Index.pdf" and "Tabular.pdf"
Can I use multiple codes?
Yes, use the number of codes needed to adequately describe the patient. List the diagnosis, condition, problem, or other reason for the encounter/visit shown in the medical record to be chiefly responsible for the services provided, and list additional codes that describe any coexisting conditions. Pay close attention to notes included with the codes; some codes cannot be used with other codes.
There are codes for Right, Left, or Unspecified. If the problem is bilateral, do I choose Unspecified or use 2 codes for both Right and Left?
This is a good example of the need to follow the guidance for each specific code. Do not assume that the instructions for one code will apply elsewhere. Some codes indicate right, left, and bilateral. Some indicate right and left but not bilateral, so if the condition affects the right and left you would use both. For some codes, such as torticollis, you might think a side would be appropriate but the code does not provide that option. Below is an example of very specific instructions for a condition:
Codes from category I69, Sequelae of cerebrovascular disease, that specify hemiplegia, hemiparesis, and monoplegia identify whether the dominant or nondominant side is affected. Should the affected side be documented but not specified as dominant or nondominant, and the classification system does not indicate a default, code selection is as follows:
- For ambidextrous patients, the default should be dominant.
- If the left side is affected, the default is nondominant.
- If the right side is affected, the default is dominant.
Can I use ICD 10 codes to report signs and symptoms?
Yes, signs and symptoms, and even "unspecified" codes, are at times not only acceptable but necessary. While you should report specific diagnosis codes when they are supported by the available medical record documentation and clinical knowledge of the patient's health condition, at times signs, symptoms, or unspecified codes are the most accurate code choices. Code each encounter to the level of certainty known for that encounter.
In an outpatient setting do our codes need to match the physician's?
No. Your coding needs to be as complete as you can make it based on confirmed information that you identify during the visit. You may use codes for signs or symptoms pertinent to the physical therapy services you provided--codes that the physician may not have included.
If I suspect my patient has a condition, such as a herniated disc, but he or she has had no imaging, do I code for what I suspect?
No, you code to the level you can confirm. If a herniated disc is not confirmed, you cannot code that one is present.
Should I report ICD-10 codes such as BMI if I believe it will influence the episode of care?
Yes, in this case, consider BMI (Z68 Body mass index [BMI]) an "Other Diagnoses," which is described as "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded."
In an outpatient setting, how do you determine the first-listed condition?
The Health Insurance Portability and Accountability Act (HIPAA) requires assigning ICD-10-CM diagnosis codes according to the ICD-10-CM Official Guidelines for Coding and Reporting. The ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 state:
"List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions." Page 102.
"Codes for symptoms, signs, and ill-defined conditions from Chapter 18 are not to be used as principal diagnosis when a related definitive diagnosis has been established." Page 96.
"Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider." Page 101.
Please note: APTA is aware of the many questions about the first-listed diagnosis for patients receiving outpatient physical therapist services. For clarification, APTA contacted the ICD-10 Cooperating Parties, which include the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and the Centers for Disease Control and Prevention. The Cooperating Parties agree that with the transition to ICD-10 it is important that all health care providers code consistently.
APTA recognizes that payers have not been consistent with instructions on the first-listed diagnosis, and physical therapists may not have been coding according to the guidelines above. Going forward with ICD-10, APTA believes the first-listed diagnosis should be consistent with the ICD-10 Coordinating Parties, payers, and other organizations.
If you follow the ICD-10-CM Official Guidelines for Coding and Reporting, and your claim is delayed or denied, complete the Online Complaint Form on APTA's website so the association can help you resolve the issue.
Can the ICD-10 code change throughout the episode of care?
Yes, if the diagnosis becomes more definitive or additional diagnoses develop then add the appropriate ICD-10 code. Also add codes for identified signs and symptoms if they were not initially included as part of the diagnostic codes.
Is there a Medicare list of ICD-10 codes that would qualify for an automatic therapy cap exception based upon clinical condition or complexity?
There is no longer a list of specific ICD-9 codes that would qualify for an exception to the therapy cap. CMS does not have plans to issue a list of ICD-10 codes that would qualify for an exception. The beneficiary may qualify for the cap exceptions at any time during the episode when covered services that are documented as medically necessary exceed the therapy caps. All requests for exception are in the form of a KX modifier added to claim lines. It is important that the documentation indicate that there is a need for continued skilled therapy. You can use the automatic exceptions process for any diagnosis for which you can justify services exceeding the cap.
Do PTs need to submit documentation for automatic exceptions from the therapy cap?
No specific documentation is submitted for automatic process exceptions. Medicare beneficiaries will be automatically excepted from the therapy cap, and you will not be required to submit documentation for an exception, if the beneficiary meets the criteria for an automatic exception. You are responsible for consulting guidance in the Medicare manuals and in the professional literature to determine if the beneficiary qualifies. If claims are selected for medical review via an Additional Documentation Request (ADR), you must submit documentation justifying the services. If medical records are requested for review, you may include, at your discretion, a summary that specifically addresses the justification for therapy cap exception.
What are aftercare codes, and when do I use them?
Aftercare visit codes (Z codes) cover situations in which the initial treatment of a disease has been performed or the injury or disease has been removed, and the patient requires continued care during the healing or recovery phase or for the long-term consequences of the disease. Do not use the aftercare Z code if treatment is directed at a current, acute disease. Use the diagnosis code in these cases.
Also, do not use the aftercare Z codes for aftercare for injuries that are still present. For aftercare following an injury, assign the acute injury code with the appropriate 7th character (for subsequent encounter). (ICD-10-CM Official Guidelines for Coding and Reporting FY 2015. Page 89)
For injuries, the appropriate 7th characters identify subsequent care with the diagnosis code. Use the acute injury code with the appropriate 7th character for subsequent encounter (eg "D").
To avoid payment delays or denials, check with your payers for their requirements on the use of aftercare codes.
Aftercare code examples:
Patient is seen by the PT after a total knee replacement to remove osteoarthritis in the right knee. Codes include:
- Z47.1 Aftercare following joint replacement surgery
- Z96.651 Presence of right artificial knee joint
Some common aftercare codes (Z codes) that physical therapists use include:
Z44: Encounter for fitting and adjustment of external prosthetic device. (Includes: removal or replacement of external prosthetic device. Excludes 1: malfunction or other complications of device presence of prosthetic device (Z97.-))
- Z44.1 Encounter for fitting and adjustment of artificial leg
- Z44.11 Encounter for fitting and adjustment of complete artificial leg
- Z44.111 Encounter for fitting and adjustment of complete right artificial leg
Z47: Orthopedic aftercare (Excludes 1: aftercare for healing fracture-code to fracture with 7th character D)
- Z47.1 Aftercare following joint replacement surgery
- Use additional code to identify the joint (Z96.6-) (e.g. Z96.641 Presence of right artificial hip joint)
Z47.8: Encounter for other orthopedic aftercare
- Z47.81 Encounter for orthopedic aftercare following surgical amputation
- Z47.82 Encounter for orthopedic aftercare following scoliosis surgery
- Z47.89 Encounter for other orthopedic aftercare
Z48: Encounter for other postprocedural aftercare (Excludes1: encounter for follow-up examination after completed treatment (Z08-Z09); Excludes2: encounter for attention to artificial openings (Z43.-); encounter for fitting and adjustment of prosthetic and other devices (Z44-Z46)
- Z48.0: Encounter for attention to dressings, sutures and drains (Excludes1: encounter for planned postprocedural wound closure (Z48.1))
- Z48.00: Encounter for change or removal of nonsurgical wound dressing; Encounter for change or removal of wound dressing NOS
Z48.2: Encounter for aftercare following organ transplant
- Z48.21 Encounter for aftercare following heart transplant
- Z48.22 Encounter for aftercare following kidney transplant
- Z48.23 Encounter for aftercare following liver transplant
- Z48.24 Encounter for aftercare following lung transplant
- Z48.28 Encounter for aftercare following multiple organ transplant
- Z48.280 Encounter for aftercare following heart-lung transplant
- Z48.288 Encounter for aftercare following multiple organ transplant
Use of the 7th Character
What is the 7th character, and when do I use it?
ICD-10 added the code extensions (7th character) for injuries and external causes to identify the encounter: initial, subsequent, or sequela. The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. The code extension to identify encounter must always be in the seventh position of the data field, so if a code that requires a 7th character does not have a 6 characters, use a placeholder X to fill in the empty character(s).
Do all codes have 7 characters?
No, ICD-10-CM diagnosis codes may contain 3, 4, 5, 6, or 7 characters. Codes with 3 characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth-sixth characters, which provide greater detail. Codes for injury or trauma generally have a 7th code. In addition, it is used in the Obstetrics, Musculoskeletal, and External Cause chapters.
Use a 3-character code only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable.
How and when do I use the 7th character?
The 7th character focuses on the patient's condition and the specific circumstance related to the treatment of the condition; not the health care provider being seen. This means "initial" or "subsequent" encounter is based on the patient's course of treatment and not whether it is his or her first visit vs follow-up treatment with a provider.
A = initial encounter
- Definition: When the patient is receiving active treatment for the condition
- Examples: surgical treatment, emergency department encounter and evaluation and treatment by a new physician
D = subsequent encounter
- Definition: 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: cast change or removal, removal of external or internal fixation devices, medication adjustment or other aftercare and follow-up visits following treatment of the injury or condition
S = sequela
- Definition: Complications or conditions that arise as a direct result of a condition
- Example: scar formation after a burn
- NOTE: This is typically a second code. The presenting complication is listed first.
The common fracture extensions include greater detail: Example:
- 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 = Sequelae
Refer to the tabular section of the ICD-10 coding guidelines to identify if a 7th seventh character is required and what it is.
When do I use an X as a placeholder?
Some ICD-10 categories indicate there is an applicable 7th character. The applicable 7th character is then required for all codes within the category, unless the notes in the Tabular List instruct otherwise. The 7th character must always be in the 7th character position. If a code that requires a 7th character is fewer than 6 characters (3, 4, or 5 characters), use a placeholder X to fill in the empty characters.
When submitting a claim for the first physical therapy encounter with the patient, should I use the "initial encounter" 7th character?
As noted above, not all ICD-10 codes require use of a 7th character. If the requires a 7th character, you need to determine whether the patient is in an active phase of care or a healing or recovery phase. In most instances, physical therapy would be considered part of the healing or recovery phase of care. If the patient is in the healing and recovery phase, then you would report the "subsequent encounter" code for the first physical therapy visit.
If a patient comes to me under direct access, do I use the 7th character for an initial visit?
Before you try to figure out if a visit is initial, subsequent, or sequelae, determine if the code requires a 7th character. If it does not, then the initial, subsequent, and sequelae characters are irrelevant for that code.
If a patient comes to you under direct access and has not seen another provider for the condition and you are providing active treatment, it would be considered the initial encounter. This is true for private practice and hospital-based outpatient services. In this scenario, if a seventh character is required for the ICD-10 code, you would use the "initial" 7th character for this first visit and use "subsequent" as the 7th character for visits after that.
What is the "sequela" 7th character, and when do I use it?
A sequela is the residual effect (produced by the condition) after the acute phase of an illness or injury has ended. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as recent pain due to an old injury. Examples of sequela include: scar formation resulting from a burn, deviated septum after a nasal fracture, and infertility caused by tubal occlusion from past tuberculosis. Reporting sequela generally requires 2 codes sequenced in the following order: the condition or nature of the sequela, then the sequela code.
When using 7th character "S," use both the injury (or other condition) code that precipitated the sequela and the code for the sequela itself. Add the "S" only to the injury code, not the sequela code. The "S" identifies the injury or condition responsible for the sequela. The specific type of sequela, such as a scar, is sequenced first, followed by the injury code.
An exception to the above guidelines is when the code for the sequela is followed by a manifestation code identified in the tabular list and title, or the sequela code has been expanded (at the 4th, 5th or 6th character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect.
Is there a time limit for coding a subsequent visit?
The use of the initial or subsequent visit is not based on time. "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. If your patient is still in the healing and recovery phase and you are not seeing him or her initially under direct access, you would use "subsequent" if the appropriate code requires the seventh character. Examples of subsequent care are: cast change or removal, an x-ray to check healing status of fracture, removal of external or internal fixation device, medication adjustment, and other aftercare and follow-up visits following treatment of the injury or condition.
Does ICD-10 require different supporting documentation from what ICD-9 required?
As with ICD-10 and all billing codes, your documentation should support the code you use.
Do I need to include the ICD-10 code in my documentation?
No. While you would need to document a diagnosis, you do not need to include the actual ICD-10 code in your documentation; however, you must documents all the details including test and measures that were performed, patient complaints and comments, and identified past medical history that led you to use those ICD-10 codes.
Will my documentation be different when using ICD-10?
Not necessarily. As noted above, your documentation needs to continue to support any codes you provide. As there is more detail in ICD-10 it is possible that you may have more details in your notes depending on how detailed your notes were under ICD-9.