One of the new concepts in ICD-10-CM is the seventh character to denote the encounter type. In ICD-10-CM, coders will use the same basic diagnosis code throughout treatment, with only the seventh character changing.
In ICD-9-CM, coders report a code from V54 for orthopedic aftercare. For example, if a patient is being seen for aftercare for a healing traumatic fracture of the hip, coders would report V54.13.
The ICD-9-CM Official Guidelines for Coding and Reporting instruct coders to report the aftercare codes (subcategories V54.0x, V54.2x, V54.8x, or V54.9) for encounters after the patient has completed active treatment of the fracture and is receiving routine care during the healing or recovery phase. Examples of fracture aftercare include:
- Cast change or removal
- Removal of external or internal fixation device
- Medication adjustment
- Follow-up visits following fracture treatment
Coders generally report the aftercare code as the first-listed or principal diagnosis. Coders may also use an aftercare code as an additional code when the physician provides some type of aftercare in addition to treating the main problem necessitating the admission.
Consider a patient with a traumatic finger amputation who presents with an amputation stump and concern for infection at the amputation site.
The physician finds no obvious signs and symptoms of infection at the amputation site, and the patient is receiving antibiotics presumably as a prophylactic measure for infection. In this case, the aftercare code V54.89 (other specified rehabilitation procedure) is the most appropriate ICD-9-CM code to report for this encounter, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, C-DAM, executive director of the Foundation for Physician Documentation Integrity.
The patient's status is post initial treatment of the traumatic amputation, and he or she is currently in the healing or recovery phase. The physician isn't directing the current treatment toward a current injury. Therefore, report only code V54.89, Krauss says.
However, in some cases, coders run into problems with payers when they follow the ICD-9-CM sequencing rules for aftercare codes. "I've heard of horror stories of hospital billing departments resequencing the codes because the insurance company won't pay for that V code," says Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-approved ICD-10-CM/PCS trainer, AHIMA ICD-10 ambassador, and senior consultant with the Haugen Consulting Group in Denver. "But the guidelines in ICD-9 specifically tell us to do that."
Change for ICD-10-CM
Coders won't face that problem in ICD-10-CM because they won't be reporting specific aftercare codes. They will continue to report the injury code with different seventh characters to identify what type of treatment the patient is receiving.
ICD-10-CM does include a code for orthopedic aftercare: Z47.89 (encounter for orthopedic aftercare). "However, we do not use this code for orthopedic aftercare for injuries," Pollard says. "What we code instead is the code for the injury with the seventh character for subsequent care."
Coders will also report a Z code when a condition is no longer present, says Anita Rapier, RHIT, CCS, senior coding consultant for the American Hospital Association in Chicago.
For example, a patient suffering from severe osteoarthritis of the hip undergoes a hip replacement procedure. The patient then comes in for rehabilitation. Coders should report code Z47.1 (aftercare following joint replacement surgery) and not a code for osteoarthritis, Rapier says.
The aftercare changes don't apply solely to fractures or other injuries. They also apply for admissions or encounters for rehabilitation for sequelae of a cerebrovascular accident (CVA), Rapier says. ICD-10-CM includes a category of codes (I69) specifically for reporting sequelae of a CVA.
For example, a patient suffered a CVA two months ago and is experiencing right-sided dominant hemiplegia following a CVA. The patient is admitted for rehabilitation services. Coders would report I69.351 (hemiplegia and hemiparesis, following cerebral infarction affecting right dominant side), Rapier says.
Seventh characters
When a patient comes in for treatment of injuries, poisonings, and certain other consequences of external causes, coders will usually find the appropriate code in Chapter 19 in ICD-10-CM. Many of the codes in this chapter require a seventh character, with most codes only including three choices:
- A, initial encounter
- D, subsequent encounter
- S, sequela
For certain closed fractures, coders have three or four additional seventh character choices. ICD-10-CM also includes 10 seventh characters for open fractures of the femur, lower leg, and forearm.
Don't confuse initial encounter with first visit. Coders will assign seventh character A when the patient is receiving active treatment, such as an ED visit, surgery, and evaluation and continuing treatment by the same or a different physician.
Coders will use seventh character D when the patient is receiving basically the same routine aftercare identified by the V codes in ICD-9-CM.
A sequela (seventh character S) is the same as a late effect in ICD-9-CM. "Whatever was a late effect in ICD-9 is now a sequela in ICD-10," Pollard says.
Fracture aftercare example
A patient comes into the ED with a displaced fracture of the right intertrochanteric femur. Coders would report S72.141A (displaced intertrochanteric fracture of right femur, initial encounter), Rapier says.
The physician determines that the patient requires surgery for the fracture. Coders will again report S72.141A because surgery is considered active treatment, Pollard says.
The patient is then admitted for an inpatient rehabilitation stay following the surgery. During the stay, the patient received physical and occupational therapy and fracture aftercare. Assign code S72.141D, (displaced intertrochanteric fracture of right femur, subsequent encounter), Rapier says.
Reimbursement impact
Facilities will see a change in MS-DRG assignment and consequently a change in reimbursement when they begin reporting ICD-10-CM codes for fractures.
Currently in ICD-9-CM, the above case would be reported with V57.89 as the principal diagnosis and 820.21 for the intertrochanteric fracture, Pollard says. That groups to MS-DRG 945 (rehabilitation with CC/MCC). Using an average hospital's blended rate of $4,556 times the MS-DRG relative weight (1.3804) equals $6,289 in reimbursement, Pollard says.
In ICD-10-CM, coders will no longer report a Z code. Instead, they will use a code from category S72, which now groups to MS-DRG 561 (aftercare, musculoskeletal system and connective tissue without CC/MCC), Pollard says. MS-DRG 561 has a relative weight of 0.6408, leading to a payment of $2,919.
That's probably not the best news for hospitals with rehabilitation units paid on the MS-DRG system, Pollard says.
Data considerations
ICD-10-CM codes are designed to follow a patient all the way through treatment, which raises several data considerations. "This sounds great on paper," Pollard says. "You're able to know that the patient came in with a fracture, then went to physical therapy." In addition, if the patient comes back with a sequela, facilities will be able to track that.
The problems start with documentation. "How often do you get documentation down to the specific part of the bone and laterality on a sequela?" Pollard says. How often is the physician documentation that good?
The physician's documentation is likely to be much more specific on the initial encounter than it would be for subsequent encounters and sequelae, Pollard says. Physicians don't always identify sequelae as such, which means coders won't be able to assign the fracture code with a seventh character S.
Another problem arises for patients who suffered their initial injury prior to ICD-10-CM implementation. The ICD-9-CM codes don't provide as much detail as the ICD-10-CM codes, so coders may not have the level of detail necessary in documentation for subsequent encounters to report the most specific code.
Editor’s note: This article was originally published in the April issue of Briefings on Coding Compliance Strategies.Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.