227 By now, you may know that the term for a late effect in International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) is sequela. In addition to changing the terminology for describing a late effect of a disease or injury, ICD-10-CM also approaches different types of sequelae in different ways. In this article, we will review the guidelines for reporting sequelae and look at some examples of codes that are used to report them. Guidelines The guidelines for ICD-10-CM instruct ■■ A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. ■■ 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 that caused by a previous injury. ■■ Coding of sequela generally requires 2 codes sequenced in the following order: The condition or nature of the sequela is sequenced first (ie, the patient’s residual condition or complication that represents the sequela is sequenced first). The sequela code is sequenced second. ●● This guideline applies except when the code for the sequela is followed by a manifestation code identified in the ICD-10-CM tabular list and title (eg, the tabular list instructs code first sequelae of traumatic intracranial injury codes S06.- when reporting pseudobulbar effect code F48.2) or the sequela code has been expanded to include the manifestation. ■■ The code for the acute phase of an illness or injury is not used in conjunction with a code for the sequela. (Exception: A current injury code is reported for a burn that is still in the acute phase of healing, while a sequela code may be reported at the same encounter related to effects of another healed burn.) ■■ The external cause-of-injury code with the seventh character S for sequela should be used with any report of a late effect or sequela resulting from a previous injury. Some examples may help illustrate these guidelines. Example 1 Probably the most discussed approach to identifying an encounter to address a sequela is the use of seventh character S when reporting an injury, poisoning, or external cause of injury. Most categories of injury in ICD-10-CM include 3 choices for the seventh character appended to complete each code: A, initial encounter D, subsequent encounter or S, sequela. Appendix B-2 Late Effects or Sequela (continued on page 228)
Previous Page Next Page