231 The revisions to International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) guidelines in 2015 provide guidance on the appropriate reporting of initial or subsequent encounters for injuries. Previously, the guidelines instructed that an initial encounter was reported for active treatment, which included evaluation and treatment by a new physician. The revised guidelines clarify that seventh character A is appropriately reported for any encounter for active treatment of a fracture, injury, or complication of care. Per ICD-10-CM guidelines, examples of active treatment are surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician. Because the guidelines specify that a sub- sequent encounter addresses the recovery or healing phase, the active treatment required for an initial encounter may be considered to be the visits, interventions, and assessments that are applied during the initial course of the injury to establish a pattern conducive to healing and recovery. The following example illustrates encounters for injuries with active treatment and with routine care during the recovery or healing phase: A teenaged girl presents to her pediatrician with wrist pain since falling from her bicycle 2 days ago. She notes that there is not much bruising and she can move her wrist but continues to have pain, especially at the base of her thumb. The pediatrician orders radiographs and finds no evidence of fracture but suspects a scaphoid fracture. A splint is applied and an appointment to return for a repeat radiograph is made for 2 weeks. Diagnosis is sprained right radiocarpal joint with possible scaphoid fracture. The girl returns for repeat radiograph in 2 weeks. A non-displaced scaphoid fracture is now visualized. A cast is applied and the girl is scheduled for routine follow-up visits. Diagnosis is non-displaced right distal scaphoid fracture. In this scenario, the same physician provides active treatment of the injury twice. The diagnosis at the end of the first encounter was sprained right radiocarpal joint, reported with code S63.521A. Seventh character A is appropriate for the active treatment of this injury. Although the second visit was with the same physician, there was active treat- ment of the right scaphoid fracture, so code S62.014A is reported. For both encounters, the cause of injury was a fall from a bicycle. Code V18.0XXA, pedal cycle driver injured in non-collision transport accident in non-traffic accident, is reported for each of the encounters for active treatment. Note: Reporting of external cause-of-injury codes is recommended to provide accident information to the payer but is not a requirement of ICD-10-CM. State regulations may require reporting of external cause of injury in a facility setting. Follow-up encounters during the healing phase of the scaphoid fracture will be reported with S62.014- appended with the appropriate seventh character to describe a subsequent encounter. Applicable seventh characters are 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 Appendix B-4 Applying the 2015 ICD-10-CM Guidelines for Initial Encounters (continued on page 232)
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