ICD-10 7th Character Use Guidelines

insurance claim form
October 10, 2015
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We are understandably receiving a lot of questions regarding how and when to use the ICD-10 7th character.

The ICD-1o 7th character is only required when the ICD-10 rules specifically ask for the 7th character and give you a choice as to which of several characters to use. For PT/OT, a 7th character is typically only required in the case of injuries.

The most common 7th characters are A, D, and S.  As a therapist, you almost always provide care during the healing or recovery phase of an injury and will therefore use the D character.  More specifically, the following is an explanation of when each character is used.

A=Initial encounter which is when the patient is receiving active treatment for the injury/condition. Examples include surgery, an ED encounter or evaluation/treatment by a new physician.  Therapists will typically not use the A character because most of your patients have first been seen by a physician or other provider.  However, if you are treating a direct access patient who has not seen a physician or another provider first and you are providing active treatment for the injury, you would use the A 7th character for active treatment of the injury and generally the D character for follow-up visits during the healing/recovery phase.

D=Subsequent encounter which is for encounters after the patient has received active treatment for the injury/condition and is receiving routine care during the healing or recovery phase.  Most PT/OT, including your initial eval, is regarded as a subsequent encounter during an episode of care.  So, for the vast majority of PT/OT care requiring a 7th character, you should use D.

S=Sequela which is when the patient is being treated for complications or conditions that arise as a direct result of a condition, such as recent pain due to an old injury or treatment of scar formation after a burn.  A sequela is the residual effect (produced by the condition) after the acute phase of the injury has ended. There is no time limit on when a sequela code can be used. If you need to use the S 7th character, use both the injury/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 scar, is sequenced first, followed by the injury code.

As an alternative to these A, D and S 7th characters, fracture coding typically requires one of the following 7th characters; however, the ICD-10 tables or whatever tool you are using should specifically ask for one of these characters.

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

Keep in mind that Medicare has adopted a policy under which it will not deny your claim if your 7th character is wrong or even if you leave off the 7th character; however, other payers have not formally adopted a similar policy.