Solving ICD-10’s Seventh Character Conundrum

Some ICD-10 codes mandate the addition of a seventh character. Some codes have the seventh character options of just “A,” “D” and “S” while others have more options. Due to ambiguity surrounding the description of these characters, there has been great confusion over the selection of “A” versus “D.” Let us clear that up.

ICD-10 defines the seventh characters of “A” as “initial encounter” and “D” as “subsequent encounter.”¹ This can immediately lead to confusion as many of us already have an understanding of the terms “initial” and “subsequent” as they relate to selecting an appropriate evaluation and management CPT code. ICD-10 defines an “initial” encounter as one in which the physician is providing active treatment. The ICD-10 guidelines state that one should use the “subsequent” delineation “after the patient has received active treatment for the condition during the healing or recovery phase.” These definitions are very different than the ones we think of when it comes to CPT for the same terms.

For proper selection of the seventh character when considering “A” versus “D,” not only must we differentiate “initial” and “subsequent” from their CPT definitions, but we must also understand what is considered active treatment. The ICD-10 guidelines provide examples of active treatment including, “surgery, emergency department encounter, and evaluation and continuing treatment by the same or a different physician.” Active care involves care that is not merely a follow-up for the problem or injury.

When To Use An ‘A’ Code
Some examples of active care are clearer than others. If a patient comes to your office with a new injury and you evaluate the problem and render active care, choosing the seventh character of “A” would be appropriate if the ICD-10 code directs you to choose a seventh character for the presenting problem. Note that not all codes require a seventh character. Also keep in mind that the selection of the seventh character “A” does not require that this be the first time this patient has ever seen you or someone in your practice.

This is the difference between the definitions of “initial” in CPT versus ICD-10. In this scenario, initial would be appropriate for the evaluation and management CPT code if it were for a new patient. However, for ICD-10, initial is only appropriate if you provided active care.

This can also come into play in the inpatient setting. If you see a patient in the hospital and the ICD-10 code for the problem you are treating requires a seventh character, “A” would be the appropriate choice if you are providing active care whether this patient has received care from you or your practice previously or not. For care provided in the days that follow the first time you see the patient during the same hospitalization, the seventh character of “A” would continue to be appropriate as long as you continue to provide active care.

You may have a situation when you see a patient for the first time and order studies on day one, interpret those studies and make recommendations on day two, and operate on day three. The seventh character of “A” would be appropriate for each of those days. Again, this is different from the definition of “initial” when considering CPT evaluation and management codes for which you would only use an “initial” code the first time you see the patient and not on subsequent days of the same admission.

When To Use A ‘D’ Code
Situations in which you would use “D” for the seventh character are those in which you do not provide active care and do provide what most of us would think of as follow-up care. The ICD-10 guidelines give examples of subsequent encounters as those that include “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.”²

An example of this situation is if you see a patient who initially presented to a primary care provider with a lower extremity problem and that doctor provided the active treatment and subsequently referred the patient to you for follow up. Whether or not the patient is new to your practice, the appropriate ICD-10 seventh character code in this situation would be “D” as you are providing care after the patient has already received active treatment for the condition. If this patient was new to your practice, this would be a scenario in which “initial” would be appropriate for the evaluation and management code, resulting in the selection of 9920X, but “subsequent” would be appropriate for the ICD-10 code.

Another example would be seeing a patient for an ankle sprain, providing active treatment by dispensing a brace or some form of immobilization, and having that patient follow up in two weeks. The first visit, when the active treatment occurred, would receive a seventh character of “A” and the follow-up visit two weeks later would receive a seventh character of “D.”  

Why You Should Code To The Highest Specificity
As I have noted in previous Practice Builders columns, you must code to the highest specificity and your documentation must support the code. If a code has the option of being seven characters long, you must code all seven characters or risk the claim being denied. Documentation should support the code by indicating whether the care provided was active care or follow-up care. The coding for the same problem may change throughout your course of care as illustrated in the sprained ankle example above. This is something that did not happen as often or perhaps ever with ICD-9.

One thing to keep in mind is that CMS has granted a one-year grace period in which it will not deny Medicare claims based on which diagnosis code you selected as long as you submit a valid ICD-10 code from an appropriate “family” of codes. This does not mean that we do not have to code to the highest specificity. It does not mean we can get away with using a five character code when it is supposed to be seven characters long.

It does mean that if you code to the highest specificity and make an error in choosing “A” versus “D” for the seventh character, CMS will forgive that error during this first year grace period. Keep in mind that only CMS announced this grace period and at the time of this writing, no other payer has done the same.

Final Notes
Be aware that the definitions of “initial” and “subsequent” differ when considering an ICD-10 seventh character versus applying the same terms to CPT evaluation and management coding. Use “initial” when providing active care and “subsequent” after the patient has received active treatment. These designations may change throughout your care of the same problem depending on where the patient is along the course of care.

Dr. Lehrman is on the APMA Coding Committee, is an expert panelist on Codingline.com, and is a Fellow of the American Academy of Podiatric Practice Management (AAPPM).

References

1. APMA Coding Resource Center. Available at https://www.apmacodingrc.org .
2. Coding for ICD-10-CM: more of the basics. Available at https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2014-12-01-ICD-10-Presentation.pdf .
3. Natale C. Get to know the 7th character in an ICD-10 code. ICD-10 Watch. Available at www.icd10watch.com/blog/get-know-7th-character-icd-10-code . Published March 30, 2015.