Medical history has been dealing with ICD- 9 until gradual changes in coding and catering to health issues using specific codes. Since ICD-10 has been introduced, medical billers and coders need to meet a range of new concepts and guidelines to deal with the difference between initial sequela vs subsequent encounter classification of codes for diagnosis.
Many expert coders are familiar with the process and the initial concepts of using subsequent and sequelae for describing the reasons for visiting hospitals. The initial sequela visit typically defines the admitting reason by the physician of a hospital or a nursing home. Or in the case of a consultant, the first visit is said to be a consultation, when the payer does not recognize the codes for consultation.
When a patient is admitted to the hospital, the insurance provider follows the hospital procedure and these services will be billed under subsequent encounter codes. However, when the patient gets discharged and at a later time gets admitted again, the process of billing will be started with an initial code and as it relates to the previous the bill will show the repetition of switching back to subsequent codes.
To diagnose coding for a range of diseases including poisoning and injuries, the ICD-10 coding system introduced the initial and subsequent concepts of coding. In this regard, ICD-10-CM brings in a new concept, sequelae, which is introduced to be used after the subsequent treatment and the active phase of injury or ailment.
The official ICD-10-CM guidelines see the initial encounter concept of coding to utilize;
“while the patient receives treatment for any condition.” It also describes that these codes can be used for surgical treatment, treatment taken or evaluation done by another physician, or for an emergency encounter.
In ICD-10-CM, the initial encounter is denoted by the seventh character of the letter A. In the ICD-10-CM the subsequent encounter is described as “once the patient received active treatment for the given condition and has received routine care for the condition throughout the therapeutic or recovery phase.” For example, the removal of the medication adjustments, fixation device, and cast change. In all of these encounters, D is the code of ICD-10-CM.
In addition, sequelae encounter has been used for complicated situations that come in after a direct accumulative health condition. For instance, the guidelines define the formation of a scar after a burn injury. In such cases, the initial ICD-10-CM code will be used as the reason for the first visit of the patient.
In the above condition, when the patient is being seen for the buildup of scar would have listed scar for the first diagnosis code. In addition, the sequelae code or the second code will be marked for the procedure and treatment given on the later dates for the causes of the scar which is of course burn in this example. These conditions will identify the code which will end with S.
Now see how the ICD-10-CM coding works in a real example of burn injury. A patient is being treated for a burn injury that he got from the hot burning water scalded on her left lower leg which was being heated on the kitchen stove.
When the patient came to check on the doctor, he was admitted to the emergency room. The doctor would use the code T24.032A to provide the initial report and to start the procedure. The code is used to describe the burn on the leg to an unspecified degree. The T31.0 will also be used because the burn occupies the body part with less than 10 percent of the whole leg area along with X12.XXXA for interacting with other hot fluids.
Here the confusion of codes needs to be clear. If a patient sought care in an emergency room for instant care and treatment. Later he went to another physician to consult as an outpatient for the continuation of the burn treatment; the physician would use the same code with A for the active injury encounters. The codes will be the same.
On the other hand, if the situation changes, after having intact care in the emergency room of a hospital and later the same patient visits the same doctor in his clinic or private care center as an outpatient, the use of encounters will be different. The physicians will use X12.XXXD for interacting with hot liquids and T24.032D for the burn of less than ten percent.
It also needs to be clear that the seventh letter of A in ICD-10-CM is used for active injury treatments. No matter how many times a person takes treatment for his burn issue, A will be used while billing. Suppose, if visiting doctors and having medicines are not working for the patient, he needs a surgical intervention for his burn, A will be still there as the seventh letter for the codes used for surgical encounters. This is because the injury is still considered an active treatment.
As said, no matter how many visits a patient may have for follow-ups and treatment of the burn injury, regardless of the number of visits, A will be continued for all medical visits.
Now suppose that the burn has healed and the patient needs treatment for the scars on his left leg. In this condition, the encounter of primary care will be diagnosed with L90.5 only for the scar treatment. Here the initial reason for the burn is healed now the scar treatment will be considered sequelae, and the encounter code will be T24.0032S which describes the reason for the scar, not the actual treatment.
It might get complicated initially to use the initial, subsequent, and sequelae encounters, but since there’s no choice, you will get comfortable as you keep using them.