Injuries are the big headache in ICD 10 coding. Since, the time ICD 10 has been implemented, their has been high increase in coding errors in injury and fracture coding.

Though, we have overcome the common errors of ICD 10 , we need to still learn more to improve our coding skills. ICD 10 has very interesting codes like the Z3A category codes, unilateral and bilateral codes for extremities, injury codes with 7th character etc.

The use of initial (A), subsequent (D) encounter in injury codes is always a hot topic to discuss. So, let use learn some new elements in this topic.

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Initial (A) Versus Subsequent (D) Encounter

The use of initial encounter (A) or acute care for any injury can be stopped if the patient has is going through the routine recovery or healing phase. Yes, this is little difficult to understand, but we will try to understand with an example.

Suppose, a patient has a fracture and the physician treats him, this will be the “active treatment” or “acute care” visit. Now, the patient in under routine care for the condition during healing phase. When the patient again comes to the physician that visit will be either initial or subsequent depending on the status of the condition or injury.

Examples of Active Treatment:

Surgical Treatment
Emergency department encounter
Continuation of IV antibiotic administration
Wound VAC dressing changes
Evaluation and continuing (ongoing) treatment by the same or a different physician

Yes, if the patient during healing phase is recovering well and the treatment is going in right direction, then this visit will be considered as follow-up routine visit and this will be considered as Subsequent encounter (D as 7th character). So, in this case we can say the patient condition is responding to the treatment.

But, if the patient injury is not healed and the treatment was not successful, the physician has to again give the patient “active treatment” by applying cast or ordering MRI exam. In such case, this subsequent visit will not a reported as subsequent encounter. Since, the physician decides to gives the patient the active treatment, this subsequent visit will be coded as Initial Encounter (A as 7th character)

Maximum Medical Improvement (MMI) concept

This concept is good to understand the use of A and D as 7th character while coding injury codes. Medical coders can use “A” as active treatment, till the treatment reaches to Maximum Medical Improvement.

As we have seen in the above example, if the patient injury is not healed or improved from active treatment, then we should not considered the subsequent visit as subsequent encounter.

Only, the routine subsequent visit, where the patient has achieved MMI, can be coded as “Subsequent Encounter” with D as 7th character.