Amazing Coding Guide for Sequela encounter ICD 10 Codes

In ICD 10, the injury codes are still creating lot of problems for medical coders.  They are still not able to use and differentiate between the intial, subsequent and sequela ICD 10 codes. The use of 7th character for initial and subsequent encounter can be understood after coding some injury charts, but the use of Sequela ICD 10 codes are still a big confusion for coders.

As per the definition of ICD-10-CM,  the seventh character ‘S‘ is used for complications or conditions that arise as a direct result of an injury, such as scar formation after a burn. The scars are sequelae of the burn.” In other words, sequela are the late effects of an injury.

The 7th character is really expanded too much and given really great specificity to injury ICD 10 codes. Before learning ahead of Sequela, checkout the below post to know more about ICD 10 injury codes.

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What exactly Sequela means?

Sequela conditions are happens to stay for long time like chronic conditions, which are a result of any injury or trauma. For example, if a patient has a knee injury which got healed after few days, but the knee pain is still present even after months. This is called chronic pain and will continue to occur even when their is no injury. Hence, in such scenario chronic pain due to trauma is reported.

Documentation for coding Sequela ICD 10 codes

Before using any Sequela ICD 10 codes, do check properly the documentation. The documentation should clearly support the use of Sequela ICD 10 codes. A direct link between the condition and the original cause of that condition, should be clearly documented before assigning a sequela category ICD 10 code. 

For example, if a patient has “aphasia” documented in the record, it is important to determine when the aphasia was present. Is it a new condition associated with a current condition, such as a stroke? If so, a code from the I69 category is not appropriate. I69 category includes the codes for sequelae of a cerebral infarction.

On the other side, if the same aphasia condition is not a new condition, and occurred due to previous cerebrovascular problem, in that scenario, the provider’s documentation should clearly specify “aphasia” as a residual condition.

Use of specific and clear documentation by the provider can help in the correct coding of sequela ICD 10 codes. For example, if the provider clearly documents a link between a condition and the original cause of that condition. If the above example has “”aphasia due to previous cerebral infarction” documented in the report, the coder  can confidently code the sequela condition.

Finally, if their is no presence of any residual of aphasia and the report clearly documents the presence of cerebral infarction in the past, in that case the a personal history Z code (Z86.73) should be used. The ICD 10 Z code Z86.73 denotes the  Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits.

The supporting documentation for Sequela conditions can be found in History and physical (H&P), progress notes, operative notes, discharge summary and consultations.