Cracking the Code

Initial vs Subsequent Encounter

Sometimes, there is confusion about when to assign the seventh character for diagnosis codes S00-T88 with “A” for initial encounter or “D” for subsequent encounter. “Initial encounter” for an injury does not always equate to an “initial visit.” Per Chapter 19 of FY2022 ICD-10-CM Official Guidelines for Coding and Reporting, assignment of the seventh character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time. Some examples of active treatment are surgical treatment, emergency department encounter, and evaluation and treatment by a new physician. Some examples of routine care during the recovery phase are cast change or removal, removal of external or internal fixation device, medication adjustment, and other aftercare and follow up visits following injury treatment.

In conclusion, active treatment occurs when the provider sees the patient and develops a plan of care. The patient following that plan is when a subsequent encounter occurs. If the patient is receiving active treatment for their condition, then it is appropriate to assign “A” for the seventh character. If the patient has completed active treatment for their condition but is receiving routine care during the healing or recovery phase, then it is appropriate to assign “D” for the seventh character.

Q: A patient presents to the ED for removal of sutures of their laceration to the right middle finger. Patient tolerates procedure well and is discharged home.
A: S61.212D, Laceration without foreign body of right middle finger without damage to nail, subsequent encounter
X58.XXXD, Exposure to other specified factors, subsequent encounter
Reference: CD-10-CM Official Guidelines for Coding and Reporting FY 2022 Section I.C.19.a.
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