“We had a patient present with a fracture of her foot. The debate in the office is the ICD-10-CM definition of “subsequent care” as it refers to trauma. We saw the patient, diagnosed a fracture and chose to treat the fracture with conservative care. Would those follow up visits be considered “subsequent care” or “initial care” while we follow through with the initial treatment for the fracture?”
So, the issue in question is the ICD-10-CM definition of “subsequent care” with respect to trauma. ICD-10-CM codes that are directly related to trauma need to be coded to 7th characters. There are two groups of 7th characters for ICD-10-CM codes that are linked to trauma.
The first group of ICD-10-CM trauma diagnosis codes are those that are not related to fractures.
Non-Fracture Seventh Character Codes:
A = Initial encounter
D = Subsequent encounter
S = Sequela
The second group of ICD-10-CM trauma codes are those that are related to fractures.
Fracture Care Seventh Character Codes:
A = Initial encounter for closed fracture
B = Initial encounter for open fracture
D = Subsequent encounter for normal healing fracture
G = Subsequent encounter for delayed healing fracture
K = Subsequent encounter for fracture with non-union
P = Subsequent encounter for fracture with mal-union
S = Sequela of fracture
Whether the incident of trauma is a fracture or is not a fracture, the “Initial Encounter” is the first time that the patient is seen for the trauma and is treated for the incident of trauma. The “Subsequent Encounter” is representative of the follow up care of the incident of trauma.
In the above post, the patient was apparently seen for a fracture of the foot. The physician chose to treat the fracture with conservative care. I am making the assumption that the physician chose not to treat the fracture using a “fracture care code (ie. closed treatment of the fracture without manipulation),” but chose to treat the fracture by periodically seeing and treating the patient and billing for the “conservative care” by treating the patient via an E/M service. If this is the course of treatment, two issues need to be addressed.
First of all, the ICD-10-CM code that is used for all of the follow up encounters needs to have a 7th character that designates that this is a subsequent encounter.
Secondly, the rules for billing an E/M service must be followed:
1. E/M is NOT a synonym for an office visit.
2. It is a 2 part process:
a. “E” stands for EVALUATION. Using a Medically Appropriate History and/or Examination and *Medical Decision Making, you formulate a WORKING DIAGNOSIS.
This shows MEDICAL NECESSITY.
b. “M” stands for management. Using the working diagnosis, you now have to do something about it. In other words, you have to TREAT THE PROBLEM. Diagnosing a problem is not sufficient.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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