The 7th Character

How important is the 7th character for Medicare/Medicaid claims?

authors Lynne Jeter

The tempo of physician practices has been disrupted since the Centers for Medicare & Medicaid Services (CMS) changed the International Classification of Diseases (ICD) code set from 9 to 10, effective Oct. 1, 2015.

But changing from using a 30-year-old coding system with a few thousand codes and few characters, to the expanded coding system with tens of thousands of codes containing up to 7 characters, has made the transition difficult.  

Another stumbling block: the new 7th character.

“Yes, it’s confusing,” admitted optometrist Jeffrey P. Schultz, OD, of Asheville Eye Associates in Asheville, NC. “The 7th character isn’t always needed, but if the claim isn’t submitted correctly, it gets kicked back. We can’t afford that.”

Sue Bowman, senior director of coding policy and compliance for the American Health Information Management Association (AHIMA), concurred with Schultz: “Codes for which a 7th character applies are invalid if the 7th character is missing.”

Bowman explained the 7th character is used in chapters concerning musculoskeletal, obstetrics, injuries, and external causes. The most common 7th characters are for initial encounter, subsequent encounter, and sequelae, Bowman noted.

“The 7th character for initial encounter is used as long as the patient is receiving active treatment for the condition,” said Bowman, citing these examples: surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician.


More Specifically …

Nelly Leon-Chisen, director of coding and classification for the American Hospital Association (AHA), explained the 7th character for subsequent encounters is assigned after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.

“For aftercare of injuries, the acute injury code with the appropriate 7th character for subsequent encounter should be assigned rather than the aftercare ‘Z’ codes, which are reserved for non-injury related conditions,” she explained. “Fracture malunions and nonunions are assigned the appropriate 7th character for subsequent encounter for malunion or nonunion, unless the patient delayed seeking fracture treatment.”

Leon-Chisen rattled off several examples where a 7th character for “subsequent encounter” would be applied:

  • Rehabilitation therapy encounters;
  • Cast or splint adjustment;
  • Dressing changes;
  • Suture removal;
  • Removal of external or internal fixation device;
  • Medication adjustment;
  • Follow-up x-rays to determine healing status of fracture; and
  • Follow-up visits to check healing status, regardless of same or different provider.

The 7th character for sequela is used for the residual effect or conditions that arise as a direct result of an acute condition, such as scar formation after a burn, said Leon-Chisen, noting other examples: traumatic arthritis following a previous gunshot wound; quadriplegia because of a spinal cord injury; auricular chondritis due to previous burns; and chronic respiratory failure following a drug overdose.


Example of Appropriate Application of 7th Character Use

Bowman traced the steps for the appropriate application of 7th Character use with a patient seen in the Emergency Department after falling down a flight of stairs.

“The patient was diagnosed with a displaced fracture of the medial malleolus of the right ankle,” she said. “In step 1, we look up the term in the alphabetic index: fracture, traumatic, ankle, medial malleolus (displaced) and we get code S82.5 DASH, with the DASH indicating that additional characters are needed, which we’ll find in the tabular list.”

In step 2, the code is verified in the tabular list.

“At S82 fracture of the lower leg, including ankle, there are a couple of notes to provide guidance,” Bowman pointed out. “First, there’s a note stating that a fracture not indicated as displaced or nondisplaced should be coded to ‘displaced.’ Second, a fracture not indicated as open or closed should be coded to ‘closed.’ There’s also a note that instructs … the appropriate 7th character is to be added to all codes from category S82.”

In the next step, S82.5 fracture of medial malleolus “confirms that we’re in the right place,” said Bowman. “We selected S82.51 for displaced fracture of medial malleolus of right tibia. Depending on the code book used, there may be a symbol or figure to indicate that a placeholder character ‘x’ is needed before assigning the 7th character. In some code books, the publisher has already pre-populated the character ‘x.’ This is an initial encounter and the correct code assignment is S82.51xA.”

Concurrently, the same patient was referred to an orthopedist for further evaluation and treatment. The same ICD-10-CM code is assigned since treatment remains active.

“When the same patient returns to the orthopedist for follow-up to assess the healing status, a malunion is diagnosed,” said Bowman. “Now the code has changed and we’re using the 7th character for subsequent encounter with malunion. Notice the 7th character is ‘P,’ rather than ‘D.’ Although ‘D’ is the most common 7th character for subsequent encounter, it’s not the only one. Check the tabular list to determine which 7th character value is applicable as they may vary from category to category.”

Bowman noted that when the same patient was admitted for surgical treatment of the malunion, the code S82.51xP remains in effect.

“The only exception is in the case of delayed treatment … so the first presentation for care is a malunion or nonunion,” she explained.

Post-surgery, the same patient returns to the orthopedist for follow-up to assess the healing status.

“The 7th character for this visit is now changed to ‘D’ for subsequent encounter, closed fracture, routine healing, since the malunion is no longer present and the fracture is healing well,” Bowman emphasized. “When the same patient has an outpatient physical therapy encounter, the same code with the 7th character of ‘D’ (S82.51xD) is assigned.”


Still Confused?

Coding questions may be submitted to Coding Clinic Advisor (see link below), a free service that used the same process for ICD-9-CM questions.

“Be sure to formulate an actual coding question and not just ask us to code your entire superbill or an entire record, validate your code assignment, or (ask) ‘what’s the code for XYZ?,’” cautioned Leon-Chisen. “We can only address specific coding problems submitted with supporting medical record documentation. Along with your question, specify whether it refers to a certain setting – for example, skilled nursing facility, home health, or acute hospital inpatient. We cannot answer questions on payment or coverage issues, or on the general equivalence maps (GEMS).”

Leon-Chisen emphasized that the pro bono arm of the organization isn’t able to support requests for ICD-10-PCS coding advice related to hospital outpatient procedures, since ICD-10-PCS is the HIPAA standard for inpatient hospital procedure coding only.



  • American Health Information Management Association (AHIMA) ICD-10 Library
  • American Hospital Association (AHA) ICD-10 Information
  • American Medical Association’s (AMA) “How to Report Issues with ICD-10 Medicare Claims”
  • CMS ICD-10
  • Coding Questions

More in Clinical

Clinical  May 04

The Pill, Prescriptions, Pharmacists & Physicians

‘The Pill’ made headlines and stirred up controversy in the late 1950s and early 1960s as the nation debated whether or not women…

Clinical  Apr 21

The Bidens at AACR

On April 20, Vice President Joe Biden and Jill Biden, EdD, addressed over 4,000 attendees during the American Association for Cancer…

Clinical  Apr 12

Zika Legislation Headed to President's Desk

On April 12, Chairman Lamar Alexander (R-Tenn.) made the following statement as Senate health committee-passed legislation to spur…

Business  Apr 07

Planning for Long-Term Care

“A man who procrastinates in his choosing will inevitably have his choice made for him by circumstance.” – Hunter S. Thompson

Clinical  Apr 07

Plan to Address Mental Health Crisis

A bipartisan U.S. Senate group looks to ease the burden on Americans suffering from mental health and substance abuse disorders…

Clinical  Apr 06

Artificial Intelligence, Real Results

Developers have created a new tool that combines predictive analytics with artificial intelligence to improve outcomes and decrease…

Clinical  Apr 06

Surgeons Test Technology with Potential to Expand Lung Transplant Donor Pool

Organ transplant patient Michele Coleman receives a follow-up exam a few months after surgeons at Washington University School of Medicine in St. Louis gave her a new set of lungs.

Clinical  Mar 29

AMA on Ending Opioid Epidemic

Opioid and heroin abuse have skyrocketed in America prompting new guidelines and regulations from the CDC and FDA. The AMA weighed in…

Clinical  Mar 28

Cells Have Strategies to Get Back on Track After Replication Stress

In a recent review paper published in Nature Structural & Molecular Biology, Saint Louis University scientist Alessandro Vindigni, Ph.D., describes the strategies cells use when their DNA faces replication stress, challenges that may derail a…

Clinical  Mar 03

Findings may guide design of new drugs

Genetic errors identified in a new study led by Washington University School of Medicine in St. Louis may reduce risk of heart attacks…

Business  Feb 29

‘Trigger Tool’ Available for Hospitals and SNFs

How can ‘trigger tools’ identify adverse events?

Clinical  Feb 29

Cancer Stats & Facts

Each year the American Cancer Society releases the latest data as a litmus test of where the nation stands in the fight against cancer.

Clinical  Feb 24

Technology may improve treatment for deadly brain cancer

Using a laser probe, neurosurgeons at Washington University School of Medicine in St. Louis have opened the brain’s protective…

Clinical  Feb 23

Ending the Opioid Epidemic

Read the Feb. 22 joint statement by National Governors Association Health & Human Services Committee Chair Massachusetts Gov. Charlie Baker; Vice Chair New Hampshire Gov. Maggie Hassan; American Medical Association Chair-Elect Patrice A. Harris, MD, MA

Business  Feb 08

Challenging Population Health Management Issues

The nation’s leading forum on innovations in population health is slated for March 7-9 in Philadelphia.

Clinical  Feb 08

Prevent, Protect, Improve

Healthways and Dr. Dean Ornish have teamed up on a secondary intervention proven to not only treat heart disease but also to reverse…

Clinical  Feb 04

Scientists More Effectively Control Pain by Targeting Nerve Cell’s Interior

New research indicates that the location of receptors that transmit pain signals IS important in how big or small a pain signal will…

Business  Jan 26

Taken for Granted: A New Era in Care – the New SSM Health Saint Louis University Hospital

Patient-centered design will enhance the new state-of-the-art academic facilities.

Clinical  Jan 26

New Outpatient Care Center Under Construction in South St. Louis County

Washington University School of Medicine in St. Louis and Barnes-Jewish Hospital (BJH) are building a new outpatient facility in south…

Clinical  Jan 26

Bhayani Named Holekamp Family Chair in Urology

Sam Bhayani, MD, who recently was appointed chief medical officer of the Faculty Practice Plan at Washington University School of Medicine in St. Louis, has been named the Holekamp Family Chair in Urology at Barnes-Jewish Hospital (BJH) and the School

Clinical  Jan 18

Team Develops Wireless, Dissolvable Sensors to Monitor Brain

A team of neurosurgeons and engineers has developed wireless brain sensors that monitor intracranial pressure and temperature and then…

  Load more content