The 7th Character
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.”
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