7th Character: Initial, Subsequent, & Sequela
Initial Encounter (A)
The seventh character "A" designates what is referred to as an "Initial Encounter" in coding. However, this title is a bit deceptive, as it does not only apply to initial visits, but also applies to each consecutive visit thereafter in which the patient is receiving active care.
The "A" is appropriate for the initial evaluation of a patient, even if the patient has been evaluated and has received treatment elsewhere by another provider. Additionally, if the plan of care is adjusted, such as with surgical intervention, care becomes "active" once again, even if it had previously progressed into what is referred to as the "subsequent encounter" in coding.
Subsequent Encounter (D)
Subsequent Encounters, as designated by the 7th character "D," are defined as “encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase." Examples include cast change/ removal, medication adjustment, and other aftercare and/or follow up visits following injury treatment.
Subsequent codes can be reported with the "D" character for as long as the provider is treating the patient in the recovery phase after a plan of care has been established. Once the plan of care is adjusted (such as due to a set-back) the care becomes active again, designated with the "A." Therefore, the seventh character can teeter-totter between the "A" and the "D" several times throughout the course of treatment, under certain circumstances.
Often confused with the seventh character "D" for subsequent codes, the seventh character "S" sometimes has new coders saying, "Seq... well.... uhhhhh?" Sequela, is a Latin word that means "that which follows." Therefore, medically speaking, a sequela is a condition which is a consequence, or residual effect, of a previous disease, injury, or other trauma. A sequela is typically a chronic condition that follows an acute condition. For ICD-10-CM purposes, the seventh letter "S"which is used to designate the treatment of a sequela, is attached to the original injury code, NOT the sequela itself.
Reporting of sequelae usually require at least two codes:
(FIRST): The sequela condition that is currently being treated as a result of the sequela
(SECOND): The sequela code (the original injury code followed with the seventh character "S")
There is no time limit on reporting sequelae. Some sequelae are quickly apparent, such as paralysis following a stroke, or may appear later, such as a contracture following a tendon injury.
NEVER use the code for the acute phase of an illness or injury that led to the sequela with a code for the late effect. Sequelae are NOT reported as symptoms.