Hi Kate! Great video, you definitely picked a difficult topic but you did a good job. As you can tell by now and by the comments posted below coding definitely has many gray areas. Yes, we have coding guidelines and coding clinics but sometimes it comes to the interpretation of the coder based on the documentation available in chart. The ICD-10-CM Official Guidelines for Coding and Reporting provides guidance for how and when to correctly apply the 7th character of sequela. 10. Sequela (Late Effects) A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Examples of sequela include: scar formation resulting from a burn, deviated septum due to a nasal fracture, and infertility due to tubal occlusion from old tuberculosis. Coding of sequela generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is sequenced second. An exception to the above guidelines are those instances where the code for the sequela is followed by a manifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect. See Section I.C.9. Sequelae of cerebrovascular disease See Section I.C.15. Sequelae of complication of pregnancy, childbirth and the Puerperium See Section I.C.19. Application of 7 characters for Chapter 19 Also, here are the links to the ICD-10-CM and ICD-10-PCS 2019 updates. Any 2019 changes are listed in BOLD formatting. No updates have been made to the guidance for sequela for 2019. 2019 ICD-10-CM Coding Guidelines www.cdc.gov/nchs/icd/data/10cmguidelines-FY2019-final.pdf 2019 ICD-10-PCS Coding Guidelines www.cms.gov/Medicare/Coding/ICD10/2019-ICD-10-PCS.html
I was just working thru an example in my class in which a sequela was coded as an initial encounter because the patient was referred to a new physician and the injury (a crushing injury that caused necrosis of tissue down to bone which caused a major ulcer) was still being treated (yet they still referred to it as a "late effect" in the medical report) so instead of using the D code you'd use the A which was alittle bit puzzling to me at first.
Phil Adams that is interesting! I know sequels with injuries is a bit different but I didn’t want to venture into that topic since I’m not 100% confident with that yet. Could you reply with the office note, etc from the example you were working on?!
OK I couldn't post the entire example cause the thing would be several pages but I think this paragraph might be sufficient. "To report that the ulcer is a late effect of a crush injury, index the main term crush and the sub-term leg. The code listed in the index is S87.8-. The dash indicates the need for additional characters. The Tabular List indicates a 5th character of 2 to report a crush injury of the left leg. This code requires a 6th character placeholder of X and a 7th character of A to indicate the episode of care. The final code is S87.82XA; crushing injury of left lower leg, initial encounter. Coding Enrichment: This patient’s crush injury is reported with a 7th character of A for an initial encounter because the patient is still receiving active treatment in the way of being seen by a new provider. Refer to coding guideline I.C.19.a for further clarification."
Just for grins I figured I'd try posting the example itself and see how long that would be: Try not to fall asleep reading it...."Operative Report Adjacent tissue transfer and surgical rearrangement to left leg defect, estimating it to be 15-16 sq. cm. Surgical preparation and creation of recipient site by excision of deep necrotic open wound with considerable eschar and scar tissue, skin, subcutaneous tissue, fascia, muscle, and down to bone. Diagnosis: Open necrotic ulcer of the leg, 16 sq. cm. in size, extending through full-thickness skin, subcutaneous tissue, fascia, muscle, and down to bone. Indications: The patient was referred from ___ [PLACE] with a complicated leg injury with subsequent development of deep necrotic ulcer, which had been getting worse over time. The injury happened nearly 1 month ago from a crush injury involving the left lower extremity. From the time of the original injury until now, the necrosis appears to be mostly due to extensive crush injury involving the tissue. There is no exudate and no signs of infection. Operation in Detail: After sterile preparation and draping in the normal sterile fashion, and local anesthetic, using a 15-blade scalpel and iris scissors, the wound was debrided of devitalized and necrotic tissue until healthy tissue with adequate bleeding was achieved. This involved excision of skin, subcutaneous tissue, fascia, and muscle, and at the deepest margins the tissue was extremely crushed and devitalized and mostly due to this, as evident by the nature of the injury and the tissue involved. After 25 minutes was spent doing extensive debridement, the wound was irrigated with antibiotic saline solution. Since there was bone exposed, covering the wound was necessary. On preoperative evaluation, the patient did have a possible dorsalis pedis and posterior tibial pulse. He did have swelling in the area. He had been worked up for diabetes at ___ [PLACE] and all his workup turned out to be negative. The patient states he has never smoked more than a couple of cigarettes a day and states that for 10-15 years he has smoked 2 cigarettes a day. The decision was made for local tissue rearrangement with a rotation advancement flap. It was based proximally on a more robust blood supply. An incision was made with a scalpel, including the fascia; hence, a fascia-cutaneous rotation advancement flap was developed superiorly based on a fairly robust pedicle, including the fascial components. This allowed fascial advancement. The fascia was released proximally, in order to allow further advancement so that the fascia was advanced and would cover the exposed bone defect. The subcutaneous and fascia layers were reapproximated using 4-0 PDS sutures, hence, placing no significant tension on the skin closure. The skin was closed using 4-0 PDS suture. Some undermining was done in order to take further tension off of the closure. The patient tolerated the procedure well. No complications occurred throughout. The patient understands the importance of elevating the leg to prevent swelling. There is a possibility of future development of a newer ulcer or flap necrosis and development of an ulcer, which would result in more conservative treatment. The patient apparently had adequate blood supply to the flap throughout the procedure. Post procedure the patient also had good normal pinprick bleeding and good capillary refill to the distal end of the flap. The patient was given distinct postoperative instructions and will follow up back in my office for re-evaluation and suture removal in 2-3 weeks. He will follow up next week if there are any problems or concerns with the flap, which were discussed in detail. Estimated blood loss was less than 50 cc."
Phil Adams I actually wouldn’t consider that a sequela, but I understand why it’s the 7th character initial. Since this patient is seeing a new doctor in a different facility for the very first time it is the initial encounter. Let me expand on that, so this patient saw Dr X for this injury at South Medical Group but was referred to Dr Z at North Health Center for further treatment. So this current encounter with Dr Z is the initial encounter and any follow up of this injury with Dr Z would be subsequent encounters. So Dr Z has never treated this patient and injury before so the coding needs to reflect that which would mean the very first encounter with Dr Z would be initial even though the patient has been dealing with this injury for over a month. Hopefully that makes sense!
Do you mind me asking what online course you are taking or was taking? I've just ran across your videos and hope they help me understand better. I an 50. So needless to say this is my first time taking an online course so between that and my brain not being used for many years, I am struggling. I am taking Career Step online course. And I feel like having a teacher in front of me would be a lot better for me. LOL And also I am having trouble understanding the excludes 1 and 2. Do you have a video on that. Thanks, Jacqueline
Jacqueline Harris I took AHIMAs online coding Basics Program which doesn’t have a teacher in front of you which might not be the best option for you. As far as excludes 1 and 2, I do have a video that covers conventions in ICD-10. Excludes 1 means the codes listed CANNOT be used with the code you are looking at usually because they are codes that contradict each other and cannot be present at the same time. Excludes 2 means the codes listed can be used with the code you are looking at usually because they are codes that most commonly happen together.
Hi Kate... I have a doubt regarding coding Dementia with behavioral disorder. Now, if the patient has agitation. Do we need to code F0391 + agitation code or just F0391?
thanks so much! this helped me understand it so much more
Hi Kate
You are doing great job
thanks for this- in the process of getting my NP degree in women’s health and this was helpful with one of my courses!
Hi Kate!
Great video, you definitely picked a difficult topic but you did a good job. As you can tell by now and by the comments posted below coding definitely has many gray areas. Yes, we have coding guidelines and coding clinics but sometimes it comes to the interpretation of the coder based on the documentation available in chart.
The ICD-10-CM Official Guidelines for Coding and Reporting provides guidance for how and when to correctly apply the 7th character of sequela.
10. Sequela (Late Effects)
A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Examples of sequela include: scar formation resulting from a burn, deviated septum due to a nasal fracture, and infertility due to tubal occlusion from old tuberculosis. Coding of sequela generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is sequenced second.
An exception to the above guidelines are those instances where the code for the sequela is followed by a manifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect.
See Section I.C.9. Sequelae of cerebrovascular disease
See Section I.C.15. Sequelae of complication of pregnancy, childbirth and the
Puerperium
See Section I.C.19. Application of 7 characters for Chapter 19
Also, here are the links to the ICD-10-CM and ICD-10-PCS 2019 updates. Any 2019 changes are listed in BOLD formatting. No updates have been made to the guidance for sequela for 2019.
2019 ICD-10-CM Coding Guidelines
www.cdc.gov/nchs/icd/data/10cmguidelines-FY2019-final.pdf
2019 ICD-10-PCS Coding Guidelines
www.cms.gov/Medicare/Coding/ICD10/2019-ICD-10-PCS.html
Coder Garcia thank you so much for all of this information!!!!! So glad you’re watching my videos no helping out where I desperately need it!!!!
I was just working thru an example in my class in which a sequela was coded as an initial encounter because the patient was referred to a new physician and the injury (a crushing injury that caused necrosis of tissue down to bone which caused a major ulcer) was still being treated (yet they still referred to it as a "late effect" in the medical report) so instead of using the D code you'd use the A which was alittle bit puzzling to me at first.
Phil Adams that is interesting! I know sequels with injuries is a bit different but I didn’t want to venture into that topic since I’m not 100% confident with that yet. Could you reply with the office note, etc from the example you were working on?!
OK I couldn't post the entire example cause the thing would be several pages but I think this paragraph might be sufficient. "To report that the ulcer is a late effect of a crush injury, index the main term crush and the sub-term leg. The code listed in the index is S87.8-. The dash indicates the need for additional characters. The Tabular List indicates a 5th character of 2 to report a crush injury of the left leg. This code requires a 6th character placeholder of X and a 7th character of A to indicate the episode of care. The final code is S87.82XA; crushing injury of left lower leg, initial encounter.
Coding Enrichment: This patient’s crush injury is reported with a 7th character of A for an initial encounter because the patient is still receiving active treatment in the way of being seen by a new provider. Refer to coding guideline I.C.19.a for further clarification."
Just for grins I figured I'd try posting the example itself and see how long that would be: Try not to fall asleep reading it...."Operative Report
Adjacent tissue transfer and surgical rearrangement to left leg defect, estimating it to be 15-16 sq. cm.
Surgical preparation and creation of recipient site by excision of deep necrotic open wound with considerable eschar and scar tissue, skin, subcutaneous tissue, fascia, muscle, and down to bone.
Diagnosis: Open necrotic ulcer of the leg, 16 sq. cm. in size, extending through full-thickness skin, subcutaneous tissue, fascia, muscle, and down to bone.
Indications: The patient was referred from ___ [PLACE] with a complicated leg injury with subsequent development of deep necrotic ulcer, which had been getting worse over time. The injury happened nearly 1 month ago from a crush injury involving the left lower extremity. From the time of the original injury until now, the necrosis appears to be mostly due to extensive crush injury involving the tissue. There is no exudate and no signs of infection.
Operation in Detail: After sterile preparation and draping in the normal sterile fashion, and local anesthetic, using a 15-blade scalpel and iris scissors, the wound was debrided of devitalized and necrotic tissue until healthy tissue with adequate bleeding was achieved. This involved excision of skin, subcutaneous tissue, fascia, and muscle, and at the deepest margins the tissue was extremely crushed and devitalized and mostly due to this, as evident by the nature of the injury and the tissue involved.
After 25 minutes was spent doing extensive debridement, the wound was irrigated with antibiotic saline solution. Since there was bone exposed, covering the wound was necessary.
On preoperative evaluation, the patient did have a possible dorsalis pedis and posterior tibial pulse. He did have swelling in the area. He had been worked up for diabetes at ___ [PLACE] and all his workup turned out to be negative.
The patient states he has never smoked more than a couple of cigarettes a day and states that for 10-15 years he has smoked 2 cigarettes a day.
The decision was made for local tissue rearrangement with a rotation advancement flap. It was based proximally on a more robust blood supply. An incision was made with a scalpel, including the fascia; hence, a fascia-cutaneous rotation advancement flap was developed superiorly based on a fairly robust pedicle, including the fascial components. This allowed fascial advancement. The fascia was released proximally, in order to allow further advancement so that the fascia was advanced and would cover the exposed bone defect. The subcutaneous and fascia layers were reapproximated using 4-0 PDS sutures, hence, placing no significant tension on the skin closure. The skin was closed using 4-0 PDS suture. Some undermining was done in order to take further tension off of the closure. The patient tolerated the procedure well. No complications occurred throughout. The patient understands the importance of elevating the leg to prevent swelling. There is a possibility of future development of a newer ulcer or flap necrosis and development of an ulcer, which would result in more conservative treatment.
The patient apparently had adequate blood supply to the flap throughout the procedure. Post procedure the patient also had good normal pinprick bleeding and good capillary refill to the distal end of the flap. The patient was given distinct postoperative instructions and will follow up back in my office for re-evaluation and suture removal in 2-3 weeks. He will follow up next week if there are any problems or concerns with the flap, which were discussed in detail.
Estimated blood loss was less than 50 cc."
Phil Adams I’m actually going to save that op report and assign CPT and PCS codes!
Phil Adams I actually wouldn’t consider that a sequela, but I understand why it’s the 7th character initial. Since this patient is seeing a new doctor in a different facility for the very first time it is the initial encounter. Let me expand on that, so this patient saw Dr X for this injury at South Medical Group but was referred to Dr Z at North Health Center for further treatment. So this current encounter with Dr Z is the initial encounter and any follow up of this injury with Dr Z would be subsequent encounters. So Dr Z has never treated this patient and injury before so the coding needs to reflect that which would mean the very first encounter with Dr Z would be initial even though the patient has been dealing with this injury for over a month. Hopefully that makes sense!
i got it! 😊
The scenario that came to mind as you were explaining is h.pylori infection where the infection is treated and eradicated but ulcers can return.
Great job explaining this!
This is so informative, thank you!
Garcia Donald Perez Brian Harris Maria
Well explained...😊
Do you mind me asking what online course you are taking or was taking? I've just ran across your videos and hope they help me understand better. I an 50. So needless to say this is my first time taking an online course so between that and my brain not being used for many years, I am struggling. I am taking Career Step online course. And I feel like having a teacher in front of me would be a lot better for me. LOL And also I am having trouble understanding the excludes 1 and 2. Do you have a video on that. Thanks, Jacqueline
Jacqueline Harris I took AHIMAs online coding Basics Program which doesn’t have a teacher in front of you which might not be the best option for you. As far as excludes 1 and 2, I do have a video that covers conventions in ICD-10. Excludes 1 means the codes listed CANNOT be used with the code you are looking at usually because they are codes that contradict each other and cannot be present at the same time. Excludes 2 means the codes listed can be used with the code you are looking at usually because they are codes that most commonly happen together.
@@codingwithkate3792 hi
Hi! Thanks for these videos. Just curious if you’ve had any luck with getting a coder position?
Carinna Dailey thank you!!! I’m hoping to have an update on that pretty soon!
... interesting...
Sequela of Injuries video please!!
Hi Kate... I have a doubt regarding coding Dementia with behavioral disorder. Now, if the patient has agitation. Do we need to code F0391 + agitation code or just F0391?
Hi Kate. Are you going to pursue getting a CCS? are you in the process?
Maria Moore I am going to pursue getting my CCS when my CCA expires in 2020!
HELLO, CAN YOU GIVE MORE TOPICS AND EXERCISES ABOUT SEQUELA
Have you used an Encoder other than in the classroom?
I WOULD LIKE TO DO MORE EXERCISES IN Y0UR VIDEOS