Initial, Subsequent, and Sequela 7th Character Assignment for Injuries, Poisonings, and Fractures

Explore the distinction between initial, subsequent, and sequela 7th character assignment for injuries, poisonings, and fractures in this episode of “In the kNOW.”  The usage of these 7th characters is intended to illustrate the care received for a particular patient encounter.  Let’s look at the meaning of each of these terms to help develop a better understanding of their application.

The 7th character used for initial care is “A” for active care which is explained as:

• Emergency room care 
• Surgical care  
• Evaluation/treatment by same/different physician

It is important to remember that not all surgical care will be active treatment however.  Consider a patient who had a Colles fracture with ORIF and now has a nonunion.  The internal fixation device must be removed so that is a procedure that will be performed after the patient had the active (initial) surgery for the repair and will not carry the “A” designation.  

Additionally, not every physician visit will be active care, even it is the first time a physician sees a patient.  For example, a boy had an ankle fracture and received surgical treatment.  Now, his family has moved to a new city and he has to see a new orthopedist in follow-up. That visit will be of a subsequent nature and carry the appropriate 7th character to reflect that status.

Active care may also be staged or necessitate multiple visits/physicians.

“D” is the 7th character used to show subsequent care for routine healing and recovery.  This can be used in a variety of circumstances such as:

• X-rays to monitor fracture healing
• Cast change/removal
• Internal/external fixation device removal
• Adjustment of medication
• Other types of aftercare or follow up visits

The 7th character for sequela is “S”.  A sequela is a condition/complication that is a direct result of another condition.  Think scar as a result of a burn.  The scar is the sequela.  An important note for sequelae is that there is no time table for a sequela.  It can be evident immediately after an injury or condition like dysphagia following a stroke, or it can take years to manifest such as the development of pleural calcifications years after TB.

The number of 7th characters expands when we talk about fractures.  Here the 7th character will tell if the fracture is:

• Closed/open  (A, B)
• Routine/delayed healing  (D, G)
• Nonunion/malunion  (K, P)
• Sequela  (S)

We’ll find another layer of specificity for those fractures that are designated with the Gustilo classification; open fractures of the forearm, femur, and lower leg.  These 7th characters take into consideration which type of Gustilo classification fits the fracture as outlined below:

• B=initial, open, type I or II
• C=initial open, type IIIA, IIIB, or IIIC
• E=subsequent, open, type I or II routine healing
• F=subsequent, open, type IIIA, IIIB, or IIIC routine healing
• H=subsequent, open, type I or II delayed healing
• J=subsequent, open, type IIIA,IIIB, or IIIC delayed healing
• M=subsequent, open, type I or II nonunion
• N=subsequent, open, type IIIA, IIIB, or IIIC nonunion
• Q=subsequent, open, type I or II malunion
• R=subsequent, open, type IIIA, IIIB, or IIIC malunion

With one exception, aftercare codes should not be assigned when coding care related to injuries, poisonings, and fractures because the 7th characters that have been discussed above provide a more specific indication of the type of aftercare given.  The exception is when a joint prosthesis has been previously removed due to a complication and now, at the episode of care when the replacement prosthesis will be inserted, an aftercare code is appropriate (Z47.3X)-aftercare following explantation of joint prosthesis (staged procedure).   

A final thought, for complications, active treatment relates to the treatment directed to the condition described by the code, not the problem that caused the condition which may have occurred earlier.  For instance, if a patient had a hip fracture and had to have a joint prosthesis which became infected, the code would be for the complication of the joint prosthesis which is infected, not the hip fracture which no longer exists but caused the need for the joint prosthesis. 

Now you are In the kNOW!!

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.