1. PLACEHOLDERS AND 7TH DIGIT CODE ASSIGNMENTS
Greater Orlando AAPC Chapter
April 17, 2018

2. USE OF PLACEHOLDER “X”
PLACEHOLDER “X” The letter "X” serves as a placeholder when a code contains fewer than six characters and a seventh character applies. The "x” also allows for future expansion of the codes. When reporting ICD-10-CM codes, coders must add a placeholder so the seventh character is in the correct position.
Example:
Fracture, Nose, Nasal Bones
S02.2 Requires 7th digit of “A”
Therefore, 5th digit and 6th digit are required. Since there are no 5th/6th digits for S02.2, placeholder “X” is assigned to both digits
Code needs to look like: S02.2_ _ A 
S02.2XXA Fracture of nasal bones, initial encounter for closed fracture

3. USE OF PLACEHOLDER “X” (continued)
Example:
Injury, Crush of Right Ankle
S Requires 7th digit of “A”
Therefore, 6th digit is required. Since there is no valid 6th digit for S97.01, placeholder “X” is assigned to 6th digit.
Code needs to look like: S97.01_A
S97.01XA Crushing injury of right ankle, initial encounter

4. 7TH Character for Injuries and Fracture Care
In Chapter 19 and Chapter 20, the seventh character provides specific information about the episode of care (e.g., initial episode, subsequent episode, and sequelae).
A, initial encounter: Used while the patient is receiving active treatment for the condition. Some examples include surgical treatment, ED encounter, and evaluation and continuing treatment by the same or a different physician.
D, subsequent encounter: Used after the patient received active treatment for the condition and is receiving routine care during the healing or recovery phase. Examples of subsequent care include cast change or removal, an x-ray to check healing status of a fracture, removal of external or internal fixation device, medication adjustment, and other aftercare and follow-up visits following treatment of the injury or condition.
S, sequelae: Used for complications or conditions that arise as a direct result of a condition, such as a scar formation caused by a burn.

5. Fracture Extensions
Categories for traumatic fractures have more available options for the seventh character. Assignment of the seventh character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time, according to the Official Guidelines for Coding and Reporting.
When used with fracture codes, it provides additional details, such as whether the fracture is closed or open (with type), whether there is routine or delayed healing, and whether the fracture was a nonunion or malunion.
Category S42 requires more specifics on the state of the fracture (Fracture of shoulder and upper arm):
A - Initial encounter for closed fracture B - Initial encounter for open fracture D - Subsequent encounter for fracture with routine healing G - Subsequent encounter for fracture with delayed healing K - Subsequent encounter for fracture with nonunion P - Subsequent encounter for fracture with malunion S - Sequela

6. Extremity Fractures – Gustilo Classifications
When coding extremities, fractures are based on Gustilo open fracture classifications. For example, this would apply when reporting codes for fractures in Category S52 (Fracture of the forearm), S72 (Fracture of Femur) and S82 (Fracture of Lower Leg). 
The following extensions are to be used to ensure a complete code:
B - Initial encounter for open fracture type I or II C - Initial encounter for open fracture type IIIA, IIIB, or IIIC E - Subsequent encounter for open fracture type I or II with routine healing F - Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing H - Subsequent encounter for open fracture type I or II with delayed healing J - Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing M - Subsequent encounter for open fracture type I or II with nonunion N - Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion Q - Subsequent encounter for open fracture type I or II with malunion R - Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion

7. Further Information from Coding Clinic
Additional Information Available from:
Coding Clinic, 1st Quarter, 2015, Page 3
7th character "A", initial encounter is used while the patient is receiving active treatment for the condition. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician.
7th character "D" subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Examples of subsequent care are: cast change or removal, an x-ray to check healing status of fracture, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition

8. Marsha S. Diamond, CPC, COC, CPMA, CCS, AAPC Fellow
QUESTIONS/COMMENTS??
CONTACT INFORMATION:
Marsha S. Diamond, CPC, COC, CPMA, CCS, AAPC Fellow
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