Initial, Subsequent, and Sequela Confusion

Although reports indicate much of the transition to International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) has gone well, there are still some areas that continue to raise questions. High on this list is the use of seventh characters for initial or subsequent care and care for late effects of injury. Can you answer the following questions based on ICD-10-CM guidelines for reporting encounters related to injuries?

The physician is not treating conditions associated with current abuse, but the behavioral and emotional complaints are a direct result of previous abuse and would be classified as late effects or sequela. ICD-10-CM guidelines tell us sequela may appear soon after an injury or arise later. A physician’s documentation indicating a problem or condition is due to an injury supports reporting a code for sequela. In answer to this first question, codes representing the specific...

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