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Part of mastering ICD-10-CM requires an understanding of the new terminology. In ICD-9-CM, codes identifying residual effects following treatment for the acute phase of an illness or injury are designated as late effect codes. In ICD-10-CM, the term “late effect” has been replaced with sequela.

General Guidelines

The ICD-10-CM guidelines define a sequela as “the residual effect (condition produced) after the acute phase of an illness or injury has terminated.” The general coding guidelines in ICD-10-CM for coding of sequelae are essentially the same as coding of late effects in ICD-9-CM and are as follows:

  • There is no time limit on when a sequela code can be used
  • The residual effect may be present early or may occur months or years later
  • Two codes are generally required: one describing the nature of the sequela and one for the sequela
  • The code for the acute phase of the illness or injury is never reported with a code for the late effect

Exceptions to the above guidelines include:

  • In some instances the code for the sequela is followed by a manifestation code identified in the tabular list and title
  • The sequela code may also be expanded at the fourth, fifth, or sixth character levels to include the manifestation

Injury Guidelines For Sequela

There are additional guidelines for reporting sequelae of injuries. The code that describes the sequela is reported first, followed by the code for the specific injury with a seventh character of S to identify the condition as a sequela of the injury. Coding guidelines for Chapter 19 Injuries, Poisoning, and Certain Other Consequences of External Causes state the following in regard to coding of sequelae:

“Seventh character ‘S’, sequela, is for use for complications or conditions that arise as a direct result of a condition, such as scar formation after a burn. The scars are sequelae of the burn. When using seventh character ‘S,’ it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The ‘S’ is added only to the injury code, not the sequela code. The seventh character ‘S’ identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code.”

Coding Example 1

Chronic left ankle instability following Grade III sprain of the calcaneofibular ligament six months prior.

M24.272 Disorder of ligament, left ankle

S93.412S Sprain of calcaneofibular ligament of the left ankle, sequela

Rationale: A Grade III ankle sprain involves complete tear of the involved ankle ligaments. Instability of the ankle is reported with a code from subcategory M25.37- if the condition is not further qualified as due to an old ligament injury. However, since we know that the instability is due to a Grade III sprain (complete tear) of the calcaneofibular ligament, the correct subcategory is M24.27-

Coding Example 2

Patient with T3 unstable burst fracture with retropulsion of the T3 vertebral body into the spinal canal and complete paralysis below the clavicle at the time of the injury two years ago. Following surgical stabilization there was no neurological improvement of complete paralysis of lower extremities. The patient is seen to assess ongoing needs related to complete paraplegia.

G82.21 Paraplegia, complete

S24.112S Complete lesion at T2-T6 level of thoracic spinal cord, sequela

S22.032S Unstable burst fracture of third thoracic vertebra, sequela

Rationale: The complete paraplegia is a sequela of the burst fracture of the T3 vertebral fracture and resulting spinal cord injury.

Coding Example 3

The patient is admitted for release of scar contractures of the flexor surface of left elbow following healing of second and third degree burns of this region.

L90.5 Scar conditions and fibrosis of skin

T22.322S Burn of third degree of left elbow, sequela

Rationale: Scar contractures due to burn injury are reported with code L90.5 that is the first-listed or principal diagnosis and the burn injury is reported as a secondary code to identify the cause of the sequela.

About the Author

Lauri Gray, RHIT, CPC, has worked in the health information management field for 30 years. She began her career as a health records supervisor in a multi-specialty clinic. Following that she worked in the managed care industry as a contracting and coding specialist for a major HMO. Most recently she has worked as a clinical technical editor of coding and reimbursement print and electronic products. She has also taught medical coding at the College of Eastern Utah. Areas of expertise include: ICD-10-CM, ICD-10-PCS, ICD-9-CM diagnosis and procedure coding, physician coding and reimbursement, claims adjudication processes, third-party reimbursement, RBRVS and fee schedule development. She is a member of the American Academy of Professional Coders (AAPC) and the American Health Information Management Association (AHIMA).

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