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Physicians and hospital administrators realize that optimizing workflows to accommodate urgent care and emergent services will require additional data collection needs under ICD-10. The seventh character under ICD-10 defines the “type of encounter”. As I mentioned in my earlier article, sensibly and tactfully preparing for ICD-10 can be achieved successfully with a high level of transparency.

Certain ICD-10-CM categories have applicable seventh characters. Chapter 19 – “Injury, poisoning, and certain other consequences of external cause” require a 7th character, or as notes in the tabular list instruct. The seventh character also must always be the seventh character in the data field. If a code that requires a seventh character does not include the full seven characters, a placeholder X must be used to fill in the empty character fields.

Here are some helpful seventh-character references:

Seventh-character requirement for the coding categories stated:

Chapter 13: M = Musculoskeletal

  • Most of the codes in Chapter 13 have site and laterality designations.
  • A seventh character is required for coding of pathologic fractures.

Chapter 15: O = Obstetrics

  • Where applicable, a seventh character is to be assigned for certain categories (O31, O32, O33.4 – O33.7, O35, O36, O40, O41, O60.1, O60.2, O64, and O69) to identify the fetus to which the complication code applies.
  • Assign seventh character “0:”
    • For single gestations;
    • When the documentation in the record is insufficient to determine the fetus affected and it is not possible to obtain clarification; or
    • When it is not possible to clinically determine which fetus is affected.

Chapter 18: R = Symptoms & Signs

  • The coma scale codes (R40.2) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease codes, or sequela of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale codes should be sequenced after the diagnosis code(s). These codes, one from each subcategory, are needed to complete the scale.
  • The seventh character indicates when the scale was recorded. The seventh characters should match for all three codes.

Chapter 19: S-T = Injury & Poisoning

  • Most categories in Chapter 19 have a seventh-character requirement for each applicable code. Most categories in this chapter also have three seventh-character values (with the exception of fractures): A (initial encounter), D (subsequent encounter) and S (sequela). Categories for traumatic fractures have additional seventh-character values.
    • The seventh character A, initial encounter, is used while the patient is receiving active treatment for a condition.
    • The seventh character D, subsequent encounter, is used for encounters occurring after the patient has received active treatment of a condition, when he or she is receiving routine care for the condition during the healing or recovery phase..
  • The after-care Z codes should not be used for such care for conditions such as injuries or poisonings, for which characters are provided to identify subsequent care. For example, for after-care of an injury, assign the acute injury code with the seventh character of D (subsequent encounter).
  • The seventh character S, sequela, is for used for complications or conditions that arise as a direct result of a condition, such as scar formation following a burn (the scars are sequela of the burn). When using 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 (i.e. scar) is sequenced first, followed by the injury code.

Coding professionals also will code the size and depth of an injury under ICD-10, something that may not be captured in the documentation.

  • A – Initial encounter
    • Surgical treatment
    • Emergency department encounter
    • Evaluation and treatment by a new physician
    • D – Subsequent encounter
      • Healing or recovery phase
      • Cast change or removal
      • Removal of external or internal fixation device
      • Other after-care and follow-up visits following treatment of an injury or condition
      • S – Sequela encounter
        • Complications or conditions that arise as a direct result of a condition
          • An example, again, would be scar formation after a burn. The scars are sequela of the burn.

Coding of Traumatic Fractures

  • The principles of multiple coding of injuries should be followed while coding fractures. Fractures of specified sites are coded individually, by site, in accordance with both the provisions within categories S02, S12, S22, S32, S42, S49, S52, S59, S62, S72, S79, S82, S89 and S92, and the level of detail furnished by medical record content.
  • A fracture not indicated as open or closed should be coded as closed. A fracture not indicated as displaced or non-displaced should be coded as displaced.

More specific guidelines are as follows:

Initial vs. subsequent encounters for fractures

Traumatic fractures are coded using the appropriate seventh characters for initial encounter (A, B, C) while the patient is receiving active treatment for the fracture. Examples of active treatment include surgical treatment, emergency department encounters and evaluation and/or treatment by a new physician. The appropriate seventh character for initial encounter also should be assigned for a patient who delayed seeking treatment for a fracture or nonunion.

Subsequent treatment of fractures are coded using the appropriate seventh character indicating subsequent care for encounters occurring after the patient has completed active treatment of the fracture (D-R).

  • D, E, F – Subsequent treatment with routine healing
  • G, H, J – Subsequent treatment with delayed healing
  • K, M, N – Subsequent treatment with nonunion
  • P, Q, R – Subsequent treatment with malunion

Chapter 20: V, W, X, Y = External Causes of Morbidity

  • Sequela, once again, are reported using the external cause code with the seventh character S designating sequela. These codes should be used with any report of a late effect or sequela resulting from a previous injury.

As you can see from the above seventh character examples, documentation will be instrumental to applying the appropriate coding. Lack of documentation in the medical record will cause delays in the filing of your claims and also possibly create negative impacts on your revenues.

There are several references from the CDC I found helpful, as the codes are still in draft format.  Although this code classification range predominately is utilized for secondary diagnosis and mortality or cause of injury, it essentially denotes the reason for an encounter. Consider the modification of current workflows to accommodate the additional specificity and granularity requirements of data collection demands. Organizations always should seize every opportunity to collect as much information as possible during the initial encounter. Staff in charge of registration and triage should ask any authorized family members or proxies for any pertinent information related to incidents of injury in order to optimize patient flow and meet revenue data capture requirements.

About the Author

Anita Archer has extensive management experience in the healthcare industry, with an emphasis on revenue cycle management and systems implementation and support. She is a certified professional coder and an AHIMA-approved ICD-10-CM/PCS trainer, and has been responsible for revenue cycle improvements in physician practices, hospitals and ancillary services. She has extensive system implementation experience and is a superb project manager and team leader. Anita is currently the director of regulatory compliance at Hayes Management Consulting.

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Injury Data and Resources:


Reports on the comparability of cause-of-death classification between CID-9 and ICD-10:




These are the standard definitions the Safe and Active Communities (SAC) Branch uses in creating data tables from hospital discharge and death certificate data. All years of hospital discharge data are coded using ICD-9. Starting in 1999, death certificates were coded using ICD-10 cause codes.


ICD-10-CM Official Guidelines for Coding and Reporting 2012:



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