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Shore up your knowledge of sequela coding

JustCoding News: Inpatient, June 18, 2014

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We are in the business of healthcare, and our primary goal is to help patients feel better. Each condition is often not alone when invading or attacking the human body. You know about co-morbidities (other conditions unrelated to the primary condition but present in the same body at the same time). You know about manifestations (secondary conditions directly caused by the primary condition). Now let’s discuss sequelae, also known as late effects.
A sequela (late effect) is the remaining or lasting condition produced after the acute stage of a condition or injury has ended. This effect may be identified very quickly after the initial illness or injury, such as hemiplegia after a stroke, or it may become evident at a later time. A scar that has formed as an aftereffect of a burn, laceration, wound, or other injury is a perfect example of a sequela.
Reporting a late effect will require at least two codes, in the following order:
  1. The sequela condition—the  condition that resulted and that is being treated, such as the malunion of a fracture
  2. The sequela code
While your training and knowledge would enable you to connect a late effect with the original condition in many cases, you are certainly familiar with our golden rule: If it’s not documented, it didn’t happen. If it didn’t happen, you cannot code it. Therefore, to accurately report the physician’s treatment of a sequela, you must abstract the connection from the notes:
  • Scarring
  • Nonunion of a fracture
  • Malunion of a fracture
These three diagnoses are automatically categorized as sequelae because this is the only way they could occur–as the result of another injury. Otherwise, the connection can only be made when the physician or healthcare professional specifically documents the new condition as a sequela of a previous condition.
Sequelae of cerebrovascular disease
When the physician identi?es a condition, such as a neurologic deficit, as a late effect of cerebrovascular disease, a cardiovascular accident (CVA), or other diagnosis originally reported with an ICD-9-CM code from the 430-437 range, report this sequela using a code from category 438 (Late effects of cerebrovascular disease) to connect the current problem with the original condition.
In ICD-10-CM, when the original diagnosis is from the I60-I67 range, use ICD-10-CM code category I69 (Sequelae of cerebrovascular disease) to connect the current and original conditions.
Sequelae of complications of pregnancy, childbirth, and the puerperium
Similar to the codes in category 438 or I69 for reporting the sequelae of cardiovascular disease, ICD-9-CM and ICD-10-CM include a dedicated code for reporting sequela of a complication with the pregnancy, the birth of the child, and/or a complication of the puerperium.
When that complication creates a condition that requires treatment or services after the postpartum period (the six-week timeframe after delivery), and the condition is documented as a late effect of a pregnancy complication, you will use ICD-9-CM code 677 (late effect of complication of pregnancy, childbirth, and the puerperium) or ICD-10-CM code O94 (sequelae of complication of pregnancy, childbirth, and the puerperium). Remember to sequence these codes after the code to report the specific complication or condition.
Sequelae of external causes
A condition considered to be a late effect or sequela of an injury must be documented as such. Sequelae of external cause codes are used with a code reporting a sequela of a previous (not current) injury.
In ICD-9-CM, late effect E codes for use of reporting a sequela of an earlier injury or poisoning include:
  • E929, late effects of other transport accident
  • E959, late effects of self-inflicted injury
  • E969, late effects of injury purposely inflicted by other person
  • E977, late effects of injuries due to legal intervention
  • E989, late effects of injury, undetermined whether accidentally or purposely inflicted
  • E999.1, terrorism secondary effects
These codes should be reported for encounters to treat the late effect, but not for a follow-up to check healing. There are no codes available to report the late effects of an adverse reaction to a drug, a surgical complication, or a medical misadventure.
In ICD-10-CM, a sequela is indicated by using a seventh character of “S” for sequela with both the injury code and the external cause code.
Seventh character S for sequela (ICD-10-CM only)
When available, the seventh character S stands for sequela. When reporting a code using the seventh character S, you must use both the original injury code from which the sequela came, and the code for the sequela condition itself. The S is used with the injury code only, not the sequela code. This is your way, as the coder, to explain the injury that was responsible for the resulting condition (the sequela). The sequela condition code is sequenced first, followed by the injury code with the seventh character S.
The exceptions to the rule
When a late effect code’s description already includes all of the details, you will need to report only that one code. For example, you would only report ICD-9-CM code 438.12 (dysphasia, late effect of cerebrovascular disease) or ICD-10-CM code I69.021 (dysphasia following nontraumatic subarachnoid hemorrhage). These combination codes report all of the information otherwise explained in the two codes typically required for sequelae.
The second exception is when a notation directs you to report this differently. Sometimes it is challenging to remember, but the official guidelines for both ICD-9-CM and ICD-10-CM state that any notation in the tabular list takes precedence over a direction from the guidelines.
Lastly, one more guideline reminds you that because a late effect can only be used when it occurs after the acute phase of the injury or illness has already passed, a code for the acute illness and a code for the late effect cannot be reported at the same time for the same patient.
Editor’s note: Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, of Safian Communications Services in Orlando, Florida, is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee. Email her at ssafian@embarqmail.com.

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