Q/A: Do I Use 7th Character A for all Sprain/Strain Care Until MMI?

July 15th, 2019 - Wyn Staheli, Director of Research
Categories:   Modifiers   Chiropractic   Physical Medicine|Physical Therapy   Diagnosis Coding  
0 Votes - Sign in to vote or comment.

Question: 

It is in regards to the Initial and Subsequent 7th digit (A and D) for sprains and strains. Recently, I have been told that I should continue with the A digit until the patient has reached Maximum Medical Improvement (MMI) and then switch over to the D place holder. Is that correct?

Answer: 

Yes and no. It would be no according to Section I.C.19.a of the ICD-10-CM Official Coding Guidelines which states (emphasis added):

7th character “D,” subsequent encounter, is used for encounters after the patient has received active treatment of a 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.”

For most specialties, "active care" is when a patient receives initial "care" (e.g., evaluation, diagnostic testing, ordering treatment) for an injury. It could also be indicated when there is a significant treatment plan change. For example, if the injury didn't heal as anticipated (conservative treatment plans weren't working) and the decision was made to apply a cast or get an MRI. Then the application of the cast or the MRI would be reported as active care "A", but then follow-up visits would return to subsequent "D". Therefore, for most types of care, it would be inappropriate to use "A" for follow-up visits until the patient reaches MMI. However, if a payer policy provides guidance that differs from this standard, then it would be appropriate to follow the payer's standards.

Chiropractic care is an excellent example of when it could be appropriate to use "A" for a more extended period of time. For example, Medicare only covers chiropractic services which are in the active or corrective phase of care which must be reported with modifier AT "Active Treatment". So a review of a MACs LCD list of ICD-10-CM codes meeting medical necessity for sprains and strains all end in the 7th character "A" because Medicare only covers subluxations in the active treatment phase. This is because soft tissue injuries undergoing chiropractic manipulative treatment can take weeks of 'active treatment' until they are resolved. So as long as the patient is improving and meeting the standards of active care, then it would be appropriate to use "A". Therefore, be aware of the payer policies regarding the type of service being provided.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

2023 ICD-10-CM Code Changes
October 6th, 2022 - Christine Woolstenhulme, CPC, CMRS, QCC, QMCS
In 2022 there were 159 new codes; the 2023 ICD-10-CM code update includes 1,176 new, 28 revised, and 287 deleted codes, a substantial change from last year. The 2023 ICD-10-CM codes are to be used for discharges from October 1, 2022 through September 30, 2023, and for patient encounters from ...
Emergency Department - APC Reimbursement Method
September 15th, 2022 - Christine Woolstenhulme, CPC, CMRS, QCC, QMCS
CMS pays emergency department visits through a payment method using Ambulatory Payment Classifications (APCs). Most payers also use the APC reimbursement system; however, there may be some differences in payer policies (always review your specific payer policy). APCs are the primary type of payment made under the OPPS, comprising groupings ...
Why Medical Coding and Billing Software Desperately Needs AI
September 7th, 2022 - Find-A-Code
It has been said that the healthcare industry is notoriously slow in terms of technology adoption. One need only look at how convoluted medical coding and billing are to know that it needs a technology injection. Specifically, medical coding and billing software desperately needs artificial intelligence (AI).
CMS says Less Paperwork for DME Suppliers after Jan 2023!
August 18th, 2022 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Attention providers, suppliers, billers, and vendors who bill Durable Medical Equipment (DME) to Medicare!  Currently, a supplier receives a signed Certificate of Medical Necessity (CMN) from the treating physician or creates and signs a DME Information Form (DIFs); these are required to be sent with the claim. However, this is about ...
Things to Consider Before Upgrading Medical Billing Software
August 11th, 2022 - Find-A-Code
Your practice has utilized the same medical billing software for years. The medical billing staff says it is time for a change. You don't necessarily disagree, but you also don't know where to begin your search for new software. There are so many vendors offering so many products that making sense of it all can be challenging.
Calendar Year 2023 Medicare Advantage and Part C & D Payment Policies
August 9th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Each year CMS publishes an Advance Notice of the upcoming years Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies and asks for comments related to it. Each of the comments are carefully reviewed and responded to and often are impactful to changes seen between the Advance Notice and final publication referred to as the Rate Announcement. With health equity as a primary focus for 2023, CMS announced some policy changes that may impact your organization.
How CMS Determines Which Telehealth Services are Risk Adjustable
August 9th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Medicare Advantage Organizations (MAOs) have gone back and forth on whether or not to use data collected from telehealth, virtual Care, and telephone (audio-only) encounters with Medicare beneficiaries for risk adjustment reporting, but the following published documents from CMS cleared that up once and for all by providing an answer to a question specifically related to this question.



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2022 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association