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  
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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.

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