Medical coding expert, Betsy Nicoletti, M.S., CPC, led our three-part ICD-10 webinar series as part of our free, month-long ICD-10 Boot Camp. Here, she addresses the remaining questions we’ve received about the new coding system after the final webinar in our series.

You can read Part One of the Q&A here.

To download any or all of the webinars in this series, please visit this page. We want you to succeed through this transition.

Question: Are we required to report the 7th character external code or is it only recommended?

Answer: If a 7th character is required for that category of code you are required to report it. Without it, the code is not complete and valid.

Can you please specify again where the best place is to download the guidelines?
You can buy the book or look on the CDC website.


Can you please clarify when to use the A, D, S extensions? 
This is from the ICD-10 General Guidelines: 

Most categories in chapter 19 have a 7th character requirement for each applicable code. Most categories in this chapter have three 7th character values (with the exception of fractures): A, initial encounter, D, subsequent encounter and S, sequela. Categories for traumatic fractures have additional 7th character values.

7th character “A”, initial encounter is used while the patient is receiving active treatment for the condition. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.

7th character “D” subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Examples of subsequent care are: cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition.

The aftercare Z codes should not be used for aftercare for conditions such as injuries or poisonings, where 7th characters are provided to identify subsequent care. For example, for aftercare of an injury, assign the acute injury code with the 7th character “D” (subsequent encounter).

7th 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 7th 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 7th 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.

Do you have a recommendation for Podiatry specialty? Book? Manual?
I’m sorry, I don’t. Check with your specialty society.

How many ICD-10/pointers can be used per encounter? Is it 4 as it was before?
The 5010 form allows for 12 diagnosis codes. Your software may limit you.

I understand that the reimbursement policy does not change from ICD-9 to ICD-10, however, if there is no code available in ICD-10, what do you recommend? For Example, if our office has always used “Ulcer of limb 454.0” as the diagnosis for the placement of an Unna boot, but there is no code  that matched for ICD-10, what ICD-10 code do you suggest we use?
Look at the codes for non-pressure ulcer or pressure ulcer.  Category L89 and L97.

I would like to reconfirm about physician sent claims spanning the dates of inpatient services. I received this from Optum ( UBH) verbatim  for services spanning September into October, the date of discharge determines which ICD code set to apply DC’s on or before 9/30/2015 use ICD -9-CM discharges on or after 10/1/2015  bill using ICD-10-CM. You said the hospital had a different set of rules … could you explain?
For hospitals, use the date of discharge.  On a CMS call, they stated to use ICD-9 codes if the admission was Sept. 30 and before.  The official guidelines say date of discharge—you may have to check with your payers.

If a patient is being seen for ongoing therapy how does that code?
I don’t know what type of therapy you mean.  Use a valid ICD-10 code after October 1.

If we were to receive denials, in what capacity would they deny? What wording would be used to look out for? I don’t think it would specifically say wrong code, right?
These would be medical necessity denials. The procedure code and diagnosis code don’t match; this procedure isn’t covered for this service.

Is it mandatory to use W codes on all Injuries ie: fractures, trauma, lacerations, The S codes.
This is not required by ICD-10 but is payer determined. If your payer required E codes, then use the external cause codes.

Is there still a need for modifiers?
Yes, use CPT modifiers. Don’t change anything about your CPT coding.

Osteopathic Manipulation: when treating a pregnant patient for back pain, will I need to code for pregnancy?
There is an ICD-9 and ICD-10 code for pregnancy, incidental. Use that.

Regarding musculoskeletal, are we limited in the number of diagnoses?
5010 allows 12 codes per line item.

There are a lot of ICD10 books out there, how do we know which is the one you mentioned at the beginning of the webinar.
They all have the same information.  

What about using icd 10 codes when prescribing blood work? Should the icd 10 codes used to prescribe a particular lab test be specific?
I answered this on the call.

What difference will ICD-10 make for CPT?

What if a patient comes in for acute asthma exacerbation?  Then returns for follow up. How do you code the follow-up?
This is a clinical question. The provider needs to state “acute exacerbation” or “uncomplicated.”

Where would I find what the providers need to include in their documentation with the new codes?
You need to do a gap analysis by diagnosis code for your frequent codes. Then, look in the ICD-10 book.

For codes that don’t cross over in podiatry, how do we formulate code? For example, when deformed metatarsal 733.99 procedure code 28308 is utilized, what ICD 10 code would be utilized?
Look at M89.30, M89.8×9, M94.8×9, or start in the index.

Would physical therapy fall in the harder conversion list because of the external causes?
If you are using external cause codes now, it will be difficult.

Wound care question:  I’m currently not listing right or left. Will I need to even if ICD-10 states in description right or left?
You should be putting right or left in the note and then selecting the diagnosis code that describes the condition and location.

When listing the ICD-10 codes, which one should go first or what is the order of codes? Is there a rule that the code with 7th digit should go first? Unless the 7th digit is sequela and then the injury code should go first?
The ICD-10 book, like ICD-9, gives explicit instructions in some places about sequencing.  There are instructions in the general guidelines at the front of the book and within the body of the book.  Please look at these.