V97.33XXD: How the heck can you get sucked into a jet engine more than once?

A common misconception about the 7th character extensions in ICD-10 is the use of the A, D or S extensions on the External Causes of Morbidity, such as “V97.33 Sucked into jet engine”. This category of codes requires a seventh character to report the episode of care. “A” initial encounter, “D” subsequent encounter or “S” sequela.

I have heard many funny jokes about the codes in Chapter 20, External Causes of Morbidity. While seminar audiences laugh at the idea of a subsequent encounter, sucked into a jet engine, it is a good opportunity to clarify the use of the 7th character extensions.

The 7th character extension is reported on the primary code, usually from Chapter 19: Injury, Poisoning and Certain other consequences of External Causes. Codes in Chapter 19 should be followed by a code from Chapter 20 to report the cause of the injury. Both of these codes require a 7th character to report the episode of care.

Let’s say that a person was actually sucked into a jet engine, and went to the Emergency Department with a fractured ankle. Otherwise, he had only minor superficial injuries (did I mention the patient is Iron Man? No, that would be a HIPAA violation).

Primary Diagnosis: S82.51XA Displaced fracture of the medial malleolus of the right tibia, initial encounter

Second Diagnosis: V97.33XA Sucked into jet engine, initial encounter

The patient is whisked away to the Emergency Department where Dr. Derek “McDreamy” Shepherd repairs the fractured ankle, applies a cast, and sends the patient home. Two weeks later, Iron Man arrives at Dr. Shepherd’s office for an x-ray and cast check. He’s recovering amazing well (of course).

Primary Diagnosis: S82.51XD Displaced fracture of the medial malleolus of the right tibia, Subsequent encounter

Second Diagnosis: V97.33XD Sucked into jet engine, Subsequent encounter

So, the A, D, or S explains where the patient is, in the course of the treatment and recovery from the injury. The subsequent extension “D” is not intended to report multiple, identical injuries!

In these early days of ICD-10 we are seeing lots of questions about the extensions. Remember, they do not affect payment, and are informational.

The episode of care has nothing to do with whether or not the physician has seen the patient before for this condition, or if the physician is even treating the condition. What matters is whether the injury or condition is receiving active treatment, or is in the healing or recovery phase, or has terminated, and has now resulted in a residual effect. These are the definitions:

  • 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 continuing treatment by the same or a different 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, 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.
  • 7th character “S” sequela is used for a late effect. A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated.

Seventh character extenders are required for all acute fractures, as well as pathologic fractures. For example, a patient with osteoporosis with a current pathological fracture, to report a follow up visit, you would use a code like M80.88XD Osteoporosis with current pathological fracture, vertebra(e) subsequent encounter for fracture with routine healing. I would use the 7th character “D”, unless it is known that the current fracture has delayed healing, nonunion, or malunion. Delayed healing would mean that the fracture takes longer than usual to heal, given appropriate therapy. This may happen in older patients, especially those with systematic factors. Nonunion would mean that the fracture fails to heal, for example when the bone lacks adequate stability, blood flow, or both. Malunion means that the fracture has healed, but in a less than optimal position.

For orthopedics and physical therapy there seems to be a lot of question about “active care” and physical therapy. When you read the guidelines the Emergency Department, Surgery, and evaluation by a new physician are the most common circumstances when “A” is appended.

For “D”, it is the routine healing and recovery phase. Physical therapists are wondering if PT is “active care” and the patient should be reported with an “A” instead of a “D”. For a fracture this is clear but in instances of a torn rotator cuff, the patient isn’t recovered until finishing a course of therapy.

For therapy simplify it by saying, treatment plan is active but once doing the treatment plan then that is subsequent or routine. Try to remind everyone that the guidelines are vague and that the 7th character extenders are not tied to payment, so try not to get too stressed about them. It is also possible that a person was doing well and a provider switched to D and now needs to switch back to A.