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Tip: Description of Visit Type and Laterality Attribute Choices

Visit types are the “7th” digit the code that would be added to a diagnosis code.

Code sets that commonly require the “7” digit be added to the diagnosis code.

M00-M99 series
S00-T00 series
Always refer to the ICD-10-CM code references to determine code requirements.

Initial Visit:
Initial encounters would be an “A” added as the 7th character of the diagnosis code if the visit is to be reported as an initial visit.

Definition of an Initial Visit and a reason why the code choice is an initial visit:

Use Initial visit as long as the patient is receiving active treatment.
Examples of active treatment include surgical treatment, emergency department encounter, evaluation and treatment by a new physician.
Subsequent Visit:
Subsequent visit would be a “D” and the 7th character reported on the diagnosis code if the visit is to be reported as a subsequent visit.

Definition of a Subsequent Visit and a reason why the code choice is a Subsequent visit:

Use Subsequent Visit for encounters after the patient has completed active treatment.
Examples – To be used for treatment of problems associated with the healing, cast change or removal, removal of internal or external fixation device, medication adjustment, other aftercare and follow-up visits following treatment of the injury or condition.
Sequela Visit:
Sequela visit would be an “S” and the 7th character reported on the diagnosis code if the visit would be considered a Sequela visit.

Definition of a Sequela Visit: For complications or conditions that arise as direct result of a condition such as scar formation after burn scars are sequential of the burn. When using the seventh 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 a 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.

For bilateral sites, the final character of the codes in the ICD-10 indicates laterality
– The right side is usually character “1”
– The left side character “2”
In those cases where a bilateral code is provided, the bilateral character is usually “3”.
The unspecified side is either a character “0 or 9”, depending on whether it is a fifth or sixth character. An unspecified side code is also provided should the side not be identified in the medical record. (SIDE CODESHOULD NOT BE USED IF AT ALL POSSIBLE)
In cases where there is not a bilateral code provided, it is necessary to bill each laterality code separately.
Including Attributes to Searches in Health Language Inc. ® (HLI) System
The visit status can be used in the search engine to narrow the search for appropriate diagnosis code.

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