5 Things Every Pt Must Know About ICD-10's 7th Character

The number seven is replete with cultural significance: There are seven days in the week, seven seas, and seven deadly sins. Some people even consider the number seven to be an especially lucky numeral. But for those trying to learn the ropes of coding with ICD-10, the number seven has taken on a whole new meaning.

As this blog post explains, “…the seventh character represents one of the most significant differences between ICD-9 and ICD-10 because ICD-9 does not provide a mechanism to capture the details that the seventh character provides.” Because clinicians and coders haven’t had to account for those details for, oh, the last 35 years or so, they’ve had a tough time wrapping their heads around this tricky caboose of a character. And that’s especially true in the physical therapy space, as ICD-10 coding guidance often is more relevant to physicians than anyone else in the healthcare community.

With that in mind, here are a few PT-specific tips for filling the seventh position:

1. If you need to include a seventh character, you will see instructions to do so.

The seventh character only applies to certain categories of codes. This is why it’s so important that you check the instructions for each category and subset of codes. As this blog post explains, “You must assign a seventh character to codes in certain ICD-10-CM categories as noted within the Tabular List of codes—primarily Chapter 19 (Injury, poisoning and certain other consequences of external causes) and Chapter 15 (Pregnancy, childbirth and the puerperium).”

If you don’t see instructions to include a seventh character, then leave the seventh position blank. Adding a seventh character to a code that does not require one will make the entire code invalid.

2. For most PT-related codes requiring a seventh character, there are three options.

In general, when it comes to seventh characters, the injury chapter—Chapter 19—is the one to which PTs need to pay the most attention. For injuries, poisonings, and other external causes, the seventh character provides information about the episode of care, and the ICD-10 codes for most of these conditions require one of the following seventh characters:

A – Initial encounter

This indicates that the patient is receiving active treatment for his or her injury, poisoning, or other consequences of an external cause. However, contrary to popular assumption, this phase of treatment is not limited to the patient’s first visit. In other words, you can use “A” as the seventh character on more than just the first claim. In fact, you can use it on multiple claims.

D – Subsequent encounter

This describes any encounter that occurs after the active phase of treatment has ended. During this phase of treatment, the patient is receiving routine care while healing or recovering from his or her injury.

S – Sequela

The seventh character “S” is reserved for complications or conditions that arise as a direct result of an injury. A commonly used example of a sequela is a scar that results from a burn.

3. The majority of PT encounters fall into the “D” bucket.

One of the most popular questions we get here at ICD10forPT is, “Which physical therapy encounters qualify as active treatment?” And while we haven’t been able to come up with a one-size-fits-all answer to this inquiry, here’s what we’ve deduced from our research: According to this CMS document, examples of active treatment include “initial evaluation of the condition, which may be in the emergency room or at a physician’s office or clinic, encounter for surgical treatment of the condition, and evaluation and continuing treatment by the same or a different physician.” For these types of encounters, use of the seventh character “A” is appropriate.

The document goes on to note that appropriate uses of the seventh character “D” include encounters “for rehabilitation, such as physical and occupational therapy.” Based on this guidance, it’s safe to say the majority of PT visits occur during the healing/recovery phase of treatment (and would thus require the subsequent encounter designation). However, it appears that the “initial encounter” designation is appropriate in situations involving evaluation.

4. If you add a seventh character to a code with fewer than six characters, you must fill each empty slot with a placeholder “X.”

Let’s say, for example, that you’ve selected the diagnosis code S44.11, Injury of median nerve at upper arm level, right arm. As indicated at the beginning of the S44 code category, you must add a seventh character to this code. You determine that, because the patient is receiving routine care for the injury in the healing and recovery phase, the appropriate seventh character is “D.” However, because this particular code contains only five characters, you’ll need to insert an “X” in the sixth position before you can put “D” in the seventh position. This ensures that the first five characters correctly link to the required seventh character (leaving the sixth position blank, on the other hand, would dissociate the “D” with the rest of the code). Thus, the correct code would be S44.11XD, Injury of median nerve at upper arm level, right arm, subsequent encounter.

5. Fracture codes have their own set of seventh character options.

Typically, PTs receive fracture diagnosis codes from referring orthopedic physicians and surgeons. However, it’s important to know the differences between the seventh characters that apply to fractures and those used for other diagnoses. Here is the list of the ultra-specific seventh characters reserved for fracture coding:

  • A – Initial encounter for closed fracture.
  • B – Initial encounter for open fracture.
  • D – Subsequent encounter for fracture with routine healing.
  • G – Subsequent encounter for fracture with delayed healing.
  • K – Subsequent encounter for fracture with nonunion.
  • P – Subsequent encounter for fracture with malunion.
  • S – Sequela.

To make matters even more confusing, certain categories of fracture codes require seventh characters from a special list that accounts for the type of fracture. There are 16 seventh characters contained within the list, which you can review in more detail in this blog post. A final word on fracture coding: As the aforementioned post explains, the fracture aftercare codes that appear in the ICD-9 code set will go away forever on October 1. Instead, those coding for traumatic fracture aftercare will “assign the acute fracture code with the appropriate seventh character.”


Even if seven isn’t your lucky number, these five tips should get you on the path to seventh-character success without too much misfortune. Still have questions? Submit ’em in the question module at the bottom of this page, and we’ll do our best to get you an answer.