Fractures: choosing the 7th character
The single most common reason a fracture claim rejects. Walks the encounter type, healing status, and fracture type to the correct 7th character.
Answer from what the documentation actually says. Every answer cites the ICD-10-CM guideline or tabular note it rests on, so you can defend the code you land on.
Is this the patient's first encounter for ACTIVE treatment of the fracture, a follow-up during healing, or a late effect?
The distinction is about the TREATMENT, not the calendar. 'Initial' means active treatment is being given — that includes a second surgeon operating on the same fracture weeks later. 'Subsequent' means routine aftercare during healing. This is the point coders most often get wrong.
The full guide, written out
Every path through the questions above, with the outcome each one reaches and the ICD-10-CM source it rests on. Use the interactive version to walk your own chart note; use this one to see the whole decision at once.
- Is this the patient's first encounter for ACTIVE treatment of the fracture, a follow-up during healing, or a late effect? → Active treatment (ED visit, surgery, new physician evaluating and treating)
- Is the fracture open or closed? → Closed (or not documented)
7th character A — Initial encounter for closed fracture
7th character A. Active treatment of a closed fracture.
- ⚠ 'Initial' is about active treatment, not about being the first visit. A new physician providing active treatment still uses A.
- ⚠ If the documentation does not state open, code it closed.
Source: ICD-10-CM Official Guidelines I.C.19.a; Chapter 19 7th-character definitions.
- Is this the patient's first encounter for ACTIVE treatment of the fracture, a follow-up during healing, or a late effect? → Active treatment (ED visit, surgery, new physician evaluating and treating)
- Is the fracture open or closed? → Open — Gustilo type I or II
7th character B — Initial encounter for open fracture type I or II
7th character B. Active treatment, open fracture, Gustilo type I or II — which is also the default when the note says 'open' without classifying it.
Source: ICD-10-CM Official Guidelines I.C.19.c.
- Is this the patient's first encounter for ACTIVE treatment of the fracture, a follow-up during healing, or a late effect? → Active treatment (ED visit, surgery, new physician evaluating and treating)
- Is the fracture open or closed? → Open — Gustilo type IIIA, IIIB, or IIIC
7th character C — Initial encounter for open fracture type IIIA, IIIB, or IIIC
7th character C. Active treatment, open fracture, Gustilo type III.
Source: ICD-10-CM Official Guidelines I.C.19.c.
- Is this the patient's first encounter for ACTIVE treatment of the fracture, a follow-up during healing, or a late effect? → Routine healing / aftercare (cast check, follow-up X-ray, medication management)
- How is the fracture healing? → Healing normally
- Was the fracture open or closed? → Closed
7th character D — Subsequent encounter, closed fracture, routine healing
7th character D. Aftercare during normal healing of a closed fracture.
- ⚠ Do NOT use an aftercare Z code for fracture aftercare. The 7th character does that job.
Source: ICD-10-CM Official Guidelines I.C.19.a.
- Is this the patient's first encounter for ACTIVE treatment of the fracture, a follow-up during healing, or a late effect? → Routine healing / aftercare (cast check, follow-up X-ray, medication management)
- How is the fracture healing? → Healing normally
- Was the fracture open or closed? → Open type I or II
7th character E — Subsequent encounter, open type I/II, routine healing
7th character E.
Source: ICD-10-CM Chapter 19 7th-character definitions.
- Is this the patient's first encounter for ACTIVE treatment of the fracture, a follow-up during healing, or a late effect? → Routine healing / aftercare (cast check, follow-up X-ray, medication management)
- How is the fracture healing? → Healing normally
- Was the fracture open or closed? → Open type IIIA/IIIB/IIIC
7th character F — Subsequent encounter, open type IIIA/B/C, routine healing
7th character F.
Source: ICD-10-CM Chapter 19 7th-character definitions.
- Is this the patient's first encounter for ACTIVE treatment of the fracture, a follow-up during healing, or a late effect? → Routine healing / aftercare (cast check, follow-up X-ray, medication management)
- How is the fracture healing? → Delayed healing
- Was the fracture open or closed? → Closed
7th character G — Subsequent encounter, closed fracture, delayed healing
7th character G.
Source: ICD-10-CM Chapter 19 7th-character definitions.
- Is this the patient's first encounter for ACTIVE treatment of the fracture, a follow-up during healing, or a late effect? → Routine healing / aftercare (cast check, follow-up X-ray, medication management)
- How is the fracture healing? → Delayed healing
- Was the fracture open or closed? → Open type I or II
7th character H — Subsequent encounter, open type I/II, delayed healing
7th character H.
Source: ICD-10-CM Chapter 19 7th-character definitions.
- Is this the patient's first encounter for ACTIVE treatment of the fracture, a follow-up during healing, or a late effect? → Routine healing / aftercare (cast check, follow-up X-ray, medication management)
- How is the fracture healing? → Delayed healing
- Was the fracture open or closed? → Open type IIIA/IIIB/IIIC
7th character J — Subsequent encounter, open type IIIA/B/C, delayed healing
7th character J.
Source: ICD-10-CM Chapter 19 7th-character definitions.
- Is this the patient's first encounter for ACTIVE treatment of the fracture, a follow-up during healing, or a late effect? → Routine healing / aftercare (cast check, follow-up X-ray, medication management)
- How is the fracture healing? → Nonunion — it is not healing
- Was the fracture open or closed? → Closed
7th character K — Subsequent encounter, closed fracture, nonunion
7th character K. The fracture is not healing.
Source: ICD-10-CM Chapter 19 7th-character definitions.
- Is this the patient's first encounter for ACTIVE treatment of the fracture, a follow-up during healing, or a late effect? → Routine healing / aftercare (cast check, follow-up X-ray, medication management)
- How is the fracture healing? → Nonunion — it is not healing
- Was the fracture open or closed? → Open type I or II
7th character M — Subsequent encounter, open type I/II, nonunion
7th character M.
Source: ICD-10-CM Chapter 19 7th-character definitions.
- Is this the patient's first encounter for ACTIVE treatment of the fracture, a follow-up during healing, or a late effect? → Routine healing / aftercare (cast check, follow-up X-ray, medication management)
- How is the fracture healing? → Nonunion — it is not healing
- Was the fracture open or closed? → Open type IIIA/IIIB/IIIC
7th character N — Subsequent encounter, open type IIIA/B/C, nonunion
7th character N.
Source: ICD-10-CM Chapter 19 7th-character definitions.
- Is this the patient's first encounter for ACTIVE treatment of the fracture, a follow-up during healing, or a late effect? → Routine healing / aftercare (cast check, follow-up X-ray, medication management)
- How is the fracture healing? → Malunion — healed in the wrong position
- Was the fracture open or closed? → Closed
7th character P — Subsequent encounter, closed fracture, malunion
7th character P. The fracture healed in a poor position.
Source: ICD-10-CM Chapter 19 7th-character definitions.
- Is this the patient's first encounter for ACTIVE treatment of the fracture, a follow-up during healing, or a late effect? → Routine healing / aftercare (cast check, follow-up X-ray, medication management)
- How is the fracture healing? → Malunion — healed in the wrong position
- Was the fracture open or closed? → Open type I or II
7th character Q — Subsequent encounter, open type I/II, malunion
7th character Q.
Source: ICD-10-CM Chapter 19 7th-character definitions.
- Is this the patient's first encounter for ACTIVE treatment of the fracture, a follow-up during healing, or a late effect? → Routine healing / aftercare (cast check, follow-up X-ray, medication management)
- How is the fracture healing? → Malunion — healed in the wrong position
- Was the fracture open or closed? → Open type IIIA/IIIB/IIIC
7th character R — Subsequent encounter, open type IIIA/B/C, malunion
7th character R.
Source: ICD-10-CM Chapter 19 7th-character definitions.
- Is this the patient's first encounter for ACTIVE treatment of the fracture, a follow-up during healing, or a late effect? → A problem arising later from the healed fracture (e.g. arthritis, deformity)
7th character S — Sequela
7th character S. Use when coding a condition that ARISES FROM a healed fracture — the late effect, not the fracture itself.
- ⚠ With S, you code BOTH the condition caused by the sequela AND the injury code with S. The condition is sequenced FIRST; the injury code with S is sequenced second.
- ⚠ S is not for a fracture that is still healing. That is D, G, K, or P.
Source: ICD-10-CM Official Guidelines I.C.19.a, 'sequela' 7th character.