What is Diagnosis Code Refinement (Episode of Care)?

Some Diagnoses in the system need "Refinement" in order to define the 7th character extension code and define the episode of care.  (Initial encounter = active treatment, Subsequent encounter = routine care after the active treatment, and sequela = complications that arise as a direct result of a condition).  These types of diagnoses include:  Abrasions, Lacerations, Arthropod bites, etc.

When refinement is needed, you will not see the ICD-10 code on your coding screen.  It will be blank as shown in the screenshot below:

You will want to click into the billing codes section, where you will see any diagnoses that need refinement.  The 7th digit extension code will be showing as a question mark:

When you click on the diagnosis, it will take you to the episode refinement screen where you can select the one that identifies the current episode of care:

Once you have selected the appropriate refinement, the question mark will be replaced with the correct extension code, which will then generate the coding for your note:

PLEASE NOTE THAT YOU WILL NEED TO FIRST SIGN OFF ON YOUR NOTE BEFORE CLICKING INTO THE BILLING SECTION TO REFINE THE CODE.  IF YOU REFINE THE CODE BEFORE SIGNING OFF ON THE NOTE, IT WILL NOT BE PERMANENT TO THE NOTE AND WILL NEED TO BE ADDED AGAIN AFTER YOU SIGN OFF.