Coding Rule is effective for event records with an event end date on or after 1 January 2016
Ref No: TN1028 | Published On: 15-Dec-2015 | Status: Current
SUBJECT: Coding from findings on medical imaging (radiological) reports
Q:
How do you decide when a finding on a radiological report should be used to inform coding?
A:
ACS 0010General abstraction guidelines, test resultsdifferentiates between results/findings:
- that clearly add specificity to a documented condition which may be used to inform code assignment
- where the relationship between test results and a documented condition is unclear, test results are not to be used to inform code assignment without clinical confirmation.
Examples:
•Conditions/manifestations (where the classification assumes a causal link),that are listed in test results and not documented or confirmed by the clinician, are not to be used to inform code assignment. For example:
oPatient with documented diabetes mellitus has a finding of fatty liver on an ultrasound report; do not use the fatty liver to assign E1-.72 *diabetes mellitus with features of insulin resistance.
oAlthough the classification links pneumonia and COPD, both conditions must be documented or confirmed by the clinician before applying the guidelines in ACS 1008Chronic obstructive pulmonary disease (COPD)
oAlthough the classification links ureteric calculus and hydronephrosis, both conditions must be documented or confirmed by the clinician to inform code assignment
•Metastases/secondary neoplasms that are identified in medical imaging reports but not documented or confirmed by the clinician are not to be used to inform code assignment.
Where clinical advice is unavailable to clarify the significance of a test result or imaging finding and a documented condition, clinical coders should not use the test result to inform code assignment.
Included in the answer for the following query there are references to Ninth Edition however the response provided is applicable to current Eighth Edition coding practice. See published coding rule ‘Multiple trauma June 2010’ in the document ‘Coding Rules – 2012 and prior’ on the coding query webpageclick here
Q:
Can radiological findings be used to identify all injuries in a multiple injury case?
A:
ACS 1907Multiple injurieshas been amended for Ninth Edition to incorporate previously published advice:
When coding theinitialadmission of a multiple trauma, all injuriesdocumentedmust be coded to represent the totality of multiple trauma.
ACS 1907 and the previous Coding Rule which informed the Ninth Edition update applies to multiple trauma where there is documentation of multiple injuries ranging from severe and life threatening to less severe e.g. contusions and grazes. The ACS specifies all documented injuries including contusions and grazes (unless associated with a more severe injury of the same site) must be coded to represent the totality of trauma.
In addition, the guidelines must be applied in conjunction with ACS 0010General abstraction guidelines, test results.Therefore, radiological findings may be used to provide specificity to a documented condition (such as the site of a fracture). Do not code conditions identified on test results that are not documented in the clinical record or confirmed by the clinician.
(Coding Rules, December 2015)
Ref No: Q2977 | Published On: 15-Dec-2015 | Status: Current
SUBJECT: Vacuum assisted wound closure (VAC) Dressings
Q:
Should VAC dressings be coded and if so, how many times should the code be assigned?
A:
Vacuum assisted wound closure (VAC) is a type of wound dressing which uses negative pressure to promote wound healing. The wound is covered with open cell foam or gauze dressing that moulds to the wound bed. A drainage tube is attached, the wound is then sealed and vacuum or negative pressure is applied via a pump. The suction pressure removes or 'debrides' loose tissue and has been shown to reduce swelling, aid wound closure and promote formulation of granulation tissue.
Dressings are routine treatment for burns, wounds and ulcers, however vacuum dressings are not, nor are they a routine part of any significant procedure being performed. ACHI classifies vacuum dressings as nonexcisional debridement:
90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue
or
90686-00 [1627] Nonexcisional debridement of burn.
Do not apply the guidelines in ACS 0020 Multiple/bilateral procedures, ACS 1203 Debridement or ACS 1911 Burns whencoding vacuum dressings, instead apply the following guidelines for their application or replacement (change):
•when performed with cerebral anaesthesia (including that with excisional debridement), assign once for each operating theatre session.
For example:
oDay 1 - excisional debridement of soft tissue of ulcer and application of vacuum dressing performed in theatre under general anaesthetic, assign:
90665-00 [1628] Excisional debridement of skin and subcutaneous tissue
and
90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue
and the appropriate anaesthetic code.
oDay 5 – change of vacuum dressing performed in theatre under general anaesthesia, assign:
90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue and the appropriate anaesthetic code.
•when performed without cerebral anaesthesia, assign once only for the episode of care
For example:
oDay 1 – patient transferred with vacuum dressing in situ:
No code is assigned.
oDay 2 – change of vacuum dressing performed on the ward, assign:
90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue,once only.
oDay 4 – change of vacuum dressing performed on the ward.
As 90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue has already been assigned for this episode, no additional code is required.
•when vacuum dressings are performed with cerebral anaesthesia in an operating theatre and without cerebral anaesthesia on the ward in the same episode of care, assign once for each operating theatre session.
A code for any change of dressings undertaken on the ward is not required.
For example:
oDay 1 – vacuum dressing applied in operating theatre under general anaesthetic, assign:
90686-01 [1628]Nonexcisional debridement of skin and subcutaneous tissue
and the appropriate anaesthetic code.
oDay 3 – change of vacuum dressing undertaken on the ward.
As 90686-01 [1628]Nonexcisional debridement of skin and subcutaneous tissue has already been assigned for this episode, no additional code is required.
oDay 5 – change of vacuum dressing undertaken on the ward.
As 90686-01 [1628]Nonexcisional debridement of skin and subcutaneous tissue has already been assigned for this episode, no additional code is required.
oDay 6 – excisional debridement and application of new vacuum dressing in operating theatre under general anaesthetic, assign:
90665-00 [1628]Excisional debridement of skin and subcutaneous tissue and
90686-01 [1628]Nonexcisional debridement of skin and subcutaneous tissue
and the appropriate anaesthetic code.
oDay 9 – change of vacuum dressing undertaken on the ward.
As 90686-01 [1628]Nonexcisional debridement of skin and subcutaneous tissue has already been assigned for this episode, no additional code is required.
As VAC dressings are classified to nonexcisional debridement, ACS 0042 Procedures normally not coded, point 7 – Dressings, does not apply.
This will be clarified in ACS 0042 Procedures normally not coded, point 7 – Dressings and the classification of wound dressings has been highlighted for review in a future edition of ACHI.
(Coding Rules, December 2015)
Coding Rules - Current as at 16-Dec-2015 18:13 / Page 1 of 21Australian Consortium for Classification Development / ACCD Classification Information Portal
Ref No: TN1029 | Published On: 15-Dec-2015 | Status: Current
SUBJECT: Osteoarthritis and ACS 0003 Supplementary codes for chronic conditions
Q:
A patient is admitted for a total knee replacement due to osteoarthritis (OA) in the knee, but also has clinical documentation of OA in the shoulder (which does not meet the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses). Should U86.2 Arthritis and osteoarthritis be assigned in addition to M17.1 Other primary gonarthrosis?
A:
Osteoarthritis (OA) is a degenerative disease that may affect any joint of the body. Depending on the progression, it may affect different joints at different times.
ACS 0003 Supplementary codes for chronic conditions states that the supplementary codes are not to be assignedin addition to another chapter code for the same condition.
Therefore, once OA of a specific site meets the criteria for code assignment as per ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses, do not assign U86.2 Arthritis and osteoarthritis for OA of another site.
(Coding Rules, December 2015)
Coding Rules - Current as at 16-Dec-2015 18:13 / Page 1 of 21Australian Consortium for Classification Development / ACCD Classification Information Portal
Coding Rule is effective for event records with an event end date on or after 1 January 2016
Ref No: TN1035 | Published On: 15-Dec-2015 | Status: Current
SUBJECT: Low magnesium
Q:
What is the correct code to assign for a documented low serum magnesium level, confirmed as low on biochemistry, and for which magnesium replacement is given (i.e. Mg 0.42 on admission commenced on Magmin 3 tabs TDS)? Is it correct to follow the advice in the Coding Rule Use of abbreviations, symbols and test results values (originally published 15 September 2009 and updated 15 September 2015) and follow the index pathway Deficiency/magnesium to assign E61.2 Magnesium deficiency as per the example of low potassium cited in this Coding Rule?
A:
The index pathways in ICD-10-AM for low magnesium are not consistent with those for low potassium. For low potassium following the lead terms Deficiency, Depletion, Hypokalaemia, Hypopotassaemia or Syndrome result in only one code, E87.6 Hypokalaemia. However three different codes may be assigned for low magnesium depending on the lead term chosen:
E83.4 Disorders of magnesium metabolism
E61.2 Magnesium deficiency
R79.0 Abnormal level of blood mineral
For low magnesium without further specification use the lead term Hypomagnesaemia to assign E83.4 Disorders of magnesium metabolism in categoryE83 Disorders of mineral metabolism which is the same block where low potassium is classified (Metabolic disorders (E70-E89)).
Do not follow the index pathway Deficiency/magnesium to assign E61.2 Magnesium deficiency,in block E50-E64 Other nutritional deficiencies, unless there is documentation to support that the patient has a dietary deficiency.
Codes in category E61 Deficiency of other nutrient elements and E83 Disorders of mineral metabolism are mutually exclusive as per the excludes notes at E61 and E83.
R79.0 Abnormal level of blood mineral is also inappropriate, as this is a symptom code in Chapter 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) and is only to be used when a more specific code is not available elsewhere in the classification. R79.0 excludes both disorders of mineral metabolism (E83.-) and nutritional mineral deficiency (E58-E61).
See also Coding Rule Use of abbreviations, symbols and test results values (originally published 15 September 2009 and updated 15 September 2015).
(Coding Rules, December 2015)
Ref No: Q2855 | Published On: 15-Dec-2015 | Status: Current
SUBJECT: Injection of markers into lesions of the gastrointestinal tract
Q:
What is the correct procedure code for injection of markers such as lipoidol/ histoacryl markers into gastrointestinal tract lesions?
A:
Endoscopic tattooing or marking is a commonly used method for marking lesions of the gastrointestinal tract (oesophageal, gastric, colonic).
There are different types of markers used for different purposes:
•Radiolucent markers such as carbon particles (SPOT) or India ink, are primarily used to mark a lesion to facilitate location of the lesion in subsequent surgery or follow up.
•Radio-opaque markers such as Lipoidol, are used to demarcate lesion margins for precise delivery of image guided radiotherapy. Demarcation of the lesion in the gastrointestinal tract is usually performed endoscopically. Markers are injected into the normal mucosa around the circumference of the lesion, outlining its margin.
For injection of tattooing markers (of any type) into lesions of the oesophagus, stomach or intestine, assign an appropriate code for the type of endoscopy with injection/administration of tattooing agent using the following index pathways as appropriate:
Oesophagoscopy (flexible)
- with
- - administration of tattooing agent 30473-07 [1005]
OR
Injection (around) (into) (of) – see also Administration
- agent (to)
- - tattoo
- - - by
- - - - colonoscopy (to caecum) 32090-02 [905]
- - - - - to hepatic flexure 32084-02 [905]
- - - - panendoscopy (to duodenum) 30473-07 [1005]
- - - - - to ileum 30473-08 [1005]
Appropriate codes are:
30473-07 [1005] Panendoscopy to duodenum with administration of tattooing agent
30473-08 [1005] Panendoscopy to ileum with administration of tattooing agent
32084-02 [905] Fibreoptic colonoscopy to hepatic flexure with administration of tattooing agent
32090-02 [905] Fibreoptic colonoscopy to caecum with administration of tattooing agent
Improvements to ACHI will be considered for a future edition.
Reference:
Australian New Zealand Clinical Trials Registry (ANZCTR) n.d., Phase II Feasibility Study of Lipidiol Markers for Radiation Therapy Localisation and Response Assessment in the Multi-Disciplinary Team Management of Oesophageal-Gastric Cancer, viewed 12, Oct 2015,
(Coding Rules, December 2015)
Ref No: Q2885 | Published On: 15-Dec-2015 | Status: Current
SUBJECT: Dysexecutive Syndrome
Q:
How do you code dysexecutive syndrome?
A:
Dysexecutive syndrome is a broad term referring to acquired changes in the executive functioning of the brain such as personality, behaviour and executive cognitive functions (eg. planning, insight, judgement etc). Underlying causes can range from traumatic brain injury to ageing to neurological disease such as dementia and Parkinson’s disease and the changes can be permanent or temporary. Whilst frontal lobe syndrome is synonymous with acquired personality changes, damage to other regions in the brain can also produce these changes and have thus been referred to as dysexecutive syndrome.
Clinical advice has clarified that as there is no specific code for dysexecutive syndrome in ICD-10 nor ICD-10-AM, as a best fit assign F07.0 Organic personality disorder following the index pathway:
Syndrome
- brain
- - personality change F07.0
Assign a code for the underlying cause if known, as per ACS 0002 Additional diagnoses, Problems and underlying conditions.
Indexing improvements will be considered for a future edition of ICD-10-AM.
(Coding Rules, December 2015)
Ref No: Q2925 | Published On: 15-Dec-2015 | Status: Current
SUBJECT: Debridement of burn performed with change of dressing
Q:
Should debridement, trimming of skin and de-roofing of blisters performed with change of burn dressings be coded?
A:
ACCD considers the statement in ACS 1203 Debridement, ‘most debridements are excisional’ refers to debridements performed in an operating room, as per the reference to ‘surgeon’. ACS 1911 Burns, Dressing/debridement of burns refers to these procedures being performed in the ‘operative episode’ and refers clinical coders to the excisional debridement codes in block [1627].
Clinical advice confirms that debridement, de-roofing of blisters and trimming of skin during a change of burn dressing, performed on the ward with no anaesthesia, is nonexcisional debridement. This type of nonexcisional debridement is an inherent component of changing a burn dressing and is not to be coded as per ACS 0016 General Procedure Guidelines, Procedure Component.
Improvements to the classification of wound management have been flagged for review in a future edition of ACHI.
(Coding Rules, December 2015)
Note: Referalso to NZCA coding queryDebridement on ward or in Emergency department
Ref No: Q2957 | Published On: 15-Dec-2015 | Status: Current
SUBJECT: Prematurity and documentation of gestational age
Q:
Does ‘prematurity’ need to be documented in the clinical record or is documentation of gestational age sufficient to assign codes from P07.2 Extreme immaturity or P07.3 Other preterm infants? Should these codes be routinely assigned or do they need to meet ACS 0002 Additional diagnoses?
A:
Prematurity is a significant indicator of neonatal morbidity and mortality and as such should be documented in the clinical record. However clinicians may use the gestational age to reflect this, particularly for those closer to 37 completed weeks, and not specifically document the term premature.
The Tabular note at P07 Disorders related to short gestation and low birth weight, not elsewhere classified, also reinforces the importance of gestational age by the instruction to give priority of assignment to gestational age over birth weight.
As per Coding Rule O60 Preterm labour and delivery, where specific codes are to be assigned when applicable for delivery episodes, codes from P07.2- Extreme immaturity and P07.3- Other preterm infants should always be assigned for neonates with a gestational age documented as less than 37 completed weeks.
ACS 1618 Low birth weight and gestational age has been flagged for review for a future edition.
(Coding Rules, December 2015)
Ref No: Q2985 | Published On: 15-Dec-2015 | Status: Current
SUBJECT: Elevated PSA
Q:
What is the principal diagnosis where elevated PSA is documented as the indication for aprocedure, but the histopathological finding is BPH or adenocarcinoma?
A:
An elevated PSA is an abnormal test result that is commonly used as an indicator for a number of male urogenital disorders such as prostate cancer, benign prostatic hypertrophy (BPH), urinary tract infection (UTI) and prostatitis. If such conditions are identified or confirmed on histopathology, then these conditions should be coded and not the abnormal test result (elevated PSA) as per ACS 0001 Principal diagnosis /Problems and underlyingconditions.
However, if no such condition is identified by the clinician or there was no clear finding confirmed on the histopathology report, assign R79.8 Other specified abnormal findings of blood chemistry for the elevated prostate specific antigen (PSA) only, following the index pathway:
Elevated, elevation
- prostate specific antigen (PSA) R79.8 Other specified abnormal findings of blood chemistry
See also Coding Rule ‘Clinical diagnosis versus histology’.
(Coding Rules, December 2015)
Ref No: Q2991 | Published On: 15-Dec-2015 | Status: Current
SUBJECT: Inadvertent or intentional removal of devices requiring replacement
NOTE:thismaybeachangeincodingpractice
Q:
What is the correct code to assign when a device or tube is inadvertently or intentionally removed requiring replacement, e.g. a gastrostomy tube being pulled out or falling out requiring replacement?
A:
Mechanical complications are device malfunctions or failures. Devices can fail or malfunction because they are improperly implanted, break down, wear out or migrate out of position.
A gastrostomy tube or device which is inadvertently or intentionally pulled out is not a device malfunction or failure and is not to be classified as a mechanical complication.
Inadvertent removal of a gastrostomy tube may require review or replacement; it should not be classified to T85.5 Mechanical complication of gastrointestinal prosthetic devices, implants and grafts. However, assign Z43.1 Attention to gastrostomy if the gastrostomy received attention or management during the episode of care.