HS317b - Coding & Classification of Health Data
Lab - Endocrine
Examples:
Type 1 diabetes with diabetic nephropathy and hypertension secondary to renal disease
and hypertension secondary to renal disease. FBS levels ranged from 6 to 9 mmol/L and
were controlled with insulin.
PVD and gangrene due to NIDDM; diabetes controlled with insulin; FBS levels ranged
from 6 to 11 mmol/L. The patient required amputation through metatarsophalangeal
joint, left great toe with flap closure.
Uninodular toxic nodular goitre with thyrotoxicosis
Substernal partial right thyroidectomy
ESRD due to type 1 diabetic nephritic syndrome; diabetes controlled with insulin; FBS
levels within controlled range.
Type 1 diabetic developed hypoglycaemia following insulin injection even though she
had taken only the prescribed dose of insulin and did not alter her exercise or eating
regimen.
Type 1 diabetes mellitus, controlled with insulin, diabetic osteoarthrosis, right knee
Procedures
Bypass Grafts (revascularization)
To code:
 Pay attention to anatomical sites
 Read inclusion or exclusion notes at the beginning of each anatomical site section.
 Bypass procedures of the arteries and veins are coded to the anatomical site in
which the vessel originates
Aorto-femoral bypass graft, using left saphenous vein.
1.KA.76.MX-XX-A /
/
1.KR.58.LA
L
/
Bypass procedure involving the artieries, code to most proximal site. (originates in aorta;
therefore code to aorta)
HS317b - Coding & Classification of Health Data
Lab - Endocrine
Autologenous veins…usually the saphenous vein. ---use to bypass occlusive lesions of
the superficial femoral, popliteal or tibial arteries. Dacron is commonly used for an
arterial prosthesis to bypass disease in the aortoiliac.
When resection is performed with a graft, the procedure is classified to partial excision of
the artery with an appropriate qualifier to describe the type of material used for the repair.
Resection right anterior tibial artery with PTFE (polytetrafluoroethylene) graft.
1.KG.87.LA-XX-N R
/
Amputations:
Disarticulation:
When the incision is made through bone
When the incision is made through a joint
Below knee amputation:
1.VQ.93.~~ Amputation tibia and fibula
Amputation through knee
1.VG.93.~~
Debridement of ulcer of foot and ankle.
Debridement of ulcer based on intent and anatomical site (deepest involvement (skin or
soft tissue which includes muscle, tendon))
Intent:
Dressing,
Repair,
Destruction
Partial excision
Radical excision
Minor Debridement of foot/ankle
1.WV.59.~~ Destruction, soft tissue foot and ankle
Excisional Debridement
1.WV.87.~~ Excision, partial soft tissue foot and ankle
Excision that involves removal of bone with other soft tissue
1.~~.91.~~ Excision, radical of bone + anatomical site.
Demonstrate in Folio where description of approaches are.