New Zealand 8th Edition Regional Coder Training Workshop FAQs
ACS 0019 Procedure not Completed or
Interrupted
Minimally invasive (keyhole) procedure proceeding to open procedure
Q: If a diagnostic laparoscopy was performed and the clinicians decided to try and excise the tissue/organ
laparoscopically while they were in there but it didn’t work and had to convert to open, how would you code that?
R: As the intention was to perform a diagnostic laparoscopy it should be coded as per scenario B.
Q: What code do you assign if the patient is admitted for a diagnostic laparoscopy with the intention to perform a
laparoscopic procedure but an issue arises and they convert to an open procedure?
R: This case would be code as per scenario B above. See published FAQ next page.
Q: What about if the patient is admitted for a diagnostic laparoscopy with the intention to perform either a
laparoscopic or open procedure and they perform laparoscopic division of adhesions then convert to an open
procedure – would you still code the diagnostic laparoscopy?
R: In this case diagnostic laparoscopy wouldn’t be coded as laparoscopy is included in the ‘laparoscopic division of
adhesions’. Use free text on the code descriptor to specify the circumstances.
Q: How do you code a case where say two procedures during one operative episode were attempted to be
performed laparoscopically, however both had to be converted to an open procedure?
R: The procedure code 90343-01 [1011] Laparoscopic procedure proceeding to an open procedure would be assign
twice and sequenced after each ‘open’ procedure.
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Published Coding Rules FAQ
ACS 0020 Bilateral/Multiple Procedures
Q: Injection of botox multiple sites – do we code each site?
R: Yes.
Refer to ACS 0020 Bilateral/multiple procedures – Multiple procedures Classification point 4.
ACS 0042 Procedures Normally Not Coded
Q: If a procedure is performed under CT or MRI guidance are the CT and MRI coded?
R: No. Refer to ACS 0042 Procedure normally not coded point 13 Imaging services.
Q: MRCP and EUS – do we still code?
R: As per ACS 0042 Procedures normally not coded, codes from ACHI Chapter 20 Imaging services should only be
coded if one of the bullet points in ACS 0042 applies or if ACHI instructs you to do so.
The bullets points are:
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Note:
 Some codes on this list may be required in certain standards elsewhere in the Australian Coding Standards. In
such cases, the standard overrides this list and the stated code should therefore be assigned as described in the
relevant standard.
 The listed procedures should be coded if cerebral anaesthesia is required in order for the procedure to be
performed (see ACS 0031 Anaesthesia).
 These procedures should be coded if they are the principal reason for admission in same-day episodes of care.
This includes patients who are admitted the day before or discharged on the day after a procedure because a
same-day admission is not possible or practicable for them (eg elderly patients, those who live in remote
locations).
Q: What about fat grafts and bone grafts – do we code these as an additional procedure?
R: Yes when the graft is specifically not included in the ACHI code, block or where ACHI instructs you to do so.
ACS 0044 Chemotherapy
Q: ACS 0044 refers to same day and multi-day episodes of care for chemotherapy.
Therefore should the
chemotherapy procedure code be assigned only when the reason for the episode of care is for chemotherapy?
R: Although the ACS describes scenarios where patients are admitted specially for chemotherapy, the intention of
the ACS is that chemotherapy should be coded whenever performed. NCCH have advised that consideration will be
given to rewording the ACS for clarity in a future classification.
ACS 0048 Condition Onset Flag
Q: Where a patient has COPD and pneumonia, it would be coded as COPD with acute lower respiratory infection
and pneumonia. Therefore, would the COF value for the COPD with infection be a 2 and the pneumonia will be a COF
of 1?
R: Yes this would be correct if the pneumonia arose during the admitted episode of care.
See FAQs next page.
Q: When a patient is on approved leave and involved in a MVA, what is the place of occurrence?
R: The place of occurrence assigned will be Y92.4- Street and highway and the COF value assigned is 1.
Refer to ACS
0048 Condition onset flag, guide for use bullet point 11.
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Published Coding Rules FAQs
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ACS 0104 Viral Hepatitis
Q: What code is assigned if there is documentation of ‘carrier’, can we still code it? or do we code it to past history?
R: No, carrier status is no longer clinically correct, therefore is not coded.
Refer to the general classification
guidelines table in ACS 0104 for guidance on code assignment for the specific type of hepatitis.
As per ACS 0104 Viral hepatitis – Classification point 1 Past history of hepatitis
‘A past history code may be assigned for hepatitis A or hepatitis E when the history meets ACS 2112 Personal history.
When a past history of hepatitis B, hepatitis C or hepatitis D is documented, assign:



hepatitis B: B18.1 Chronic viral hepatitis B without delta-agent
hepatitis C: B18.2 Chronic viral hepatitis C (except when documented with terms such as 'cured', 'cleared' or
'with SVR' – see 4. Cured/cleared hepatitis C below)
hepatitis D: B18.0 Chronic viral hepatitis B with delta-agent’
‘The concept of 'carrier (state) of viral hepatitis' is no longer clinically correct; therefore, Z22.51 Carrier of viral
hepatitis B, Z22.52 Carrier of viral hepatitis C and Z22.59 Carrier of other specified viral hepatitis should never be
assigned.’
In the circumstances where ‘carrier’ is documented coders should consult with the clinician to verify the status of the
hepatitis.
During the training workshops clinical coders were advised that it would be a good idea to inform the relevant
clinicians of the changes in hepatitis coding so they get the appropriate documentation within the clinical record.
ACS 0110 Sepsis, Severe Sepsis and Septic
Shock
Q: Where severe sepsis is documented but there is no mention of the localised and/or generalised infection, what
code is assigned?
R: Severe sepsis is defined as sepsis with organ dysfunction or organ failure.
As per the classification of severe
sepsis in ACS 0110 ‘where there is no stated origin of the infection, assign a code for the generalised or systemic
infection’. Therefore following the Alphabetic index assign the appropriate sepsis code followed by R65.1 Systemic
inflammatory response syndrome [SIRS] of infectious origin with acute organ failure. Assign code(s) for the organ
failure as appropriate.
Where there is only documentation of severe sepsis and no organ dysfunction/failure is documented consult with
the clinician.
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Q: If you have documentation of sepsis due to pneumonia, do you just code the pneumonia?
R: Refer to ACS 0110 Sepsis, severe sepsis and septic shock – Sepsis. If it is determined that the sepsis is localised eg,
pneumonia, assign a code for the pneumonia. Refer to NCCC Q&A December 2012 – Staphylococcal pneumonia with
sepsis.
If the documentation supports generalised sepsis and pneumonia assign the appropriate codes for both sepsis and
pneumonia.
Q: If infection and trauma are documented what SIRS code do you assign?
R: Refer to ACS 0110 Sepsis, severe sepsis and septic shock – Classification section.
‘Where there is documentation of SIRS, assign first a code for the aetiology (infection, trauma etc) followed by the
appropriate code from category R65 Systemic inflammatory response syndrome [SIRS].
Where both an infectious and noninfectious aetiology is recorded in conjunction with SIRS, such as trauma and then
infection, assign either R65.0 Systemic inflammatory response syndrome [SIRS] of infectious origin without acute
organ failure or R65.1 Systemic inflammatory response syndrome [SIRS] of infectious origin with acute organ failure,
as appropriate.’
Q: If there is documentation of SIRS with organ failure, however the organ failure is not documented as ‘acute’ what
SIRS code do you assign?
R: Following the ICD-10-AM Alphabetic Index ‘with acute organ failure’ is an essential modifier, therefore the organ
dysfunction/failure must be documented as acute. Refer to clinician to confirm the diagnosis of acute organ failure.
Where confirmation of organ failure is not possible follow the Alphabetic Index for Syndrome, systemic
inflammatory response, ‘infectious’ or ‘noninfectious’, as ‘without acute organ failure’ is a non-essential modifier.
ACS 0111 Healthcare Associated
Staphylococcus Aureus Bacteraemia
Q: If hospital acquired Staphylococcus aureus pneumonia is documented do you assign Y95 Nosocomial condition or
U90.0 Healthcare associated Staphylococcus aureus bacteraemia? Pneumonia looks at blood samples so would
bacteraemia need to be documented?
R: Yes.
Bacteraemia needs to be documented within the clinical record and meet the criteria in ACS 0001 Principal
diagnosis or ACS 0002 Additional diagnoses.
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Q: Are we to still assign the code Y95 Nosocomial condition when a condition is documented as hospital acquired?
We have been told we don’t need to assign Y95 as the COF value of 1 for the condition indicates it’s hospital
acquired.
R: Y95 should be assigned where a condition is documented as hospital acquired.
In ICD-10-AM Tabular List code
A49.9 Bacterial infection, unspecified has a ‘use additional code’ instruction for Y95.
Y95 should not be omitted from coding due to a COF value of 1 being assigned for a condition.
ACS 0112 Infection with Drug Resistant
Microorganisms
Q: Where there are multiple bacterial agents eg, E coli, Enterococcus, MRSA and they are resistant to different
types of antibiotics and the MRSA is methicillin, how would you code these cases? Would it be coded to Z06.52
Resistance to methicillin as per the Excludes note?
R: In this scenario as there are multiple bacterial agents that are resistant to multiple antibiotics (not included in
MRSA) each resistance should be coded following the ICD-10-AM Alphabetic Index and Tabular List instructions.
Q: Does the resistance apply to all infections?
R: Yes.
Where there is documentation of resistance you should code accordingly.
Q: MRSA carrier status - do we still code the history?
R: Yes.
Refer to published Coding Matters coding query December 2009 – Methicillin resistant or multi-resistant
Staphylococcus aureus (MRSA) or Vancomycin resistant Enterococcus (VRE).
Q: When there is documentation of ‘Non-multiresistance MRSA (nmMRSA)’ what does that mean?
R: “nmMRSA (non-multiresistant MRSA or sometimes referred to as community-associated MRSA) are strains that
have arisen in the community and cause similar types of infection to other strains of S. aureus found in the
community. They are usually resistant to all penicillins, cephalosporins and methicillin (oxacillin), plus up to two of the
non-beta-lactam antibiotics (erythromycin, cotrimoxazole, gentamicin, rifampicin, fusidic acid, ciprofloxacin,
tetracycline).”
Reference: Methicillin resistant Staphylococcus aureus (MRSA) in the community – Information for clinicians
http://www.health.qld.gov.au/chrisp/resources/nmMRSA_clinical.pdf
Where nmMRSA is documented in the clinical record refer to the microbiology result to obtain further information
with regards to the drug resistance.
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Q: Documentation of MSSA (Methicillin Sensitive Staph Aureus), what does that mean?
R: MSSA can mean either ‘Methicillin Sensitive Staphylococcus aureus’ or ‘Methicillin-Susceptible Staphylococcus
aureus’. Both these mean the Staphylococcus aureus infection is not resistant, but is sensitive to antimicrobial
treatment, therefore it is not appropriate to assign a code from category Z06 Resistance to antimicrobial drugs.
Q: If there is documentation of the resistance on the discharge summary can you code the resistance?
R: Refer to ACS 0010 General abstraction guidelines.
Verify the documentation of resistance on the discharge
summary by reviewing the documentation within the clinical record for the episode of care.
Q: What about if there is documentation within the clinical record of UTI and when you go to the microbiology
report it shows E coli and ESBL resistance, can you code the resistance?
R: No.
Refer to published FAQ next page.
Q: Is the above question/response only applicable for UTIs or is it for all infections?
R: It is applicable to all infections.
Q: If MRSA is documented what code do you assign?
R: MRSA can mean either ‘Methicillin’ or ‘Multi’ Resistant Staphylococcus aureus, therefore refer to documentation
within clinical record to confirm MRSA. In the absence of any documentation for methicillin, or multiple specified
antibiotics, assign code Z06.67 Resistance to multiple antibiotics.
Q: Does the resistance have to be documented by the clinician?
R: Yes. Refer to published FAQ next page.
Q: If the infection is documented and you check the lab result and it shows MRSA can you code the staph aureus but
not the resistance?
R: Yes.
As per ACS 0010 General abstraction guidelines – test results, the identification of Staphylococcus aureus is
adding specificity to an already documented condition. However as per published advice the resistance must be
documented in the clinical record for the episode of care.
Q: If MRSA is documented but only one drug is specified what code(s) are assigned?
R: Assign the specific code for the known drug (eg, Z06.61 Resistance to vancomycin) and assign a single unknown
code (eg, Z06.60 Resistance to unspecified antibiotic).
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Q: Why was the code Z06.74 Resistance to tuberculostatic drug(s) created when they are mostly antibacterials?
R: The code is for tuberculosis-resistant drugs that are not necessarily antibacterials, in the same way
antineoplastics can only be applied to drugs (any drugs) that are neoplasm resistant.
Published Coding Rules FAQs
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ACS 0401 Diabetes Mellitus and Intermediate
Hyperglycaemia
Q: When there is documentation of truncal obesity, abdominal obesity or central obesity is this enough
documentation to code obesity in relation to diabetes mellitus?
R: Section 3 DM and IH with features of insulin resistance classification bullet point four includes ‘increased intraabdominal visceral fat deposition’ and the last bullet point includes ‘obesity’, ‘morbid obesity’ and ‘overweight’.
Therefore documentation of ‘truncal obesity’, ‘abdominal obesity’ or ‘central obesity’ would be appropriate in
determining DM with features of insulin resistance.
Q: Can documentation of metabolic syndrome be coded as features of insulin resistance?
R: Yes if the patient suffers from DM.
Following the Alphabetic Index metabolic syndrome is assigned E1-.72
Diabetes mellitus with features of insulin resistance.
Diabetes, diabetic (controlled) (mellitus) E1-.9
….
- with
….
- - metabolic syndrome E1-.72
Q: Can documentation of BMI be interpreted as obesity and coded to insulin resistance?
R: BMI is not always an indication of overweight or obesity as it could just mean increased weight.
Refer to the
clinical record for other documentation or consult with the clinician to confirm a diagnosis of overweight or obesity.
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Q: Criteria for Diabetic Foot (2d) Previous amputation(s) of affected and/or contralateral lower limb – what if the
amputation was due to an unrelated condition eg, amputation many years ago due to trauma?
R: If the amputation was due to another cause eg, trauma the amputation status contributes to the criteria of
diabetic foot, see FAQ next page.
Q: What code is assigned for a metabolic acidosis in Type 2 diabetes mellitus?
R: Clinical advice received suggested coders consult with their clinicians to confirm the diagnosis when the
documentation is ‘diabetes mellitus with metabolic acidosis’ or similar. Comments received were:
“The vast majority of cases will be either diabetes – ketoacidosis, or lactic acidosis, and if it is coded “metabolic” I
suspect that the clinicians will have actually meant either of these.”
“It may be as patients with type 2 DM and significant dehydration, no ketoacidosis may be acidotic due to poor
perfusion, or alcohol binge with mild elevation of betahydroxybutyrate, and patients with ketoacidosis may also have
lactic acidosis.”
In the situations where confirmation of diagnosis cannot be obtained from the clinician, assign the code E87.2
Acidosis as ‘metabolic acidosis’ is not index under the lead term ‘Diabetes’ and there is no default code for the index
entry ‘acidosis’.
Q: During an episode of care a patient was diagnosed with a stage III or IV pressure ulcer of the foot which required
treatment (daily dressings). History includes type 2 DM and neuropathy which meets the criteria of diabetic foot.
Can L89.2-L89.3 Decubitus ulcer and pressure area stage III/IV be assigned as an additional code to E11.73 Type 2
diabetes mellitus with foot ulcer due to multiple causes?
R: Refer to ACS 0401 Diabetes mellitus and intermediate hyperglycaemia – section 6 Diabetic foot.
In the
classification box it states ‘additional codes for the specific complications of DM or IH should be assigned in
accordance with Rule 4a and Rule 4b’.
In this scenario the pressure ulcer meets the criteria of ACS 0002 Additional diagnoses, therefore an additional code
for the stage III/IV pressure ulcer (L89.2-L89.3) would be assigned.
Q: Can previous documentation be used to assign a more specific code for diabetes?
R: Yes. Refer to published NCCC FAQ June 2012 – Documentation of diabetes mellitus.
Q: What code is assigned in the situation where a patient has a history of IOL following removal of a congenital
cataract?
R: The classification links diabetes with cataracts, but not congenital cataracts, so the presence of an IOL in this
scenario should not be coded as an eradicated condition in diabetes.
Q: Does CKD have to meet ACS 0401 Diabetes mellitus and intermediate hyperglycaemia - Rule 4b?
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R: No. CKD does not have to meet ACS 0002 Additional diagnoses in diabetes mellitus. Refer to ACS 1438 Chronic
Kidney disease – Diabetic nephropathy and the ‘use additional code’ instruction in the ICD-10-AM Tabular List for
E09.2-, E1-.21, E1-.22. See FAQ below.
Published Coding Rules FAQs
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ACS 0402 Cystic Fibrosis
Q: We have cystic fibrosis patients frequently admitted for a ‘tune up’ and are administered antibiotics etc.
In these
cases what code should be assigned as the principal diagnosis?
R: The appropriate cystic fibrosis code. See FAQ below.
Q: Why do the cystic fibrosis events frequently reject from the NMDS?
I had a case where I coded cystic fibrosis
(E84.-) and pancreatic insufficiency (K86.8) and it rejected. When I looked in the ICD-10-AM Tabular List under K86.8
Other specified diseases of pancreas there was an Excludes for cystic fibrosis so I deleted the K86.8 code then
resubmitted the event and it loaded.
R: Cystic fibrosis (CF) events frequently reject from the NMDS due to the low age flag edit on the manifestation
codes reported with CF. In the example below K86.8 has a low age of 10, which means any NMDS events reported
with this code and the age is less than 10 the event will reject as a warning. To over write the NMDS warning
resubmit the event with the A2 function; this means ‘add ignoring any warnings’.
Clinical coders should not omit diagnosis/procedure codes in order to get an event loaded in the NMDS.
clinical_code
J339
J47
K868
clinical_code_type
A
A
A
clinical_code_system
14
14
14
clinical_code_description
Nasal polyp, unspecified
Bronchiectasis
Other specified diseases of pancreas
death_flag
Y
Y
Y
gender_flag
B
B
B
low_age
0
0
10
high_age
121
121
121
Published Coding Rules FAQ
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ACS 1006 Ventilatory Support
Q: Does the code assignment for combined ventilatory support only relate to neonates (28 days or less)?
Was thinking about neonates who are transferred from one hospital to another and are over the 28 day neonate
definition?
R: Yes.
Refer to ACS 1607 Newborn/neonate and 1615 Specific interventions for the sick neonate.
Where the neonate is transferred from one hospital to another and is over 28 days of age the combined ventilatory
support ACHI code 92211-00 [571] Management of combined ventilatory support, > 96 hours should not be assigned.
As per ACS 1607 Newborn/neonate the definition is:
‘A neonate is a liveborn who is less than 28 days old. The neonatal period is defined in Australia as:
"…exactly four weeks or 28 completed days, commencing on the date of birth (day 0) and ending on the completion
of day 27. For example, a baby born on 1 October remains a neonate until completion of the four weeks on 28
October and is no longer a neonate on 29 October" (METeOR: 327284) (Australian Institute of Health and Welfare
2012).’
Also refer to the note at the beginning of ACS 1615 Specific interventions for the sick neonate
‘Note: These interventions should also be coded when used in the ongoing care of sick infants, who, after 28 days
are still in the birth episode (see ACS 1607 Newborn/neonate). For any infants who have been separated and
then readmitted, interventions for the sick neonate may still be assigned, if documentation indicates that the
condition requiring intervention, originated in the perinatal period.’
ACS 2114 Prophylactic Surgery
Q: If a patient was admitted for a right mastectomy due to neoplasm and also has a left mastectomy
prophylactically during the same operative episode during one episode of care would the principal diagnosis be the
neoplasm with an additional code for the prophylactic surgery (Z40.0- Prophylactic surgery for risk-factors related to
malignant neoplasms)?
R: ACS 2114 Prophylactic surgery is specifically describing episodes where the admission is solely for prophylactic
surgery and it does not deal with this scenario specifically but the principle is the same, therefore a code from Z40.0Prophylactic surgery for risk-factors related to malignant neoplasms should be assigned as an additional diagnosis.
NCCH will consider clarifying this in the ACS in a future edition.
Q: If the patient was admitted for prophylactic surgery but the results came back positive for cancer, is the
neoplasm coded as the principal diagnosis or an additional diagnosis?
R: The reason for admission is for prophylactic surgery irrespective of whether neoplasm is diagnosed.
ACS 0002
Additional diagnoses should still be applied to determine if the neoplasm should be coded.
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Q: If the patient has a lesion and they are admitted for a biopsy of the lesion and the histopathology report shows
neoplasm can you code the case to neoplasm?
R: Yes.
This is a diagnostic procedure therefore as per ACS 0001 Principal diagnosis after study the final diagnosis
will be the finding on the histopathology report.
Q: What code is assigned for the gene mutation BRCA 1 or BRCA 2 when this is the reason for prophylactic surgery?
R: There is no code available in the ICD-10-AM classification to capture the BRCA gene mutation.
Therefore where
this risk factor is present clinical coders should follow the ICD-10-AM Alphabetic Index, ‘Admission (for), prophylactic
surgery, organ removal for risk-factors related to malignant neoplasm’ and assign the appropriate Z40 Prophylactic
surgery diagnosis code. Use free text on the code descriptor to specify the BRCA gene mutation.
The diagnosis codes R89 Abnormal findings in specimens from other organs, systems and tissues and Q99.9
Chromosomal abnormality, unspecified are not appropriate to assign for BRCA gene mutation.
Anaemia
Q: What if the clinician has actually documented ‘anaemia due to neoplasm’?
R: The codes D63.0* Anaemia in neoplastic disease and D63.8* Anaemia in other chronic diseases classified
elsewhere no longer exist in 8th Edition, therefore assign the code for the specified type of anaemia documented.
Q: Can you assign more than one anaemia code eg, iron deficiency anaemia and acute posthaemorrhagic anaemia?
R: Yes.
More than one anaemia code can be assigned in the cases where the specified types of anaemia are
documented.
Atrial Fibrillation/Atrial Flutter
Q: What code do you assign for PAF?
R: Coders should consult the clinician to clarify if they mean ‘paroxysmal’ or ‘persistent’.
Reference: http://emedicine.medscape.com/article/151066-overview#aw2aab6b2b2
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Q: Can you assign more than one code or do you use the hierarchy and only assign one code?
R: Generally only one type is present, however in long stay patients there could be more than one type present.
Clinical coders may need to consult the clinician to confirm the diagnosis.
Haemorrhoids
Q: What if the documentation states thrombosed Grade III haemorrhoids?
How should it be coded?
R: If you have documentation of the degree (grade, stage) that takes precedence over thrombosed, strangulated or
ulcerated, therefore assign the code for the degree (K64.2 Third degree haemorrhoids) and not the thrombosed
(K64.8 Other specified haemorrhoids).
Hernia
Q: What code should be assigned when there is documentation of obstruction and gangrene, for example
abdominal hernia?
R: Follow the ICD-10-AM Alphabetic Index – the subterm ‘gangrene’ has a non-essential modifier (NEM) ‘(and
obstruction)’, therefore, gangrene and obstruction are included in the one code K45.1. See example below.
Hernia, hernial (acquired) (recurrent) K46.9
….
- abdomen, abdominal K46.9
- - specified site NEC K45.8
- - - with
- - - - gangrene (and obstruction) K45.1
- - - - obstruction K45.0
….
Q: Can intestinal obstruction be coded as an additional code with hernia?
R: No. Follow the ICD-10-AM Alphabetic Index.
Obstruction, obstructed, obstructive
….
- intestine (mechanical) (paroxysmal) (postinfective) K56.6
- - with
- - - adhesions (intestinal) (peritoneal) K56.5
- - - hernia – see Hernia/by site/with obstruction
….
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Insertion of Seeds/Fiducial Markers into
Prostate
Q: How will we know what procedure code to assign?
R: Refer to clinical documentation within the clinical record to confirm if seeds or fiducial markers are inserted.
Where documentation is not available clinical coders should consult with the clinician (eg, radiation team).
Jaundice
Q: Jaundice in extreme prematurity documented as due to ABO and premature can you assign P55.1 ABO
isoimmunisation of fetus and newborn and P59.0 Neonatal jaundice associated with preterm delivery?
R: Yes.
The classification does not prohibit both codes from being assigned.
Laparoscopic Colectomy [913]
Q: Would hand assisted procedure be coded under these laparoscopic procedures?
R: Yes.
McRoberts Manoeuvre
Q: Should the procedure code 90477-00 [1343] Other assisted procedures to assist delivery be assigned for
McRoberts manoeuvre?
R: No.
In New Zealand there is no requirement to code McRoberts manoeuvre. This coding practice was confirmed
via a published query which was created in 2002, see below.
In October 2010 a coding query was published (see below) by NCCH advising that the procedure code assignment for
McRoberts manoeuvre is ‘optional’.
In ICD-10-AM 8th Edition the diagnosis code O83 Other assisted single delivery includes ‘single delivery assisted
(facilitated) by McRoberts manoeuvre’. Clinical coders were asked at the 8th Edition training workshops what their
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thoughts were with regards to assigning a procedure code for McRoberts or continuing with current practice and not
coding it. Feedback received was mixed but more were leaning towards coding the McRoberts manoeuvre.
Advice was obtained from the Ministry’s Chief Medical Office as to whether McRoberts manoeuvre should be coded
as a separate procedure or not. The advice received was that since there is no international requirement and that
there are other manoeuvres that can be used during labour/delivery, McRoberts manoeuvre does not need a
separate code assigned. Therefore, New Zealand should continue with current coding practice and not code it as a
procedure.
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Respiratory Failure – Type 1/Type 2
Q: Does type 1/type 2 respiratory failure have to be documented?
R: Yes.
The specific type of respiratory failure must be documented.
Q: If hypoxaemia is documented can we code that to type 1 respiratory failure?
R: No.
The specific documentation of type 1/type 2 must be present within the clinical record for the episode of
care.
General Frequently Asked Questions
Q: Can you use existing (previous) documentation?
R: Previous documentation can be used to obtain specificity of an already documented condition within the current
episode of care. Refer to the Introduction section of the ACS and ACS 0010 General abstraction guidelines.
Q: Are we to still use free text for drug eluting stents (DES)?
R: Yes.
Free text should be used on any code where the code descriptor lacks specificity.
Q: Can you be audited on the sequencing of the codes?
R: Yes.
The classification provides sequencing rules for: principal diagnosis, principal procedure and certain coding
standards provide sequencing instructions.
Q: What happens if you disagree with the auditor?
R: Each DHB should have an arbitration process in place.
If your DHB currently does not have a documented
arbitration process in place, then one should be developed so all coders are aware of the process.
Q: Can the sequence of codes be changed in order for the case to group to a better DRG?
R: No.
Refer to the webpage Casemix and diagnosis related group (AR-DRG) allocation, click here
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