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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 0010 General abstraction guidelines, test results differentiates 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:
o Patient 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.
o Although the classification links pneumonia and COPD, both conditions must be documented or
confirmed by the clinician before applying the guidelines in ACS 1008 Chronic obstructive pulmonary
disease (COPD)
o Although 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 webpage click here
Q:
Can radiological findings be used to identify all injuries in a multiple injury case?
A:
ACS 1907 Multiple injuries has been amended for Ninth Edition to incorporate previously published advice:
When coding the initial admission of a multiple trauma, all injuries documented must 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.
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In addition, the guidelines must be applied in conjunction with ACS 0010 General 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)
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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 when coding 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:
o Day 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.
o Day 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:
o Day 1 – patient transferred with vacuum dressing in situ:
No code is assigned.
o Day 2 – change of vacuum dressing performed on the ward, assign:
90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue, once only.
o Day 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.
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• 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:
o Day 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.
o Day 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.
o Day 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.
o Day 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.
o Day 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)
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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
assigned in 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)
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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 category E83 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)
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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, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12613000239763
(Coding Rules, December 2015)
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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 ICD10-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)
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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: Refer also to NZCA coding query Debridement on ward or in Emergency department
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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)
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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 a procedure, 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 underlying conditions.
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)
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Ref No: Q2991 | Published On: 15-Dec-2015 | Status: Current
SUBJECT: Inadvertent or intentional removal of devices requiring
replacement
NOTE: this may be a change in coding practice
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.
(Coding Rules, December 2015)
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Ref No: Q2988 | Published On: 15-Dec-2015 | Status: Current
SUBJECT: Limbal stem cell deficiency and resulting corneal
conjunctivalisation
Q:
What is the correct diagnosis code to assign for limbal stem cell deficiency resulting in corneal
conjunctivalisation?
A:
Limbal Stem Cell Deficiency (LSCD) is characterised by a loss or deficiency of the stem cells in the limbus
(the edge of the cornea where it joins the sclera) which act as a ‘barrier’ to conjunctival epithelial cells
preventing them from migrating on to the corneal surface. When these stem cells are lost, the corneal
epithelium is unable to repair and renew itself, resulting in epithelial breakdown and defects leading to
corneal conjunctivalisation, neovascularisation, scarring and chronic inflammation, which may lead to
corneal opacity and visual impairment or blindness. Causes of LSCD may be genetic, idiopathic or acquired
such as infection, trauma and drugs.
Corneal conjunctivalisation is the pathological process whereby the conjunctival epithelial cells in the
limbus migrate on to the corneal surface to replace the normal corneal epithelium.
Limbal stem cell deficiency resulting in corneal conjunctivalisation should be classified to H18.8 Other
specified disorders of cornea following the Index pathway:
Disease
- cornea
- - specified NEC H18.8
Assign external cause codes as appropriate.
Improvements to ICD-10-AM will be considered for a future edition.
(Coding Rules, December 2015)
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Ref No: Q2989 | Published On: 15-Dec-2015 | Status: Current
SUBJECT: Multiple osteotomies and procedures performed in
combination on the maxilla and mandible (Le Fort I segmental (sectional)
maxillary osteotomy)
Q:
What is the correct code to assign for a Le Fort I segmental (sectional) maxillary osteotomy?
A:
The Le Fort I osteotomy is one of the most commonly used procedures to correct midface deformities. It
allows for correction in three dimensions including advancement, retrusion, elongation, and shortening.
Various osteotomies are used to correct midfacial deformities and the choice of the procedure depends on
the specific deformity.
A Le Fort I osteotomy is a bilateral procedure on the maxilla. The traditional Le Fort I osteotomy with
advancement is standard treatment and adequate for most midfacial maxillofacial deformities. There are
two codes in ACHI for Le Fort I osteotomy depending on whether or not internal fixation is used:
45726-01[1705] Osteotomy of maxilla, bilateral
45729-01[1706] Osteotomy of maxilla with internal fixation, bilateral
However a standard Le Fort I osteotomy may be modified to address specific clinical situations. It is also
often indicated in conjunction with a bilateral sagittal split (ramal) osteotomy (a procedure performed on
the mandible).
If the transverse dimension of the maxilla needs to be altered (expanded) or if there are steps in the
occlusion, a segmental (multi-piece) Le Fort I osteotomy, a variant of the standard Le Fort I (one-piece)
osteotomy, proceeds after the down-fracturing of the Le Fort I segment. Segmentation is then effected
through additional osteotomies. Once the osteotomies are completed, the segments are mobilised and a
splint used to position the maxilla in the appropriate place.
Le Fort I sectional maxillary osteotomy in the literature is more commonly referred to as Le Fort I segmental
maxillary osteotomy and as noted above is a variant of the standard Le Fort I osteotomy. While ACHI does
not have a specific code for this variant of the Le Fort I osteotomy it provides codes for multiple
osteotomies and procedures performed in combination on the maxilla and mandible.
Where multiple (more than two) osteotomy procedures are performed on the maxilla, such as occurs in a
segmental (sectional) osteotomy or where a combination of procedures are performed on the maxilla and
mandible, such as occurs when a standard Le Fort I osteotomy is performed in combination with bilateral
sagittal split (ramal) osteotomy, follow the excludes notes in blocks [1705] and [1706] and assign an
appropriate code from block [1707] Osteotomy or ostectomy of mandible or maxilla, procedures in
combination or [1708] Osteotomy or ostectomy of mandible or maxilla with internal fixation, procedures in
combination as appropriate.
Count the procedures according to the number of osteotomies performed, for example:
• a standard Le Fort I osteotomy with bilateral sagittal split (ramal) osteotomy equals four procedures;
bilateral osteotomy (two procedures) on maxilla plus bilateral osteotomy (two procedures) on
mandible.
• a segmental (sectional) Le Fort I osteotomy equals two procedures for the standard Le Fort I
osteotomy plus the number of additional osteotomies performed as part of the segmental (sectional)
osteotomy variant of the procedure.
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Therefore a Le Fort I segmental (sectional) osteotomy with bilateral sagittal split (ramal) osteotomy is
classified to block [1707] or [1708] (depending on whether internal fixation is used) and equals a minimum
of four procedures plus the number of additional osteotomies performed as part of the segment (sectional)
variant. Often it will equate to ≥ 6 procedures:
45747-00 [1707] Osteotomies or ostectomies of mandible and maxilla, ≥ 6 procedures
or
45752-00 [1708] Osteotomies or ostectomies of mandible and maxilla, ≥ 6 procedures, with internal
fixation.
Improvements to this area of the classification will be considered for a future edition of ACHI.
(Coding Rules, December 2015)
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Ref No: Q2993 | Published On: 15-Dec-2015 | Status: Current
SUBJECT: Use of the subterms in (due to) in ICD-10-AM Alphabetic Index
Q:
Should conditions documented together, but without a stated causal relationship documented, both be
coded when they are indexed with the terms in (due to)?
A:
Even though ‘in’ is a preposition, it is not one of the prepositional subterms listed in the convention for
prepositional terms in the General arrangement of the alphabetic index of diseases.
The indexing of a condition with the subterm in (due to) in ICD-10-AM Alphabetic Index implies a cause and
effect relationship between two conditions.
The following index entries assign a single code that describes a cause and effect relationship between two
conditions:
Encephalopathy (acute)
- in (due to)
- - birth trauma P11.1
P11.1 Other specified brain damage due to birth trauma
Myelopathy (spinal cord)
- in (due to)
- - degeneration or displacement, intervertebral disc NEC M51.0
M51.0 Lumbar and other intervertebral disc disorders with myelopathy
Other index entries with the subterm in (due to) assign two codes; that is, a dagger and asterisk pair to
describe the cause and effect relationship between two conditions as in the following example:
Pyelonephritis (see also Nephritis/tubulo-interstitial)
- in (due to)
- - sepsis NEC A41.-† N16.0*
A41 Other sepsis
N16.0* Renal tubulo-interstitial disorders in infectious and parasitic diseases classified elsewhere
Where the ICD-10-AM Alphabetic Index has linked two conditions using the subterms in (due to), this index
entry should be followed except where a specific cause for the condition has been otherwise indicated in
the clinical record.
For example, if the patient has pyelonephritis and sepsis during the same episode of care as per the above
example, unless documentation identifies that the pyelonephritis is definitively due to another cause, the
index pathway should be followed to inform code assignment. The causal relationship between
pyelonephritis and sepsis is assumed unless otherwise indicated.
The classification of diabetes mellitus is governed by the specific guidelines in ACS 0401 Diabetes mellitus
and intermediate hyperglycaemia – see General classification rules for DM and IH and in particular Rule 3.
ACCD will consider adding explanatory text in the conventions for the use of the subterm in (due to) in ICD10-AM Alphabetic Index, in a future edition.
(Coding Rules, December 2015)
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Ref No: Q3008 | Published On: 15-Dec-2015 | Status: Current
SUBJECT: Assignment of U codes from patient documentation
Q:
On the patient's preoperative questionnaire in response to the question "Are you being treated for high
blood pressure", the answer is ‘Yes’ and anti-hypertensive medication is included in the list of current
medications. There is no other mention of hypertension in the record (same-day episode). Should a ‘U’
code for hypertension be assigned when it has not been documented by the clinician?
A:
The Introduction to the Australian Coding Standards states:
“The responsibility for recording accurate diagnoses and procedures, in particular principal diagnosis, lies
with the clinician, not the clinical coder.
A joint effort between the clinician and clinical coder is essential to achieve complete and accurate
documentation, code assignment, and reporting of diagnoses and procedures”.
Assignment of codes for diagnoses and procedures assumes that these have been documented by a
clinician. This principle applies to the assignment of supplementary codes for chronic conditions.
While it is not expected that clinical coders should follow-up clinicians for assignment of ‘U’ codes, it is
assumed they should be allocated to conditions that have been documented by a clinician.
Therefore, in the absence of supporting clinical documentation, a ‘U’ code should not be assigned based on
documentation of patient response(s) alone. This includes where the form has been signed by a clinician,
which confirms the form has been completed or sighted but does not necessarily corroborate the clinical
content.
As per the Ninth Edition Education FAQs, it is not necessary to review medication charts to inform code
assignment. Medications may be given for more than one diagnosis, and the presence of a prescribed
medication is not an indication of a diagnosis. ACS 0003 Supplementary codes for chronic conditions (Errata
3 update) also confirms that conditions may be assumed to be current unless there is documentation that
indicates otherwise.
(Coding Rules, December 2015)
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Australian 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: Q3012 | Published On: 15-Dec-2015 | Status: Current
SUBJECT: Admission for removal of ureteric stent; calculus is still present,
stent left in situ
NOTE: this may be a change in coding practice
Q:
Is it correct to assign Z46.6 Fitting and adjustment of urinary device if a patient has been admitted for
removal of a ureteric stent, but after review the stent is left in situ due to the presence of ureteric calculus?
A:
The note at Z40–Z54 Persons encountering health services for specific procedures and health care states:
Categories Z40–Z54 are intended for use to indicate a reason for care. They may be used for patients who
have already been treated for a disease or injury, but who are receiving follow-up or prophylactic care,
convalescent care, or care to consolidate the treatment, to deal with residual states, to ensure that the
condition has not recurred, or to prevent recurrence.
• Where a patient is admitted for removal of a ureteric stent (ureteric calculus has not recurred or is not
still present and the stent is removed), assign:
Z46.6 Fitting and adjustment of urinary device
by following the index pathway:
Removal
- ureteral stent Z46.6
• Where a patient is admitted for removal of a ureteric stent, but the clinician indicates that the calculus is
still present and therefore the stent is not removed as planned, assign a code for the calculus as
principal diagnosis. For example:
N20.1 Calculus of ureter
Assign Z96.0 Presence of urogenital implants as an additional diagnosis if the stent is left in situ.
If the stent is removed and another stent is inserted (ie the stent is replaced), assign a code for the calculus
as principal diagnosis. It is not necessary to assign Z46.6 or Z96.0 in this scenario.
(Coding Rules, December 2015)
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Australian 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: Q3015 | Published On: 15-Dec-2015 | Status: Current
SUBJECT: ACS 0011 Admission for surgery not performed
Q:
What is the principal diagnosis for a same day episode of care, where the procedure is cancelled due to
another condition, and that condition is investigated or treated, but the patient is still discharged that same
day?
A:
ACS 0011 Admission for surgery not performed lists three examples with codes for conditions that are the
reason for cancellation of an elective procedure:
 In examples 2 and 4 the conditions listed as the reason for cancellation do not meet the criteria in either
ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses, as they do not require admitted patient
care. These conditions are coded to indicate the reason for the cancellation of the procedure and are
sequenced after the relevant code from category Z53 Persons encountering health services for specific
procedures, not carried out.
 Example 5 differs in that the pneumonia meets the criteria for assignment in ACS 0001 Principal
diagnosis. That is, the pneumonia is chiefly responsible for occasioning the episode of admitted patient
care.
Other examples include:
 Patient with osteoarthritis admitted for arthroscopy of the knee. The procedure is cancelled when the
patient complains of chest pain. The patient was seen by a cardiologist, and blood tests and ECG were
performed, but no cause was found for the chest pain. The patient was discharged later in the day and
the arthroscopy was rescheduled. Assign:
R07.4 Chest pain, unspecified
M17.1 Other primary gonarthrosis
Z53.0 Procedure not carried out because of contraindication
 Patient with breast cancer was admitted for same-day chemotherapy. The chemotherapy session was
cancelled as the patient was anaemic. The patient was transfused with two units of packed cells and
discharged home that afternoon. Assign:
D64.9 Anaemia, unspecified
Z51.1 Pharmacotherapy session for neoplasm
C50.9 Breast, unspecified
M8000/3 Neoplasm, malignant
Z53.0 Procedure not carried out because of contraindication
See also ACS 0002 Additional diagnoses/Additional diagnosis reporting referred to in other standards.
(Coding Rules, December 2015)
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Australian 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: Q3016 | Published On: 15-Dec-2015 | Status: Current
SUBJECT: Revision procedures for obesity
Q:
Can 30514-01 [889] Revision procedure for obesity be assigned in addition to codes from block [881]
Gastrostomy, gastro-enterostomy or gastro-gastrostomy?
A:
30514-01 [889] Revision procedure for obesity is only assigned as an additional code with any of the specific
obesity procedures listed as inclusion terms at 30514-01 in the Tabular List (Code first: obesity procedure(s)
performed (see block [889])) :
• biliopancreatic diversion (30512-02 [889] Biliopancreatic diversion)
• duodenal-jejunal bypass (90940-00 [889] Duodenal-jejunal bypass [DJ bypass])
• gastric bypass (30512-00 [889] Gastric bypass or 30512-03 [889] Laparoscopic gastric bypass)
• gastroplasty (30511-08 [889] Gastroplasty)
• ileal interposition (90941-00 [889] Ileal interposition)
• sleeve gastrectomy (30511-10 [889] Sleeve gastrectomy [SG])
Each of the above procedures requires a change to the patient’s anatomy. The assignment of 30514-01
[889] is a flag to indicate that the procedure is more complex due to anatomical changes from a previous
obesity procedure.
30515-00 [881] Gastro-enterostomy may be assigned with gastric bypass or biliopancreatic diversion as per
the instructional notes (code also when performed: gastro-enterostomy). This includes when gastric bypass
or biliopancreatic diversion are performed following a previous failed obesity procedure. Gastroenterostomy or gastro-gastrostomy may also be performed without a code from block [889] following a
failed obesity procedure.
If gastro-enterostomy or gastro-gastrostomy is performed following a failed obesity procedure without
one of the above obesity procedures from block [889], assign 30515-00 [881] Gastro-enterostomy or
30375-31 [881] Gastro-gastrostomy, as applicable but do not assign 30514-01 [889] Revision procedure for
obesity as an additional code.
The code also when performed notes at 30515-00 [881], 30375-31 [881] and 30514-01 [889] will be deleted
as part of the third errata to Ninth Edition, December 2015.
(Coding Rules, December 2015)
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Australian 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: Q3022 | Published On: 15-Dec-2015 | Status: Current
SUBJECT: Complications of anaesthesia; in labour and delivery, and during
the puerperium.
Q:
Do the includes notes at O74 Complications of anaesthesia during labour and delivery and O89
Complications of anaesthesia during the puerperium relate to the timing of the complication or when the
anaesthetic was administered?
A:
The ICD-10-AM includes notes at O74 Complications of anaesthesia during labour and delivery and O89
Complications of anaesthesia during the puerperium are based on those in ICD-10:
O74 Complications of anaesthesia during labour and delivery
Includes: maternal complications arising from the administration of a general or local anaesthetic, analgesic
or other sedation during labour and delivery
O89 Complications of anaesthesia during the puerperium
Includes: maternal complications arising from the administration of a general or local anaesthetic, analgesic
or other sedation during the puerperium
The sentence structure of the above includes notes makes their meaning ambiguous. However, the two
blocks are distinguished by the timing of the complication. That is, codes from these blocks should be
assigned according to when the complication occurred; either during labour and delivery, or during the
puerperium, not when the anaesthetic was administered.
For example, assign:
O74.5 Spinal and epidural anaesthesia-induced headache during labour and delivery
when an anaesthesia-induced headache caused by spinal and/or epidural anaesthesia occurs during
labour and delivery.
Assign:
O89.4 Spinal and epidural anaesthesia-induced headache during the puerperium
when an anaesthesia-induced headache caused by spinal and/or epidural anaesthesia occurs during the
puerperium.
(Coding Rules, December 2015)
Coding Rules - Current as at 16-Dec-2015 18:13
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