AUDIT DISCUSSION CASES
CLINICAL CODING ADVISORY GROUP WA
January 2013
Performance Activity and Quality Division
AUDIT DISCUSSION CASES
WA CODING ADVISORY GROUP
JANUARY 2013
Audit cases from the ADRG 801 audits will resume in March and April 2013.
In the meantime refinements of the Diabetic Foot classification guidelines
(December Q&A) make discussion of the following diabetic foot cases timely:
The clinical classification guidelines for diabetic foot were recently modified to
emphasise that the principal diagnosis remains subject to the ‘after study’ rule.
The following cases were found in WA Teaching and metropolitan Non-teaching
Hospitals immediately after the introduction of the new diabetes rules (July 2012).
They illustrate that coders need to be mindful of:

the WA Coding Committee advice on Diabetic Foot (see Appendix 1).

ACS 1210 (see Appendix 2)

the ‘ after study’ principle (see Appendix 3).
PERFORMANCE ACTIVITY QUALITY DIVISION
DEPT HEALTH WA
Page 2
AUDIT DISCUSSION CASES
CASE: 01
WA CODING ADVISORY GROUP
JANUARY 2013
Admission Date: 25/7/2012
Separation Date: 28/7/2012
ORIGINAL
AUDIT
L03.02
B95.6
E11.42
E11.73
E11.73
L03.02
B95.6
E11.42
90686-01
90686-01
ORIGINAL
J64B
AUDIT
K60B
Cellulitis –Cscc
Diabetes -Cscc
wt:
wt:
PRINCIPAL DIAGNOSIS
Additional Diagnoses
PRINCIPAL PROCEDURE
Other Procedures
DRG Version 6.0
Discharge Summary:
0.63
0.97
Cellulitis
Diabetes Mellitus – Peripheral Neuropathy.
Case History:
84 year old woman, known T2DM, admitted via ED
Presenting complaint: red swollen painful toe, difficult weight bearing on background of DM2
and 3 weeks non-healing toe ulcer.
On admission: ulcer/ cellulitis on dorsum of 3rd toe, known peripheral neuropathy
For IV antibiotics, ulcer dressings, + podiatry
Podiatrist on ward: debridement (non-excisional) of ulcerated area toe,
On discharge: XXXX Nursing Service to continue ulcer dressings.
PERFORMANCE ACTIVITY QUALITY DIVISION
DEPT HEALTH WA
Page 3
AUDIT DISCUSSION CASES
WA CODING ADVISORY GROUP
JANUARY 2013
CLASSIFICATION NOTES
1. The discharge summary makes no mention of the ulcer which is clearly present and clearly
treated. In line with WA Coding Committee advice (Appendix 1), the clinician should have been
asked to review the summary before coding, as principal diagnosis, ‘cellulitis of toe’ (L0302).
2. The examples given in the ACS 0401 do not address ulcer and cellulitis both present on
admission. Therefore they do not apply here. The sequencing remains subject to ACS 1210:
ACS 1210
- sequence the skin ulcer code as principal diagnosis, and the cellulitis as additional, if the ulcer
is treated.
The code for skin ulcer, of the foot/toe, where diabetic foot criteria are met, is:
E1173 (diabetes with skin ulcer- multiple causes).
This is then sequenced before the cellulitis L0302.
Note: Failure to consider ACS 1210 (Appendix 2) can disadvantage the hospital. A medical
admission for diabetic foot ulcer with neuropathy (E1173, E1142) , even without cellulitis, arrives
at K60B.
3. Documentation Issue: Reviewing the case in totality, this cellulitis appears to be associated
with a foot ulcer, which itself is diabetic and likely neuropathic. The inadequate discharge
summary should have been challenged to check if the principal diagnosis assigned is in line with
the ‘after study’ principle. For example, a principal diagnosis which would tie in all 3 elements of
the summary, and include (from the inpatient notes) the ulcer, might be:
 Diabetic neuropathic foot ulcer with cellulitis
PERFORMANCE ACTIVITY QUALITY DIVISION
DEPT HEALTH WA
Page 4
AUDIT DISCUSSION CASES
WA CODING ADVISORY GROUP
CASE: 02 Admission Date: 6/7/ 12
JANUARY 2013
Separation Date: 26/ 7/ 12
ORIGINAL
AUDIT
L024
E1173
E1151
E1122
N185
I10
T828
Z8643
E1173
L024
E1151
E1122
N185
I10
T828
Z8643
PRINCIPAL PROCEDURE
30223-01
35303-06
Other Procedures
35303-06
35303-06
35303-06
30223-01
13100-00
13100-00
ORIGINAL
801A
AUDIT
K09B
OR Procedures Unrelated to Principal
Diagnosis W/O CC
Other endocrine, nutritional, metabolic
OR proc + Smcc
wt:
wt:
PRINCIPAL DIAGNOSIS
Additional Diagnoses
DRG Version 6.0
7.23
3.12
Discharge summary: Foot abscess
R) SFA / popliteal artery stenosis
L) upper limb fistula stenosis
CASE HISTORY:
ED Notes: “Via ED: 6/7/12
74 year old man, from XXX hospital, with foot ulcer
Past medical history, DM 2, HT, ESRF on haemodialysis, ex smoker”
“there is soft tissue infection of plantar ulcer, without osteomyelitis”
Inpatient progress notes: type 2 DM, admitted under Vascular Reg with non-healing foot wound.
I&D is performed but the ulcer does not heal. The patient is found to have SFA popliteal artery
stenosis and ultimately on day 12 goes for angioplasty.
He is also on regular dialysis, but the AVF blocks.
Theatre 1: incision and drainage of abscess foot: (anaesthetist: infected ulcer sole of foot)
Theatre 2: balloon angioplasty popliteal and SFA stenosis
Theatre 3: fistulogram and balloon venoplasty to AVF stenosis
PERFORMANCE ACTIVITY QUALITY DIVISION
DEPT HEALTH WA
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AUDIT DISCUSSION CASES
WA CODING ADVISORY GROUP
JANUARY 2013
CLASSIFICATION NOTES
ACS 1210 does not apply here. There is no cellulitis.
The original coding is challenged on the following grounds:
1) The discharge summary makes no mention of the ulcer which is clearly present and clearly
treated. The ulcer fails to heal, extending the length of stay (LOS). There is associated PVD,
treated on day 12, by angioplasty.
Furthermore the abscess is actually an infected plantar ulcer.
In line with WA instructions (Appendix 1), the clinician should have been asked to review the
summary before coding ‘abscess’ as principal diagnosis.
2). Documentation Issue: Reviewing the total episode, this abscess appears to be associated
with a foot ulcer, which itself is both diabetic and likely ischaemic. The most unsatisfactory
aspect of the discharge summary is that it fails to mention two of the critical LOS- extending
variables:
 diabetes itself
 and a non-healing ulcer.
.
With an 801DRG resulting and therefore requiring justification, this documentation should not be
accepted uncritically. The clinician should assess the principal diagnosis in light of the definition
of principal diagnosis (ACS 0001) with particular attention to the ‘after study’ principle
(Appendix 3).
For example, is this, after study, an episode of care chiefly occasioned by:
 infected (abscessed) ischaemic foot ulcer , in a type 2 diabetic?
PERFORMANCE ACTIVITY QUALITY DIVISION
DEPT HEALTH WA
Page 6
AUDIT DISCUSSION CASES
CASE: 03
WA CODING ADVISORY GROUP
Admission Date: 14/07/2012
JANUARY 2013
Separation Date: 26/07/2012
ORIGINAL
AUDIT
L0311
L0311
S9082
S9082
B956
B956
E1165
R02
E1173
E1165
Z9222
Z9222
PRINCIPAL PROCEDURE
90665-00
90665-00
DRG Version 6.0
ORIGINAL
J12C
AUDIT
J12A
Lower limb procs +ulcer/cellulits-Ccc
Lower limb procs +ulcer/cellulits+-Ccc
wt: 2.32
wt: 7.51
PRINCIPAL DIAGNOSIS
Discharge Summary:
principal diagnosis:
other conditions:
complications:
foot cellulitis
nil
nil
CASE HISTORY
A 54 year old woman, via ED.
Presenting complaint: cellulitis right metatarsal, bleeding blister;
foot versus cat bowl one week ago, – seen by GP – antibiotics commenced
PMH: DM2 on insulin, HTN
ED notes: from GP with grossly infected toe, wound swab : staph aureus
on examination :discharging wound; no ulcer –, admit for IV clindamycin,
– for review of medications.
poor diabetic control
Progress notes (day 1): diabetic foot ulcer; for bone scan ? OM
blister with granulating area; small area of necrosis under granulation, debrided (by RMO on
ward)
Bone scan: no Osteomyelitis
Diamicron, Lantus and Metformin adjusted for better DM control.
PERFORMANCE ACTIVITY QUALITY DIVISION
DEPT HEALTH WA
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AUDIT DISCUSSION CASES
WA CODING ADVISORY GROUP
JANUARY 2013
CLASSIFICATION NOTES
The criteria for diabetic foot ulcer are not met. Early in the progress notes the ‘wound’’ is
described as ‘diabetic foot ulcer’. Diabetic foot ulcers can be traumatic in origin.
Yet in this case, none of the other criteria for ‘diabetic foot’ are present. At least one of
the following would be required:
 PVD
 peripheral neuropathy
 specified deformities of foot/toe
 amputation status of lower limb, any part, any side
Nor is there a final diagnosis, after study, of ‘diabetic foot’, against which E1173 could be
justified.
On the documentation as it currently stands, E1173 is not assignable.
If ulcer is present, L97, E1169 would be assignable.
(L97 would then displace cellulitis as principal -ACS 1210).
One doctor (ED) states –‘no ulcer’. Another (progress notes) states ‘ulcer’.
On balance there is no mention of ulcer on summary, though the summary is clearly inadequate
in its detail and therefore unreliable.
DOCUMENTATION ISSUE
Neither E1173 nor L97, E1169 could be assigned without clinical consultation.
With a clearly inadequate summary however, clinical consultation is recommended.
In the interim, cellulitis (L0311) is assigned as principal.
Incidental notes:
‘Necrotic’ is coded with an additional diagnosis for skin necrosis (R02), and meets ACS 0002 by
requiring debridement. However the pathway “ diabetes with gangrene: E1169” is not followed
unless the word ‘gangrene’ is documented.
– see also WA Coding Committee Jan 2010, item 9.6.
‘Diabetic foot ulcer’ in the progress notes, by one doctor, is not sufficient documentation of the
condition ‘diabetic foot’. This can mean ‘foot ulcer in diabetes’ – see ACS 0401 page 107 or
the 2012 update section 5 “foot ulcers in DM”.
ACS 401 in regard to Diabetic Foot requires that:
 either the specific criteria are met or
 the final diagnosis is ‘diabetic foot’ (so stated).
The ‘grossly infected toe” was not further enlarged upon, and could be inflammation around the
blister. Cellulitis of toe would need to be clearly stated before adding, in addition, L0302. Note
that when cellulitis does involve both foot and toe, and is confirmed as such, ICD 10 requires
both codes to be assigned. Since this case already needs to be queried, confirming the extent
of cellulitis would be recommended.
PERFORMANCE ACTIVITY QUALITY DIVISION
DEPT HEALTH WA
Page 8
AUDIT DISCUSSION CASES
WA CODING ADVISORY GROUP
JANUARY 2013
APPENDIX 1
Coding Committee WA: Diabetes / Education / Diabetic Foot(The following extract is from Education Resources, published by the Coding Education Team,
Dept of Health WA and approved by the Coding Committee WA).
Ref:
http://www.clinicalcoding.health.wa.gov.au/education/diabetes.cfm
Diabetic foot codes sequencing
ACS 0001 must be followed when assigning the principal diagnosis in the case of diabetic foot.
Cases with a condition from diabetic foot criteria other than L97 listed as the PD should be queried
with the clinician before assigning a code other than E1-.73 as the PD.
Example:
65 year old female with type 2 diabetes mellitus admitted with left foot cellulitis. The patient also has
PVD and peripheral neuropathy which limit her mobility. She was treated with IV antibiotics and
discharged.
Principal diagnosis on discharge: Cellulitis
The case was queried with the treating clinician and they confirmed that diabetic foot would best
reflect the principal diagnosis in this case.
Principal Diagnosis E11.73 Type 2 diabetes mellitus with foot ulcer due to multiple causes
Additional Diagnosis L03.11 Cellulitis of lower limb
E11.51 Type 2 diabetes mellitus with peripheral angiopathy, without gangrene
E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy
The criteria for diabetic foot have been met. As cellulitis was listed as the PD, the case
was queried with the treating clinician and she agreed that diabetic foot should be
assigned as the PD. If the criteria for diabetic foot were met but the ‘diabetic foot’
diagnosis itself did not met ACS 0001 (i.e.: was not nominated by the clinician) then the
cellulitis would have been assigned as the PD and E11.73 as an additional diagnosis.
PERFORMANCE ACTIVITY QUALITY DIVISION
DEPT HEALTH WA
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AUDIT DISCUSSION CASES
WA CODING ADVISORY GROUP
JANUARY 2013
APPENDIX 2
Australian Coding Standard 1210
1210 CELLULITIS
Where cellulitis is associated with an open wound or with a skin ulcer, sequence the
complicated wound code or the skin ulcer code as principal diagnosis and cellulitis
as the additional diagnosis if the wound or ulcer is treated.
For wounds not requiring treatment or treated earlier, with the current episode being for
treatment of the cellulitis, sequence cellulitis as principal diagnosis with the complicated
wound as an additional diagnosis.
If the clinical coder is in doubt about the sequencing, clinician confirmation should
be sought.
NB: underlining and bold emphasis added by author
PERFORMANCE ACTIVITY QUALITY DIVISION
DEPT HEALTH WA
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AUDIT DISCUSSION CASES
WA CODING ADVISORY GROUP
JANUARY 2013
APPENDIX 3
Diabetic foot, ACS 0001 and the ‘after study’ principle
– Q&A December 2012- extract
Assign E1-.73 *Diabetes mellitus with foot ulcer due to multiple causes when:
• 'diabetic foot' is documented in the clinical record, or
• the criteria specified in ACS 0401 Diabetes mellitus and intermediate hyperglycaemia, 6.
Diabetic foot are met.
Additional codes for the specific complications of DM or IH should be assigned in accordance
with Rule 4a and Rule 4b.
Sequencing of codes for diabetic foot should be determined by:
• ACS 0001 Principal diagnosis, with particular attention to:
� the 'after study' principle
� Two or more interrelated conditions, each potentially meeting the definition for principal
diagnosis
� Two or more diagnoses that equally meet the definition for principal diagnosis
• ACS 0002 Additional diagnoses.
(Coding Q&A, December 2012)
PERFORMANCE ACTIVITY QUALITY DIVISION
DEPT HEALTH WA
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