Coding Rules - Current as at 16-Dec-2019 17:27



Coding Rules published 16 December 2019 – Status CurrentContents TOC \o "1-1" \h \z \u Adhesions divided during caesarean without labour PAGEREF _Toc32388750 \h 2Removal or replacement of a failed (meaning ineffective) implanted device PAGEREF _Toc32388751 \h 3Post tonsillectomy haemorrhage PAGEREF _Toc32388752 \h 4Cardiorenal syndrome PAGEREF _Toc32388753 \h 5COF values for suspected conditions in neonates PAGEREF _Toc32388754 \h 6Assignment of R79.83 and D68.3 in the same episode of care PAGEREF _Toc32388755 \h 7Application, replacement and removal of endoluminal sponge for negative pressure wound treatment (NPWT) PAGEREF _Toc32388756 \h 8Vaping-related disorders; use of WHO code for emergency use PAGEREF _Toc32388757 \h 9Assignment of a code for glaucoma with implantation of an iStent? PAGEREF _Toc32388758 \h 10Closed reduction of fracture of the acetabulum PAGEREF _Toc32388759 \h 11Dexamethasone intravitreal implant (Ozurdex?) PAGEREF _Toc32388760 \h 12ACHI code for percutaneous cholecystostomy PAGEREF _Toc32388761 \h 13Ref No: Q3423 | Published On: 16-Dec-2019 | Status: CurrentAdhesions divided during caesarean without labourQ:What ICD-10-AM code is assigned for pelvic adhesions, divided during caesarean section?A:The ICD-10-AM Alphabetic Index below is inconsistent with other index entries for O65.5 Labour and deliver affected by abnormality of maternal pelvic organs that specify conditions complicating ‘labour or delivery’:Adhesions, adhesive (postinfective)- pelvic, pelvis (see also Adhesions/peritoneum)- peritoneum, peritoneal (male)- - female pelvic (postpartal) (to uterus)- - - affecting- - - - labour and delivery O65.5- - - - pregnancy O34.8Classification guidelines in ACS 1506 Fetal presentation, disproportion and abnormality of maternal pelvic organs should specify that codes in category O64–O66 may be assigned ‘during labour and/or delivery’.Therefore, assign O65.5 Labour and delivery affected by abnormality of maternal pelvic organs where division of adhesions are required during caesarean section, regardless of when the adhesions are first diagnosed.ACS 1506 Fetal presentation, disproportion and abnormality of maternal pelvic organs and the inconsistent index entry were amended in Eleventh Edition Errata 3.Published 16 December 2019,for implementation 01 January 2020.Ref No: Q3444 | Published On: 16-Dec-2019 | Status: CurrentRemoval or replacement of a failed (meaning ineffective) implanted deviceQ:What ICD-10-AM code is assigned when a failed (meaning ineffective) implanted device is removed or replaced?A:An implanted device may be considered ‘failed’, or ineffective, if it did not achieve the expected outcome.A device may be documented as ‘failed’, meaning it was ineffective, as the indication for elective removal or replacement. In these scenarios, the failed device is not a complication and therefore, a postprocedural complication code is not assigned.Example 1 – Removal of a failed (ineffective) device:Patient admitted for a gastric band removal due to ‘failed lap band’. Documentation stated that there was no failure of the device, but the patient did not experience any significant weight loss and remained morbidly obese more than two years following insertion of the gastric band.Assign Z45.89 Adjustment and management of other implanted devices. Follow the ICD-10-AM Alphabetic Index:Management (of)- implanted device NEC- - specified NEC Z45.89Example 2 – Replacement of a failed (ineffective) device:Patient with chronic pain admitted for neurostimulator and lead exchange due to ‘initial device being ineffective’. Documentation stated that there was no mechanical failure of the device, but the patient did not experience any pain relief following the insertion of the initial neurostimulator. Patient reported effective pain management post replacement of the device.Assign R52.2 Chronic pain. Follow the ICD-10-AM Alphabetic Index:Pain(s)- chronic (intractable) R52.2Published 16 December 2019,for implementation 01 January 2020.Ref No: Q3439 | Published On: 16-Dec-2019 | Status: CurrentPost tonsillectomy haemorrhageQ:Is ‘post tonsillectomy haemorrhage’ classified as a procedural complication?A:Haemorrhage is the most common and potentially devastating event after a tonsillectomy. There are two types of haemorrhage (Perth Children’s Hospital 2018):Primary haemorrhage where bleeding occurs within 24 hours after surgery; andSecondary haemorrhage where bleeding occurs between 24 hours to 14 days after surgery.ACS 1904 Procedural complications states:Conditions may arise during or in the period following a procedure. Some of these are considered to be ‘procedural complications’ while others are not. Qualifying terms such as ‘intraoperative’, ‘postoperative’ or ‘postprocedural’ may be documented in the clinical record, however these terms may only refer to the timing of an event that occurred during, or after, the procedure. Conditions described in this way should be assigned procedural complication codes only if they meet the following criteria:Documentation clearly states that the condition arose as a complication of the procedure (the terms ‘secondary to’ or ‘due to’ infer a causal relationship in contrast to terms such as ‘postop’, ‘following’ or ‘associated with’)?Certain conditions where the relationship is inherent in the diagnosis (eg infection or bleeding of a surgical wound, stoma or anastomosis, wound dehiscence, transfusion related acute lung injury)‘Post tonsillectomy haemorrhage’ is classified as a procedural complication in ICD-10-AM as it meets the criteria in the second dot point above; that is, the relationship is considered inherent in the diagnosis.Assign T81.0 Haemorrhage and haematoma complicating a procedure, not elsewhere classified where post tonsillectomy haemorrhage is documented. Follow the ICD-10-AM Alphabetic Index:Haemorrhage, haemorrhagic- postprocedural T81.0Code also external cause and place of occurrence codes.References:Perth Children’s Hospital 2018, Post tonsillectomy haemorrhage, viewed 8 November 2019, 16 December 2019,for implementation 01 January 2020.Ref No: Q3430 | Published On: 16-Dec-2019 | Status: CurrentCardiorenal syndromeQ:What code is assigned for cardiorenal syndrome?A:Cardiorenal syndrome (CRS) is a general term used to describe clinical conditions in which cardiac and renal dysfunctions coexist.CRS is classified to category I13 Hypertensive heart and kidney disease in ICD-10-AM, as per ICD-10 WHO, which assumes a causal relationship between hypertension and heart and/or kidney disease.For classification purposes, assign I13.9 Hypertensive heart and kidney disease, unspecified for CRS not otherwise specified (NOS) by following the ICD-10-AM Alphabetic Index:Syndrome — see also Disease- cardiorenal (see also Hypertensive/cardiorenal) I13.9Where CRS is documented with chronic kidney disease and heart failure, follow the above Alphabetic Index cross reference:Hypertension, hypertensive (accelerated) (benign) (essential) (idiopathic) (malignant) (primary) (systemic) I10- cardiorenal (disease) I13.9- - with- - - CKD stage 5 (kidney failure) I13.1- - - - and heart failure (congestive) I13.2Amendments may be considered for a future edition.Published 16 December 2019,for implementation 01 January 2020.Ref No: Q3428 | Published On: 16-Dec-2019 | Status: CurrentCOF values for suspected conditions in neonatesQ:What COF value is assigned for observation codes in neonates?A:ACS 0048 Condition onset flag, defines a condition with an onset flag of 1 (COF 1) as:A condition which arises during the episode of admitted patient care and would not have been present or suspected on admission.Codes from category Z03.7 Observation and evaluation of newborn for suspected condition not found are assigned for newborns who are suspected of having an abnormal condition that is ruled out or not confirmed after examination and observation.As these neonatal conditions are suspected but not confirmed, assignment of COF 1 is inappropriate. Therefore, assign COF 2 Condition not noted as arising during the episode of admitted patient care to codes from category Z03.7 Observation and evaluation of newborn for suspected condition not found.Published 16 December 2019,for implementation 01 January 2020.Ref No: Q3427 | Published On: 16-Dec-2019 | Status: CurrentAssignment of R79.83 and D68.3 in the same episode of careQ:Can R79.83 and D68.3 be assigned in the same episode of care?A:R79.83 Abnormal coagulation profile and D68.3 Haemorrhagic disorder due to circulating anticoagulants are mutually exclusive and cannot be assigned in the same episode of care. This is supported by the Excludes note in the ICD-10-AM Tabular List for both codes.Published 16 December 2019,for implementation 01 January 2020.Ref No: Q3411 | Published On: 16-Dec-2019 | Status: CurrentApplication, replacement and removal of endoluminal sponge for negative pressure wound treatment (NPWT)Q:What codes are assigned for application, replacement and removal of a sponge, as part of endoluminal NPWT, for anastomotic leakage in the rectum or presacral space?A:Endo-SPONGE? is a proprietary name for a type of sponge used in endoluminal negative pressure wound treatment (NPWT) (B Braun n.d.).Endoluminal NPWT is a minimally invasive method used in the management or prevention of septic complications of surgery such as anastomotic leakage. In endoluminal NPWT, a sponge is introduced via endoscopy and connected to a drainage system. The wound is drained through the use of suction to create a vacuum effect.Endoluminal NPWT is similar in technique to sponges used in endoscopic vacuum assisted closure (EVAC).Endo-SPONGE? and EVAC are placed either within a cavity or intraluminally, which differentiates them from other vacuum assisted closure (VAC) dressings that are applied topically on the surface of a wound (Gestring 2019).Where a sponge (eg Endo-SPONGE?) is inserted into the rectum or presacral space, as part of endoluminal NPWT, assign 90314-00 [942] Other procedures on rectum. Follow the ACHI Alphabetic Index:Procedure- rectum NEC 90314-00 [942]Where a sponge is removed from the rectum or presacral space, as part of endoluminal NPWT, assign 92086-00 [1896] Removal of other device from gastrointestinal tract. Follow the ACHI Alphabetic Index:Removal- device- - gastrointestinal tract NEC 92086-00 [1896]Where the procedure is performed using a minimally invasive technique, also follow the guidelines in ACS 0023 Laparoscopic/arthroscopic/endoscopic surgery.See also Q3390 ‘Endoscopic vacuum-assisted closure (EVAC) of gastrointestinal defect’ published on 15 March 2019.References:Braun, n.d., Endo-SPONGE? Endoluminal vacuum therapy, viewed 19 September 2019,?, M. 2019, Negative pressure wound therapy, viewed 22 November 2019, 16 December 2019,for implementation 01 January 2020.Ref No: TN1511 | Published On: 16-Dec-2019 | Status: CurrentVaping-related disorders; use of WHO code for emergency use*Effective from 25 September 2019*Vaping-related disorders are disorders that result from inhaling a vaporised solution (aerosol) via an electronic delivery system. These products frequently contain flavourants, usually dissolved into propylene glycol and/or glycerine. They may also contain doses of nicotine, and other substances and additives. These disorders may also be documented as electronic cigarette related damage or disorders, or e-cigarette or vaping product use-associated lung injury (EVALI).The exact causation of and mechanism leading to the disorders is currently unclear. The substance or substance combination leading to vaping-related disorders has not yet been identified. While lung disorders related to vaping are recognised, other organs may be affected as well. Although vaping devices may resemble cigarettes, they do not contain tobacco and it is not appropriate to assign Z72.0 Tobacco use, current.Concern has arisen due to an increase in the incidence of vaping-related disorders internationally. As a result, the World Health Organization (WHO) has advised that effective from 25 September 2019, U07.0 Emergency use of U07.0 is assigned for vaping-related disorders, to monitor vaping-related disorders internationally.CLASSIFICATIONWhere documentation states that a condition or symptom is vaping related, assign:A code for the condition as per the guidelines in ACS 0001 Principal diagnosis and ACS 0002 Additional diagnosesU07.0 Emergency use of U07.0 as an additional diagnosisNote: DO NOT assign U07.0 to flag that a patient uses a ‘vape device’.Bibliography:Australian Government Department of Health 2019, About e-cigarettes, DOH, Canberra, viewed 16 October 2019, for Disease Control and Prevention 2019a, Outbreak of Lung Injury Associated with E-cigarette Use, or Vaping, US Department of Health and Human Services, viewed 1 October 2019, for Disease Control and Prevention 2019b, THC Products May Play a Role in Outbreak of Lung Injury Associated with E-cigarette Use, or Vaping, US Department of Health and Human Services, viewed 1 October 2019, Foundation 2019, Vaping related disorder, viewed 2 October 2019, 16 December 2019,for implementation 01 January 2020.Ref No: Q3483 | Published On: 16-Dec-2019 | Status: CurrentAssignment of a code for glaucoma with implantation of an iStent?Q:When a patient is admitted for implantation of an iStent?, is a diagnosis code for glaucoma assigned if there is no documentation of the term ‘glaucoma’ in the health care record?A:The iStent? procedure involves placement of a small titanium implant during minimally invasive glaucoma surgery (MIGS) to lower eye pressure and treat mild-to-moderate open-angle glaucoma (Eye Doctors of Washington 2019). Significant and safe reductions in intraocular pressure (IOP) and medication dosage have been observed after iStent? or iStent inject? implantation with concomitant cataract surgery (Guedes et al. 2019).Question 10 of the 2018 HIMAA and NCCH Conference Eleventh Edition Education states:Q10:Is a code also assigned for glaucoma when an iStent is performed?Answer:Yes, iStent intervention is only performed when a patient has both a cataract and glaucoma.Do not interpret the above advice as implying that a glaucoma code is assigned without specific documentation of ‘glaucoma’, when an iStent? is inserted.ACS 0010 Clinical documentation and general abstraction guidelines/Roles and responsibilities in the documentation and abstraction process states:It is not the role of a clinical coder (or clinical documentation improvement specialist (CDIS)) to diagnose. Clinical documentation of accurate diagnoses is the responsibility of the clinician.The listing of clinical concepts (eg diseases and interventions) on the front sheet and/or the discharge summary (or equivalent) for an episode of care is the responsibility of the clinician. These responsibilities include identifying and documenting the principal diagnosis, and listing all additional diagnoses and interventions performed during the episode of care. Each diagnostic statement and intervention must be as informative as possible in order for the clinical coder to classify the clinical concept to the most specific ICD-10-AM or ACHI code.Follow the above guidelines from ACS 0010 when the indication for iStent? implantation is not documented. If documentation within the health care record is inadequate for complete and accurate classification, seek further information from the clinician.References:Eye Doctors of Washington 2019, iStent? for Microtrabecular Bypass, viewed 12 November 2019, , R.A.P., Gravina, D.M., Lake, J.C. Guedes, V.M.P. Chaoubah, A. 2019, ‘Intermediate results of iStent or iStent inject implantation combined with cataract surgery in a real-world setting: a longitudinal retrospective study’, Ophthalmology and Therapy, vol. 8, no. 1, pp. 87–100, viewed 12 November 2019, 16 December 2019,for implementation 01 January 2020.Ref No: Q3475 | Published On: 16-Dec-2019 | Status: CurrentClosed reduction of fracture of the acetabulumQ:What code is assigned for closed reduction of a fracture of the acetabulum?A:Closed reduction of an acetabulum fracture with internal fixation is classified in ACHI to 47498-00?[1479] Internal fixation of fracture of acetabulum. Follow the ACHI Alphabetic Index:Reduction- fracture (bone) (with cast) (with split)- - acetabulum- - - with internal fixation (closed) 47498-00 [1479]ACHI does not include a code for closed reduction of an acetabulum fracture without internal fixation. Assign 90552-00 [1491] Other repair of hip by following the ACHI Alphabetic Index:Repair- hip NEC 90552-00 [1491]Amendments may be considered for a future edition.Published 16 December 2019,for implementation 01 January 2020.Ref No: Q3456 | Published On: 16-Dec-2019 | Status: CurrentDexamethasone intravitreal implant (Ozurdex?)Q:What ACHI code is assigned for a dexamethasone intravitreal implant?A:Ozurdex? is the brand name for a dexamethasone intravitreal implant that is injected into the vitreous body in the posterior segment of the eye. The dissolving implant is a slow-release rod-shaped drug delivery system used to treat conditions such as diabetic macular oedema or retinal vein occlusion and posterior segment uveitis (Rx List 2018).Assign 90078-00 [208] Other procedures on vitreous for insertion of Ozurdex? implantation. Follow the ACHI Alphabetic Index:Procedure- vitreous (eye) NEC 90078-00 [208]References:Rx List 2018, Ozurdex?, viewed 4 October 2019, 16 December 2019,for implementation 01 January 2020.Ref No: Q3451 | Published On: 16-Dec-2019 | Status: CurrentACHI code for percutaneous cholecystostomyQ:What code is assigned for percutaneous cholecystostomy if ‘trocar’ is not documented in the clinical record?A:Cholecystostomy involves placement of a drainage catheter in the gallbladder to prevent the gallbladder from becoming too swollen (Stanford Children’s Hospital n.d.). Percutaneous cholecystostomy (PC) is an alternative treatment to cholecystectomy, which allows immediate decompression and drainage of the inflamed gallbladder in some high-risk surgery patients such as the critically ill or patients with multiple comorbidities (Pablo Juan 2015).Seldinger and trocar are two widely used percutaneous drainage techniques for catheter placement into vascular and nonvascular anatomical spaces (Hilal et al. 2017).The indexing at Cholecystostomy/trocar is incorrect. Assign 90348-00 [961] Percutaneous aspiration of gallbladder for percutaneous cholecystostomy, including where trocar or Seldinger technique is documented. Follow the ACHI Alphabetic Index:Aspiration- gallbladder- - percutaneous (closed) (needle) 90348-00 [961]The ACHI Alphabetic Index at Cholecystostomy/trocar will be amended in Eleventh Edition Errata 4.References:Hilal, G.T., Mustafa, O., Rusen, A., Fahrettin, K., Fatma, A.E.O., Baki, H. Utku, M.Y. 2017, ‘Comparison of seldinger and trocar techniques in the percutaneous treatment of hyatid cysts’, Word Journal of Radiology, vol. 9, no. 11, viewed 11 November 2019,?, A.B. Juan, J.D.P. 2015, ‘Ultrasound guided percutaneous cholecystostomy in acute cholecystitis: case vignette and review of the technique’, Journal of Ultrasound, vol. 18, no. 4, viewed 11 November 2019,? Children’s Hospital, What is a cholecystostomy? Standford Children’s Hospital, viewed 11 November 2019,? ??Published 16 December 2019,for implementation 01 January 2020. ................
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