AUSTRALIAN CODING STANDARDS FOR ICD 10 AM …

INDEPENDENT HOSPITAL PRICING AUTHORITY

AUSTRALIAN CODING STANDARDS

FOR ICD-10-AM AND ACHI

THE INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS, TENTH REVISION, AUSTRALIAN MODIFICATION

THE AUSTRALIAN CLASSIFICATION OF HEALTH INTERVENTIONS

ELEVENTH EDITION 1 JULY 2019

Australian Consortium for Classification Development

ACCD consortium partners

NATIONAL CENTRE FOR CLASSIFICATION IN HEALTH

Australian Coding Standards for ICD-10-AM and ACHI

TABLE OF CONTENTS

ACKNOWLEDGEMENTS ............................................................................................................ix

ABBREVIATIONS ........................................................................................................................xi

INTRODUCTION ....................................................................................................................... xiii

GENERAL STANDARDS FOR DISEASES............................................................................................... 1

0001 0002 0003 0005 0008 0010 0011 0012 0015 0025 0026 0048 0049 0050 0051 0052

Principal diagnosis......................................................................................................................... 1 Additional diagnoses ..................................................................................................................... 4 Supplementary codes for chronic conditions ............................................................................... 14 Syndromes................................................................................................................................... 17 Sequelae....................................................................................................................................... 18 Clinical documentation and general abstraction guidelines......................................................... 19 Intervention not performed or cancelled...................................................................................... 27 Suspected conditions ................................................................................................................... 28 Combination codes ..................................................................................................................... 30 Double coding............................................................................................................................. 30 Admission for clinical trial or therapeutic drug monitoring ........................................................ 30 Condition onset flag.................................................................................................................... 31 Disease codes that must never be assigned................................................................................... 36 Unacceptable principal diagnosis codes ....................................................................................... 37 Same-day endoscopy - diagnostic ................................................................................................ 37 Same-day endoscopy - surveillance.............................................................................................. 38

GENERAL STANDARDS FOR INTERVENTIONS................................................................................. 43

0016 0019 0020 0022 0023 0024 0029 0030 0031 0032 0037 0038 0039 0042 0044 0047 0053

General procedure guidelines ...................................................................................................... 43 Intervention abandoned, interrupted or not completed ............................................................... 44 Bilateral/multiple procedures....................................................................................................... 46 Examination under anaesthesia ................................................................................................... 49 Laparoscopic/arthroscopic/endoscopic surgery ............................................................................ 49 Panendoscopy.............................................................................................................................. 50 Coding of contracted procedures................................................................................................. 50 Organ, tissue and cell procurement and transplantation ............................................................. 51 Anaesthesia.................................................................................................................................. 53 Allied health interventions .......................................................................................................... 55 Paediatric procedures................................................................................................................... 56 Procedures distinguished on the basis of size, time, number of lesions or sites ............................ 56 Reopening of operative site.......................................................................................................... 57 Procedures normally not coded ................................................................................................... 57 Pharmacotherapy......................................................................................................................... 58 Adhesions .................................................................................................................................... 61 Robotic-assisted intervention....................................................................................................... 61

SPECIALTY STANDARDS....................................................................................................................... 63

1

Certain infectious and parasitic diseases ......................................................................... 65

0102 HIV/AIDS (human immunodeficiency virus/acquired immune deficiency syndrome)............... 65

0104 Viral hepatitis .............................................................................................................................. 69

0109 Neutropenia ................................................................................................................................ 73

0110 SIRS, sepsis, severe sepsis and septic shock.................................................................................. 73

0111 Healthcare associated staphylococcus aureus bacteraemia .............................................................. 77

0112 Infection with drug resistant microorganisms ............................................................................. 78

Australian Coding Standards 2019

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Australian Coding Standards for ICD-10-AM and ACHI

2 0222 0229 0233 0234 0236 0237 0239 0241 0245

3

0302 0303 0304

4 0401 0402

5 0503 0505 0506 0512 0521 0530 0531 0533 0534

6 0604 0605 0625 0627 0629 0630 0631 0633 0634 0635

7 0701 0724 0733 0742

8 0804 0807 0809

Neoplasms................................................................................................................................ 81 Lymphoma .................................................................................................................................. 81 Radiotherapy ............................................................................................................................... 82 Morphology................................................................................................................................. 82 Contiguous sites .......................................................................................................................... 83 Neoplasm coding and sequencing ............................................................................................... 84 Recurrence of malignancy ........................................................................................................... 85 Metastases ................................................................................................................................... 86 Malignant neoplasm of lip........................................................................................................... 87 Remission in malignant immunoproliferative diseases and leukaemia......................................... 87

Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism .................................................................................... 89 Blood transfusions....................................................................................................................... 89 Abnormal coagulation profile due to anticoagulants ................................................................... 89 Pancytopenia ............................................................................................................................... 91

Endocrine, nutritional and metabolic diseases............................................................... 93 Diabetes mellitus and intermediate hyperglycaemia .................................................................... 93 Cystic fibrosis ............................................................................................................................ 103

Mental and behavioural disorders................................................................................... 105 Drug, alcohol and tobacco use disorders ................................................................................... 105 Mental illness in pregnancy, childbirth and the puerperium ..................................................... 109 Adjustment/depressive reaction...................................................................................................111 Personality trait/disorder ............................................................................................................111 Admitted patient without sign of mental illness .........................................................................111 Drug overdose ............................................................................................................................111 Intellectual impairment/intellectual disability........................................................................... 112 Electroconvulsive therapy (ECT) .............................................................................................. 112 Specific interventions related to mental health care services ......................................................113

Nervous system .................................................................................................................... 115 Cerebrovascular accident (CVA).................................................................................................115 Stroke extension .........................................................................................................................116 Quadriplegia and paraplegia, nontraumatic................................................................................116 Mitochondrial disorders .............................................................................................................118 Stereotactic radiosurgery, radiotherapy and localisation .............................................................119 Quadriplegic hand surgery ........................................................................................................ 120 Benign shuddering attacks......................................................................................................... 121 Stereotactic neurosurgery .......................................................................................................... 121 Cerebrospinal fluid drain, shunt and ventriculostomy............................................................... 122 Sleep apnoea and related disorders............................................................................................. 123

Eye and adnexa .................................................................................................................... 125 Cataract..................................................................................................................................... 125 Corneal calcium chelation ......................................................................................................... 126 Haemodilution .......................................................................................................................... 126 Orbital and periorbital cellulitis ................................................................................................ 126

Ear, nose, mouth and throat (ENMT)............................................................................... 127 Tonsillitis................................................................................................................................... 127 Functional endoscopic sinus surgery (FESS) ............................................................................. 127 Intraoral osseointegrated implants............................................................................................. 127

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Australian Coding Standards for ICD-10-AM and ACHI

9 0909 0920 0925 0933 0934 0936 0940 0941 0943

10 1002 1004 1006 1008 1012

11 1103 1120 1122

12 1204 1216 1217 1221

13 1307 1308 1309 1311 1316 1319 1329 1330 1343 1348 1352 1353 1354

14 1404 1428 1429 1433 1434 1437 1438

Circulatory system................................................................................................................ 129 Coronary artery bypass grafts.................................................................................................... 129 Acute pulmonary oedema.......................................................................................................... 132 Hypertension and related conditions ......................................................................................... 132 Cardiac catheterisation and coronary angiography .................................................................... 134 Cardiac and vascular revision/reoperation procedures ............................................................... 135 Cardiac pacemakers and implanted defibrillators ...................................................................... 136 Ischaemic heart disease...............................................................................................................141 Arterial disease .......................................................................................................................... 146 Thrombolytic therapy ............................................................................................................... 149

Respiratory system .............................................................................................................. 151 Asthma ....................................................................................................................................... 151 Pneumonia .................................................................................................................................151 Ventilatory support.....................................................................................................................152 Chronic obstructive pulmonary disease (COPD) ...................................................................... 156 Influenza due to identified influenza virus.................................................................................157

Digestive system .................................................................................................................. 159 Gastrointestinal (GI) haemorrhage.............................................................................................159 Dehydration with gastroenteritis ................................................................................................159 Helicobacter pylori .......................................................................................................................159

Skin and subcutaneous tissue........................................................................................... 161 Plastic surgery.............................................................................................................................161 Craniofacial surgery .................................................................................................................. 162 Repair of wound of skin and subcutaneous tissue...................................................................... 163 Pressure injury........................................................................................................................... 164

Musculoskeletal system and connective tissue ............................................................ 167 Disc disorders with myelopathy................................................................................................. 167 Disc lesion ................................................................................................................................. 167 Dislocation or complication of hip prosthesis ............................................................................ 167 Exostosis.................................................................................................................................... 167 Cement spacer/beads ................................................................................................................. 167 Meniscus/ligament tear of knee, NOS ...................................................................................... 168 Silastic button arthroplasty........................................................................................................ 168 Slipped disc ............................................................................................................................... 168 Erosion of knee.......................................................................................................................... 168 Spinal fusion.............................................................................................................................. 168 Juvenile arthritis ........................................................................................................................ 169 Bankart lesion ........................................................................................................................... 169 SLAP lesion............................................................................................................................... 169

Genitourinary system.......................................................................................................... 171 Admission for kidney dialysis .................................................................................................... 171 Diethylstilboestrol (DES) syndrome ......................................................................................... 171 Loin pain/haematuria syndrome ............................................................................................... 171 Bladder retraining ..................................................................................................................... 171 Ovarian cysts............................................................................................................................. 172 Infertility and in vitro fertilisation (IVF) .................................................................................. 172 Chronic kidney disease.............................................................................................................. 173

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Australian Coding Standards for ICD-10-AM and ACHI

15 Pregnancy, childbirth and the puerperium .................................................................... 179 1500 Diagnosis sequencing in obstetric episodes of care..................................................................... 179 1505 Delivery and assisted delivery codes .......................................................................................... 180 1506 Fetal presentation, disproportion and abnormality of maternal pelvic organs............................ 184 1511 Termination of pregnancy (abortion)......................................................................................... 184 1521 Conditions and injuries in pregnancy........................................................................................ 187 1544 Complications following pregnancy with abortive outcome .......................................................191 1548 Puerperal/postpartum condition or complication...................................................................... 194 1549 Streptococcal group B infection/carrier in pregnancy................................................................ 199 1550 Discharge/transfer in labour...................................................................................................... 199 1551 Obstetric perineal lacerations/grazes.......................................................................................... 201 1552 Premature rupture of membranes, labour delayed by therapy.................................................... 203

16 Certain conditions originating in the perinatal period............................................... 205 1602 Neonatal complications of maternal diabetes ............................................................................ 205 1605 Conditions originating in the perinatal period .......................................................................... 205 1607 Newborn/neonate...................................................................................................................... 206 1610 Sudden infant death syndrome/apparent life threatening event................................................. 207 1611 Observation and evaluation of newborn and infants for suspected condition not found ........... 208 1613 Massive aspiration syndrome ..................................................................................................... 208 1615 Specific diseases and interventions related to the sick neonate................................................... 209 1617 Neonatal sepsis/risk of sepsis.......................................................................................................211

17 Congenital malformations, deformations and chromosomal abnormalities ........ 213 (This chapter intentionally left blank)

18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified..................................................................................................... 215

1805 Acopia ........................................................................................................................................215 1807 Acute and chronic pain ..............................................................................................................215 1810 Skin tear and frail skin ...............................................................................................................217

19 Injury, poisoning and certain other consequences of external causes................... 219 1901 Poisoning....................................................................................................................................219 1902 Adverse effects ............................................................................................................................219 1903 Two or more drugs taken in combination.................................................................................. 221 1904 Procedural complications .......................................................................................................... 223 1905 Closed head injury/loss of consciousness/concussion ................................................................. 231 1906 Current and old injuries ............................................................................................................ 233 1907 Multiple injuries ........................................................................................................................ 233 1908 Open wound with artery, nerve and/or tendon damage............................................................. 234 1909 Adult and child abuse................................................................................................................ 234 1910 Skin loss .................................................................................................................................... 235 1911 Burns......................................................................................................................................... 236 1912 Sequelae of injuries, poisoning, toxic effects and other external causes...................................... 238 1914 Degloving injury ....................................................................................................................... 240 1915 Spinal (cord) injury.................................................................................................................... 241 1916 Superficial and soft tissue injuries.............................................................................................. 244 1917 Open wounds ............................................................................................................................ 246 1918 Fracture and dislocation ............................................................................................................ 246 1919 Open intracranial injury............................................................................................................ 247 1920 Open intrathoracic/intra-abdominal injury ............................................................................... 248 1922 Crushing injury......................................................................................................................... 248 1923 Contact with venomous/nonvenomous creatures....................................................................... 249 1924 Difficult intubation................................................................................................................... 252

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