Clinical Coders’ Society of Australia



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Dear Fellow CCSA members,

Welcome to another Codelink newsletter.

We don’t get the opportunity to publish as often as we would like because material related to Clinical Coding is not always easy to find. Thank you to Joan Knights (WA Rep) for creating the Codelink newsletter for us, not an easy task. If you come across any articles of interest, send them along and we can share with our members via Codelink or on our website.

As you are aware, it has been an interesting time for the CCSA and your Management Committee is doing its best to get back on track. We have nearly completed our memberships and a spreadsheet on member details is close to finishing. Mitchell has done a great job with the membership and next year it will be much simpler and easier. Shorty our State Committee reps will get in touch to make sure we have member details correct. If you know someone who has been left off or details duplicated, or incorrect, then let us know so we can get it right.

Shortly we will be making an announcement on the upgrade of our website, with a members’ only area where we will be able to communicate with each other, ask questions, etc. We will also place our education material in the members’ only area and possibly a place to advertise for Hospitals looking for Coders, or Coders looking for positions, etc. We will also have a Powerpoint presentation on the history of the CCSA and where we are going.

Healthscope’s Allamanda Hospital is our sponsor and we are always looking for assistance to keep the CCSA going. If you think your hospital might like to assist with sponsorship let me know. It doesn’t have to be a large donation, all assistance will help with costs.

Your Management Committee are all volunteers and some have been on the committee since inception in 1996. They can’t be on the committee for ever, so if you have an interest in helping, let me know. It doesn’t involve a lot of work and is very rewarding. We still don’t have a Victorian representative, so if any Vic members would like to come on board let me know. We would love a Victorian representative on our Committee.

I’m still sending out letters of introduction to the Health Industry and have now covered the Federal and State Governments, most health funds and other stake holders in Health. So far I have received very positive replies and the CCSA is getting recognition as a society that represents Clinical Coders.

Finally, a big thank-you to you all our CCSA members. We have been through a difficult time and I believe we have come through bigger and better. Our membership has grown, but we can still have more members, so tell your friends about us, and with our new website, we will have a lot to offer………..

To the members who have stuck with us, thank you. To our new members, thank you for becoming part of the CCSA family.

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Inside this issue:

page

Presidents Report 1

✓ Obstetric items 3

✓ Obstetric Quiz 6

✓ Board Member Contact 8

Volume 19, Issue 1,

May 2015

President report continued….

It’s your CCSA not the Management Committees, so if you have any ideas or thoughts on how we could do it better, get in touch. I love hearing from you the members, unfortunately not that many say g’day. Say hello to your State reps, they never get to hear from anyone. It’s always encouraging if members just let you know they appreciate the efforts of the committee. A couple of members always say thank you and it’s really appreciated.

Mal

CCSA President and QLD Representative

Our Tassie rep Julie would like your thoughts on the following, you can email your thoughts to me.

Coding Consistency Exercise -can you help?

One of our members recently noticed a scenario that they would have coded differently from the answer provided. Curious as to the degree of variance that there might be, they asked a group of Coders to all code the same scenario (independently of each other) and send their responses. There was definite variance; CCSA are interested in repeating this exercise for our members because we think we can provide some valuable information to the ACCD and educators. If you are willing, please code the scenario below using 8th edition (without discussing with anyone) and email maltune@.au with just your codes and state (we won’t look at, publish or retain any Coder names). We will publish collated results (de-identified) in the next Codelink issue.

An elderly female was admitted for treatment of a stroke (cerebral infarction). During admission the patient complained of burning pain at/around the IV insertion site. On examination, there were clear signs of redness and swelling around the IV site and the IV catheter was removed. On day 8 the patient developed fever, rigors and her left forearm was markedly swollen with pus discharging from the old IV entry site. A wound swab confirmed a coagulase-negative staphylococcus infection. Blood cultures showed no growth. A diagnosis of sepsis secondary to IV site infection was made and she was commenced on antibiotic treatment.  

Note: The Clinical Coder clarified with the Clinician and established that the sepsis was systemic rather than just a localised infection.

Coding Times Exercise -can you help?

ACCD have produced online education for 9th edition ICD-10-AM/ACHI/ACS . They have advised that the videos and exercises should take about one day in total (many may complete in sections).

CCSA is aware that there are often coding throughput benchmarks but we have no indication as to how reliable these actually are (Coders coding with different cases and documentation and often being told they have to do xx/day, etc). There is some opportunity for getting a rough idea of the real variance in coding time, if we can ask Coders to submit the genuine total times (at least roughly) they take to 1) view the videos; 2) complete the exercises; and 3)do the certificate quiz (keeping a separate breakdown the 3 total times).

CCSA are expecting considerable variation but we don't think that education (or coding) is a competitive race, it's about coders feeling comfortable that they understand the material (and have worked out the questions they still need answered) so they are confident when they have to code with it.

If you are willing, please email Mal ( as above ) with just your times to 1) view videos; 2) complete exercises 3) complete quiz and whether you have been coding 2 years (we won’t look at, publish or retain any Coder names). We will publish collated results (de-identified) in the next Codelink issue.

Clinical Coders’ Society of Australia

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Clinical Coders’ Society of Australia

OBSTETRICS - FAILURE TO PROGRESS & PROLONGED LABOUR

Failure to progress in first or second stage of labour

Q:

There has been confusion regarding the clinical meaning of "failure to progress in 1st stage" or "failure to progress in 2nd stage" of labour. How do you code these conditions?

A:

Failure to progress (FTP) is a general term that may indicate protracted/prolonged cervical dilation or fetal descent or complete arrest/cessation of cervical dilation or fetal descent.

FTP in labour may be caused by:

·ð fetal size/malpresentation

·ð pelvic size/shape/inadequacy

·ð abnormal uterine cont• fetal size/malpresentation

• pelvic size/shape/inadequacy

• abnormal uterine contractility

Failure/to/ progress (in labour) NEC is classified to O62.9 Abnormality of forces of labour, unspecified as per the index pathway below:

Failure, failed

- to

- - progress (in labour) NEC O62.9

Note that O62.9 is a 'not elsewhere classified' code, so where documentation specifies the cause of the FTP, code the cause instead of O62.9.

The clinical scenarios cited (FTP 1st stage and FTP 2nd stage) do not specify any cause for the FTP. Therefore O62.9 Abnormality of forces of labour unspecified should be assigned in both of these incidences.

Where prolonged labour (stage one or stage two) is documented with failure to progress, also assign an appropriate code from O63 Long labour.

(See also Coding Rules: Failed trial of labour and failure to progress)

(Coding Rules, March 2014)

Failed trial of labour and failure to progress

Q:

What is the difference between failed trial of labour and failure to progress?

A:

Current clinical advice regarding these terms provided the following information:

Failure to progress (in labour) - is a description rather than a diagnostic term, therefore, where possible, coders should assign a code for the underlying condition resulting in the 'failure to progress'. The patient must be in an active phase of labour (ie. cervix is dilated to ≥d 4cms and regular contractions are occurring with or without ruptured membranes), before failure to progress can be established. Underlying causes may include cephalopelvic disproportion, fetal malpresentation, incoordinate uterine action (primary uterine inertia or secondary uterine inertia), cervical dystocia or maternal exhaustion. The clinician will consider why labour is not progressing, make a diagnosis and then use interventions such as amniotomy and/or augmenting labour with oxytocins.

In the absence of documentation of an underlying cause for 'failure to progress' clinical advice indicates that the correct code to assign is O62.9 Abnormalities of forces of labour, unspecified following the index pathway:…..

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Failure, failed

- to

- - progress (in labour) NEC O62.9

Failed trial of labour - is also a description rather than a diagnostic term, therefore coders should assign, where possible, a code for the underlying condition resulting in a caesarean birth after trial of labour (TOL). A trial of labour can be undertaken because of potential problems due to small maternal size, large fetal size or for patients who have had a previous caesarean section to see if a vaginal delivery can be achieved. Other terminology used to describe this type of trial of labour include 'trial of scar', VBAC (Vaginal Birth after Caesarean) attempt or 'trial of vaginal birth after Caesarean' (TOVBAC). Trials of labour fail because women fail to progress, usually because of fetal malpresentation, cephalopelvic disproportion or fetal distress. Conditions that may result from a failed trial of labour include uterine rupture or fetal distress. See also ACS 1506 Malpresentation, disproportion and abnormality of maternal pelvic organs.

In the absence of documentation of an underlying cause for 'failed trial of labour' clinical advice indicates that the correct code to assign is O66.4 Failed trial of labour, unspecified following the index pathway:

Failure, failed

- trial of labour (with subsequent caesarean section) O66.4

The NCCC will consider indexing improvements for additional terms under failed trial of labour in a future edition of ICD-10-AM. This advice supersedes advice published in Coding Matters, March 2009 (Volume 15, Number 4), Failure to progress in labour, which will be retired from 31 December 2012.

(Coding Q&A, December 2012)

Malpresentation, disproportion and abnormality of maternal pelvic organs

Q:

When should codes from O32–O34 versus O64–O66 be assigned?

A:

The codes from O64–O66 are assigned when a condition classifiable to O32–O34 is first diagnosed during labour, OR requires care and/or intervention during labour because it is considered that the condition has affected the labour and/or delivery. This is consistent with the guidelines in ACS 1506 Malpresentation, disproportion and abnormality of maternal pelvic organs; this includes notes at O32–O34 and the relevant index entries.

To summarise the guidelines in ACS 1506:

• Where care or intervention is required due to malpresentation, disproportion or abnormality of the maternal pelvic organs before the onset of labour, assign a code from block O32–O34 (that is, known before onset of labour, care or intervention required before onset of labour, e.g. breech presentation diagnosed before the onset of labour and proceeds to elective caesarean section without labour).

• Where the malpresentation, disproportion or abnormality of maternal pelvic organs requires care and/or intervention during labour, assign a code from blocks O64–O66 (that is, known before onset of labour, care or intervention required during labour; this includes failed trial of labour).

• Where the malpresentation, disproportion or abnormality of maternal pelvic organs is first diagnosed during labour, assign a code from blocks O64–O66 (that is, not known before onset of labour).

Amendments to ACS 1506 will be considered for a future edition of the Australian Coding Standards.

(Coding Rules, September 2014)

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Clinical Coders’ Society of Australia

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Clinical Coders’ Society of Australia

Definition of Prolonged Labour

Labour is divided into three stages - the dilation of the cervix, the delivery of the baby, and the delivery of the placenta. For first-time mothers, labour takes around 12 to 24 hours. Women who have undergone childbirth before can expect about seven hours of labour.

Recognising the start of labour

Braxton-Hicks contractions are sometimes mistaken for labour. These ‘false’ contractions usually start halfway through the pregnancy and continue for the duration. These contractions visibly harden and lift the pregnant belly. It is not known what triggers the onset of labour, but it is thought to be influenced by the hormone oxytocin, which is responsible for causing uterine contractions. Some of the signs and symptoms of going into labour may include:

• Period-like cramps

• Backache

• Diarrhoea

• A small bloodstained discharge as your cervix thins and the mucus plug drops out

• A gush or trickle of water as the membranes break

• Contractions.

The first stage of labour

The first stage of labour is concerned with the thinning of the cervix and its dilation to around 10cm. The different phases include:

• The latent phase - generally, this stage is the longest and the least painful part of labour. The cervix can thin out over weeks, days or hours and be accompanied by mild contractions. The contractions may be regularly or irregularly spaced, or else they may not even be noticed them at all.

• The active phase - the next phase is marked by strong, painful contractions that tend to occur around three or four minutes apart and last up to a minute or so. The cervix dilates to around 7cm.

• The transition phase - the contractions become more intense, painful and frequent. It may feel like the contractions are no longer separate but running into each other. The cervix may take around an hour or so to dilate the final 3cm. It is not unusual to feel a strong urge to go to the toilet as the baby’s head pushes against the rectum.

The second stage of labour

Once the cervix is dilated to around 10cm, the second stage of labour can begin. The contractions should now be regular and spaced apart As each contraction builds to a peak, the patient may feel the urge to bear down and push. The sensation of the baby moving through the vagina is described as a stretching or burning, particularly as the baby’s head crowns (appears at the vaginal entrance). Once the head has emerged, the delivery staff will turn the body to deliver the shoulders. The rest of the baby will then slip out. The second stage of labour typically lasts around 15 minutes to one hour.

Third stage of labour

The placenta is then delivered, usually five to 30 minutes later. The uterus gently contracts to loosen and push out the placenta. The patient may not be able to feel these contractions.

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Obstetrics Quiz

Please note these are fictitious cases only.

Q1.

Pt has a known history of unstable lie, first noted in outpatient appointment. Booked for a LSCS 25/8 at 39+1. On 23/8 pt starts contracting and has a SROM, presenting to birthing suite 5cm dilated. Team advice for a Cat 2 Emergency LSCS immediately. Spinal anaesthetic with ASA 2.

Would you code this to an Emergency Caesarean? YES/NO

Neuraxial block, ASA 2, emergency 92508-20

Neuraxial block, ASA 2, unspecified 92508-29

Answer:

No, elective LSCS as per ASC1541.

92508-29. The ASA Emergency score is not reflected by the operation but from the anaesthetic administration.

Q2.

34F presents to outpatient appointment for monitoring of suspected IUGR. Pt has been admitted directly from OP to commence IOL for IUGR. Pt goes on to have a SVD of a small baby which is transferred to SCN care.

Is the IUGR or O80 the Principal Diagnosis?

Answer:

O80 should be Principal Dx. ACS0001 – “where patient is admitted for delivery - assign from O80-O84 as the PD”

Tip: Check carefully when the decision for delivery has been made. Was it in the outpatient appointment or during admission?

Q3.

This pt. is 34 weeks gestation and complaining of cramping and tenderness. She is admitted with APH. After two days of no spotting she was prepared for discharge when she begins to bleed, an ultrasound reveals marginal placenta praevia. Decision made to do an Emergency LSCS.

What is the principal diagnosis?

Answer:

Placenta praevia with haemorrhage will be principal diagnosis. O82 will be an additional diagnosis. ACS0001 states the “where patient is admitted for management of an antepartum condition, assign the antepartum condition as the PD. If patient delivers during the episode, assign O80-O84 as an ADx.

Question to ask your-self: Was this pt. planned to deliver or to go home to await delivery?

Q4.

23F 40+2 wks arrives to delivery suite with regular contractions. Pt admitted to labour ward with CTG monitoring. During admission, contractions become more painful, pt requesting epidural. Evidence of decelerations noted on CTG. Plan: IV Syntocinon, IV Penicillin, Anaesthetic review, assess after epidural, discuss with pt for possible CS. PHx: GpB Strep +ve, LSCS in 2008. Pt is 7cm dilated, epidural inserted and IV Syntocinon commenced. After 1hr, pt is fully dilated, CTG noted episodes of bradycardia, ventouse cup applied, episiotomy done. Delivery of alive female infant on third pull given to paeds team. Perineum checked with no extension. Epidural still working episiotomy sutured.

Clinical Coders’ Society of Australia

Clinical Coders’ Society of Australia

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Which coding scenario is more accurate?

1 | |2 | |Delivery vacuum O81 | |Delivery vacuum O81 | |Group B Strep Carrier | |Labour and delivery with fetal anomaly O68.0 | |Fetal distress during labour | |Vaginal Birth after Caesarean | |Maternal care to uterine scar from previous surgery | |Group B Strep Carrier | |Single liveborn | |Prophylatic pharmacotherapy | | | |Single liveborn | |Vacuum Delivery | | | |Induction of labour | |Vacuum delivery | |Episiotomy | |Episiotomy | |Neuraxial for labour | |Augmentation, medical after onset of labour | |IV antibiotics | |Neuraxial during labour and delivery | |

Answer:

Scenario 2.

• ACS0001 for Vacuum Delivery

• Fetal bradycardia indexed to O68.0 complicating labour/delivery

• ACS1506 VBAC as opposed to O34.2 Maternal care for uterine scar

• ASC1549 Gp B Strep Gp treated with antibiotics. (Antibiotics not coded ASC0042)

• Augmentation instead of Induction. Pt in labour for Syntocinon. Not to be confused with Syntocinon used for 3rd stage.

• ACS0031 for neuraxial block for pain relief and anaesthetic for episiotomy repair

Q5.

Previous CS wanting a VBAC. FTP at 6cm proceeding to an emergency caesarean.

Would you code O34.2 Maternal care for uterine scar or O66.4 Failed trial of labour?

Answer:

ASC1506 Maternal care for Uterine scar O34.2

Q6.

When would you use Failure to Progress NOS, O62.9

a) Pt 9cm, shoulder dystocia noted. Documented as FTP due to dystocia.

b) FTP with deep transverse arrest

c) Obstructed labour

d) Documented as uterine inertia.

Answer:

None.

Failure to progress (in labour) is a description rather than a diagnostic term, therefore where possible coders should assign a code for the underlying condition resulting in the ‘failure to progress’. The patient must be in the active phase (cervix is dilated >= 4cm and regular contractions). Try to find why the labour is not able to progress, if no documentation of an underlying cause for ‘failure to progress’ correct code to assign is O62.9 Abnormalities of forces of labour, unspecified.

Remember:

New articles welcome!

We are looking for article of your Clinical Coder experience and Medical Science updates.

Contact the Editor - Joan Knights

Joan.Knights@health..au

CCSA Board Member Contact List

QLD |President |Mal Tune |041 3332945 |Malcolm.Tune@.au | |NSW |Public Officer |Michelle Wedd |07 5524 8331 |Michelle.Wedd@health..au | |NT |Treasurer |Mary McKay |08 8987 0273 |mary.mckay@.au | |SA |Representative |Jillian Carlson |08 8204 4168 |Jillian.Carlson@health..au | |ACT |Representative |Sharon Neill

|0262444300 |Sharon.Neill@.au | |VIC |Representative |Vacant | | | |TAS |Representative |Julie Turtle |03 6233 6706 |Julie.Tutle@dhhs..au | |WA |Representative |Joan Knights |08 9382 6350 |Joan.Knights@health..au | |SEC |Secretary |Kathy Frampton |043435 8802 |Denece.Frampton@health..au | |

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Clinical Coders’ Society of Australia

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