# VICC queries

Query Text:
37year old obstetric patient originally pregnant with twins however suffered FDIU of one twin at 17/40.  Admission was for delivery of surviving twin.  Was querying whether FDIU should be coded in delivery admission ie using codes O02.1, O09.2 or is this covered by using O31.2. If I include these codes to complete the whole picture, the episode groups to a non-obstetric DRG (O63Z) which is unacceptable, despite using an outcome of delivery code (Z37.3).

Is it acceptable to simply use O31.2 to reflect the complication?

Response:
The correct principal diagnosis to assign in this scenario is:
O31.1 Continuing pregnancy after abortion of one fetus or more

O02.1 Missed abortion should not be assigned as per the ‘excludes’ note at the beginning of the O00-O08 chapter Pregnancy with abortive outcome which states: 

Pregnancy with abortive outcome (O00 -O08)
Excludes:  continuing pregnancy in multiple gestations after abortion of one fetus or more (O31.1)

In AR-DRG V5.0 this episode groups to O60A Vaginal delivery with catastrophic or severe CC when Z37.3 Twins, one liveborn and one stillborn (or Z37.0 Single live birth) is assigned.

The Victorian ICD Coding Committee recommends use of Z37.0 Single live birth because the death of a fetus at 17 weeks makes this an abortion, and not a birth per ACS 1510 Pregnancy with abortive outcome.


Query Text:
Could you please inform us on how we should code Pathological crush # due to fall, with osteoporosis.  We have thought to code:
M80.9x Osteoporosis with pathological fracture with the external cause codes W19 Unspecified fall Y92.9 Unspecified place of occurrence and U73.9 Unspecified activity.  Or do we code the trauma site code (as Pdx) with the external cause codes?  Could you please inform us of the correct codes for this situation?
Thanks

Search Details: We found this information on the www.bonetumour.org website:

Pathological fracture definition: It is a fracture occurring in a bone weakened by a pathological lesion following a trival injury.

Response:
The Victorian ICD Coding Committee agrees with the enquirer's code selection.  In this scenario the correct principal diagnosis to assign is:
M80.9x Osteoporosis with pathological fracture

External cause code are not routinely required but may be assigned if you have documentation of a fall or other injury.


Query Text:
Please advise how to code Magnetic Resonance Cholangiopancreatography (MRCP)?  We code the MRI abdomen 90901-05 [2015] and are not sure whether to code the cholangiography 58936-00 [1976] or some other appropriate code.  This affects the DRG.

Search Details:
NCCH query 855, 3/3/1999  states to code Magnetic resonance cholecystopancreatography to 90901-05 [2015] Magnetic resonance imaging of abdomen and 58924-00 [1976] Cholecystography.

I searched on the internet regarding MRCPs and www.fhshealth.or talks about the MRCP procedure.  It does not seem very invasive, similiar to just a MRI.

Response:
The VICC sought advice from NCCH who agrees that 90901-05 [2015] Magnetic Resonance Imaging of abdomen is the correct code to assign for Magnetic Resonance Cholangiopancreatography (MRCP).

The NCCH has amended advice given in Query 855.


Query Text:
I wish to further clarify information regarding the coding of anaemia and related descriptions contained in Query #1944 ICD Coding Newsletter Second Quarter 2004-05.

It has become common practice in our hospital for clinicians to document anaemia and its treatment in the following ways:

1. 'Down arrow Hb Transfuse 2 units packed cells'

2. 'Down arrow  Hb' Transfusion given.

3. Monitor Hb readings and when Hb  <90 transfuse 2 units.  Entries further along say 'Hb 85 - patient received 2 units packed cells'.

Prior to query #1944, we coded anaemia on the basis of a down arrow as per examples in VICC query #1735 (Nov 2001).

Queries back to the clinicians asking them to document anaemia are not always received graciously, rather the clincians are puzzled that we need to ask for clarification as they consider a patient to be anaemic whenever transfusions are given.

Can we code anaemia in the above examples?

Search Details: 
VICC coding queries #1735 & #1944

Response:
The Victorian ICD Coding Committee agreed that a downward arrow can be interpreted as meaning ‘low’.  Low haemoglobin is indexed to D64.9 Anaemia, unspecified.  Therefore for scenarios 1 and 2, anaemia can be coded.  For scenario 3, there is no documentation indicating that the patient has anaemia, and therefore this cannot be coded.  

Hopefully if your doctors are constantly made aware/reminded of the documentation requirements for coding anaemia (and other conditions) then this should eventually reduce the number of queries referred back to them when the documentation is lacking.


Query Text:
14 year old male with suspected snake bite. Has 2 marks on leg but VDK test negative and no actual sighting of a snake. 

Example 1 on page 258 of standards says to use open wound code but the VDK test in this example has detected contact with a brown snake. My query is how to code the above scenario when the only evidence is 2 marks on leg that could of been due to a branch, rock or anything?

Response:
The Victorian Coding Committee notes that the question is not about whether the snake was venomous or not, but rather whether this is in fact a snakebite.  Therefore what is being coded is ‘query’ snakebite.

In this case, the principal diagnosis should be Z03.8 Observation for other suspected diseases and conditions (as per ACS 0001 Principal diagnosis Codes from the Z03.0-Z03.9 series, medical observation and evaluation for suspected diseases and conditions’).


Query Text:
Scenario: Patient (male) admitted for PESA (Percutaneous Epididymal Sperm Aspiration) under GA as part of IVF procedure.  The sperm obtained is sent to the IVF laboratory.

According to ACS1437, the appropriate diagnosis code would appear to be Z31.2 In vitro fertilisation.  However, system edits (both at hospital level, Victorian DHS level and NCCH ASCII file level) prevent the entry of this diagnosis code for a male patient.  ACS1437 is reproduced below, with emphasis added (underlined).

Infertility
When an admission for investigation or treatment of infertility (either male or female), a code from category N97 Female infertility or code N46 Male infertility should be assigned as principal diagnosis.

IVF
When an admission is specifically for IVF procedures, and the principal diagnosis is “IVF” or “infertility”, Z31.2 In vitro fertilisation should be assigned as the principal diagnosis code.  An additional code from category N97 Female infertility, for the type of infertility may be assigned if known, including N97.4 Female infertility associated with male factors.

As PESA is a procedure carried out specifically for IVF, and the standard states “either male or female”, according to the standard when admission is specifically for PESA and IVF (or infertility) has been documented as the principal diagnosis, Z31.2 should be assigned.

The NCCH  database contains the following query, number 1914, dated 15/03/2004:
Q. What code is used for Principal Diagnosis for males being admitted for IVF treatment? 

A. Male admitted for aspiration of sperm for IVF under LA. (Female admitted at same time for TVOR). If Z31.2, In vitro fertilisation is used, it is ungroupable. Z31.2 appears the most appropriate code, but have only up to this stage tended to be assigned for the females only. A male infertility code is not appropriate as it is not treatment for the infertility, but IVF treatment.  The NCCH suggests Z31.3 'Other assisted fertilisation methods' for the scenario cited.

In addition, Coding Matters Volume 11 Number 3 December 2004 states:
“Aspiration of sperm for IVF
The NCCH received a query regarding code assignment for male patients admitted for aspiration of sperm for IVF. Z31.3 Other assisted fertilisation methods should be assigned for these cases. Assign also an appropriate procedure code, as per documentation.”

We are following this advice from NCCH, but feel that Z31.2 is the correct code for males admitted for IVF procedures according to the Standard and current code indexing.

Would VICC consider suggesting to NCCH either
(a) That indexing for Admission for IVF be amended to direct male admissions to Z31.3 and female admissions to Z31.2 and that ACS1437 Infertility be amended to reflect that for IVF procedures, Z31.2 is appropriate for female patients and Z31.3 for male patients, in line with their advice in Coding Matters
or
(b) That the ASCII file be amended to enable Z31.2 to be used for both male and female patients where admission is for IVF (as ASC1437 Infertility currently directs).

Response:
The Victorian ICD Coding Committee recognises the issues highlighted by the enquirer and has referred the enquirer’s suggestions to the NCCH.  In the meantime coders should follow the advice provided in Coding Matters Volume 11 Number 3 December 2004.


Query Text:
A lady had presented with multiple antenatal admissions for small APHs, so induced on this occassion for this reason, although on admission no APH present.  Admitted for Prostin + ARM + Syntocinon.

Would the Principal Diagnosis be APH or a Z code to show past history, in this particular case the HIM assigned Z35.2 Supervision of pregnancy with poor obstetric history?

Response:
ACS 1513 Induction notes that induction of labour is performed for many reasons including for ‘previous antepartum haemorrhage’.  A patient admitted for induction of labour for previous antepartum haemorrhages, should be coded to O46.x Antepartum haemorrhage, not elsewhere classified.


Query Text:
A 'gritty' placenta. Could you please advise what you would consider the better code to describe this. 

Some coders here use O43.1 Malformation of placenta and some O43.8 Other placental disorders

Response:
Clinical information obtained by the Victorian ICD Coding Committee indicates that gritty placenta is more common in post-dates pregnancies and has no clinical importance.  (http://showcase.netins.net/web/placenta/placentaltriage101.htm).  

The Committee advises that gritty placenta should not be coded.


Query Text:
A patient was admitted with  a relapse of schizophrenia.  The symptoms included being distracted by voices.  This relapse occured when the patient ceased his Clozapine in a previous admission ( due to physical health complications) and commenced amisulpiride.

In the past I have simply coded these episodes to the Principal diagnosis.  However, I am wanting to know whether we can find a code that shows that the relapse was due a change in medication. Maybe a Z code.
 
Suggestions: 
F20.9 Schizophrenia, unspecified
and
Z76.8 Persons encountering health services in other specified circumstances 
or
Z92.28 Personal history of long term (current) use of other medicaments - other medicaments 
 
Your thoughts would be greatly appreciated.

Response:
There are no codes to indicate that a change to the status of a condition is due to a change in medication, and no codes to indicate this are required.  

For this scenario, code F20.9 Schizophrenia, unspecified.

If there is a need at local level to collect this information then the Z codes mentioned above may be appropriate.  However, coders must ensure that these codes, if assigned for this purpose, are not transmitted to VAED.


Query Text:
ACS 1904 Procedural complications states:
For the purposes of this coding standard a procedural complication is defined as:

A condition or injury which is related to a surgical/procedural intervention rather than being related to the patient's disease process.

I find this at odds to the Victorian ICD Coding Committee article published in November 2001 (Coding Feature) which requires a cause and effect statement in the record before coding the condition as a procedural complication.

It appears that following the ACS compared to the VICC directive gives a different answer, for example  ‘post-op ileus’ – ACS = K91.3 Postprocedural intestinal obstruction; VICC = K56.7 Ileus, unspecified

Could the Committee please clarify the coding of procedural complications?

Response:
This query was referred to the NCCH who provided the following advice:
"ACS 1904 PROCEDURAL COMPLICATIONS is currently being reviewed for a future edition of ACS as part of a public submission."

The VICC will await  clarification from the NCCH review of ACS 1904 Post procedural complications.  Please note that while some aspects of the Post procedural complications article published in the November 2001 ICD Coding newsletter have been superseded by later advice, the article is not at odds with ACS 1904 as both advise that a cause and effect relationship is required before a post procedural complication code can be assigned.


Query Text:
A 50 year old male presented with diabetic foot with cellulitis of the toe with a LOS of 60 days. Debridement of the cellulitic toe was undertaken on the ward and the general surgeon documented in the progress notes  (R)5th toe - bone nibbled back and tendon debrided indicating that the excisional debridement of the soft tissue involved the bone (30023-01 [1566]). 

When I group the episode, it goes to 901Z Extensive O.R. related to Principal Diagnosis and the episode becomes an outlier as the high trim point = 36 days. Alternatively, if I use the procedure code 30023-00 [1566] excisional debridement of wound of soft tissue, the episode groups to K01Z diabetic foot procedures which becomes an inlier which is more accurate

If I use both procedure codes, the DRG remains at K01Z.

I would like to ask you the following questions in relation to this query:
1) Does the documentation support the allocation of 
30023-01 excisional debridement of soft tissue involving the bone?
 
2) If so, should both debridement codes be allocated to ensure that the episode groups to K01Z?

3) Or do adjustments need to be made to the DRG procedure code table to include 
30023-01 excisional debridement of soft tissue involving the bone.

Response:
The information that you have provided supports the assignment of:
30023-01[1566] Excisional debridement of soft tissue involving the bone or cartilage

30023-00 [1566] Excisional debridement of wound of soft tissue cannot be used in addition to this code because of the ‘excludes’ note at this code excluding ‘excisional debridement of soft tissue including bone or cartilage’.

The Victorian ICD Coding Committee will notify the Commonwealth of this grouping issue.


Query Text:
Doctors at our hospital have advised that all AICD units have both pacemaker and defibrillator functionality.  One lead from the AICD unit performs both functions (pacing and defibrillating).  This lead is placed into the right ventricle.

Depending on the pacemaker function required depends on the number of leads to be inserted.

The problem that coders face is how should we capture the fact that one of the leads doubles up to act as a defibrillator lead as well as a pace maker lead?  If we code each one out, it appears that an extra lead has been inserted when it hasn't.

A Biventricular AICD unit requires a lead to pace the atrium and a lead to both ventricles.

38524-00 Insertion of automatic defibrillator generator
38521-03 Insertion of defibrillation electrodes (leads) for automatic defibrillator (1 electrode)
38281-13 Insertion of permanent triple chamber pacemaker
90214-00 Insertion of permanent triple chamber transvenous electrodes (3 electrodes)

Looking at these codes it would appear that 4 wires have been inserted but in reality only 3 wires have been inserted.  To code 2 pacing electrodes with a triple chamber pacemaker would not appear correct.

The same occurs with an AICD (VVI 40). This is a unit with one lead to the right ventricle.  It both has a pacing threshold of 40 beats per minute (indicated by VVI 40) and a defibrillator coil.

To code the pacemaker VVI without an electrode would not follow the ‘includes note’ in the procedure code.

Therefore we have been coding:
38524-00 Insertion of automatic defibrillator generator
38521-03 Insertion of defibrillation electrodes (leads) for automatic defibrillator (1 electrode)
38281-02 Insertion of permanent single chamber pacemaker, VV
38278-01 Insertion of permanent transvenous electrode into ventricle (1 electrode)

Again this creates a picture that 2 electrodes have been inserted when in fact only one has been inserted.

Can the VCC please advise if we are interpreting the errata and 'code also' notes correctly?  If not, please advise how we should be coding these cases.

Search Details: 
Discussion with Cardiologists at Box Hill Hospital.
Review of NCCH Query 2072.
Vol 3 errata under blocks 650 - 653.

Response:
The Victorian ICD Coding Committee recognises the difficulties in assigning codes for these procedures and will prepare a public submission for NCCH requesting a review of AICD and pacemaker codes and coding standards.  Until these codes can be reviewed and updated appropriately, assign a code for each component performed knowing that the end result will not precisely match the actual procedure performed.  The codes that you have provided in your query are appropriate.


Query Text:
Patient was admitted for Right Breast Pain, with the procedure documented as Exploration. The patient has a breast implant which was removed and reinserted after the cavity was irrigated.  I am unsure whether to code just the breast exploration code or if I should include codes for the removal and insertion or the replacement of the prosthesis. 
The options we are considering;

1) 31551-00 [1742] Incision and Drainage of Breast

2) 31551-00 [1742] Incision and Drainage of Breast
    45548-00 [1758] Removal of Breast Prosthesis
    45524-00 [1753] Augmentation mammoplasty, Unilateral

3) 31551-00 [1742] Incision and Drainage of Breast
    45552-00 [1758] Removal of breast prosthesis with complete excision of fibrous capsule and replacement of prosthesis.

Options 2 & 3 are not ideal as they both imply a new implant is inserted. In the third option the excision of a fibrous capsule was also not performed.

Response:
Option 1, 31551-00 [1742] Incision and Drainage of Breast is the appropriate code for this procedure.  

Removal of the prosthesis is a part of the operative approach to enable access for irrigation; therefore this is not coded separately.


Query Text:
Would like some advice on how to code the insertion of a Unispacer into a knee joint.  The Unispacer is a small metallic, kidney-shaped insert which is held in place by its geometry and the surrounding soft tissue structures.  It is used as an alternative to TKR in patients with low grade arthritis to provide a smooth surface for the bones to glide over and improve joint stability.  It is also used to correct the deformity of a meniscectomy and relieve the consequent imbalance of forces after meniscectomy.  Our Orthopaedic department suggested coding:

Arthroplasty, knee, partial 49517-00 [1518]. 

This problem with the partial knee arthroplasty code is the index specifies ‘ - - for joint replacement’. As the ‘Unispacer’ insert is not for joint replacement it was thought this may not be appropriate.

An alternative code is a NEC Repair of the Knee 90598-00 [1520]  which is also not ideal.

Search Details: www.scortho.net/unispacerprocedure.html

Response:
The correct code to assign for this procedure is:
90551-00 [1496] Implantation of prosthetic device of leg.  

The index look up is:
Implantation
¯
-prosthesis, prosthetic device
--leg


Query Text:
After AIHW have analysed data supplied by jurisdictions, they send back episodes to the jurisdictions that they confirmed, including what they believe to be mismatches in sex and procedure codes.

Feedback to Victoria included 3 episodes where 55300-00 [1943] Transrectal ultrasound of prostate, bladder base and urethra was coded for females.  This data combination for 2004-05 results in a rejection, which hospitals must fix in order to submit their coding (in line with the ASCII).

Upon investigation it was noted that for all 3 episodes, the procedure that the coder was trying to reflect was a bladder scan.  This procedure is used routinely to measure the volume of urine in the bladder to determine whether the patient may need to be catheterised.  It is noted that this procedure should not normally be coded as per ACS 0042 Procedures not normally coded, however if a hospital does choose to code the procedure, there appears to some issues with the indexing of bladder scan.  The current indexing is listed below:

Ultrasound
-bladder (base) 
--with prostate and urethra (transrectal) 55300-00 [1943]

We would like to suggest that the indexing be changed as listed below. 

-bladder (base) 55038-00 [1943]
--with prostate and urethra, transrectal 55300-00 [1943] 

Notes:
 55038-00 [1943] Ultrasound of urinary tract appears to be the best fit of the current codes, however there could be scope to create a new code.
 Transrectal is currently a non-essential modifier, yet is in the title of the code, implying that it is required if the code is to be used

Response:
In the ICD-10-AM Procedures classification 'and' means 'and' and not 'or' (per ACS 0040 Conventions Used in the Tabular List of Procedures) 

In this scenario, code 55038-00 [1943] Ultrasound of urinary tract is the most appropriate code for this procedure.  

55300-00 [1943] Transrectal ultrasound of prostate, bladder base and urethra cannot be coded for females, as all of these organs must be scanned before this code can be used.

Note that there will be a new code in ICD-10-AM Fifth Edition for ultrasound of the bladder.


Query Text:
How do you recommend coding HELLP syndrome (haemolysis, elevated liver enzymes and low platelet count)?   We are currently coding it to O14.1 - severe pre-eclampsia.  Is this correct?

Please note: At the Perinatal Unit we code Perinatal forms which are sent in from hospitals.   We do not submit any information to the VAED.

Response:
Thank you for your query to the Victorian ICD Coding Committee.
You are correct.  The code for HELLP syndrome is O14.1 Severe pre-eclampsia.  This is indexed under:
Syndrome
-HELLP


Query Text:
Female patient admitted for same day IV infusion of Zometa.  What procedure code should be used?
Infusion chemo agent 96199-00 (1920) or
Infusion pharmacological agent 96199-09 (1920)

Response:
Same day admissions for IV pharmacotherapy are coded in accordance with ACS 0044 Chemotherapy.  If the patient is admitted for pharmacotherapy for a neoplasm or neoplasm related condition, this is coded as an antineoplastic agent.  If the patient is admitted for pharmacotherapy for a condition other than a neoplasm or neoplasm related condition, this is coded as another pharmacological agent.

See #2810 Chemotherapy drug administered for non-neoplasm conditions.


Query Text:
1/ If transfer of umbilicus is documented but repair of musclo-aponeurotic layer is NOT documented can we assume repair is radical?

2/ Is repair of rectus sheath part of the musculo-aponeurotic layer?

Search Details: 
ABDOMINOPLASTY
-abdominal apron 30165-00 [1666] 
--with 
---excision of skin and subcutaneous tissue 
----and repair of musculo-aponeurotic layer 
-----and transposition of umbilicus 30177-00 [1666] 
[Extracted from NCCH ICD-10-AM, July 2004, A.]

Response:
The VICC sought clarification from NCCH regarding the indexing of abdominoplasty:
"The NCCH agrees there are inconsistencies in the indexing of abdominoplasty.  

In response to the questions you have posed the NCCH advises that the breakdown in the index should include entries for abdominoplasty NEC, radical and subumbilical.  Some of the currently listed entries should be non-essential modifiers rather than index entries as they are already documented as 'Includes' notes in the ACHI Tabular List.  Please also refer to ACS 0041 CONVENTIONS USED IN THE ALPHABETIC INDEX OF INTERVENTIONS.

This will be reviewed for a future edition of ACHI."

In the meantime the VICC advises that all three components of the procedure currently listed as essential modifiers in the index, must be documented before 30177-00 [1662] Lipectomy of abdominal apron, radical can be assigned.  

For the case cited, VICC determined that rectus sheath repair is repair of musculo-aponeurotic layer and therefore 30177-00 [1662] can be assigned.


Query Text:
I would like to draw attention to what appears to be a discrepancy in the procedure default codes for lift versus meloplasty;

Meloplasty default code is unilateral wheras the lift codes default to bilateral.

Response:
The VICC referred this query to the NCCH who provided the following advice:

"The NCCH agrees that there is ambiguity in the indexing of meloplasty and cheek lift.  The default code for meloplasty should be  45588-00 [1675] Facelift, bilateral to be consistent with the default for Lift, cheek (bilateral).

The indexing of meloplasty will be reviewed for a future edition of ACHI."


Query Text:
I would like some clarification about standard ACS1808 - Incontinence. The standard states that incontinence can be coded when it is persistent prior to admission.
If a patient is admitted and incontinence is noted on the admission form as being present prior to the admission can this be coded? What is the definition of 'persistent'?    

Often the only documentation in the record is in the nursing notes where it is noted that the patient is wearing pads, are we able to code incontinence in this instance?

If a patient is admitted from a nursing home with an IDC because they are incontinent can the incontinence then be coded for the admission episode?

Response:
1. Incontinence present on admission can be coded if this is not a symptom of an acute condition directly related to the patient's admission.  For example incontinence for two days secondary to a UTI would not be coded as this is a symptom of an underlying condition.

2. A persistent condition should be a long standing condition as opposed to a short term condition presenting as a symptom of an underlying condition.

3. Incontinence must be documented for this to be coded, regardless of the patient's use of aids.

4. For a patient admitted from a nursing home with an IDC in situ, Incontinence can be coded if this is documented as the reason for the insertion of the IDC and is not a symptom of an underlying condition.


Query Text:
Could you please advise when looking in index for OA of the L4-L6, etc. would you go straight to OA, - Spine in the index or follow the path of OA, Joint, Vertebral column, or alternatively go to OA, primary, vertebral column, or OA localised, vertebral. (The  different codes in turn lead to a different DRG with a very different weight),.

Response:
Osteoarthritis 
¯
-spine (see also Spondylosis) M47.9- 

is the appropriate index look up for this condition.  

The subterms 'joint', 'primary' and 'localised' can only be used if these terms are documented in the patient’s record.  

The subterms ‘joint’ and ‘primary’ are also NEC entries and would only be used when a more specific sub term is not available.  

The sub term ‘localised’ directs coders to M19.9- Arthrosis unspecified which has an ‘excludes’ note for spine.


Query Text:
Just wanted some clarification on what conditions/diseases were to be coded even if they did not meet the 'additional diagnosis criteria'. We understood that those conditions listed as speciality standards on page 10 of the ACS were coded routinely (ie. did not have to meet associated criteria)or are we misinterpreting this instruction? Your query from the Third quarter 2004-2005 no. 2001 both the person who put in the query and the response implies diabetes must meet the additional criteria? We always code diabetes as an additional condition if present.

Response:
The list of specialty standards in ACS 0002 Additional Diagnoses indicates that these are standards that contain advice to code certain conditions that may not meet the criteria for coding as additional diagnoses.  For example ACS 0401 Diabetes mellitus and impaired glucose regulation contains advice to assign codes for many conditions in addition to the code for diabetes.  This standard does not state to 'always code' diabetes, therefore diabetes must meet ACS 0002 Additional Diagnoses before it can be coded.  Thus, when diabetes does meet criteria outlined in ACS 0002 Additional Diagnoses, there are certain conditions, for example hypertension and hypercholesterolaemia, that must be coded if they exist in the patient.  These conditions do not have to meet additional diagnoses criteria in this circumstance.   

The coder must refer to the advice in each of the listed ACS.


Query Text:
There is ongoing discussion amongst our coders regarding category O68 Labour and delivery complicated by fetal stress [distress].  

Some coders tend to use code O68.8 Labour and delivery complicated by other evidence of fetal stress, arguing that the evidence of fetal distress is electrocardiographic which is the CTG, and that all heart rate information on the unborn baby is by CTG (or internal CTG).

Other coders use O68.0 Labour and delivery complicated by fetal heart rate anomaly which includes bradycardia, tachycardia, heart rate irregularity.  These coders argue that the CTG is simply the method of measuring the heart rate, and that fetal distress occurs when there is documented bradycardia, tachycardia, fetal distress or more commonly variable decelerations or other documented heart rate anomalies,

Because it could be argued that CTG is a measure of fetal heart rate when documentation such as non-viable CTG or non-reassuring CTG is noted, is this really just an indication of fetal heart rate anomaly/irregularity anyway?

The coders who use O68.8 also use this when non-viable CTG or non-reassuring CTG is documented, for the obvious connection regarding CTG in documentation.  However for these cases when meconium is also documented, they revert to O68.1 Labour and delivery complicated by meconium in amniotic fluid which suggests a perception that there us a precedence for collecting information higher up at the 4th digit level.

Similarly with O68.3 Labour and delivery complicated by biochemical evidence of fetal stress.  We don't use this as a method of diagnosis of fetal distress at our hospital but ask the hypothetical question - which would you code in a case where fetal distress is diagnosed by both CTG and biochemically?

Can you please advise, but a 'depends on the documentation of a case' response would not be satisfactory as we are querying whether a hierarchical system applies in category O68, based on the 4th digit.

Response:
There is no hierarchical system that applies to categories within O68 Labour and delivery complicated by fetal stress [distress].  More than one code can be used if appropriate.

If there are specific fetal heart rate anomalies documented (for example bradycardia, 'heart rate irregularity', tachycardia) assign the specific code:
O68.0 Labour and delivery complicated by fetal heart rate anomaly

Note that this code excludes with meconium in amniotic fluid (O68.2).  Therefore if there was meconium in the liquor and a specific fetal heart rate anomaly, assign only code:
O68.2 Labour and delivery complicated by fetal heart rate anomaly with meconium in amniotic fluid.

If you have documentation of 'abnormal CTG' or 'non-reassuring CTG' only as the reason for intervention (with no specific heart rate anomalies documented) assign the code:
O68.8 Labour and delivery complicated by other evidence of fetal stress.


Query Text:
I am querying how to code MRI BRAIN AND CEREBRAL CELL STUDY.  I rang the reporting radiologist to enquire what the procedure involved and he stated 'to help plan the neurosurgery to be performed.  3 Dimensional acquisitions are made, using surface markers to determine where to make the incision for neurosurgery'.

Do we code 90901-00 [2015] MRI of brain or 40803-00 [1] Intracranial sterotactic localisation?  We have decided to code MRI brain only for the interim.

Search Details: The report is as follows:

MRI BRAIN AND CEREBRAL CELL STUDY - (GHB)
CLINICAL INDICATION:
Two week history of headache.  Right parietal lesion seen on CT.  Past history of melanoma 20yr ago.
FINDINGS:
There is an ill defined mass involving both cortex and underlying white matter situated predominately within the right temporal lobe, extending superiorly into the inferior aspect of the right parietal lobe.  The lesion extends medially to involve the lateral fibres of the splenium of the corpus callosum, although no extension across the midline is shown. There is a moderate amount of mass effect, with effacement of the overlying sulci, the right sylvian fissure, the temporal horn of the
right lateral ventricle, and to a lesser extent the body of the right lateral ventricle, with slight subfalcine shift to the left and a mild degree of mass effect on the right lateral aspect of the midbrain.  Following intravenous contrast administration, there is predominantly ring enhancement in a dominant focus, which is superficially placed, with at least one other small focus of ring enhancement more anteriorly within the right temporal lobe.  No other intra or extra axial lesion is shown.
Paranasal sinus disease noted.  A Stealth study was performed with fiducial markers in place, with the data downloaded to disc in preparation for surgical planning.
CONCLUSION:
The right, predominately temporal and to a lesser extent parietal, lesion has features compatible with a primary glial tumour, the presence of central necrosis and ring enhancement is compatible with a glioblastoma multiforme.  Involvement of the splenium of the corpus callosum noted,however no extension across the midline is shown.

Response:
This query was referred to the NCCH who provided the following advice:
The NCCH agrees that 40803-00 [1] Intracranial stereotactic localisation is the appropriate code for the case cited.  There is an includes note for magnetic resonance imaging (MRI) at this code.

Please also refer to ACS 0629 Stereotactic Radiosurgery, Radiotherapy and Localisation for further information regarding intracranial stereotactic localisation.

The NCCH will investgate MBS item number 40800 Stereotactic anatomical localisation, which was not used in ACHI because it was mapped to 40801.


Query Text:
Please advise if we code out DSA's with all other procedures.  For example Coil embolisation, insertion of inferior venacava (IVC) filter, peripheral angioplasty. 

For example, coding of percutaneous angioplasty/ insertion stent left iliac artery with DSA 1 run.  In addition to coding 
35309-06 [754] Percutaneous transluminal balloon angioplasty with stenting- single stent, do we code 60048-00 [1996] DSA of lower limb, &lt;= 3 data acquisition runs, unilateral OR do we code intraoperative arteriography 35200-00 [719] OR do we not code the DSA at all?


Search Details: NCCH queries: 798, 1305, 1941

Response:
A DSA performed with another interventional procedure (as described in the query) should be coded as an intraoperative angiography.

If the DSA is performed for diagnostic purposes, and then the procedure proceeds to include intervention, for example DSA performed and proceeds to embolisation, the DSA should be coded as a diagnostic and not an intraoperative angiogram.


Query Text:
23 year old male admitted following MVA with fracture sternum & fracture nose.  Patient was taken to theatre for ORIF fractured sternum under general anaesthetic.

Codes assigned:
S22.2 fracture of sternum
S02.2 fracture of nasal bones
and appropriate external cause, place of occurence & activity codes

47467-00 [1377] Open reduction of fracture of sternum
and appropriate anaesthetic codes

When grouping, in the 3M Codefinder and stand alone (without codefinder) in our PAS system iPM (PiMS) both allocate DRG 901Z - Extensive OR Procedure unrelated to Principal Diagnosis.  


Search Details: 
I have checked the AR DRG Version 5.0 Definitions Manual and this DRG is not one allocated to this diagnosis code (S22.2 = E66A, E66B, E66C, W61Z, pg 103, vol 3) or procedure code (47467-00[1377] = I12A, I12B, I12C, I28A, I28B, pg 190, vol 3).

Response:
The Victorian ICD Coding Committee has forwarded this to the Commonwealth for investigation.

DRG 901Z is not listed beside codes in Appendix B of Volume 3.  To access codes that will group to 901Z when mismatched with principal diagnosis, refer to Functions, Unrelated OR procedure on page 383 of volume 2 of the AR-DRGs Definitions Manual.


Query Text:
Further to NCCH # 2010 regarding PTP implants.

The above procedure is performed at our facility for the repair of either internal sphincter dysfunction or IAS - internal anal sphincter dysfunction. Both diagnoses refer specifically to sphincter dysfunction of which both result in faecal incontinence.

I would like to suggets a more appropriate procedure code would be:
Repair
-anus, anal
--sphincter(direct)(for anal fissure)(for anal incontinence) 32126-00 [940].

This code selection groups to G11B which I believe is an appropriate DRG assigment for this procedure.

Search Details: 
http://www.urotoday.org/prod/contents/confreport/article.asp?cat=confReport&sid=184&tid=370&aid=1652

PTP IMPLANTS™ FOR THE TREATMENT OF FECAL INCONTINENCE - A NOVEL APPROACH 

Van Veggel L. 
Director of Clinical Research Uroplasty BV Hofkamp 2 6161 DC Geleen The Netherlands 

The internal anal sphincter (IAS) provides most of the resting anal pressure and is the main muscle responsible for the prevention of anal leakage. Degeneration or disruption of the lAS characteristically leads to faecal incontinence or soiling. Structural damage may result from childbirth trauma, surgical trauma such as sphincterotomy or fistula surgery, or other accidental trauma. The internal sphincter is not amenable to surgical repair as it is extremely thin (approximately 2-3 mm), and as a circular muscle, is under tension. Complex operations such as the dynamic graciloplasty or the newer artificial bowel sphincter provide an elevation in resting pressure. A further possible therapy for patients with internal sphincter dysfunction may be sacral nerve stimulation but this procedure is still experimental in faecal incontinence, and the exact indications for its use have yet to be defined. 

Augmentation of the muscle bulk could be undertaken at sites where it is deficient, or circumferentially if the whole muscle is degenerate. 

Silicone elastomer injections are relatively new for patients with faecal incontinence, but periurethral injection with silicone (Macroplastique®) has been performed for urinary stress incontinence since 1991. Circumferential injection of this material into the submucosa of the anal canal could have a similar 'bulking' effect. 

A pilot study using PTP Implants injections for sphincter augmentation for either diffuse lAS weakness or isolated lAS defects has identified and rectified some initial problems with ulceration and infection by altering the injection technique and antibiotic protocol. In a second study, this adjusted implantation technique was evaluated and proved to be satisfactory; five out of six patients had a marked improvement while both resting and squeeze pressure increased significantly. Additionally, feacal incontinence scores as well as QoL scores showed an increase. 

Currently PTP Implants are undergoing a Randomised Clinical Trial, versus saline, and a worldwide multicentre single armed investigation.

Response:
A query response on the NCCH database provides guidance for coding PTP implants™.  Response to NCCH Q2010 advises:
The procedure cited should be classified as follows:
90316-00 [942] Other procedures on anus

In the interests of data consistency, please follow this advice.

Note that this procedure is not a repair of the anus, rather is bulking up of the muscle.

Please refer to query #2656 and October 2010 ICD-10-AM/ACHI/ACS Q&A, Answers to Coding Authority questions published on the NCCC website for updated advice.


Query Text:
This is in relation to VICC query #2115 Removal of impacted wisdom teeth.

Although the index indents indicate that you need to know if it is surgical or non-surgical, if you look in the Tabular list of procedures you read that procedure code 97323-00 [458] has the statement Removal of impacted molar NOS, therefore can you code removal of impacted wisdom teeth without documentation of ‘surgical’ as 97323-00?

Response:
This query was referred to the NCCH who provided the following advice:
"The indexing for removal and extraction of teeth is currently being reviewed in conjunction with a public submission and your suggestions have been considered for a future edition of ACHI."

The VICC notes that the advice provided in query #2115 published in the Fourth quarter 04/05 ICD Coding newsletter should be applied, that is, code assignment will be based on the documentation available.  The VICC also notes the clinical update on coding of dental services published in Coding Matters Volume 7 Number 2 September 2000:
"Surgical removal of teeth - This requires an incision and reflection of the mucosa. Following the extraction of the tooth,
suturing is necessary to close the wound."  Therefore removal of impacted wisdom tooth, surgical, cannot be coded without documentation of 'surgical' or incision of mucosa.

Please refer to #2700 Extraction of impacted molars and wisdom teeth for Seventh edition advice.


Query Title:
Documentation of codes on operation report

Query Text:
We have a Dentist who operates at our theatre suite and for all his patients, he documents the actual ICD-10-AM ACHI  procedure code that are performed, for example,  97323-00 x 2, 97311-00 x 2.

Would you require actual documentation of surgical removal of a tooth or is documentation of the ICD-10-AM procedure code adequate to assign the codes?

Response:
Yes, documentation of surgical removal of tooth is required.

ACS 0010 General Abstraction Guidelines states 'Before coding any diagnosis/procedure recorded, the clinical coder must verify information recorded on the front sheet by reviewing pertinent documents in the body of the clinical record.' 

Likewise your documentation must support any code assignment by a clinician.


Query Title:
Coding and reporting of non invasive ventilation (NIV) hours for newborns

Query Text:
l have two queries, one with relation to coding NIV for newborns and the other reporting hours of NIV for newborns when occurring in an SCN/NICU.

Some coders at our hospital and at other hospitals believe that allocating an NIV code for a newborn can only take place if the duration of ventilation is greater than 1 hour. 

However ACS 1006 RESPIRATORY SUPPORT - "OTHER TYPES OF RESPIRATORY SUPPORT" states that codes for non-invasive ventilation should be assigned for neonates (age < 28 days), any duration. l would interpret this as meaning we should allocate the appropriate NIV code even if it was administered for a short period of only 2 minutes. 

In terms of reporting hours of ventilation section 3-77 of the current VAED Manual states that we are to round up to the nearest completed hour. Some coders again here and at other sites believe that this only applies after 1 completed hour. I would interpret this as meaning that if a newborn received 2 minutes of NIV in a SCN/NICU then we would round up and report 1 hour of duration to the VAED.

Coders both here and at other hospitals have been referring to Page 9 of the August 2003 ICD Coding Newsletter when accounting for their interpretation on allocation of an NIV code for newborns, as well as reporting the duration. This article states "Code the type of NIV for any duration greater than or equal to 1 hour,  < 1 hour is rounded down to 0"


l have submitted a query with relation to reporting hours of NIV to the HDSS help desk and was told that Section 3-77 of the current VAED Manual overrides the article mentioned above and that the article is outdated.

Response:
Any duration of NIV can be coded for newborns according to ACS 1006 Respiratory Support except when given for resuscitation at birth as per NCCH Q1754 (01/12/2002).  

Reporting of NIV hours to the VAED is now optional, so report hours if you choose to by following the instructions in the VAED manual page 3-77.

The advice in the article in the August 2002 ICD Coding Newsletter has been superseded by the VAED manual instructions.  Reference to the article will be removed from the VAED manual.


Query Text:
A one month old male patient presents with fever (38.9) and irritability (HR 120bpm).  The patient was admitted with initial notes indicating a 'probable UTI'.  A full septic work up was completed. Results from this indicated a UTI which grew enterobacter and klebsiella species (sensitive to Gentamicin) CSF culture was negative.  The patient was treated with antibiotics and discharged 4 days later.

According to the information provided in the medical record, we would've coded the case as:
N39.0   Urinary tract infection, site not specified
B96.1   Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified to other chapters
B96.88 Other and unspecified bacterial agents as the cause of diseases classified to other chapters

However on reading ACS 0110 Septicaemia we are slightly confused.

According to the standard the definition of SIRS is manfiested by two or more of the following:
Temperature  >38 C or <36 C
Respiratory rate >20 breaths/min or PaCO2 of <32 torr
Heart rate >90 beats/min
Leukocyte count >12,000/L or <4,000/L or >10% immune (band forms)

This patient has both a high temperature and a high heart rate (per min).   Does this mean this patient meets the defintion of SIRS and we can code it to Sepsis?  We are having trouble interpreting this standard as many of our patients presenting with fever have a septic workup, however final diagnosis is often UTI.  Most have a high temperature and are treated with IV antibiotics.  How does ACS 0108 Sepsis secondary to UTI/Urosepsis also come into play here?

Search Details: 
Septic work ups are often completed on our patients and prophylactic antibiotics commenced to cover the risk of sepsis.

Response:
A patient must have documentation of SIRS or sepsis for this to be coded.  Definition information in the ACS is provided for information only, and not for diagnostic purposes.  Coders should follow the information in the 'Classification' section of the ACS.


Query Text:
We have a small number of patients who have CHARGE Association (also known as CHARGE Syndrome).

CHARGE Association - Choanal Atresia, Posterior Coloboma, Heart defect, choanal Atresia, Retardation, Genital and Ear anomalies.

CHARGE Association refers to children with a specific set of birth defects. "CHARGE" originally came from the first letter of some of the most common features seen in these children:

C = coloboma 
H = heart defects 
A = atresia of the choanae 
R = retardation of growth and development 
G = genital and urinary abnormalities 
E = ear abnormalities and/or hearing loss 

Each time one of these patients is admitted to our hospital we are unsure of how to best code the CHARGE Association when it meets the defintion of additional diagnosis. Should we code out all of the conditions to fully capture the syndrome (which would be quite lengthy) or can it be captured through Q87.89 Other specified congenital malformation sydnromes, not elsewhere classified? 

Can you please advise?

Over the ICD editions, the congenital malformation chapter has been greatly improved and expanded with many conditions being classified into their own codes. Could consideration be given for a code to be created for CHARGE Association?

Response:
ACS 0005 Syndromes advises to code Q87.89 Other specified congenital malformation syndromes, not elsewhere classified in addition to the components/manifestations of the specific syndrome.  The standard allows for only coding the component/manifestation that is receiving treatment with Q87.89 if desired.

The Victorian ICD Coding Committee suggests that you prepare a public submission to request a new code for CHARGE Association for the next public submission period.  Submission guidelines can be found at:
http://www3.fhs.usyd.edu.au/ncch/4.7.1.htm


Query Text:
The following combination of codes has grouped to 901Z.  Please advise if this is correct.

Patient presents with a fractured orbital margin and underwent an open reduction with internal fixation of the infraorbital ridge.

Codes assigned were:
S02.8 Fractures of other skull and facial bones
plus appropriate external cause codes

45590-00 [1716] Reconstruction of orbital cavity
plus GA code.


Search Details: 
The tabular has an inclusion term for code S02.8 of Orbit NOS
There is an excludes note in Block 1370 Reduction of fracture or dislocation of other facial bone.  Excludes reduction of orbital fracture (45590, 45593 [1716])
The clinician agrees with code 45590-00 [1716]

Response:
The Victorian ICD Coding Committee has forwarded this query to the Commonwealth for consideration of allocating the code to MDC 1.


Query Text:
66 year old patient admitted with pneumonia, also has NIDDM, neuropathy and found to have a decubitus ulcer documented as stage 2.  I note the NCCH Q2008, which I think states not to follow ACS 0401 Diabetic foot, in that the decubitus ulcer would have to be stage 3 or 4 to meet the criteria for diabetic foot.  I have two questions:

1.  An errata has not been published with this advice, and bearing in mind that this advice is nearly 12 months old , should coders follow the advice in the query and go against the ACS, or wait for an errata before changing coding practice?

2. The enquirer asks in #2008 about decubitus ulcers in diabetes, not just linking it to diabetic foot, but the answer from NCCH only covers diabetic foot.  Would the coding advice in the NCCH's answer apply to any case of a diabetic with a decubitus ulcer?

Response:
This query was referred to the NCCH who provided the following advice:
"Although not published in ICD-10-AM Fourth Edition errata, ACS 0401 DIABETES MELLITUS AND IMPAIRED GLUCOSE REGULATION is currently being reviewed for inclusion in Sixth Edition.  This review includes an update of the listing  for decubitus ulcer under diabetic foot to specify Decubitus [Pressure] Ulcer L89.2 Stage III and L89.3 Stage IV.

In answer to the second part of your question if a patient has diabetes with a decubitus ulcer of a site other than the foot then it is appropriate to follow the index as follows: 
Diabetes
-with ulcer E1.-69 (diabetes mellitus with other specified complications)

Then assign the appropriate 'Decubitus [Pressure] Ulcer' code by following the general classification principles for diabetes mellitus in ACS 0401 DIABETES MELLITUS AND IMPAIRED GLUCOSE REGULATION which state:

'* In addition to the impaired glucose regulation and diabetes code(s) from E09 - E14, assign codes from other chapters when necessary, to fully describe the clinical diagnosis. These additional codes should be sequenced AFTER the E09 - E14 code(s).'"


Query Text:
An admitted patient had a number of investigations, including electromyography and nerve conduction studies on a number of nerves in the patient’s arm.   Should nerve conduction studies be coded?

ACS 0042 Procedures Normally Not Coded includes Electromyography (EMG).  Therefore, we would not code the electromyography.  However, there is no mention in the Standard of nerve conduction studies.

Procedure Block 1826 Neuromuscular electrodiagnosis inclusion terms are:
EMG [electromyography]:
·of >= 1 muscle(s)
·using concentric needle electrodes Study of neuromuscular conduction

and the Block includes codes for electromyography, conduction studies and for conduction studies with electromyography.  

It seems anomalous to code nerve conduction studies, as this would entail giving a code for nerve conduction studies alone when in fact they may have been performed in conjunction with electromyography, which ACS 0042 Procedures Normally Not Coded directs us not to code.

I have been unable to find direction on the NCCH database or in the VICC Newsletter, and fellow HIMs have differing opinions.

Could VICC please clarify whether we should or should not be coding nerve conduction studies?

Response:
If an EMG is performed by itself, this would not normally be coded.  When performed with a nerve conduction study, this can be coded, following index entry:
Study 
-conduction 
--nerve 
---1 nerve 11012-01 [1826] 
----with electromyography 11012-02 [1826] 
----repetitive 11021-01 [1826] 
-----with quantitative computerised analysis electromyography 11021-02 [1826] 
---2 or 3 nerves 11015-00 [1826] 
----with electromyography 11015-01 [1826] 
----repetitive 11021-01 [1826] 
-----with quantitative computerised analysis electromyography 11021-02 [1826] 
--->= 4 nerves 11018-00 [1826] 
----with electromyography 11018-01 [1826] 
----repetitive 11021-01 [1826] 
-----with quantitative computerised analysis electromyography 11021-02 [1826]
---single nerve fibres and muscles 
----with electromyography 11018-02 [1826]


Query Text:
Patient admitted for repositioning of pacemaker generator.  Please find attached procedure report stating generator mobilized and moved medially.  

Cardiology advised this procedure is rarely performed but this patient was severely emaciated and the generator protruded on the chest wall.  We have looked under several terms, for example reposition, adjustment, relocation.  The generator was not removed or replaced.  There is a code 38524-02 [656] Repositioning of AICD.  

Please advise how to code repositioning pacemaker generator.  Is a new code required?

Response:
From the operation report provided, the Victorian ICD Coding Committee noted that this procedure seems to be an adjustment of the skin pocket.  

Therefore in this scenario assign:
90219-00 [663] Revision of skin pocket


Query Title:
Endoscopic clipping of duodenal ulcers/bleeding vessels

Query Text:
Please advise on the coding of clipping of duodenal ulcers/bleeding vessels at endoscopy.  I have searched the database, and NCCH Q1799 appears similar, however the answer appears to be disregarding the fact that the clipping involves much more than just an OGD. I do not understand how the NCCH can say that the repair of the tear is an inherent component of an OGD, when we are required to code biopsies with OGD, heater probe coagulation, and many other additional procedures.  I have always understood that the endoscopy was coded, and also a code for any other procedures undertaken at the time.

Search Details: NCCH Q1799
Patient with a diagnosis of Mallory Weiss tear underwent clipping of the tear during an OGD. I cannot find a procedure code to reflect the clipping of the tear. For the moment I have used 90301-00 [869] 'Other procedures on oesophagus'.
Should a different code be used? For example:
30478-09 [851] Endoscopic injection of bleeding oesophagogastric junction lesion (even though it is not an injection), OR
30476-02 [856] Endoscopic banding of oesophageal varices.
The QCC agreed the most appropriate code to use would be 90301-00.Could the NCCH provide advice on coding clipping of Mallory Weiss tear.

Response:
Thank you for your query. NCCH acknowledges that there is no specific code for endoscopic repair of Mallory Weiss tear.
'Oversewing of Mallory Weiss laceration' is an inclusional term at 30375-06 [871] 'Gastrotomy'. That is, the Mallory Weiss tear repair does not require a separate code when performed as an open procedure.

Clinical advice provided to NCCH indicates that a Mallory Weiss laceration repair performed endoscopically would also not require a separate code, as it would be an inherent component of the endoscopy.

Therefore, for the case you have described, code 30473-00 [1005] 'Panendoscopy to duodenum'

Response:
This query was referred to the NCCH who provided the following advice:
"Clinical advice reaffirms that clipping of an ulcer should not be treated differently from an endoscopic repair of Mallory Weiss lesion and that an additional code is not warranted.

In ACHI Fifth Edition 'repair of Mallory-Weiss laceration' is an includes note under the following codes:

30473-00 [1005] Panendoscopy to duodenum
30473-02 [1005] Panendoscopy through artificial stoma
30473-05 [1005] Panendoscopy to ileum

A review of endoscopic procedures codes will be undertaken for a future edition of ACHI."

The VICC therefore advises that if there is an index entry for the procedure performed, assign a code for that procedure and apply ACS 0023 Laparoscopic/Arthroscopic/Endoscopic Surgery if necessary.  If there is no index entry for the procedure performed, only assign the endoscopy code.


Query Title:
Transferred neonates and ACS 1618 Prematurity and low birth weight

Query Text:
I am writing to seek clarification on advice given in query #1720 Transferred Neonates and information given in ACS 1618 Prematurity and Low Birth Weight.

In the scenarios documented in query #1720 I would have thought that Z51.88 Other specified medical care
could not be used for Scenario 1 and 3 as the admission weight was only 1510g and the standard states that you only use Z51.88 "if the infant is > 28 days old AND >= 2500g on admission".  Otherwise you would use the prematurity code as the principal diagnosis.

I am not sure that I understand the standard if the coding scenarios given in #1720 are correct.  Could you please provide clarification on this?

My next question is if I am reading the standard correctly how do I code the following scenario:
babe born at Hosp A at 640g and 25 weeks gestation. Transferred to Hosp B for NICU.  Transferred back to Hosp B 6 weeks later, documented as prematurity requiring ongoing SCN.  If I code as directed in ACS 1618 with prematurity and low birth weight codes reflecting those at birth I get DRG 963Z neonatal diagnosis not consistent with age/weight.  Yet I don't feel that I can code Z51.88 as although the baby is over 28 days, it still weighs under 2500g. 


Search Details: 
VICC query #1720
ACS 1618

Response:
The response to query #1720 was published in the May 2002 ICD Coding Newsletter, before the development of ACS 1618 Prematurity and Low Birth Weight.  

Therefore coders should apply ACS 1618 and no longer refer to query #1720.


Query Title:
Transcystic exploration of Common Bile Duct

Query Text:
33 year old female presented with a cystic duct calculi for removal. What procedure code should be assigned for a laparoscopic cholecystectomy with a transcystic exploration of the common bile duct, without retrieval of a calculus? The index does not allow you to assign a code for a laparoscopic exploration of the CBD (via cystic duct) without removal of a calculus. For example:

1. Cholecystectomy
   - laparoscopic
   -- with removal of common bile duct calculus
   --- via
   ---- cystic duct 30448-00 [965]
   ---- laparoscopic choledochotomy 30449-00 [965]

OR 

2. Exploration
   - bile duct(s)
   -- common (open) 
   --- with
   ---- cholecystectomy (with removal of calculus) 30454-01 [965]

However, 30454-01 [965] Cholecystectomy with choledochotomy cannot be assigned. A choledochotomy was not performed as the CBD was explored via the cystic duct. Also, this code excludes that via laparoscopy. The excludes note leads you to 30449-00 [965] Laparoscopic cholecystectomy with removal of common bile duct calculus via laparoscopic choledochotomy. This code includes choledochotomy, so it is incorrect. 

Therefore we are left with code 30448-00 [965] Laparoscopic cholecystectomy with removal of common bile duct calculus via cystic duct, however the calculus was not removed. The removal of the calculus is an essential modifier in the index (in example one). Can we still assign this code or should we assign only the laparoscopic cholecystectomy? The laparoscopic cholecystectomy on its own does not reflect the procedure being performed because the exploration of the CBD is time consuming and adds risk to the procedure. 


Search Details: NCCH QUERY 1430 (Not relevant)

Response:
This query was referred to the NCCH who provided the following advice:
The NCCH agrees for the case cited that 30448-00 [965] Laparoscopic cholecystectomy with removal of common bile duct calculus via cystic duct is currently the most appropriate code.

The NCCH will review these codes for a future edition of ACHI.

The VICC has provided the NCCH suggested index entry amendments for this procedure.


Query Text:
A 26 year old male was admitted with an intracranial haemorrhage.  Notes from Speech Therapist state 'moderate oropharyngeal dysphagia' requiring 'vitamised diet/ grade 2 thickshake fluids.' This modified diet was still required 6 days later when the patient was transferred to a rehabilitation facility.

ACS 0604 - Stroke states that dysphagia should only be coded when requiring nasogastric tube/enteral feeding, or still requiring treatment more than 7 days after the stroke occurred. 

Why does this differ from incontinence which can be coded if present at discharge?


Search Details: ACS 0604
NCCH Query Database - query 1722

Response:
This was referred to the NCCH who provided the following advice:
The NCCH agrees there is inconsistency in the guideline for the coding of incontinence and dysphagia in ACS 0604 Stroke with regards to the advice to code if 'present at discharge.'

This will be reviewed for a future edition of ACS.  The current guidelines should be followed in the interim.


Query Title:
Same day coronary angiograms principal diagnosis selection

Query Text:
I would like to request some coding advice regarding Pdx selection for same day coronary angiograms.
Example 1
Patient has a history of chest pain and a diagnostic coronary angiogram reveals 60% CAD for medical management.
Should the Pdx be the chest pain or the CAD?

Example 2
Patient admitted for a diagnostic coronary angiogram for a positive stress test.  Angiogram results revealed 60% CAD for medical management.
Should the Pdx be the positive stress test or the CAD?

We have asked various hospitals and have been given differing opinions.

I have referenced coding standard 0046 which talks about sameday endoscopy admissions.  If a causal link is established then the symptom should not be coded.  If a causal link is ruled out then the symptom should be coded as Pdx.  If a causal link is neither established nor ruled out then we need to apply the clinical coders creed - which I feel could lead to differing opinions.

Thank you

Search Details: ACS 0046

Response:
NCCH query Q1308 where a patient admitted for investigation of chest pain has undergone an angiogram, which revealed coronary artery disease advises:

Based on the information that you have provided, it appears that coronary artery disease was established on angiogram; therefore this should be the principal diagnosis (please assign a relevant code from category ‘I25.1- Atherosclerotic heart disease’). The chest pain does not need to be coded because a more definitive diagnosis (i.e. coronary artery disease) was established (see instructions for coding symptoms and signs in ACS 0001 PRINCIPAL DIAGNOSIS and ACS 1802 SYMPTOMS AND SIGNS and instructions for assignment of the underlying condition as principal diagnosis in ACS 0001).

The Victorian ICD Coding Committee noted that because this is not an endoscopy, ACS 0046 Diagnosis selection for same day endoscopy does not apply.


Query Text:
What procedure code should be assigned for KTP bladder neck vaporisation performed for bladder neck contracture/stenosis?

Response:
This query was originally published in the 2006-07 First Quarter ICD Coding Newsletter as follows:
The VICC has sent a referral to the NCCH requesting consideration of a new code for this procedure, as there is already a code for vaporisation of the prostate.  In the meantime, the most appropriate code for this procedure is:
36854-02 [1101] Endoscopic resection of bladder neck

The NCCH will consider developing a new code for bladder neck vaporisation for a future edition of ACHI.

On 28/04/2008 VICC was advised that the NCCH undertook further investigation of this query and has provided the following revised advice:

In our initial response we agreed with your suggestion of 36854-02 [1101] Endoscopic resection of bladder neck, however, in the process of investigating a new code for this procedure it became apparent that it is not a resection of the bladder neck but rather a destruction of tissue of the bladder neck.  This means the correct code is actually 36840-01 [1096] Endoscopic laser destruction of a single lesion of bladder <= 2cm or tissue of bladder.
 
The advice in the original query was incorrect as the bladder neck tissue is destroyed by laser when KTP vaporisation is performed, not excised/resected.  The site is not the issue so much as the actual procedure being performed.

To get to this code the correct pathway is:
Destruction 
-lesion
- - bladder (closed)(endoscopic)(single)(solitary)(with resection)
- - - by
- - - - laser (<=2cm) 36840-01


Query Text:
Use of T89.0x codes with cellulitis.  Does the presence of cellulitis following open wounds indicate that the wound is infected  (T89.02)?  It would seem that in some cases apparently uncomplicated trauma to the skin can be identified as the precipitant for the cellulitis which can manifest after the initial injury has healed.  In these cases is cellulitis considered a separate disease process but still a complication of the open wound (T89.03)?

Please advise on codes to use in the following scenarios.:
1. Patient admitted with cellulitis of the forearm following being scratched by her cat a week previously.  The scratches were healing and did not receive attention. The patient was given IV antibiotics, then switched to oral antibiotics and discharged home. 

2. Patient admitted with open wound of leg with surrounding cellulitis following walking into a trailer in the dark 2 days earlier.  The wound was debrided in theatre and the patient given IV antibiotics for several days, then discharged home on oral antibiotics.   

3.Patient admitted with cellulitis of the foot and ankle.  On examination the patient was found to have tinea of the toes which was presumed to be the entry point for the infection.  The patient was given IV then oral antibiotics and a topical treatment and podiatry attention for the tinea.

4. Patient admitted with cellulitis of the lower leg following being scratched by rose thorns while gardening 2 days previously.  The wounds were cleaned and dressed.  Dressings were changed every second day and the patient placed on IV then oral antibiotics.

Search details:
I have reviewed ACS 1210 and ACS 1917 and VICC #1793 (May 2002) which advises to use T89.03 for cellulitis following an open wound in the scenario described.

Response:
VICC members noted that the majority of the wounds referred to in this query are actually scratches which are superficial injuries rather than open wounds.  VICC members were of the opinion that the advice is ACS 1210 Cellulitis applies for open wounds only and not superficial injuries such as scratches, however the NCCH will be consulted on this.

In general if the wound is treated, then this should be coded as the principal diagnosis.  If the cellulitis is treated and the wound is not, then the cellulitis would be the principal diagnosis.  With regards to your scenarios:
1. For this patient, as the underlying cause is a scratch and not an open wound, the cellulitis is the only condition being treated, therefore the cellulitis should be the principal diagnosis:
L03.10 Cellulitis of upper limb

2. This patient has an open wound complicated by cellulitis.  As the wound is treated, code the complicated wound code, followed by a code for the cellulitis:
S81.9 Open wound of lower leg, part unspecified
T89.02 Open wound with infection
appropriate external cause codes
L03.11 Cellulitis of lower limb

3. This patient was admitted for their cellulitis.  While the tinea was later found to be the point of entry for the infection, cellulitis is not a presenting problem of tinea.  For this patient, the cellulitis should be the principal diagnosis and the tinea an additional diagnosis:
L03.11 Cellulitis of lower limb
B35.3 Tinea pedis

4. The documentation for this patient indicates that the scratches may be more than superficial injuries, however if these are documented as scratches, the cellulitis should be the principal diagnosis, followed by the superficial injury as an additional code:
L03.11 Cellulitis of lower limb
S80.7 Multiple superficial injuries of lower leg
appropriate external cause codes

The VICC has received the following advice from NCCH:
The NCCH confirms that the advice in ACS 1210 Cellulitis applies to open wounds only.
The NCCH also agrees with the coding of the scenarios cited.

The VICC also notes that cellulitis is an inflammation of the skin caused by an infection.  The presence of cellulitis following an open wound indicates an infected wound therefore the correct code to assign is T89.02 Open wound with infection.  

The advice in this query supersedes the advice published in query #1793 in the May 2002 ICD Coding newsletter.


Query Text:
Patient presents to hospital for flexible sigmoidoscopy and SPOT injection for known gastrointestinal cancer, (will be readmitted in a subsequent admission to have the cancer resected).

SPOT injection involves the administration of carbon via a sigmoidoscope to mark the location of an intestinal tumour.  

Question 1: 
What should be the principal diagnosis?  Should the neoplasm be assigned as principal diagnosis or should Z51.4 Prepratory care for subsequent treatment, NEC, be assigned?

Question 2:
What procedure code should be assigned for SPOT injection?

Response:
The VICC sought advice from NCCH who agrees that an additional code is not warranted for SPOT injection performed via a sigmoidoscope.  The sigmoidoscopy code is sufficient.

The VICC advises that in this scenario, the correct principal diagnosis to assign is the neoplasm, as per ACS 0236 - 'diagnosis or treatment of the primary malignancy'.  See NCCH queries 1214 and 1272, and VICC queries 1527 (May 2000) and 1878  (May 2003) for further information.


Query Text:
How do you code gastroscopy with EUS (endoscopic ultrasound) and FNA (fine needle aspiration) of pancreas or mediastinal mass etc? 
  
We think we should code out the aspiration of the pancreas/ mediastinal mass.  There is no code for aspiration pancreas or mediastinal mass so we referred to 'biopsy' because the pathology of the aspiration includes cells.  We have decided to code the following for the interim:
o 30473-00 [1005] Panendoscopy to duodenum
o 30075-16 [977]   Biopsy of pancreas
o 55054-00 [1949] Intra-operative ultrasound of other site

The coding of the biopsy pancreas or mediastinal mass severly affects the WIES/ DRG.

Search Details:
I spoke to the Gastroenterologist who conducts these procedures here and he explained the procedure.  The gastroscope is inserted with the needle attached to the end of the scope.  The needle is injected through the gastrointestinal wall and the organ eg. Pancreas or mediastinal mass is biopsied.

Response:
The procedure has been coded appropriately.  The decision to code this way is based upon advice published by the NCCH in query Q1042 (17/11/1999), which advises that aspiration biopsy, refers to the removal of cells for histological diagnosis.

It is correct to assign a code for the biopsy of the pancreas because the biopsy is not of the gastrointestinal tract.   This code should be sequenced first.   Therefore in your scenario code as follows:
30075-16 [977] Biopsy of pancreas
30473-00 [1005] Panendoscopy to duodenum
55054-00 [1949] Intra-operative ultrasound of other site


Query Title:
ACS 0020 Multiple/Bilateral Procedures and ECT

Query Text:
My query relates to Standard 0020 - Multiple/Bilateral Procedures.
In section (b) of the 'exceptions' the Standard instructs coders to have one code assigned 'per OPERATIVE episode'.

As multiple administrations of ECT are each performed in different OPERATIVE episodes, but often within the one PATIENT episode, strict adherence to the Standard would suggest a coder should assign 93340-02 [1907] Electroconvulsive therapy [ECT] <=12 treatments at each OPERATIVE episode (followed by the anaesthetic code), rather than once for the PATIENT episode, followed by the anaesthetic code(s) for each OPERATIVE encounter.

Example:

Patient presents with severe depressive episode without psychotic symptoms and receives 4 treatments of ECT within the current admission, before separation for further same day ECT to complete the course.

Current method of recording:

F32.20 Severe depressive episode without psychotic symptoms
93340-02 [1907] Electroconvulsive therapy [ECT] <= 12 treatments
92514-99 [1910] General anaesthetic
92514-99 [1910] General anaesthetic
92514-99 [1910] General anaesthetic
92514-99 [1910] General anaesthetic


Following Standard 0020 – Multiple/Bilateral procedures

F32.20 Severe depressive episode without psychotic symptoms
93340-02 [1907] Electroconvulsive therapy [ECT] <=12 treatments
92514-99 [1910] General anaesthetic
93340-02 [1907] Electroconvulsive therapy [ECT] <=12 treatments
92514-99 [1910] General anaesthetic
93340-02 [1907] Electroconvulsive therapy [ECT] <=12 treatments
92514-99 [1910] General anaesthetic
93340-02 [1907] Electroconvulsive therapy [ECT] <=12 treatments
92514-99 [1910] General anaesthetic

Could you please clarify the correct method of reporting multiple episodes of ECT within the same patient episode?

Response:
The NCCH has previously published information regarding the number of episodes of ECT in Coding Matters Volume 7, Number 2.  This information overrides ACS 0020 Multiple/Bilateral procedures.

The Victorian ICD Coding Committee has forwarded this query to the NCCH for consideration of removing ECT from the example box in part (b) of ACS 0020 and incorporating the advice in Coding Matters into the Classification by creating a separate category for ECT in ACS 0020 or creating a specialty standard for ECT.


Query Text:
If a patient is assessed as requiring a course of ECT exceeding 12 treatments, but receives (say) 6 treatments during one admitted episode, and then is separated to continue the course by a series of same day admissions, should the ECT code be that for less than (or equal to) 12 treatments, as the patient has not received twelve treatments within any one episode, or should the code reflect the intention to administer a course exceeding twelve treatments?

Response:
The Victorian ICD Coding Committee advises to code according to the number of ECT treatments administered in the episode.  It is not correct to code what is planned for future treatments.


Query Text:
I have been trying to code an encysted hydrocele in a 3 year old female. I have looked at the query number 1046, on the NCCH database, but I do not seem to be able to rectify my problem.  I have coded N43.0 for encysted hydrocele, and 
30614-02 for repair, but this gives a DRG of 960Z.  I have also tried N98.4, this gives an age code warning, and gives a DRG of 902Z.

I have discussed this with several HIM's and they do not appear to be able any further assistance.

Response:
As this patient is female, it is appropriate to follow the Index for female as follows:

Hydrocele (spermatic cord) (testis) (tunica vaginalis) N43.3 
-canal of Nuck N94.8 
-congenital P83.5 
-encysted N43.0 
-female NEC N94.8 

N94.8 Other specified conditions associated with female genital organs and menstrual cycle

The Victorian ICD Coding Committee has forwarded a proposal for modification of the grouper to the Commonwealth.


Query Text:
NCCH Query 2003 Patient admitted with head injury with haematoma to scalp states the following:
Question:
Initial query 12/07/04:  ACS 1905 suggests that S09.9 Unspecified injury of head should be used when no more specific diagnosis is recorded. The coder interpreted the superficial injury (S008.5) to be a more specific diagnosis and therefore coded this as the principal diagnosis. It was agreed that head injury should be the principal diagnosis as they were probably admitted for observation of the head injury rather than the superficial injury. Could you please confirm that this is the correct way to code this scenario?  Could the standard be updated to qualify what a more ‘specific diagnosis’ would be?

Resubmission 06/12/04:  Further to your response NCCH Query ID Number 2003. Members of the committee were under the impression that the term 'head injury' S09.9 generally related to an internal (cranial) injury that could not be otherwise specified. The answer to our original query seems to indicate that a laceration to the head S01.88 could be interpreted as a 'head injury' and would be used in place of the S09.9. Was this answer related specifically to the record in question (i.e. documented as a minor head injury) or is this answer to be applied to all cases. That is, if there is documentation of a laceration and a 'head injury' only the laceration should be coded?

Answer:
Initial response 18/10/04: Thank you for the clinical records relevant to this query.

Documentation in the clinical record states:
-minor head injury
-small laceration and lump to right side of forehead
-superficial laceration to right forehead
-bandaid applied to laceration
The patient was a one year old child.  Neurological observations were planned, but not conducted. The admission lasted only three hours and twenty minutes as the child's mother was ‘keen to go home and willing to observe’ the child. 

For the case cited assign:
S01.88 'Open wound of other parts of head

'S09.9 'Unspecified injury of head' is an NOS (not otherwise specified) code. It should only be used when there is no other documented injury to the head.

The NCCH will consider amendments to ACS 1905 CLOSED HEAD INJURY/LOSS OF CONSCIOUSNESS/CONCUSSION to clarify the coding of 'head injury'.

Subsequent response 06/04/05: The NCCH supports the earlier advice given for this query. The initial response was related specifically to the case cited. 

As per ACS 1905, where there is documentation in a clinical record of an injury to the head (for example, a laceration) and a nonspecific diagnosis of 'head injury', assign only a code for the laceration. The NCCH realises there are problems with the interpretation of ACS 1905 that may be causing discrepancies in code assignment between states/facilities. The NCCH will amend the standard for a future edition of ICD-10-AM to clarify this issue. Until further advice is issued, current coding practice should not be changed in order to maintain data consistency.(end of answer)

I have asked two clinicians (Director of ICU and Deputy Director of Emergency Department) about the diagnosis of ‘head injury’.  They have confirmed that a head injury is a ‘state’, that is a condition in its own right.  It would be diagnosed based on the presenting history and when ‘nothing is found’ it is not a condition that is ruled out.  Tests can be used to demonstrate head injury but they are often not sensitive or precise enough because the change may be subtle, such as a change in maths ability or processing.

Therefore I query the NCCH decision not to code ‘head injury’ when that was one of the documented conditions for this patient.  My understanding is that the code for ‘head injury’ should be assigned for documentation of a head injury and that ‘head injury’ should not be confused with an external injury to the head, such as a laceration or haematoma.  

When a patient has a ‘head injury’ they are generally observed for signs of more significant intracranial injury.  The response from NCCH states that “neurological observations were planned, but not conducted” but the patient was sent home to have continued observation by the parent, therefore I query if neurological observations were in fact conducted.  

The duration of the admission (“only three hours and twenty minutes”) is irrelevant to what codes are assigned – this is an admission decision.  The clinical documentation must determine what is coded.

What should be coded for the case cited?

Search Details: NCCH database #2003

Response:
This query was referred to the NCCH who provided the following response:
"The coding of 'head injury' has caused considerable discussion at the NCCH.  We agree with the advice that a 'head injury' is a state or 'condition' in its own right.  However, this clinical concept is not well dealt with in ICD-10-AM.

The two issues of concern are:
1. The interpretation of ACS 1905 Closed Head Injury/Loss of Consciousness/Concussion with regards to 'a more specific diagnosis' for the head injury.

2. The lack of an appropriate code for 'head injury' within ICD-10-AM (S09.9 Unspecified injury of head is non-specific and is used for 'any other site of head' including injuries to chin, brow, forehead, lip, mouth etc.)

We recognise that the previous response regarding the coding of a laceration as a 'more specific diagnosis' may not be entirely appropriate.  As stated previously we are undertaking to review ACS 1905 Closed Head Injury/Loss of Consciousness/Concussion regarding the use of S09.9 Unspecified injury of head and to clarify the phrase 'more specific diagnosis'.

In the meantime, we would strongly recommend that each site continues to apply the standard in an agreed and consistent manner (i.e. continue to code as you have done previously) until further advice is received."

The VICC advises that when there is documentation of closed head injury and other injury to head, for example, open wound that these two conditions should be coded separately.  The principal diagnosis will be determined by ACS 0001 Principal diagnosis.


Query Title:
Catheter cryoablation of accessory pathway

Query Text:
24 year old male has had a cryoablation via catheter for accessory pathway.  Clinical advice is that catheter ablation may be performed with microwave, cryotherapy or radiofrequency.

1. Could the Committee please confirm if the radiofrequency ablation catheter code (38212-01 Cardiac electrophysiological study with radiofrequency ablation) can be used for any type of catheter ablation?  The index entries for this code are:
Ablation
- arrhythmia circuit or focus — see Ablation, cardiac
- cardiac 
- - by radiofrequency with electrophysiological study 38212-01 [665] 
- - arrhythmia circuit or focus, involving 
- - - both atrial chambers 38290-00 [601] 
- - - one atrial chamber 38287-00 [601] 
- - muscle, ventricular 38518-00 [609] 
- - myocardial septal (percutaneous transluminal) 38748-01 [616] 
- - to induce complete AV block 38212-01 [665] 

Induction 
- complete AV block 
- - by cardiac ablation 38212-01 [665] 

Study 
- electrophysiological (EPS) 
- - cardiac 
- - -for follow up testing of implanted defibrillator 38213-00 [665] 
- - - with 
- - - - ablation by radiofrequency 38212-01 [665] 

The index entry:
Ablation, cardiac, to induce complete AV block 38212-01 [665], would seem to allow us to use this code for any type of catheter ablation, but if so, should the code title be changed?

2. What are the codes 38287-00 [601] Ablation of arrhythmia circuit or focus involving one atrial chamber and 38290-00 [601] Ablation of arrhythmia circuit or focus involving both atrial chambers for?  Is this for an ‘open heart’ procedure rather than a catheter procedure?  This block has an excludes note for ‘radiofrequency ablation via EPS’.  Should this be any type of catheter ablation?  If so, could the excludes note be amended and ‘via catheter’ added to the index to avoid confusion?

Response:
This query was referred to the NCCH who provided the following advice:
The NCCH agrees that there are currently no specific procedure codes for EPS with cryotherapy or microwave ablation but advises that the most appropriate code at present is 38212-01 [665] 'Cardiac electrophysiological study with radiofrequency ablation'.

The NCCH agrees that there is ambiguity with regards to the codes in 'Destruction procedures on atrium' [601], but as stated above catheter based cardiac ablations should at present be assigned to 38212-01 [665] 'Cardiac electrophysiological study with radiofrequency ablation' which is excluded in block 601.

These codes are currently the subject of a public submission and will be reviewed for a future edition of ACHI.


Query Text:
7 month old male admitted with fever.  Final diagnosis is listed as ‘fever, no clear focus’.  

On examination, the patient is noted to have mild dehydration.  Urea/electrolyte/creatinine tests performed and hyponatraemia is documented. 

The patient’s treatment was to perform bloods (FBE, Urea/electrolyte/creatinine, BC, CRP), urinalysis and give paracetamol.

Can I code the dehydration and hyponatraemia and can you please explain why or why not. 

We are of different opinions as to whether there has to be something specifically done for these conditions to code them as per ACS 0002 or whether ACS 0001 applies as they are all conditions responsible for occasioning the episode of care.

Response:
Documentation must support coding these conditions either as:
· Two or more conditions that equally meet the definition of principal diagnosis; or
· ACS 0002 Additional diagnoses

If there is no documentation in the record that supports coding as either of these, then the conditions cannot be coded.  

Based on the information provided, the fever is the principal diagnosis.  Dehydration and hyponatraemia do not meet additional diagnosis criteria and therefore are not coded.


Query Text:
Principal diagnosis:   Periodic fever unknown origin

Question:
In the index if you search under the lead term 'fever' and then select the essential modifier 'periodic' the code selected is E85.0 Non-neuropathic heredofamilial amyloidosis.  When you go to the tabular this does not appear to be the correct code for the diagnosis.  Is there an indent missing under Fever, periodic for 'Unknown Origin'?.  The clinician was adamant that the fever was periodic and not any other option e.g. persistent.  What code does the committee advise to use for a principal diagnosis of Periodic fever of unknown origin?

Response:
Clinical research indicates that a range of conditions can cause periodic fever.  Therefore following coding convention, the correct the default code is:
E85.0 Non-neuropathic heredofamilial amyloidosis

Coders should be aware that the classification makes assumptions about the cause of some conditions.

This is supported in  ICD-10-AM Tabular list, page xix which states
‘Data analysts should similarly be aware that some conditions assigned to an apparently specified category will not have been so specified on the record that was coded. When comparing trends over time and interpreting statistics, it is important to be aware that assumptions may change from one revision of the ICD to another.  For example, before the Eighth Revision, an unqualified aortic aneurysm was assumed to be due to syphilis’.


Query Text:
A recent patient has been diagnosed with “Crohns disease of the oesophagus”, a condition which the surgeon acknowledges is rare. The patient was admitted for dilatation of stricturing and findings were of  a ”severely ulcerated oesophagus, with no features to suggest reflux disease”.  In order to capture the specifics of the disease as well as the diagnosis I have coded the case as follows:
K22.2  Oesophageal obstruction
K22.1  Ulcer of oesophagus
K22.8  Other specified diseases of oesophagus
K50.8  Other Crohn’s disease

plus procedure codes.

Is this coding correct?  Am I able to use K50.8 where the diagnosis refers to the oesophagus rather than the intestine.

Response:
K50.8 Other Crohn's disease is only indexed for Crohn’s of small with large intestine or large with small intestine, neither of which are appropriate in this scenario; therefore the correct code to assign for Crohn's disease of esophagus is the default code:
K50.9 Crohn's disease, unspecified

Based on the information provided in your query, the VICC has assumed that the Crohn's disease was diagnosed in a previous admission; therefore the codes would be assigned as follows:
K22.2 Oesophageal obstruction
K50.9 Crohn's disease, unspecified
and procedure codes.

A code for the ulceration of oesophagus is not required because it is a part of the Crohn's disease.


Query Text:
Patient has a planned admission for closure/reversal of a colostomy 3 months post resection of carcinoma.  The patient has no known metastases and is not receiving any ongoing treatment for the cancer.   Do we still code the cancer for this case?  Is it still part of the cancer care/treatment? Or would you just code the cancer history?

If not, does it make any difference if the patient had metastases but does not require any treatment for it during this episode. Or must the cancer always meet the criteria for an additional diagnosis?

Response:
This query was referred to the NCCH who provided the following advice:
The NCCH advises that the closure/reversal of a colostomy 3 months post resection can be considered part of the ongoing treatment/care for the cancer (effectively the last part) and that the cancer should be coded as an additional diagnosis.

The VICC advises that if metastases are present that these should also be coded.

Please refer to #2688 Coding of cancer post surgery for Seventh edition advice.


Query Text:
At the recent NCCH ICD-10-AM Fourth edition post implementation workshop there was discussion regarding a patient who had been diagnosed with AF postoperatively, yet not coded as a postprocedural complication.  

The case study read:
'Postoperatively this gentleman was found to be in AF and was commenced on Amiodarone.  He was monitored for the effect and possible toxicity and stabilised on a dosage of 200mg daily.  This is to be reviewed and monitored by his GP after discharge'.

As this man was discharged on Amiodarone it appeared to fill the criteria of 'present on discharge' and therefore AF would be coded as a postprocedural complication.  There was no agreement on this from the NCCH.

The Coding Feature Postprocedural complications ICD Newsletter November 2001 point 4 Non-transient conditions that commonly occur as a result of surgical/procedural intervention states:
'Those patients being discharged on ongoing treatment for a postprocedural condition should be considered to have a procedural complication

Example:  A patient with postoperative atrial fibrillation discharged on Digoxin…'.

Given the above advice our coders have applied this logic to all similar cases.  Is this advice still current?

Search Details: ACS 1904
ICD Coding Newsletter Coding Feature Procedural Complications November 2001.

Response:
This query was referred to the NCCH who provided the following advice:
"The NCCH advises that in the case study cited you cannot assume that the condition, in this case atrial fibrillation, is still present at discharge simply because they have been discharged on a drug used to treat the condition, in this case Digoxin.  Either clinical documentation of the condition at discharge or verification from the clinician that the condition is still present at discharge is required. 

ACS 1904 Procedural Complications - Classification of transient conditions states 'If it cannot be determined whether a condition is transient or persistent, then the condition should not be coded as a postprocedural complication.’  It may however, still be assigned a code if it meets the criteria of an additional diagnosis (as per ACS 0002 Additional Diagnoses)."

The VICC advises that the NCCH response to this query should be taken into consideration when applying the classification of transient conditions section of ACS 1904 Postprocedural complications.  The VICC also advises that 'clincial verification' noted in the NCCH response must be documented by the clinician in the medical record specific to the episode.

This advice overrides the advice regarding atrial fibrillation in the article titled Procedural complications published in the November 2001 ICD Coding Newsletter.


Query Text:
Please advise on the procedure coding of the following;  We have had three similar cases where a patient is admitted with fibroid uterus, for a laparoscopic hysterectomy.  
This procedure is usually performed totally by laparoscope, where the uterus is 'morcellated' and sucked out via one of the laparoscopic ports.  However, in one of the cases it was documented that the 'uterus was delivered vaginally'.  The other differences are where the surgeon documents 'vaginal vault closed laparoscopically' but also 'vaginal vault closed vaginally'.   (five operation reports provided).

We have coded these cases to 35653-01 [1268] Total Abdominal Hysterectomy and 30390-00 [984] Laparoscopy

My questions are:
1.  Are we correct to assign the code for abdominal hysterectomy, or should the vaginal hysterectomy code be used?  There is no default, so a choice has to be made between abdominal and vaginal. 
2.  Does it affect code assignment with a 'laparoscopic hysterectomy' if the vaginal vault is closed laparoscopically or vaginally, or the uterus 'delivered' vaginally?

From the information in the abstract below, it would appear that there are actually 4 distinct types of hysterectomy - abdominal, vaginal, laparoscopically assisted vaginal and laparoscopic.  Interestingly, MBS provides items for Laparoscopically Assisted Hysterectomy - 35750-35756, with no mention of the approach.  These are quite separate to the Abdominal Hysterectomy and Vaginal Hysterectomy items.  
 
Research: 
"What is a "laparoscopically assisted vaginal hysterectomy" (LAVH)?
There is little debate that recovery is faster if the uterus is removed through the vagina without the need to make an abdominal incision.  Some disease processes make the vaginal approach difficult or impossible.  Such situations may include large ovarian cysts, extensive endometriosis, large fibroids, or unexplained pelvic pain where the gynecologists needs to get a good look at the pelvic organs.  In some situations, the surgeon may be able to insert a laparoscope, (a small telescope) through the belly button and be able to see the entire pelvis.  Other instruments are inserted through other tiny incisions in the abdomen.  These instruments can be used to perform parts of the hysterectomy, and to allow it to be completed through the vagina.  

In a laparoscopic hysterectomy (or LH) the entire (or most of the) procedure is done through the laparoscope.

A LAVH or LH is often less invasive than an abdominal hysterectomy, but more invasive than a vaginal hysterectomy.  If the procedure can be done vaginally, then no incisions are needed in the abdomen."

Response:
This query was referred to the NCCH who provided the following advice:
"The NCCH advises that currently the hysterectomy codes are based on both the delivery of the uterus and the approach.

As there is no code that currently describes a laparoscopic total abdominal hysterectomy the NCCH agrees it should be assigned two codes as per ACS 0023 Laparoscopic/Arthroscopic/Endoscopic Surgery which states 'If a procedure is performed laparoscopically, arthroscopically or endoscopically, and there is no code provided which encompasses both the endoscopy and the procedure, then both procedures should be coded.'

Laparoscopic abdominal hysterectomy is currently the subject of a public submission and will be reviewed for a future edition of ACHI."

The VICC therefore advises to check the operation report to determine if the uterus has been removed vaginally or abdominally.
If removed abdominally assign:
35653-01 [1268] Abdominal hysterectomy
30390-00 [984] Laparoscopy
If removed vaginally assign:
LAVH codes from Block 1269 Vaginal hysterectomy


Query Title:
Principal diagnosis for cancelled chemotherapy

Query Text:
Can you please clarify what code should be assigned as Principal diagnosis for day chemo admissions when chemotherapy is cancelled.

Coding Matters 12(2) Sept 05 contained instruction to code cancelled day chemotherapy for neoplasm to Z51.1, appropriate neoplasm codes, Z53.0 and code for condition(s) resulting in cancellation of chemotherapy.

Previously in Vic Coding Newsletter Feb 03 #1855 instructed coders that following ACS 0001 chemotherapy would not meet definition of PDx, and therefore condition being treated (that resulted in cancellation of chemo) would be PDx.

Vic Coding Newsletter June 02 contained a coding feature Admission for Chemotherapy advised that Z51.1 ... should be coded when the patient is treated with either antineoplastic or cytotoxic therapy.

Vic Coding Newsletter Aug 00 #1537 instructed once again that if chemotherapy session is cancelled and no other treatment given, admission should be cancelled as it does not meet admission criteria, or if chemo is cancelled for a condition that required further treatment this would become the principal diagnosis.

Response:
As per the coding feature titled 'Cancelled procedures' in the First quarter 2005-06 ICD Coding Newsletter, coders must first decide whether or not the admission is a legitimate admission according to the criteria discussed in the DHS Hospital Admission Policy.  

If the admission is legitimate, then the codes must be assigned according to the instructions contained in ACS 0011 Admission for surgery not performed and this is reinforced in Coding Matters Volume 12, Number 2 September 2005.

If the admission is not legitimate, then the admission must not be reported to the VAED.

Please note that this advice supersedes previous advice published in the August 2000, June 2002 and February 2003 ICD Coding Newsletters.

The following scenarios are to assist coders in code assignment:
Scenario 1:
Same day patient admitted for chemotherapy, which is cancelled because of fever.  Patient is separated same day.  Assign the following codes:
Z51.1 Pharmacotherapy session for neoplasm
Neoplasm code
Z53.0 Procedure not carried out because of contraindication
R50.9 Fever, unspecified

Scenario 2:
Intended same day patient admitted for chemotherapy, which is cancelled because of fever.  Patient becomes a multi-day stay. Assign the following codes:
Neoplasm code
Z53.0 Procedure not carried out because of contraindication
R50.9 Fever, unspecified

The VICC is preparing a public submission to NCCH suggesting an amendment to ACS 0011 Admission for surgery not performed for patients who remain in hospital overnight.


Query Text:
If a patient with diabetes is admitted for carpal tunnel syndrome is this coded as a 'with diabetes' condition?
There is no diabetes with , carpal tunnel in the index, but it does include mononeuropathy, which is what carpal tunnel syndrome is.

There is a list of conditions under E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy and carpal tunnel is not listed here, but cannot find anything in the standards to say that it is restricted to those conditions.

Response:
This query was referred to the NCCH who provided the following advice:
"The issue of whether or not carpal tunnel syndrome in a diabetic patient can be considered a diabetic mononeuropathy is currently contentious, along with a number of other mononeuropathies that fall into this category.

Given the above advice and the implications for principal diagnosis assignment, current coding practice should continue and carpal tunnel syndrome should not be coded to diabetic mononeuropathy.

Once there is an outcome of the specific debate in this area a review of diabetic mononeuropathies will be undertaken for a future edition of ICD-10-AM."

The VICC therefore advises coders not to code carpal tunnel syndrome to diabetic mononeuropathy.


Query Title:
IV Intragam infusion for Multiple Myeloma

Query Text:
Could you please advise correct coding for IV Intragam infusion for Multiple Myeloma.  If coded as day chemo it groups to R63Z ($565.1718) and if coded as transfusion it groups to R61C ($483.5469).  There is contradictory advice on the NCCH database regarding same.

NCCH database Q1992 (23/09/04)instructs to code to IV pharmacotherapy with extension of '00' as the intent is for treatment of neoplastic disease.

NCCH database Q2025 08/10/04, whilst never actually providing a coding directive, states that Intragam is derived from blood products, and was included in pharmacotherapy block [1920] due to the synthetic nature of the drug. This is obviously despite the fact that it is made from human proteins and there was a major shortage of Intragam recently due to the drop off in blood donations. 

The advice in Q2025 directly contradicts that given in NCCH database Q2042 (21/10/04) which states that Albumex has been categorised as a blood expander, and goes on to state that all ''Transfusion of blood and gamma globulins' (including extracts, synthetic/manufactured substances' are classifiable to block [1893] and should be coded in accordance with ACS 0302 Blood transfusions. 

Errata 2 instructed coders to add the following excludes note under (05) gamma globulin in block [1920], but did not add an excludes note under 13706-05 [1893].

VOL 3: 1920:–05 Gamma globulin Excludes Add when used in the treatment of neoplasms and/or neoplasm related conditions

Search Details: 
NCCH database queries 1992, 2025, 2042
Errata 2 4th edition, ICD-10-AM

Response:
The correct procedure code to assign for IV Intragam infusion for Multiple Myeloma is 13706 05 [1893] Transfusion of gamma globulin as per advice in NCCH Q2025 and the ‘excludes’ note under Block [1920] 05.  Note that transfusion may be documented as infusion.

 The VICC also notes that Multiple Myeloma is the correct principal diagnosis.

The VICC has requested NCCH give consideration to removing gamma globulin from block [1920] because it is a blood product and retain only in block [1893].


Query Title:
Open reduction and internal fixation fractured rib

Query Text:
We had a trauma patient admitted with multiple bilateral fractured ribs from a motor vehicle accident that resulted in a flail sternum. This patient underwent an open reduction and internal fixation of 7 fractured ribs with plates and screws.    

There is no code for open reduction and internal fixation of fractured rib. Could this be referred to NCCH for consideration of the creation of a code for this proceedure? In the meantime we have assigned Osteotomy of rib with internal fixation 48409-10 [1374] as ostectomy of ribs are the only codes that reflect  internal fixation of rib. Does the committee have any other suggestions for a code to be used in the mean time?

Search Details: Index entries:

OSTEOTOMY OF RIB WITH INTERNAL FIXATION

osteotomy NEC
- rib 48406-10 [1374]
-- with internal fixation 48409-10 [1374]

IMMOBILISATION OF FRACTURED RIB
Non-surgical treatment of fractured rib

Immobilisation
- fracture
-- rib 47471-00 [1373]

Response:
This query was referred to the NCCH who provided the following advice:
"The NCCH agrees that the 'best fit' code at present is 48409-10 [1374] Osteotomy of rib with internal fixation.

Please note that Standard 0020 Multiple/Bilateral Procedures should also be applied and each reduction and internal fixation of the rib coded separately.

Open reduction and internal fixation of fractured ribs is currently the subject of a public submission and will be reviewed for a future edition of ACHI."


Query Text:
An 83 year old female patient is admitted with a bleeding gastric arterio-venous malformation which is treated by an injection of adrenaline at gastroscopy.

Is Q27.3 Peripheral arteriovenous malformation, the correct code to use in this instance?  Although not stated in the index as peripheral, the actual code description in the Tabular list states peripheral and it groups to F65A Peripheral vascular disorders with CSCC.

Response:
The VICC advises that it is not correct to assign Q27.3 Peripheral arteriovenous malformation because in the index under Malformation, arteriovenous, the term aneurysmatic is an essential modifier. 

As per ACS 0034 Conventions used in the alphabetic index of diseases under Cross references 'see also' directs the coder to refer elsewhere in the index if the statement being coded contains other information that is not found indented under the term to which 'see also' is attached.  Because the term Malformation has a 'see also' cross reference to Anomaly, follow the index under Anomaly:

Anomaly, anomalous (congenital) (unspecified type) Q89.9 
↓
-artery (peripheral) Q27.9 

Therefore the appropriate code to assign in this scenario is:
Q27.9 Congenital malformation of peripheral vascular system, unspecified


Query Title:
Manual removal of placenta in an abortive episode

Query Text:
A 34 year old woman was admitted at 18 weeks gestation with an incomplete miscarriage.  The operation report only stated manual removal of placenta.  The cervix was still dilated.  There was no D&C or suctions done.  Which would be the most appropriate code?

90482-00 [1345] Manual removal of placenta
35643-01 [1267] Suction curettage of uterus following abortion or for termination of pregnancy
35643-02 [1267] Dilation and evacuation of uterus [D&E]

Response:
The correct procedure code to assign in your scenario is:
90482-00 [1345] Manual removal of placenta

It is not appropriate to assign the other procedure codes listed in your query because according to the information provided those procedures were not performed.

The diagnosis code will indicate that this is an abortive episode.


Query Title:
Open reduction and internal fixation of fracture fibular head

Query Text:
How to code an open reduction and internal fixation of fracture fibular head?

Index directs to : 
- see Reduction, fracture, ankle
--- with reduction of fracture of shaft of tibia - see Reduction, fracture, tibia, shaft

See NCCH queries Q134 (17/07/98) and Q388 (09/10/98).  Can you comment on procedure codes selected.  Other code considered was 47588-01 [1521] Internal fixation of intra-articular fracture of tibial articular surface of knee with repair or reconstruction of ligaments but there is no includes note 'that with fracture of fibula'.

Why are there no procedure codes for fibula alone and given the comments on the NCCH query responses in 1998 it is time to allocate codes to avoid this coding difficulty.

Response:
This query was referred to the NCCH who provided the following advice:
"Currently the only choice available for an open reduction of a proximal fibular fracture is a code from block 1510 Open reduction of fracture of shaft of tibia.  Either 47570-00 Open reduction of fracture of shaft of tibia or 47566-01 Open reduction of fracture of shaft of tibia with internal fixation, as they both include that with fracture of fibula.

The NCCH will consider reviewing this area for a future edition of ACHI."


Query Text:
It was noted that many of our diabetic patients are having debridement of their feet by podiatrists. These debridements are done on the ward.  ACS 1203 states that most debridements are excisional.  Therefore should we use excisional debridement as the default as non-excisional debridement is not documented?   

Additionally, as these debridements are performed by a podiatrist, should they be coded in addition to the generalised allied health podiatry intervention code?

Search Details: ACS 1203

90665-00 [1628] Excisional debridement of skin and subcutaneous tissue
90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue

Response:
As per ACS 1203 Debridement the procedure code for excisional debridement should be assigned as the default code when non-excisional debridement is not documented.

ACS 0032 Allied health interventions states that codes in other chapters may also represent interventions performed by health professionals and that a combination of the specific code and general code may be assigned.


Query Text:
The index lookup at vasospasm leads to I73.9 Peripheral Vascular Disease, unspecified. The lookup at Spasm, coronary(artery) leads to I20.1 Angina Pectoris with documented spasm, which is the code I have used.

The patient had a coronary angiogram which did not demonstrate any coronary artery disease, and is now being treated for vasospasm with Amlodipine and nitrate patches.

My concern is that there is no index entry for coronary arteries under vasospasm, and that the index entry under spasm leads to I20.1, but there is no mention of angina pectoris in this patient, nor does the condition seem appropriate to the section of codes I20 - I25 Ischaemic Heart Diseases.

Response:
Vasospasm is defined as 'sharp and often persistent contraction of a blood vessel reducing its caliber and blood flow' 
(http://www2.merriam-webster.com/cgi-bin/mwmednlm?book=Medical&va=vasospasm)

It is therefore appropriate to look up in the index Spasm, coronary (artery) to assign:
I20.1 Angina pectoris with documented spasm

As per ACS 0940 Ischaemic heart disease, angina has many underlying causes and spasm is one of them, therefore it is appropriate for spasm of coronary artery to be classified to I20.1 Angina pectoris with documented spasm.


Query Text:
I have an episode that I was coding relating to a 72 year old male with a past history of SCC of the larynx.  A total laryngectomy, tracheoesophageal fistula and permanent tracheostomy were performed on 18/2/2004.

He was recently admitted in October 2005 (LOS 16 days) with aspiration due to persistent leakage of his tracheoesophageal fistula. The diagnosis codes I used were:
T17.9  Foreign body in respiratory tract
W44    Foreign body entering into or through eye or natural orifice
T81.8  Other complications of procedures not elsewhere classified
Y83.8  Other surgical procedures 
Y92.22 Health service area 
U73.9  Unspecified activity

In this admission the tracheostomy is continually cleaned and suctioned due to sputum plugs and the tracheostomy tube is used to prevent further aspiration by inflating and deflating the cuff.  To reflect the extra care needed for this patient’s trache I coded 90179-06 (568) Management of tracheostomy however this groups into A06Z Tracheostomy or ventilation >95 hours which impacts quite considerably on the WIES. 

Without the management of tracheostomy code the DRG is E75B.  The inlier weight for this DRG is usually 0.5851 however there are 4 high outlier days which makes the cost weight for this episode 1.3427 0.5851  + (0.1894 x 4 days) = 1.3427

With the management of tracheostomy code added the DRG is A06Z.  The inlier weight is usually 16.5318 however this episode is a low outlier, which makes the cost weight for this episode 11.8525. 1.8235 + (0.6686 x 15)  = 11.8525

There is a WIES variance of 10.5098.

Consequently I added different codes to see what they would do to the DRG based on the same diagnosis codes. I changed the procedure code to 92046-00 (568) Replacement of tracheostomy tube. This did not change the initial DRG (E75B). 
I also tried 92047-00 (568) Removal of tracheostomy tube and this code did not change the initial DRG (E75B) either. 

Therefore, I am wondering why management of tracheostomy (which includes tracheostomy toilet) changes the DRG to A06Z?  Is this a grouping problem?

Response:
The VICC agrees with the procedure code assigned by the enquirer in this scenario:
90179-06 [568] Management of tracheostomy 

This query has been referred to the Commonwealth for investigation.


Query Text:
Currently according to the alphabetic index and the 3m encoder we are coding R55 Syncope and Collapse for this condition.
Our Cardiology Registrar describes a condition which is more complex than a simple faint.  The doctor stated it is an inappropriate decrease [sudden drop] in blood pressure.  Normally the body will react to some stimuli such as fear, extreme heat, high emotional levels, standing in one spot etc. by releasing adrenaline to raise the heart rate and blood pressure.  In a person with neurocardiogenic syncope the reaction to this surge of adrenaline is the opposite to normal.  Heart rate and blood pressure drop dramatically. There is little warning and treatment can include a pacemaker. The Tilt Table is used to assist the diagnosis. 

Code R55 does not adequately describe this condition.  Is this a recognised condition rather than a symptom and therefore requires a designated code?  A search of NCCH coding queries found only Query 2130.  Is this a similar scenario or not?

For now should we code R55, I95.8, G98 to reflect all the symptoms?

Search Details: 
NCCH query 2130
alphabetic index
3m encoder
tabular entries

Response:
NCCH query Q2130 refers to a syndrome, which is coded according to ACS 0005 Syndromes.  This standard is not applicable to neurocardiogenic syncope.  

Therefore as per coding convention, the correct code to assign is the default code at syncope:
R55 Syncope and collapse


Query Title:
Vitamin D deficiency in obstetric patients

Query Text:
We have a large number of obstetric patients who are Vitamin D deficient throughout their pregnancy.  These patients are treated with Ostelin during their antenatal care and after giving birth are discharged with instruction to continue daily Ostelin.

We feel that the Vitamin D Deficiency is significant condition from a coding and research perspective.  

On our obstetric delivery summaries and the discharge summaries the Vitamin D Deficiency is listed as a maternal medical condition.  Does the Vitamin D Deficiency meet additional diagnosis criteria as it is being monitored through the admission and the patient is instructed to continue with medication on discharge?  

In patients with no other complications this will change the DRG as the O80 will not be used as we would assign
O99.2 Endocrine, nutritional and metabolic diseases complicating pregnancy, childbirth and the puerperium
E55.9 Vitamin D deficiency, unspecified

Response:
If there is documentation to support that the Vitamin D deficiency is being monitored then it is appropriate to code this condition as it meets additional diagnoses criteria.  

This advice is consistent with Additional diagnoses queries and responses query seven ‘Obstetrics’ on the HDSS website.


Query Text:
We have a number of babies born at our hospital with documentation of Positional Talipes.  These patients have physiotherapy as their only treatment.  On imaging there is no bone deformity.

We have been using Q66.89 Other congenital deformities of feet. We are receiving a number of requests from the PDCU asking if the deformity is soft tissue or structural.  Is there a more specific code we could be assigning?

Response:
The VICC referred this query to the Perinatal Data Collection Unit (PDCU) who provided the following response:

The Perinatal Data Collection Unit (PDCU) is a mandated collection of births in Victoria.  The maintenance of the Birth Defect Register (BDR) is one of the functions of the PDCU.  One source of birth defect notification is the perinatal morbidity statistics form.  If diagnoses are vague or non specific, further specificity is sought for the completeness of the BDR.  In these cases a query is generated from the PDCU, or if the pediatrician’s details are available, a follow up letter will be sent.

Where a birth defect has been diagnosed at the time of birth, a descriptive diagnosis is documented on the perinatal form (not an ICD-10-AM code).  From this, a code is assigned by the PDCU coders for submission to the BDR.  The classification used for reporting birth defects is the ICD-9 British Paediatric Association (BPA) supplement (a much more detailed 5 digit classification for birth defects).

Codes such as Q66.89 Other congenital deformities of feet are very general as this code includes:  
Clubfoot NOS
Hammer toe, congenital
Talipes:  
· Asymmetric
· NOS
Tarsal coalition
Vertical talus

This code is not specific enough for the purposes of the BDR and a description of the nature of the condition is required in order to determine whether it is notifiable to the BDR or not.  For example, using the BPA classification, Clubfoot is assigned the code 75473, whereas Hammer toe is assigned 75560.  In ICD-10-AM these conditions are both classified to Q66.89 Other congenital deformities of feet.  There may also be other foot anomalies assigned to this code, which may have a more appropriate BPA code.

Therefore, for coding purposes the correct code to assign is:
Q66.89 Other congenital deformities of feet.


Query Text:
Can you please advise us the procedure code to be used for Islet cell transplantation.  This process involves isolated islet cells from donor pancreas and injecting them into the liver of patients with Type 1 diabetes. 

We code E10.9 Type 1 diabetes mellitus without complication as the principal diagnosis and 14203-01 [1906] Direct living tissue implantation.  We looked up transplantation, pancreatic tissue.  This groups to K06Z Thyroid Procedures.  This DRG does not relate to the procedure being performed.

Search Details:
www.diabetes.org.uk/infocentre/inform/islet3.htm

Response:
From the information provided, the VICC agrees with the procedure code assigned.  This is an example of the classification not keeping up with new technology as this procedure is now performed using various tissues:
· adrenal
· thyroid
· cartilage
· pancreas 
· parathyroid

 The VICC will refer this to the Commonwealth for consideration of allocating the procedure code to DRG K09Z Other Endocrine, Nutritional and Metabolic OR Procedures.


Query Text:
Please review procedure codes for suspensionoplasty of thumb.  Do others code this operation the same way? 

46324-00 [1468] Arthroplasty of carpal bone.  Please confirm that this is the correct code as there is no index entry for suspensionoplasty.

I note that the inclusion note includes 'synovectomy and tendon transfer and realignment.'  However our operation notes consistently refer to a tendon harvest that is used as a  graft.  In these cases should we also code the tendon graft 90583-00 [1569] and tendon harvest 90578-00[1564]?

Response:
The VICC agrees with the procedure code assigned by the enquirer in this scenario:
46324-00 [1468] Arthroplasty of carpal bone

The inclusion underneath the code title describes the procedure performed:
Replacement of carpal bone using adjacent tendon or other soft tissue
Resection arthroplasty of carpal bone

The includes note means that you don't have to add additional codes for these procedures as they are included in this procedure code:
Includes: synovectomy
tendon transfer or realignment

Therefore in this scenario, no other procedure codes need to be assigned.


Query Text:
Babies admitted with feeding problems for assessment and maternal education (admitted patient program at early parenting centre).  If the baby is older than 28 days, which code should be used.

Index entry for feeding problems:
Feeding 
-difficulties and mismanagement R63.3 
-faulty R63.3 
-formula check (infant) Z00.1 
-improper R63.3 
-problem R63.3 
--newborn P92.9 
---breast refusal, persistent P92.5 
---due to 
----short frenulum P92.8 
----tongue tie P92.8 
---incoordinate suck P92.8 
---specified NEC P92.8 
---uncoordinate suck P92.8 
--nonorganic F50.8

Response:
From the information provided, the babe is no longer a newborn and there is no evidence that the condition arose in the perinatal period, therefore the correct code to assign is:
R63.3 Feeding difficulties and mismanagement

If there is documentation that the condition arose in the perinatal period (first 28 days) code P92.9 Feeding problem of newborn, unspecified can be assigned as per ACS 1605 Definitions of conditions originating in the perinatal period.


Query Text:
Ecstasy.  The index provides 2 different codes for this:
Ecstasy (methylenedioxy methamphetamine)T40.9
Methylenedioxyamphetamine T43.6

I note that Methamphetamine and Amphetamine are both indexed to T43.6.

Web search: MDMA (3-4 methylenedioxymethamphetamine) is a synthetic, psychoactive drug chemically similar to the stimulant methamphetamine and the hallucinogen mescaline. Street names for MDMA include Ecstasy. 

Which code is correct?

Response:
These are two different drugs and the code assigned would depend on the documentation in the record.  

If Ecstasy is documented, code to T40.9 Other and unspecified psychodysleptics [hallucinogens]

If MDMA is documented, code to T43.6 Psychostimulants with potential for use disorder

If both are documented interchangeably, follow the excludes note under T43 Poisoning by psychotropic drugs, not elsewhere classified and assign:
T40.9 Other and unspecified psychodysleptics [hallucinogens]


Query Text:
Could the committee please advise on the coding of Ovarian Stimulation Syndrome. It occurs in some women who are going through the IVF program and is a complication of the hormone they are given to stimulate the ovarian follicle for increasing oocyte production.  The patient presents with many problems, some of which are pleural effusion, atelectasis, tachycardia, ascites, hypoalbuminaemia.  I note the NCCH Q929 from 1999, which advises to code N98.1 Y84.8, but the answer to this query appears at odds with the current ACS 1902 Adverse Effect of Drugs. 

1.  As this appears to be an adverse effect of drug treatment, should coders follow ACS 1902 and code out the manifestations, or should coders assign the code N98.1 Hyperstimulation of ovaries?

2.  Which would be the appropriate external cause code, Y42.8 'Follicle stimulating hormone, human' following ACS 1902, or Y84.8 'Other medical procedures as the cause of abnormal reaction of the patient, or of a later complication, without mention at the time of the procedure' as advised in Q929?

Response:
The VICC referred this query to the NCCH who provided the following advice:
"Ovarian hyperstimulation syndrome (aka Ovarian stimulation syndrome) is an adverse effect of fertility drug therapy.  Assign N98.1 Hyperstimulation of ovaries following the pathway:
Hyperstimulation, ovaries (associated with induced ovulation) N98.1 

Code other manifestations of the disease if they meet the criteria in ACS 0002 Additional Diagnoses.

Assign an external cause code (see ACS 1902 Adverse Effects of Drugs) by referring to the Table of Drugs and Chemicals and selecting a code for 'adverse effect in therapeutic use' for the specific drug.

Where the type of drug is not specified, assign Y42.8 Other and unspecified hormones and their synthetic substitutes by following the pathway in the Table of Drugs and Chemicals:  Hormone NEC, adverse effect in therapeutic use Y42.8.

The NCCH will consider improving the indexing of this condition for a future edition of ICD-10-AM.

Q929 has been amended to reflect this advice. See also Q2360."


Query Text:
Can you please confirm the correct code to use for 'injection of botox into salivary gland'.  Patients with excessive salivary production will often be admitted for injection of botox to help control the excessive drooling.

We have been using the advice regarding injection of botox into muscle/tendon and coding these patients to;

90560-00 [1552] Administration into soft tissue, NEC

Or should we code it to;

90140-00 [399] Other procedures on salivary gland or duct.

The second code groups the patients into a higher weighted DRG.

Response:
The following advice regarding injection of botox into muscles and tendons NEC was published in Coding Matters Volume 11 Number 4, March 2005:
Query 1428 advises coders to assign 92193-00 [1885] Injection or infusion of other therapeutic or prophylactic substance for 'injection of botox into tendons' (ICD-10-AM Second Edition).  This code was inactivated for ICD-10-AM Fourth Edition and the concept mapped to block [1920] Pharmacotherapy.  Index entries for 'Injection, botulinum toxin', direct coders to assign a code from block [1920] Pharmacotherapy with an extension of -09.  The index entries are incorrect and will be rectified.

The intention of block [1920] Pharmacotherapy is to classify 'systemic' drug administration.  This is highlighted by the exclusional term at the beginning of the block:
Excludes:
· local effect (see Index: Injection, by site or Injection, by type, by site)

Classification
In cases that describe injection of Botox into muscles and / or tendons NEC assign: 
90560-00 [1552] Administration of agent into soft tissue, not elsewhere classified

The lookup pathway in the Alphabetic Index of Procedures is: 
Injection (around) (into) (of) – see also Administration 

-muscle NEC 90560-00 [1552] 

-tendon NEC 90560-00 [1552] 

Note that this is an NEC code.  If the muscle / tendon injection is specified by site and / or condition, follow those index entries (e.g. ‘Injection, toxin botulinum, for, strabismus’ and ‘Injection, toxin botulinum, vocal cord’).

The NCCH is currently reviewing this area of the classification and will make improvements in ICD 10 AM fifth edition.

Therefore, the VICC advises that because the botox acts on the muscle to reduce the muscular activity of the salivary gland, assign procedure code:
90560-00 [1552] Administration of agent into soft tissue, not elsewhere classified.


Query Text:
I would like some advice regarding the coding of Long QT syndrome.  There is a query on the NCCH queries database (658 Q-T interval prolongation) that advises coders to use R94.3 Abnormal results of cardiovascular function studies.  This query however doesn't refer to this condition as a syndrome.  We have had a few cases at our hospital were the documentation mentions that this condition is in fact a syndrome/inherited condition.  I have discussed this with our cardiologists and they have informed me that LQTS is characterised by prolonged QT intervals on an ECG (usually detected in early childhood) and the syndrome causes abnormalities in the electrical system of the heart. The patient's heart may spontaneously go into VT or VF which is potentially life threatening and requires an insertion of an AICD. The syndrome is also characterised by frequent LOC and syncopal episodes and the patients usually have a family history of sudden death. This syndrome is also called Ramano-Ward Syndrome or Jervell and Lange-Neilsen syndrome. As there isn't a specific code for this syndrome should we then apply ACS 0005 and code the manifestations plus the Q87.89?  Would you agree with the following codes:

Principal diagnosis: 
I47.2 or I49.0 VT or VF (depending on clinical documentation of type of tachyarrythmia) 

Additional diagnosis: 
R55 Syncope
R40.2 LOC
Q87.89 Other specified congential malformations syndromes

I have faxed some clinical notes that support this query.

Search Details: ACS 0005
NCCH query 658

Response:
Manifestations of Long QT syndrome are acute, not permanent therefore should only be coded if present.  The coding will depend on the documentation in the medical record.

If coding an elective admission and there are no manifestations, assign:
R94.3 Abnormal results of cardiovascular function studies
Q87.89 Other specified congenital malformation syndromes, not elsewhere classified

If manifestations such as VT are present, assign:
A code for the manifestation
Q87.89 Other specified congenital malformation syndromes, not elsewhere classified
Do not assign codes for the symptoms.


Query Text:
Baby born at Hospital A at 36/40 gestation, birth weight 3640 gms. Transferred two days later to Hospital B due to cardiac and intestinal complications. Baby treated and transferred back to Hospital A on day 33 for further management and to establish feeding. Main problem here was poor feeding (breast and bottle) with other issues of ileostomy management, hyponatraemia, and small head circumference. Babe discharged home 19 days later. 
Codes assigned: 
Principal diagnosis  Z51.88
P07.32
Z43.2
E87.1
M89.28
Q25.1
Q21.00

This has been coded according to scenario 3 in coding query No #1720 Transferred neonates, ICD coding newsletter May 2002.

We are confused as to when you would apply P92.X Feeding problems of newborn as the Principal Diagnosis?

The code Z51.88 Other specified medical care includes establishment of breast feeding. Can you please explain why you would use P92.X? According to ACS 1618 under prematurity, Z51.88 is the Principal diagnosis with P07.XX  as an additional diagnosis.

Search Details: 
ICD coding newsletter 2002 query #1720.
NCCH queries database No 2117.
ACS 1618.

Response:
In accordance with ACS 1618 Prematurity and low birth weight, where a babe is re-admitted to Hospital A to establish feeding and babe is >28 days old and >2500 grams, assign:
Z51.88 Other specified medical care as the principal diagnosis.  

If however, babe is re-admitted to Hospital A with feeding problems as the diagnosis, the principal diagnosis to assign would be:
P92.x Feeding problems of newborn as per the second paragraph of the standard under prematurity.

In the case you describe, it appears that the feeding problem has developed post admission therefore P92.x Feeding problems of newborn can be included in your string of codes.


Query Text:
Type 1 & Type 2 respiratory failure. Doctors at this hospital are using this term regularly instead of acute or chronic. A respiratory registrar advised that Type 1 refers to low oxygen levels. Type 2 refers to high levels of carbon dioxide. As there is no specific index entry to this term do we code to unspecified or refer back to doctors for clarification of acute or chronic. There is no code for specified NEC. Please advise of any help you can give in this situation.


Search details: 
Index entries, tabular entries, relevant ACS, NCCH queries, newsletter/coding matters.

Response:
The difference between Type 1 and Type 2 respiratory failure is very complex and clinicians actually differ in their interpretation of acute and chronic respiratory failure.  

Clarification from the clinician is vital to determine whether the failure is acute, chronic or acute on chronic.  

In the absence of clinical clarification, assign the default code:
J96.9 Respiratory failure, unspecified


Query Text:
I am unsure of how to code microdiscectomies. Years ago we were advised by our surgeon to code them as rhizolysis with laminectomy (40330 - 01 [54]). We are now receiving typed op reports and I now believe we should be using a discectomy code as well.

The procedure is as follows: 
1) The back muscles (erector spinae) are lifted off the bony arch (lamina) of the spine, they are moved as opposed to cutting.

2) The surgeon is then able to enter the spine by removing the membrane over the nerve roots called the ligamentum flavum. This is done in order to visualize the nerve root.

3) Often a small portion of the inside facet joint is moved to facilitate access to the nerve root and to relieve pressure over the nerve

4) The nerve root is then moved aside and disc material is removed. 

Almost all the joints, ligaments and muscle are left and therefore the mechanical structure of the spine remains unaltered.

Please advise on the correct procedure code/codes.


Search details:
http://www.spine-health.com/topics/surg/overview/lumbar/lumb03.html

Microdiscectomy (microdecompression) spine surgery
In a microdiscectomy or a microdecompression spine surgery, a small portion of the bone over the nerve root
and/or disc material from under the nerve root is removed to relieve neural impingement and provide more 
room for the nerve to heal. A microdiscectomy spine surgery is typically performed for lumbar herniated disc.

Microdiscectomy helps leg pain
A microdiscectomy surgery is actually more effective for treating leg pain (radiculopathy) than for lower 
back pain. The impingement on the nerve root (compression) can cause substantial leg pain, and while it may 
take weeks or months for the nerve root to fully heal and any numbness or weakness get better, patients 
normally feel relief from leg pain almost immediately after a microdiscectomy surgery. 

Microdiscectomy spine surgery procedure
A microdiscectomy spine surgery is performed through a small (1 inch to 1 1/2 inch) incision in the midline 
of the low back. 

First, the back muscles (erector spinae) are lifted off the bony arch (lamina) of the spine. Since these back 
muscles run vertically, they can be moved out of the way rather than cut. 

The surgeon is then able to enter the spine by removing a membrane over the nerve roots (ligamentum flavum), 
and uses either operating glasses (loupes) or an operating microscope to visualize the nerve root.

Often, a small portion of the inside facet joint is removed both to facilitate access to the nerve root and 
to relieve pressure over the nerve.

The nerve root is then gently moved to the side and the disc material is removed from under the nerve root. 

Importantly, since almost all of the joints, ligaments and muscles are left intact, a microdiscectomy 
spine surgery does not change the mechanical structure of the patient's lower spine (lumbar spine).

Response:
This query was originally published in the 2005-06 June Database as follows:

Back surgery is complex however codes should be assigned according to the documentation, not on what the doctor advises because often clinicians  definitions are based on MBS and can be quite different to the ACHI classification.

If there is documentation of microdiscectomy, follow the lead term discectomy in the index (because there is no lead term for microdiscectomy) and assign a code accordingly.

40330-01 [54] Spinal rhizolysis with laminectomy should only be assigned if there is documentation to support the assignment of the code.


This query has been updated for Eleventh Edition as follows:

Back surgery is complex however codes should be assigned according to the documentation, not on what the doctor advises because often clinicians  definitions are based on MBS and can be quite different to the ACHI classification.

If there is documentation of microdiscectomy, follow the lead term discectomy in the Index (because there is no lead term for microdiscectomy) and assign a code accordingly.

VICC notes code 40330-01 [54] Spinal rhizolysis with laminectomy is no longer current. 40330-00 [49] Decompression of spinal nerve roots can be assigned if there is documentation to support the assignment of the code.


Query Text:
Patient with a final diagnosis of Diarrhoea due to Clostridium difficile.  I believe the correct code should be A04.7 'Enterocolitis due to Clostridium difficile', however following the Index pathway:
Diarrhoea, due to, bacteria, specified NEC A04.8 'Other specified bacterial intestinal infection', is the only code I can get to.

The other specified bacterial agents in A04 (such as E. Coli, Yersinia and Campylobacter) are all listed in the Index under Diarrhoea with their specific code.  It would appear that Clostridium difficile should also have an entry under Diarrhoea, due to, Clostridium difficile A04.7.  

We have assigned the code of A04.8, following correct classification convention, and sent a query to the clinician asking for a diagnosis of enterocolitis.  But we would be grateful if the VICC could review this anomaly.  There are also grouping implications, as A04.7 affects PCCL calculation.

Response:
The VICC referred this query to the NCCH who provided the following advice:
"Following clinical advice the NCCH agrees that A04.7 Enterocolitis due to Clostridium difficile is the correct code to assign for 'diarrhoea due to Clostridium difficile.'

This will be referred to the WHO Update and Revision Committee.

As this advice requires a change in coding practice it should not be implemented until I July 2008.  This will be published in a future edition of Coding Matters."

The VICC is aware that this may not be a change in coding practice for some coders as they have already been assigning A04.7 Enterocolitis due to Clostridium difficile for documentation of diarrhoea due to Clostridium difficile and should continue to do so.


Query Text:
A 62 year old man was admitted due to abnormal liver function tests. A CT cholangiogram was performed which showed an infected gallbladder fossa collection. The imaging report describes this procedure as a CT with contrast of the biliary tract. As there is no code for CT cholangiogram I have assigned the default code for cholangiogram which is 58936-00 (1976) drip infusion cholangiography. The addition of the cholangiogram code results in the episode grouping to DRG H42C ERCP oth therapeutic pr – cc.

Please advise if this is the correct code to assign for CT cholangiogram and whether the grouping is appropriate.

Response:
In view of the advice in the  December 2006 Coding Commandments regarding Magnetic resonance cholangiopancreatography (MRCP) which says that MRCP should be coded to 90901-05 [2015] Magnetic resonance imaging of abdomen, the VICC advises that only a code for CT is required for this scenario.


Query Title:
Non-multiresistant methicillin resistant Staphylococcus Aureus

Query Text:
One of our pathologists gave a presentation to HIMs about infections and infectious organisms.  He advised us that NMMRSA is non-multiresistant methicillin resistant Staph aureus and should be coded to Z06.32 Methicillin resistant agent.  MRSA is multi-resistant methicillin resistant Staph aureus and should be coded to Z06.8 Agent resistant to multiple antibiotics.

This conflicts with ACS 0112 Infection with drug resistant organisms which states that MRSA is methicillin resistant Staph aureus (coded to Z06.32). 

NCCH query 1702 advises to code both NMMRSA and MRSA to Z06.1 Infection with multidrug resistant  Staph aureus.

Coding Matters Vol 9 No 2 advises MRSA is Methicillin resistant Staph aureus and is the same as NMMRSA and both should be coded to Z06.1.

Could you please clarify, your advice would be appreciated.

Response:
According to ACS 0112 Infection with drug resistant microorganisms, MRSA means Methicillin Resistant Staphylococcus Aureus and should therefore be coded to Z06.32 Methicillin resistant agent.  

If there is documentation of Multi-resistant MRSA, this should be coded to:
Z06.8 Agent resistant to multiple antibiotics. 

If there is documentation of Non-multiresistant MRSA, this should be coded to:
Z06.32 Methicillin resistant agent.

For the purposes of coding, pathologist’s definitions should not be applied.

Note that NCCH Q1702 and advice in Coding Matters Volume 9 Number 2 have been superseded by ACS 0112 Infection with drug resistant microorganisms.


Query Text:
44 year old female admitted with alcoholic cirrhosis of the liver (newly diagnosed in this admission). Investigation showed oesophageal varices, portal hypertension, portal vein thrombosis and ascites.  Patient was still drinking heavily and was counselled regarding this.

Could the committee clarify if F10.1 Harmful use of alcohol, should be used as an additional diagnosis code when the term alcoholic cirrhosis is included in the header for the code K70.3.

Queries on the NCCH database seem to indicate that F10.1 Harmful use of alcohol should be used when the clear link is made between the condition and the use of the alcohol.  The link is definite when you use K70.3 Alcoholic liver disease.

This seems to contradict the logic coding in diabetes where for example if we use E1_.51 Diabetes with Peripheral vascular disease we do not code I70.2_ unless it will add to the picture eg ulceration.

Are we double coding or is this a case of needing to add the extra information.  This has been debated regarding over coding and the basis for the logic of using F10.1.

Queries on the NCCH database Q893 Alcoholic liver disease from 15/12/99 and Q2094 Alcoholic cardiomyopathy, past alcohol abuse imply that the F10.1 could/should be used.  If this code is added then it changes the DRG from H60B to H60A.

Codes used were:
K70.3  Alcoholic cirrhosis of the liver
I98.20 Oesophageal varices in dis cl/e wo bleed
K76.6  Portal hypertension
K29.6  Other gastritis
R18     Ascites

DRG H60B if we add F10.1 it becomes DRG H60A.

Response:
The VICC referred this query to the NCCH who provided the following advice:
"Assign F10.1 Mental and behavioural disorders due to the use of alcohol, Harmful use in addition to  K70.3 Alcoholic cirrhosis of liver to fully describe the clinical picture, as per guidelines in ACS 0027 Multiple Coding."

The VICC notes that in accordance with ACS 0503 Drug, Alcohol and Tobacco use disorders, an additional code should be assigned to specify the level of use disorder.   The code title Alcoholic cirrhosis of liver implies alcohol use, but doesn't specify dependence or any other specifc form of alcohol related disorder, therefore it is appropriate to add F10.1 for the scenario you describe.


Query Text:
A 52 year old female presented with a large bowel obstruction due to a local recurrence of her colon cancer at her colostomy site.

Treatment involved endoscopic placement of colonic stent.  Please advise on the most appropriate codes for this procedure.  

Could the NCCH consider creating codes for insertion of stents into the large intestine?  There are codes for oesophageal and small intestine (duodenal) stents.

Response:
The VICC referred this query to the NCCH who provided the following advice:
"Colonic stents are usually placed to relieve obstructions or strictures (often malignant) of the colon.

Specific codes for colonic and rectal stents have been created for ACHI Sixth Edition.  In the interim the NCCH advises that 32094-00 [917] Endoscopic dilation of colorectal stricture is the correct code to assign for endoscopic placement of a colonic stent, following the pathway:

Dilation
-colorectal
--stricture (endoscopic) 32094-00 [917]"


Query Text:
Please provide advice re coding of the insertion of a dual chamber pacemaker that was programmed to VVI (ie single chamber) mode.

The patient was admitted for a routine pacemaker replacement.  The original pacemaker was dual chamber with atrial and ventricular leads and programmed to DDD mode.  The new dual chambered replacement was inserted, a new ventricular lead inserted, the existing atrial lead connected, and the replacement was programmed to VVI mode.   I consulted the pacemaker technician, who assured me that dual chamber devices may be programmed to single chamber modes.

Should the pacemaker insertion be coded to 38281-02 [650] Insertion of permanent single chamber pacemaker, VVI to reflect the programming mode.  I am at a loss to know how to code a dual chambered device without an appropriate dual chamber mode.

EpisodeID: UR 063353

Search Details: 
Insertion
- pacemaker
--Cardiac
---permanent
----dual chambered device
or
----single chambered device

Response:
This should be coded to dual pacemaker insertion because it is the device's capability even though it is not being used as this in this scenario.  Therefore the correct codes to assign are:
38281-10 [651] Insertion of permanent dual chamber pacemaker, DDD
38278-01 [648] Insertion of permanent single chamber transvenous electrodes
38281-12 [655] Removal of permanent dual chamber pacemaker


Query Text:
Can you please provide some advice regarding the coding & reporting to PRS/2 of Medical Imaging procedures.

We routinely code CT's, MRI's & other nuclear imaging as we have (had) a hospital run & owned imaging business but the imaging department has now been sold to a private company, and we are not sure if this impacts the coding/reporting.

At another local private hospital they index any codable imaging procedures with an "X" as the imaging is owned by the local public hospital. They received this advice several years ago from Irene Kearsey.

Can you please advice if this is what we should be doing now our hospital no longer owns the imaging department?

Response:
Medical imaging procedures performed in privately owned radiology departments are only coded if the hospital pays for the procedure.

If you wish to collect information on the procedures performed locally, you may code the procedures and suppress transmission to the VAED.


Query Title:
ACS 0112 Infection with drug resistant microorganisms

Query Text:
ACS 0112 Infection with drug resistant microorganisms instructs coders to assign a code from Z06.x Bacterial agents resistant to antibiotics when a clinician has documented the infection as being resistant to an antibiotic. At our hospital the pathology reports will often document that the infection is resistant to an antibiotic however the clinician will not have documented it in the record. Can we apply the same logic we do when coding the type of organism and assign a code from Z06.x when it is documented only on the pathology report. (ie patient has UTI and no organism is documented, however a urine result indicates E.Coli we can code it directly from the path report). Or must it be documented by a clinician in the record?

Search Details: 
NCCH #1703 advises to only code the Z06 code when it is documented by a clinican. This was to avoid use of Z06 when a 'R' was documented on the pathology reports. Our reports actually document 'resistant to penicillin' etc, not just the R. Is this more substantial documentation and allow for coding of Z06 from path results?

Response:
If there is documentation of infection in the clinical notes, then the organism recorded on the microbiology report can be coded.  However the resistance to the organism should not be coded unless it is documented in the clinical notes as being a resistant organism, not just resistance to a drug (as per ACS 0112 Infection with drug resistant microorganisms).

This advice is consistent with NCCH advice published in Coding Matters Volume 9 Number 2 September 2002.


Query Text:
Should haemorrhoids in the rectum be coded to internal? 

Do we need documentation of internal before assigning I84.2 Internal haemorrhoids without complication?

If you follow the index there is no option for rectum.  

Amongst the coders at our organisation, we cannot agree on this topic.  The argument is that we can use our clinical knowledge to assume that the rectum is an internal organ.

Response:
The VICC considers that rectal haemorrhoids are internal.  This is supported by the following the index entry:
Varicose
- vein
-- rectum - see haemorrhoids, internal

and the includes note at I84 Haemorrhoids:
I84 Haemorrhoids
Includes: piles
varicose veins of anus and rectum

In the case citied, if you have documentation of rectal haemorrhoids, follow the index and assign:
I84.2 Internal haemorrhoids without complication.


Query Text:
We have coded Laparoscopic liver biopsy (wedge) to 30409-00 [953] Percutaneous [closed] liver biopsy + 30390-00 [984] Laparoscopy - is this appropriate?  

NCCH query database, #672 and #1012, contains old advice - codes no longer available.

 In relation to above database queries, NCCH state amendments will appear in ICD-10-AM, 2nd edn, which obviously didn't happen then or since.  Will there be a procedure code in 5th edn?


Search Details: 
NCCH query database 
NCCH #Q672:
Question
Index - Biopsy, -liver (wedge excision) 30411-00 [953] but this is called 'Intraoperative biopsy of liver'.  This procedure was not done with any other procedure.  It is also not 30409-00 [953] Percutaneous liver biopsy.  What is the correct code?  The surgeon claimed 30391, which is 'Laparoscopy with biopsy'.  Can this be a liver biopsy?
Answer
For laparoscopic wedge biopsy of liver, not performed in conjunction with any other procedure, assign '30391-00 [988] Laparoscopy with biopsy'.  The classification of intra-abdominal biopsies is under review and amendments will appear in the second edition of ICD-10-AM.

NCCH #Q1012:
Question
The patient previously had a CT scan which showed a liver lesion.  The surgeon did a laparoscopy to look for a primary site, and biopsied the liver at the same time.  I coded this to 30391-00 [988] Laparoscopy with biopsy as there is no code in the [953] block for laparoscopic liver biopsy, and I did not feel that the intra-operative biopsy code 30411-00 was appropriate because it was not an open procedure.  Q1 - did I use the right code? And Q2 will there be provision for a more specific coding of laparoscopic biopsies in future editions?  Thank you.
Answer
Thank you for your query. The code you selected is correct ie. For laparoscopic biopsy of liver, not performed in conjunction with any other procedure, assign '30391-00 [988] Laparoscopy with biopsy'.  The classification of intra-abdominal biopsies is under review and amendments will appear in the second edition of ICD-10-AM.

Response:
The VICC agrees with the procedure codes assigned by the enquirer and note that the advice in NCCH queries Q672 and Q1012 no longer applies.

The term laparoscopic is neither an essential nor a nonessential modifier under Index entry Biopsy/liver.


Query Text:
Procedure coding for (L) main bronchus sleeve resection of malignancy and reconstruction of neo secondary carina using sutures (as specifically stated on op report), via thoracotomy (other procedures performed include radical excision of lymph nodes, division of mediastinal adhesions and muscle flap - not part of query):

The procedure codes available relate to endoscopic, not open, procedures.  Block 537 relates to trachea, not bronchus.

1. Is it appropriate to code the resection and reconstruction to 38456-04 (547)?

2. Does 5th edition have expansion of open procedure codes for bronchus?

Response:
VICC agrees with the enquirer's code 38456-04 [547] Other procedures on bronchus, intrathoracic approach because the procedure performed is a resection of the bronchus.

Fifth edition does not have procedure codes for open resection of bronchus.


Query Text:
What is the correct code for Pasteurella mutocida?  I have used A28.0 Pasteurellosis which is the default using the 3M encoder.

The patient has a wound infection from a dog bite.

This record has been queried by DHS notifiable edit 358 Area code restraint.

Response:
Pasteurella mutocida is a systemic infectious disease, however in the case cited it is a localised bacterial infection of the open wound.  Therefore the correct codes to assign are:
Open wound code
T89.02 Open wound with infection
B96.88 Other and unspecified bacterial agents as the cause of diseases classified to other chapters
W54.0 Bitten by dog
Place of occurrence code
Activity code

This is supported by the excludes note at the start of Chapter 1, which says 'Excludes: certain localised infections – see body system-related chapters'.

Further information about coding organisms can be found in the February 2002 ICD Coding newsletter coding feature 'Coding organisms'.


Query Text:
This patient has had a free flap performed to repair a gun shot wound to the foot.  Before the flap was closed over they have inserted an osteoset (antibiotic impregnated bone substitute packed into ankle defect and wrapped with flap). 

ACS 1316 Cement spacer/beads advises to code the insertion of the osteoset to incision of site and injection of antibiotic. 

We feel the incision code is inaccurate because the patient already has an open wound and another incision is not being made for the insertion of the osteoset. 

Query Q1103 on the NCCH database indicates further advice would follow about how to code the insertion of an osteoset, however we cannot find any further documentation since 1999.  Can you please offer some advice as to how best code this type of insertion?

Response:
The VICC referred this query to the NCCH who provided the following advice:
"The NCCH agrees that Osteoset is a synthetic bone graft which should be coded.  The correct pathway to follow is:
Graft
-synthetic - 'see also Graft, by site'

ACS 1316 CEMENT SPACER/BEADS is not applicable to Osteoset as this refers to the type of cement spacer/beads that need to be removed.  This is not the case with Osteoset which does not require a second operation to remove the beads or insert a bone graft.

For the scenario described where Osteoset was inserted into the foot assign 48239-00 [1569] Bone graft, not elsewhere classified following the pathway:

Graft
-bone
--specified site NEC

Q1103 has been cross referenced to Q2338."


Query Title:
Endovenous laser therapy for varicose veins

Query Text:
In relation to varicose veins how would you code endovenous laser therapy?

The limited information I can get from theatre is that the procedure involves inserting a fine needle into the veins and sending the laser through this creating shock waves as such.  Nothing is left in such as coils  so I have been coding 
90223-00 [767] Other vascular procedures whereas others believe it should be 35321-00 [767] Transcatheter embolisation of blood vessel which would match the item number but I read that as including something being left in there for example glue, coils, etc. 

Some would also suggest that if you use 35321-00 [767] that you should also include a code from [727] for the interruption of the varicose veins.

Response:
The VICC referred this query to the NCCH who provided the following advice in relation to interruption of varicose veins:
"The correct code to assign for endovenous laser therapy is an appropriate code from block [727] Interruption of sapheno-femoral or sapheno-popliteal junction varicose veins, [728] Other destruction procedures on veins or [737] Reoperation procedures on veins following the pathway:

Interruption
-vein
--varicose
---lower limb "


Query Text:
Scenario given at NCCH post implementation coding workshops (4th edition):

A 33 year old male was transferred from the District Hospital following an unrelated episode of care, where he had started to withdraw from his poly drug dependence.  Upon admission the doctor noted an impression of significant symptoms of benzodiazepam, alcohol and opiate withdrawal (mainly benzodiazepam) and ordered withdrawal medication.  Detoxification was initiated and the patient agreed to be discharged to a drug/alcohol rehabilitation unit.

NCCH answer presented at the seminar:
Principal diagnosis 
F13.3 Mental and behavioural disorders due to use of sedatives or hypnotics, withdrawal state
Additional diagnoses
F11.3 Mental and behavioural disorders due to use of opioids, withdrawal state
F10.3 Mental and behavioural disorders due to use of alcohol, withdrawal state
Procedure
92009-00 [1872] Combined alcohol and drug detoxification

We would code the episode as:
F13.3 Mental and behavioural disorders due to use of sedatives or hypnotics, withdrawal state
F10.3 Mental and behavioural disorders due to use of opioids, withdrawal state
F11.3 Mental and behavioural disorders due to use of alcohol, withdrawal state
F13.2 Mental and behavioural disorders due to use of sedatives or hypnotics, dependence syndrome
F10.2 Mental and behavioural disorders due to use of opioids, dependence syndrome
F11.2 Mental and behavioural disorders due to use of alcohol, dependence syndrome
92009-00 [1872] Combined alcohol and drug detoxification

Could you please advise the correct codes to utilise for these scenarios.
Search detail:

Clinicial input:
October 25, 2005

To Whom It May Concern:

This letter is in response to a request  regarding the coding of substance use disorders, specifically the assertion that an individual in substance withdrawal is necessarily dependent on or abusive of a substance.  This assertion has no empirical evidence and is a misinterpretation of the DSM-IV-TR.  Of greater concern, what may seem to be a trivial point, risks significantly biasing substance use statistics. 

I would like to draw attention to the DSM definition of Substance Withdrawal, Abuse and Dependence.

Criteria for Substance Withdrawal (p.202):
A. The development of a substance-specific syndrome due to the cessation of (or reduction in) substance use that has been heavy and prolonged.
B. The substance –specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

As per the Criteria, one clearly can withdraw from a substance without being Dependent or meeting criteria for Abuse of that substance.  Criteria B, above, quite plainly states “clinically significant distress” which, does not necessarily beget the diagnosis of a substance use disorder.

With respect to dependence, while it is true that Withdrawal is one characteristic which may herald substance dependence it is neither sufficient nor necessary.   The Criteria specifies that at least three of seven signs must be in place, of which Withdrawal is but one.  The Criteria is as follows:

Criteria for Substance Dependence (p.197):
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
1. Tolerance
2. Withdrawal
3. The substance is often taken in larger amounts or over a longer period than was intended
4. There is a persistent desire or unsuccessful efforts to cut down or control substance use
5. A great deal of time is spent in activities necessary to obtain the substance or recover from its effects
6. Important social, occupational or recreational activities are given up or reduced because of substance use
7. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated  by the substance 

In looking at substance abuse, there is also no mention of withdrawal as the focus is on maladaptive patterns of behaviour.  Quite to the contrary, the DSM-IV-TR clearly states that abuse “does not include tolerance, withdrawal or a pattern of compulsive use” (p.198).

Criteria for Substance Abuse (p.199):
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring within a 12-month period:
(1) Recurrent substance use resulting in a failure to fulfill major obligations at work, school, or home
(2) Recurrent substance use in situations in which it is physically hazardous
(3) Recurrent substance-related legal problems
(4) Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.

It is imperative that there is an understanding that withdrawal, like intoxication, is merely a state caused by substances and is not synonymous with abuse or dependence.  If this is in fact the way is to be recorded , than certainly all medical staff should be made aware of this.  An equivalent, “more medical” example, would be the assumption that someone who presents with high cholesterol, necessarily has a diagnosis of heart disease, and therefore, heart disease should not be coded.  This is simply not the case.

In closing, I am quite concerned that those clients receiving a code for substance withdrawal currently do not receive a code for abuse, or as is proposed, would not be coded for dependence.  This has enormous potential to skew data and grossly underestimate the prevalence of substance use disorders.  It reflects a misunderstanding of the nature of substance use disorders while ignoring the DSM-IV-TR criteria.

I would gladly further this discussion and look forward to your comments.

Regards,

Substance Use Research and Recovery Focused Program

Response:
The VICC referred this query to the NCCH who provided the following advice:
"There is currently no directive preventing assignment of the .2 dependence syndrome code with the .3 withdrawal state code. The current NCCH advice is that it is unnecessary to assign both codes, as the dependence is inherent in the withdrawal state.

However ACS 0503 Drug, alcohol and tobacco use disorders will be amended in the Australian Coding Standards Sixth Edition and the above advice will be superseded as follows:

'While withdrawal rarely occurs in the absence of dependence, for consistent application of codes, 
cases of withdrawal without mention of dependence syndrome should be assigned a code only for the withdrawal because dependence syndrome cannot be assumed.

Cases of dependence syndrome with withdrawal should be assigned both a code for the dependence syndrome and a code for the withdrawal syndrome because withdrawal is not always a feature of dependence syndrome.  Dependence is syndromal (a cluster of phenomena) and withdrawal is only one non-essential criteria for dependence.' "

Given that there is some ambiguity in Coding Matters Vol 13 Number 3 which doesn't prevent coders from assigning two codes, the VICC advises that codes for both dependence and withdrawal should be assigned if documented.


Query Text:
According to ACS 1527 Post term delivery a delivery is regarded as "post-term" at or after 42 weeks gestation.  

The ACHS define it as 41 weeks as does the Perinatal Data Collection Unit.  

I was wondering why they differ?  It would make sense to me that the ACS changes it's definition to be in line with others.  Is this possible?

Response:
The VICC cannot comment on the reason why ACS 1527 Post-term delivery differs from the ACHS and the Perinatal Data Collection Unit but notes that if there is documentation of post term in the clinical notes, then it can be coded as such.  The VICC will forward this query to the NCCH for comment but you may also wish to consider submitting a public submission to the NCCH in regard to the ACS.


Query Text:
There is some confusion amongst our coders about fluid overload and other conditions, could we please ask for assistance with the following scenarios?

a) Patient admitted for THR.  During stay has acute fluid overload which requires Lasix. On summary written as 'diastolic heart failure in the setting of fluid overload'.  Do we code out I50.9 and E87.7 or just one or the other (and which one)?

b) Patient admitted with acute fluid overload, has a past history of CCF is treated with frusemide.  Do we code out both again or just the CCF or just the fluid overload?

c) Patient with ESRF admitted with acute fluid overload for dialysis.  Is this part of the ESRF?  Is this an acute condition in conjunction with the ESRF?  Do we code the overload and the ESRF?  What would be the principal diagnosis if we had to code both?

Thank you for your assistance with these scenarios.


Search Details:
Have looked through the NCCH database and the VICC query index but am unable to find any reference  to this.

Response:
The VICC cannot answer each scenario specifically without access to the whole medical record, but note the following points for consideration when coding these scenarios:
i. Fluid overload is a separate condition in its own right
ii. Fluid overload may or may not be linked to an underlying condition
iii. Potentially both conditions could be coded but ACS 0001 and criteria in ACS 0002 should be applied to determine whether to code one or both and the sequencing.

With respect to fluid overload and CCF, Coding Matters Volume 7 No 3 under Congestive heart failure advises it is not necessary to code fluid overload in a patient with CHF.  However if a patient has a history of CCF, it does not mean that they have it now.

With respect to fluid overload and ESRF, there are circumstances in which fluid overload would be coded separately.  Refer to Coding Matters Volume 5 No 3 which provides an example of a patient admitted to hospital with fluid overload due to missed dialysis and the principal diagnosis is Principal diagnosis E87.7 Fluid overload and the additional diagnosis is N18.0 End-stage renal disease.

Coders should therefore refer to the Coding Matters advice and compare with the documentation in the medical record to determine whether the fluid overload should be coded.


Query Text:
Can you please advise on the best code to use for a patient who delivers via rotational vacuum extraction.  This is a common procedure carried out in this hospital, usually performed in emergency situations where a woman requires instrumental assistance during labour (eg. Non reassuring CTG, decreased maternal effort).

During this procedure the rotation is carried out using a ventouse device with no mention of forceps rotation of fetal head (documented as Ventouse rotation).

Currently we code this procedure to 90469-00 [1338] Vacuum extraction, following the index pathway:
Delivery (spontaneous) (vertex) 90467-00 [1336] 
vacuum extraction (Ventouse) 90469-00 [1338] 
--with 
---forceps rotation of fetal head 90468-04 [1337] 

The code 90468-04 [1337] Forceps rotation of fetal head with delivery, includes delivery via vacuum and forceps.  However we don't feel that this code is appropriate because it clearly specifies rotation of fetal head via forceps.

Could you please clarify what procedure code we should use to accurately code this procedure.

Response:
Research undertaken by VICC indicates that there is an element of rotation in all vacuum extractions.  Therefore, in this scenario the appropriate code to assign is:
90469-00 [1338] Vacuum extraction 

Forceps rotation of fetal head should not be coded unless documented.


Query Text:
Would the NCCH please clarify the intent of ACS 1511 Termination of pregnancy.  The VICC note that this standard changed between second and third edition, with the sentence regarding assignment of delivery, duration of pregnancy and outcome of delivery codes being moved from under point one, to the end of the standard.  In effect this sentence now applies to all scenarios outlined in the standard changing the criteria for coding as delivery from fetal viability to liveborn status.  

Several questions have arisen from our discussion:
1.  Is it the intention of the standard, that a termination of pregnancy resulting in a liveborn fetus at any gestation should be coded with additional codes O60 Preterm delivery, O09.x Duration of pregnancy and Z37.x Outcome of delivery?

2.  In point 2 of the standard can 004.x Medical abortion  be added as an additional diagnosis?  

3.  If the pregnancy terminated after fetal viability results in a stillborn should we add O60 Preterm delivery, O09.x Duration of pregnancy and Z37.x Outcome of delivery?  If not, could the NCCH please explain?  It seems anomalous to assign these codes only if babe is born alive.

Response:
The VICC referred this query to the NCCH who provided the following advice:
"In response to the questions posed in your query in relation to ACS 1511 Termination of pregnancy  the NCCH advises the following:
1. A termination of pregnancy resulting in a liveborn fetus at any gestation should be assigned the  additional codes O60.- Preterm labour..., O09.- Duration of pregnancy and Z37.- Outcome of delivery.

2. In relation to point 2 of the standard O04.- Medical abortion may be assigned as an additional code.

3. The following codes should be assigned if a pregnancy terminated after fetal viability results in a stillborn; O60.- Preterm labour..., O09.- Duration of pregnancy, Z37.- Outcome of delivery.

ACS 1511 Termination of pregnancy will be revised and clarified for the Sixth Edition of the Australian Coding Standards."


Query Title:
Multiple behaviours in same morphology at same site

Query Text:
Can you please provide advise on the following coding queries:
1. 
DCIS and Ductal carcinoma of the breast
Patient has ductal carcinoma and DCIS of the same breast (see pathology report below).  Can we code this to:
a)C50.9 M8500/3 D05.1 M8500/2
or just code
b)C50.9 M8500/3
We have differing opinions at our hospital.

SPECIMEN AND CLINICAL NOTES ADDED HORMONE RECEPTORS - SEE ADDENDUM
Needle localised right breast biopsy.
Needle localised lesion  right breast. ? tubular  cancer. Past history of tubular cancer left breast. Short  tie anterior, medium tie inferior and long tie medial.

MACROSCOPIC
An irregular piece  of fatty tissue  weighing 42  grams which measures 64mm from  superior  to  inferior,  62mm  transversely  and  24mm from anterior to posterior.  A needle localisation wire enters the superior aspect and is directed inferomedially  to an irregular area of stromal opacity containing  microcalcification.   The tissue  is sliced in the para-sagittal plane into  15 slices, with slice  most medial and slice 15 most lateral.  A central  ill-defined  area of firm  pale tissue is
present  in  the  superior  regions  of  slices  6 to  9 and  measures 16x12x8mm  (broadest dimension  across  slices).  Remaining  tissue is almost entirely  fatty  with no  discrete lesion  seen.   The superior margin is marked black, anterior  margin with silver nitrate, inferior margin green and  posterior margin  blue. Representative  sections.
A. slice 1 (medial resection margin).
B. slice 5, superior half with tissue  medial to lesion.
C, D. slice  6,  superior half  with  lesion C  superior  quarter. D. second quarter.  
E, H. slice 7  complete. E.   lesion  superior  quarter.  
F. second quarter. 
G. third quarter.   H.  inferior  quarter.
I, J.slice 8  superior half of  lesion,.  I.   superior quarter.  J. second  quarter.
K.  slice 9 second  quarter with lateral end  of lesion.
L.  slice 10, second quarter with tissue lateral to lesion.
M. slice 15 (lateral resection margin). 

MICROSCOPIC
There is a central invasive  ductal carcinoma  with admixed high grade ductal carcinoma in situ.  The tumour  comprises angulated tubules and irregular nests of cells within desmoplastic stroma.  The tumour cells have moderate to  large pleomorphic  nuclei containing  small nucleoli and mild eosinophilic  cytoplasm.  7 mitoses  per 10 high power fields
are seen (Bloom and Richardson score:  tubule score 2, nuclear score 3 and mitoses  score  1,  total 6/9).   No  lymphovascular   invasion is identified, however, assessment is complicated by retraction artefact.
The in situ tumour is high grade, with tumour cells forming cribriform and   clinging patterns with central necrosis, without microcalcification.  Greater than  25% of the invasive tumour consists of ductal carcinoma in situ (tumour EIC positive). The total (invasive and in situ) tumour dimension measures  20x13x12mm (broadest dimension
across slices) and invasive tumour dimension 16x12x8mm. In situ tumour is situated 1.7mm  from the posterior  (closest)  margin (Block B) and 3mm from the anterior  margin (Block I).  Invasive  tumour is situated 4mm from  the posterior  margin  (Block  B). The  superior,  inferior, medial  and lateral  margins  are  greater  than 10mm.  A  biopsy site
extends  into the  tumour.   The remaining  breast  tissue  shows mild stromal  fibrosis  and minor   fibrocystic  change  with one  focus of microcalcification in  a benign lobule (Block  G).  There is extensive mural dystrophic calcification in small arteries.

CONCLUSION
Right breast:  Invasive  ductal  carcinoma
- Grade 2, with  high grade ductal carcinoma in situ with necrosis.
- total (invasive and in situ) tumour dimension 20x13x12mm.
- invasive tumour dimension 16x12x8mm.
- in situ tumour  1.7mm from  posterior  margin and 3mm  from anterior
  margin. Remaining margins greater than 10mm.
- Extensive in situ component (EIC) positive.
- No definite lymphovascular invasion identified.

Hormone   receptor   and  HER 2  studies   will  be  performed   and a supplementary report issued.

2. 
Patient admitted with Bladder carcinona described in pathology as -  non invasive   papillary  urothelial  carcinoma,  low grade (papillary TCC grade 2/3). (see pathology report below).
Do we code this to:
a) D09.0 M8130/2
or
b) C67.9 M8130/3
I have spoken with our pathologist and he mentioned that WHO have new definitions/classifications for bladder carcinomas however our Urologists have not come to agreeance and therefore pathology have been requested to document both new and old classifications in the reports.
Also patients regularly come back for TUR of bladder tumours and in one admission the pathology reports TCC however in the next admission the pathology reports non-invasive carcinoma.  Do we code to the original carcinoma or code to the new pathology.

SPECIMEN AND CLINICAL NOTES
Bladder tumour. TURBT chippings. Recurrent transitional cell carcinoma.

MACROSCOPIC
5 pieces  of  tan  tissue  ranging  in  size from  1-6mm  in  greatest dimension. All processed 1 block.

MICROSCOPIC
 The biopsies  of bladder  mucosa include  submucosa but  no muscularis propria.  There  is  papillary   urothelial   carcinoma,   comprising thickened  urothelium   containing  mildly  atypical  cells,  showing moderate nuclear  crowding, with  rare mitotic figures.  No high grade atypia or invasive component is seen.

CONCLUSION
Bladder -  non invasive   papillary  urothelial  carcinoma,  low grade (papillary TCC grade 2/3).

Response:
Answer 1:
As per advice published in Coding Matters Volume 4 Number 1 if both in situ and invasive cancer are present in the same lesion, assign behaviour code /3.
Answer 2:
In accordance with ACS 0233 Morphology, point 3, the behaviour should be assigned based on the description of the neoplasm.  In your scenario the bladder carcinoma has been descibed as non-invasive, therefore follow the index entry under non-invasive as there is no index entry for low grade.

Each episode of care of follow up patients should be coded according to the documentation for that episode. [end of response]

For Eighth edition advice please refer to ACCD advice titled Invasive and in-situ neoplasms of the prostate published in the March 2015 Coding Rules.


Query Text:
Should we be coding 'unhealthy placenta' and if so does it get coded to 043.9 Placental disorder, unspecified ?

This query was raised after the directive in the 1st quarter 05/06 coding newsletter stated to not code gritty placenta as it is not significant.  We'd been previously advised by an external auditor in April 2005 to code both unhealthy placenta and gritty placenta.
 
The suggested pathway was:
    Disease, placenta, complicating pregnancy or childbirth.

Response:
The VICC notes that the advice in the 1st Quarter 2005-06 ICD Coding newsletter supersedes the auditor advice, therefore gritty placenta should not be coded as it is of no clinical importance.  However, all other placental abnormalities should be coded in accordance with Vic 0002 Additional diagnoses. The VICC suggest following index entry Abnormal, placenta and assign:
O43.1 Malformation of placenta


Query Text:
A 15 year old female admitted into A&E with a diagnosis of Post- chroming.

Her symptoms (documented by the Clinician in the notes) include seeing things/ monsters after chroming, SOB, chest tightness, sore eyes, nausea, and abdominal cramps.  

She has a history of Chroming, marijuana and IV drugs use (speed and Ice)

Codes assigned:
T59.8 Other specified gases, fumes and vapours
Y17.8 Poisoning by and exposure to other specified gas or vapours, undetermined intent (Includes: carbon monoxide, lacrimogenic gas [tear gas], nitrogen oxides, sulfur dioxide)
Note: undetermined intent was used as documentation in the notes supports the use of this code.
Appropriate Place of Occurrence and Activity codes

Can you advise if the above codes are correct or do we need to assign code(s) from Chapter V, F10-F19 Mental and behavioural disorders due to psychoactive substance use instead (or as an Adx to the T code)?

Response:
The VICC agrees that this scenario should be coded to poisoning because it involves improper use.

A code from F10-F19 cannot be assigned unless there is documentation in the medical record of an appropriate lead term such as addiction.


Query Title:
ACS 0530 and mental health emergency presentations

Query Text:
Following the implementation of the new DHS directive, to record same day transfers from ED to inpatient psychiatric care as one episode with a Care Type 5 I am querying the correct principal diagnosis assignment for these episodes.  In particular, the application of ACS 0530 Drug Overdose. 

You will be aware that the Standard states:
'When an admission is occasioned for treatment of a drug overdose and the patient subsequently receives treatment for an associated psychiatric condition in the same episode of care, ** the overdose should be sequenced as the principal diagnosis.
**Note that in most states the episode of care will continue to be regarded as an 'acute' care type........and therefore will be coded as one episode of care.

I foresee that application of this ACS, will adversely affect our code assignment and subsequent DRG assignment.  There are numerous patients that present to ED requiring attention for their drug overdose, who once stabilised, are directly sent to an inpatient psychiatric unit for treatment of their underlying psychiatric condition(s).  For various reasons they may remain on this unit for days, weeks or months.  Recording the principal as their initial drug overdose seems incorrect.

As there was no mention of a Victorian Addition to this Standard at the recent 5th Edition Education Workshop, I seek clarification now.

Response:
The VICC advises to apply ACS 0530 Drug overdose if the circumstances of the admission justify the application of the standard.  As stated in the June 2006 Special Edition Coding Newsletter article 'Emergency admission time and assignment of principal diagnosis' for patients who attend the emergency department and are subsequently admitted it is the decision to admit, and when this occurs, which is critical in determining principal diagnosis.

It should be noted that the footnote in ACS 0530 is the NHDD reference to 'acute' care type which includes the Victorian Mental Health Care Types.  That is Victorian care types 4 (acute) and 5x (various mental health types) (for patients <65) are mapped to  acute care for purposes of Commonwealth reporting.


Query Text:
I have a grouping problem that I was hoping could be referred on for fix. We get enough of them admitted under plastic surgery unit for it to be worthwhile requesting a fix.

Toe fractures/injuries that have nail bed repair group to I30Z hand procedures due to nail bed repair code (46486-00). This is a totally inappropriate DRG for these cases and requires a grouper amendment, taking PDx and procedure code into account, to drive them to a more suitable DRG.

Patient dropped a dumbbell on foot while weight training at the gym. Nail bed repaired under LA. Codes for this particular case are as follows:
S92.4 Fracture of great toe
S91.2 Open wound of toe(s) with damage to nail
W20 Struck by thrown, projected or falling object
Y92.31 Sporting hall (indoor)
U62.3 Strength training and body building

46486-00 [1636] Primary repair of nail or nail bed


Search Details: Grouper Manuals.

Response:
The VICC advises that in AR-DRG V5.1 procedure code 46486-00 [1636] Primary repair of nail or nail bed has been added to TAB I20-3 in addition to TAB I30-3, therefore this problem has been fixed in AR-DRG V5.1.


Query Title:
Spondylogenic compression of spinal cord

Query Text:
Spondylogenic compression of spinal cord M47.1x  Other spondylosis with myelopathy.  Please confirm the range of spondylogenic conditions that could be assigned to this code. 

Spondylogenic = originating in the spine.  Does this mean conditions commencing with 'spondylo' that are documented as causing spinal cord compression can be assigned M47.1x  Other spondylosis with myelopathy?  For example, spondylolithesis, spondylolysis or any other code included in spondylopathies M45 - M49 or does only the term spondylosis meet the criteria for this code?

Response:
This query was referred to the NCCH who provided the following advice:
"The NCCH acknowledges that there are inconsistent index entries for M47.1- Other spondylosis with myelopathy…  originating from ICD-10. However, as there is no dagger and asterisk relationship for this code each case should be assessed on its merits. If another cause for the myelopathy is documented, assign an appropriate code to complete the clinical picture following the guidelines in ACS 0027 Multiple Coding."


Query Text:
Am interested to know if the committee considers calcification of the placenta to be an abnormality and should we be coding it as such?

Search details:
www.nurseminerva.com.uk/pregnanc.htm
www.gynob.com/placenta.htm

Response:
Research obtained by VICC indicates that calcification of the placenta is linked to maternal smoking and has an effect on the fetus.  

As per Vic 0002 Additional diagnoses all placental abnormalities should be coded (except for gritty placenta as advised in the 1st Quarter 2005-06 ICD Coding newsletter).

The VICC suggest following index entry Abnormal, placenta and assign:
O43.1 Malformation of placenta


Query Text:
Six week old baby admitted with Neonatal Abstinence Syndrome. Mum was on high dose of methadone.
I am unable to code P96.1 Neonatal withdrawal symptoms from maternal use of drugs of addiction as the principal diagnosis, as the case then groups to 963Z Neonatal Diagnosis not consistent with age/weight.   This is a zero valued DRG.

This appears to be a grouper anomaly.  How do you suggest this case should be coded?

Response:
As this is a known grouping issue, in keeping with previous advice in #2011 Neonate with melaena due to ingestion of maternal blood published in the 1st Quarter 2004-05 ICD Coding newsletter, the VICC recommends to look up the index entry Withdrawal, state, symptoms, syndrome, opioids and assign:
F11.3 Mental and behavioural disorders due to use of opioids, withdrawal state

The following additional diagnosis code may also be assigned:
P96.1 Neonatal withdrawal symptoms from maternal use of drugs of addiction.

The Commonwealth is planning a review of the grouping of P codes for a future version of the grouper.


Query Text:
This lady had an incision of cervix and an episiotomy during her delivery and proceeded to theatre for repair of both.  We have assigned the procedure codes:
90474-00 [1343] Incision of cervix to assist delivery 
90472-00 [1343] Episiotomy

We are unsure if to code 35618-02 [1277] Repair of cervix, or if it is inherent in the procedure code for incision of cervix to assist delivery. By adding this code the DRG changes from O60B to O02B.

We decided against 16571-00 [1344] Suture of current obstetric laceration of cervix, as it was an intentional cut not a laceration and there would be no diagnosis code to correspond.

Search Details: 
Repair
-Cervix 35618-02 [1277]

Incision
-cervix (for dilation) 35618-03 [1278] 
--to 
---assist delivery 90474-00 [1343]

Response:
The VICC referred this query to the NCCH who provided the following advice:

"The NCCH agrees that 90474-00 [1343] Incision of cervix to assist delivery is similar to an episiotomy and the repair is implied. The NCCH does not consider the addition of an 'includes note' specifying 'includes repair' necessary."


Query Text:
57 year old female with bilateral varicose veins presents for stripping and ligation. She also has insertion of venocuff device x 2 to left LSV. Below is part of the operation report.

A left groin incision was made along the skin crease.  The long saphenous vein, saphenofemoral junction and its tributaries were identified.  Where possible tributaries were preserved.  The long saphenous vein was dissected down to 5 cm distally.  The subterminal and terminal valves were identified.  A single Venucuff was then inserted to the saphenofemoral junction at the level of the terminal valve.  It was tested to the level of 5.  A further Venucuff was then inserted to the subterminal valve at the level of 4.2 cm indicated with ultrasound.  This was also tested to 5.  Following insertion competency was tested clinically using a Valsalva technique, and no reflux was identified intraoperatively.  The wounds were then irrigated with a solution of Cephazolin, and closed in the usual two layer manner following establishment of haemostasis.  The fascia was reconstituted with 2/0 Vicryl suture and the skin was closed in a subcuticular manner using 3/0 Vicryl.  

Our vascular surgeon referred me to CMBS item number 34827 which is obselete and is mapped to ACHI code 34824-00 [721] Application of external stent to superficial vein.  Is this the most appropriate code to reflect the described procedure?

This appears to be a new procedure where the venocuff device is a stent with silicone coating that is inserted into a varicose vein to assist with restoration of venous circulation without having to strip/ligate the vein. This information I have obtained from the following websites.

See: http://www.allvascular.com and http://bdb.org.uk/venocuff.htm

Response:
The VICC agrees that the most appropriate procedure code to assign in this scenario is:
34824-00 [721] Application of external stent to superficial vein.


Query Text:
Destruction
- lesion
- - larynx 
- - - by endoscopic laser 52035-00 [419] 
- - - - with microlaryngoscopy 41864-00 [523] 
- - - - - by laser 41861-00 [523] 


in both the E book, and hard copy books.

Should 'with microlaryngoscopy' be indexed under
- - - by endoscopic laser,
or should it be brought up a level?

Response:
The VICC referred this query to the NCCH who provided the following advice:
"The NCCH agrees that current indexing for destruction and excision of lesion of the larynx is incorrect.  The error in indentation will be amended in future errata."

Therefore the VICC advises that the correct index entry should be:
Destruction
- lesion
- - larynx 
- - - by endoscopic laser 52035-00 [419] 
- - - with microlaryngoscopy 41864-00 [523] 
- - - - by laser 41861-00 [523]


Query Text:
There are conflicting index entries for velamentous insertion of cord.
Index entries:

Delivery, complicated (by), velamentous insertion of cord O69.8 
O69.8 Labour and delivery complicated by other cord complications

Insertion, cord (umbilical) lateral or velamentous O43.1
O43.1 Malformation of placenta

What is the correct code? Please refer to NCCH for action.

Search Details:
Clinical information obtained from:
http://www.medterms.com/script/main/art.asp?articlekey=20497
Velamentous insertion of umbilical cord: An abnormal condition in which the umbilical cord does not insert into the placental mass but, instead, traverses the fetal membranes before it inserts into the umbilical cord. The main danger is vasa previa, a condition in which the blood vessels may be lodged between the fetus and the entrance to the birth canal. The unprotected vessels may rupture at any time during pregnancy, causing fetal hemorrhage and death.

Victorian newsletters, NCCH query database, Commandments have all been checked and no advice found. eBook 5th edition index searched for 'velamentous'. The above two entries are the only ones found.

Response:
The VICC referred this query to the NCCH who provided the following advice:
"For velamentous insertion of cord where care or intervention is required before the onset of labour assign O43.1 Malformation of placenta following the pathway:

Insertion
-cord (umbilical) lateral or velamentous O43.1 
or
Pregnancy
-complicated by
--abnormal
---placenta, placental (vessel) O43.1

Where the abnormality is first diagnosed during labour or requires care and/or intervention during labour assign O69.8 Labour and delivery complicated by other cord complications following the pathway:
Delivery
-complicated (by)
--velamentous insertion of cord O69.8"


Query Text:
Our plastics team have informed us that any digital repairs require microsurgical anastomosis.  

Can we assume that any anastomosis of digital blood vessels be coded to the microsurgical repair codes as per attached letter from our Plastics Team or does this need to be documented in the record.

Response:
Clinical advice would seem to indicate that microsurgical anastomosis of neurovascular structures is inherent in digital repairs, however there does need to be documentation in the clinical notes of microsurgical repair before it can be coded as such.  The VICC will refer this issue to the NCCH for consideration of creating an index entry under Repair, vein/artery, digit that defaults to microsurgical repair.


Query Title:
Same day chemotherapy and loading of external drug delivery device

Query Text:
I seek clarification in regards to same day chemotherapy and loading of an external drug delivery device procedure codes.

Notes state:  Patient admitted for chemotherapy for metastatic bowel cancer.  IV access into portacath, 19g surecan needle - patent, flashback blood.  Chemotherapy given in two and a half hours.  Connected to 5FU infusion to run over 46/24 via infusabottle.  To return on 28 July for removal of pump.

VICC #2084 states that you should assign 96204-00 [1920] Administration of pharmacological agent via external vascular catheter, antineoplastic agent for loading of a portacath, yet at the NCCH ICD-10-AM/ACHI/ACS Fifth Edition education workshop, exercise Pharmacotherapy (1) assigns 96207-00 [1921] Loading of implantable infusion device or pump, antineoplastic agent, for chemotherapy via a portacath.

Suggested codes for the above scenario:
96207-00 [1921] Loading of implantable infusion device or pump, antineoplastic agent (because chemotherapy was given via the portacath prior to the external pump being loaded) ;and
96208-00 [1921] Loading of ambulatory drug delivery device, antineoplastic agent (for loading of the external pump).

On 28 July patient admitted to oncology unit for removal of infusabottle.  Portacath heparin locked with normal saline - needle removed.  Discharged.  Do we use 13942-01 [766] Maintenance (alone) of ambulatory drug delivery device
or 34530-03 [766] Removal of implantable vascular infusion device or pump?

Response:
This query was referred to the NCCH who provided the following advice:
"The NCCH acknowledges that there is a problem with the codes and terminology for pharmacotherapy and drug delivery devices in ACHI Fifth Edition. The most appropriate codes to assign for the scenarios cited are:

1.  96204-00 [1920] Administration of pharmacological agent via external vascular catheter, antineoplastic agent (for administration of chemotherapy for neoplasm via portacath)

2.  96208-00 [1921] Loading of ambulatory drug delivery device, antineoplastic agent (for administration of chemotherapy for neoplasm via infusabottle)

3.  13939-01 [766] Maintenance (alone) of implantable infusion device or pump (for heparin locking of portacath and removal of needle)

These areas have been substantially revised for ACHI Sixth Edition to update terminology and clarify code selection."

The VICC notes that Maintenance (alone) of implantable infusion device or pump is not on the Type B list of the Commonwealth's Day Only Procedures Manual, therefore, unless the episode meets one of the other criteria for admission as detailed in section 2 of the VAED manual under Criteria for Admission, the episode should not be reported to the VAED.


Query Title:
Calculus of VUJ (vesico-ureteric junction) and PUJ (Pelvo-ureteric junction)

Query Text:
Can you please advise the code for calculus of VUJ (vesico-ureteric junction) and PUJ (Pelvo-ureteric junction)?

For VUJ, do you default to N20.1 Calculus of ureter only or do you add N21.0 Calculus in bladder to translate medical statements Although this implies there are 2 calculi.  One in the ureter and one in the bladder. 

For PUJ, do you default to N20.1 Calculus of ureter only or do you add N20.0 Calculus of kidney to translate medical statements? Once again, it implies there are 2 calculi.  One in the ureter and one in the pelvis/kidney.

Response:
This query was referred to the NCCH who provided the following advice:
"The NCCH agrees with your logic to assign the codes based on the higher anatomical site and that the correct code to assign for a calculus of the vesicoureteric (VUJ) junction is, therefore, N20.1'Calculus of ureter' and the correct code to assign for a calculus of the pelvoureteric junction (PUJ) is N20.0 'Calculus of kidney.'

The NCCH will consider indexing the above sites and the inclusion of an instructional note for classifying conditions occurring in more than one site (that are not indexed) at the beginning of Chapter 14, for a future edition of ICD-10-AM."


Query Text:
Mitrofanoff appendicovesicostomy creates a channel into the bladder through which a catheter can be inserted to empty the bladder. The procedure attaches the appendix between the skin and the bladder in order to provide an outlet for urine – one end is tunneled into the bladder and the other end is made into a stoma.

ACHI contains procedure codes for the formation of the mitrofanoff 37045-00 [1108] and revision of mitrofanoff 36609-00 [1087]. We have patients who are admitted for closure of mitrofanoff and we are unsure what is the best way to code them. We have been coding to; 

Closure
-stoma
--intestine NEC
--- large 30562-05 [917]

We chose this to reflect the complete closure of the stoma, however it doesn’t reflect the urinary aspect of the mitrofanoff. Or does 36609-00 [1087] Revision of intestinal urinary conduit cover both revision and closure of a mitrofanoff?

If we code a Z43.x code to reflect the attention to, do we code to Z43.4 Attention to other artificial openings of digestive tract OR Z43.6 Attention to other artificial openings of urinary tract? As the mitrofanoff is used to drain the urinary system, however it’s location & opening is through a portion of the intestinal tract.

Response:
The VICC advises that this procedure is a closure of the external opening of the bladder and that the appendix is the material that has been used to create the opening.  Therefore, following the index entries Closure, vesicotomy or Closure, cystotomy the correct procedure code to assign is:
37023-01 [1105] Closure of cutaneous vesical fistula

For patients who are admitted for closure of mitrofanoff, the correct diagnosis code to assign is:
Z43.6 Attention to other artificial openings of  urinary tract


Query Title:
Coding of routinely monitored conditions in intensive care

Query Text:
I have a query relating to the coding of routinely monitored and commonly occurring conditions in the Intensive Care Unit, particularly those relating to cardiothoracic surgery.  All major body systems are monitored in Intensive Care and adjustments made routinely as the need arises. 

The question is whether these conditions which are intensively monitored as a normal part of the post-operative period should be coded, or are common and expected outcomes of the surgery and, therefore, already included in the 'uncomplicated' DRG weighting. 

The conditions meet the definition of 'additional diagnosis' so in that respect should be coded, but some always impact on the DRG, placing the case into a 'complicated' DRG.  Examples are:

a) Atelectasis.  Often documented as 'decreased air entry' or 'basal crackles' etc, this nearly always impacts on the DRG assignment once clarified with the clinician and physiotherapists, but intensivists here say it is a very common outcome of cardiac surgery because the lungs are handled during the surgery. They question whether it should be considered a 'complication' because it is so common, although acknowledge that it changes management eg. patient is put back onto CPAP.  Physiotherapists here say it's important that it's treated, and it definately impacts on patient management.  I have encouraged them to document the term 'atelectasis' rather than 'decreased air entry', but as nearly every cardiothoracic DRG changes to one ';with complication' it will appear that we have many complications here, when what is occurring is actually very common.

b) Electrolyte levels.  ICU post-op notes refer to 'K replaced', 'mg. Replaced' etc., but transient electrolyte disturbances are an expected outcome of the surgery. 'Hypokalaemia' often affects DRG assignment in cardiothoracic cases, but if transient falls are 'expected', is it correct that it should put the case into a with complication DRG? If so, we will actively encourage clear documentation of the term 'hypokalaemia' rather than 'K replaced' etc.  

c) Urinary output.  This does not impact on DRG unless there is renal failure, however, it is continually monitored and managed and there are many notes in our records referring to 'decreased urinary output'.  Some coders have coded this as 'oliguria' but the kidneys may be functioning well and simply responding to a decreased fluid input. 

d) Blood pressure/mean arterial pressures.  Blood pressure is continually monitored and managed. Should transient drops be coded to hypotension?

Response:
The VICC notes that a DRG with CC does not necessarily reflect 'complication' of care but rather the increased complexity of a case.  It should be noted that not all conditions which occur in the postoperative period and are coded affect the DRG.  Therefore these cases are included in the uncomplicated DRG.  

Coders should not assume a diagnosis based on signs.  In response to the examples provided, the conditions must be documented before they can be coded.  For example, monitioring of decreased urinary output cannot be interpreted as oliguria.  Therefore provided the diagnoses are clearly documented,  and they meet ACS 0002 Additional diagnoses, they can and should be coded.


Query Text:
We have read ACS 0303 Abnormal coagulation profile and understand the scenarios you have made available.  We have read and re-read the standard and still require your help.  We have read FAQ's in 2002 from NCCH which didn't shed much light either.

Can you only code D68.x Other coagulation defects when it is the sole reason for admission or can you code this in scenarios 2 & 3?   Can you code this when found incidentally during admission?  

Patient admitted three times with AF.

1. First admission, patient admitted with AF - is on warfarin.  INR's are monitored during admission and warfarin dose altered. Unstable/high/low INR's have not been documented.  Coded as: 
I48 Atrial fibrillation and flutter
Z92.1 Personal history of long term (current) use of anticoagulants 

2. Second admission, patient admitted with AF - is on warfarin. Documented on discharge summary as 'Subtherapeutic INR levels' as an additional diagnosis.  Patient's INR's monitored during admission and warfarin dose altered.  Coded as:
I48 Atrial fibrillation and flutter 
D68.8 Other specified coagulation defects 
or
I48 Atrial fibrillation and flutter 
Z92.1 Personal history of long term (current) use of anticoagulants 
Unsure which option.

3. Third admission, patient admitted with AF - is on warfarin.  INRs monitored during admission.  High INR levels found day after admission. Documented as 'high INR levels- Vitamin K given' on discharge summary.  
Coded as: I48, D68.3.  Is this correct?

Response:
The NCCH has acknowledged that there are deficiencies in ACS 0303 Abnormal coagulation profile and the standard is currently being reviewed for Sixth Edition to include advice when abnormal coagulation profile occurs during an admission.  

The VICC considers that information contained in ACS 0303 can be applied to episodes where abnormal coagulation profile is not the reason for admission.  

With regards to your scenarios:
1.  The VICC agrees with the enquirer's code assignment of Z92.1 Personal history of long term (current) use of anticoagulants as the patient does not have an abnormal coagulation profile and the warfarin levels are monitored and altered therefore meeting additional diagnosis criteria.

2.  'Subtherapeutic INR levels' means that the patient is underwarfarinised, therefore as per ACS 0303 the correct code to assign is D68.8 Other specified coagulation defects.

3.  The VICC agrees with the enquirer's code assignment of D68.3 Haemorrhagic disorder due to circulating anticoagulants as the patient is overwarfarinised as per the documentation of high INR levels.

Please refer to #2721 Underwarfarinisation for Seventh Edition advice regarding scenario 2.


Query Text:
If a patient presents for a simple mastectomy, sentinel node biopsy and complete axillary clearance, which set of procedure codes below should be used?
31518-00 [1748] Simple mastectomy unilateral
30336-00 [808] Radical excision of lymph nodes of axilla
or
31518-00 [1748] Simple mastectomy unilateral
30335-00 [808] Regional excision of lymph nodes of axilla
30336-00 [808] Radical excision of lymph nodes of axilla

Apparently the surgeon performs a sentinel node biopsy prior to the clearance and sends it to pathology.  The surgeon receives the results while the patient is still in theatre and then decides whether to proceed with a complete axillary clearance.

We have recently had a research request on sentinel node biopsies.  If the first set of codes are correct, are we able to code 30335-00 [808] as an additional procedure for research purposes?

Response:
As you have pointed out sentinel node biopsy is a separate procedure to the axillary clearance even though it is of the same anatomical site and in the same operative episode, therefore as per ACS 0016 General procedure guidelines, it should be coded.


Query Title:
Infection and rejection of buccal mucosa graft

Query Text:
A patient is admitted with an infected buccal mucosa graft that was used for the first stage of a urethroplasty (phx hypospadias).  As a result of the infection parts of the graft were rejecting.

We have had debate about which code is the most appropriate code for the principal diagnosis.  There are two options that we can see:
1. T83.5 Infection and inflammatory reaction due to prosthetic device, implant and graft in urinary system

2. T86.88 Failure and rejection of other transplanted organs and tissues

We have selected T86.88 because of the exclusion note on T83 - excludes failure and rejection of transplanted organs and tissues (T86.-).

We are still not confident in this choice as the word graft is used in T83.5 but should this only apply to non-transplanted or synthetic grafts?

If you look up Complication, graft, skin  the term infection is a non-essential modifier, so do infections of transplanted organs/tissue go to T86 or to the most appropriate code from T82-T85?

Are you able to clarify how an infected transplanted tissue graft should be coded?  Does it apply to all infected transplanted tissue grafts (skin, muscle, bone, blood vessels)?

Response:
In the case cited, the graft is of the urinary tract and the buccal mucosa (not skin) is the material used to create the graft.  Therefore the correct index look up is Complication, graft, urinary organ, infection or inflammation to assign:
T83.5 Infection and inflammatory reaction due to prosthetic device, implant and graft in urinary system

The word 'graft' in the code description of T83.5 relates to any graft that is, any tissue or material.

The excludes note at T83 'excludes failure and rejection of transplanted organs and tissues (T86.-)' is a type 2 excludes note therefore because in your scenario there is also rejection of the graft, T86.88 Failure and rejection of other transplanted organs and tissues is also assigned to reflect the rejection component of the medical statement.

Complication, graft, skin (failure, infection, rejection) T86.88 Failure and rejection of other transplanted organs and tissues suggests that all complications of skin grafts should be coded as rejections.  

In response to your question regarding the coding of infected transplanted tissue graft, VICC advises that reference to the index should be made with regard to the site being grafted.  VICC also notes that infected skin graft will default to the rejection code, while infected graft of other anatomic sites will be coded to a specific code for that site. 

Apply ACS 0001 Principal diagnosis to determine which code should be used for principal diagnosis.


Query Text:
Baby is born and noted to have a two vessel cord.  No abnormality is found in the baby but the baby is seen by a paediatrician and referred for follow up and an ultrasound.

We cannot assign P02.2 Fetus & newborn affected by other and unspecified morphological and functional abnormalities of placenta - as the baby has not been affected.

Is it possible to assign Q27.0 Congenital absence and hypoplasia of umbilical artery.  Or is this making an assumption?

If we cannot assign this code then what do we use?

Response:
A two vessel cord is a single umbilical artery and one umbilical vein.  Provided there is evidence that this condition meets ACS 0002 Additional diagnoses as in the case cited, it can be coded.  Follow the index under Single, umbilical artery to assign:
Q27.0 Congenital absence and hypoplasia of umbilical artery


Query Text:
My query relates to pharmacotherapy via a portacath.

At the NCCH ICD-10-AM 5th edition workshop, Exercise - pharmacotherapy (1) stated
59 year old male with adenocarcinoma of descending colon and metastases to the liver presented to the ward on 28/4 for same day chemotherapy (C5D15 Folfiri) via portacath with no problems.

The answers were as follows.
Z51.1 Pharmacotherapy session for neoplasm
C18.6 Malignant neoplasm, descending colon
C78.7 Secondary malignant neoplasm of liver
M8140/3 Adenocarcinoma NOS
M8140/6 Adenocarcinoma, metastatic NOS
96207-00[1921] Loading of implantable infusion device or pump

On the NCCH database Query Q2131 states that IV chemotherapy via portacath is not the same as loading of the device. Where IV chemotherapy is performed via portacath, assign: 96204-00 [1920] 'Administration of pharmacological agent via external vascular catheter, antineoplastic agent'. The NCCH is aware that the above advice is in conflict with the term 'external' in the code title of 96204-xx, but considers this the best code available to classify the procedure performed. The NCCH will consider amending this area of ACHI for a future edition. A Coding Matters article will be published in the interim to clarify these classification issues. 

Does the advice from the NCCH still stand or do we now use 96207-00 [1921] for chemotherapy via a portacath?  

Search Details: 
NCCH query Q2131
NCCH 5th edition education workshop

Response:
The VICC referred this query to the NCCH who provided the following advice:
"The NCCH acknowledges that Exercise - Pharmacotherapy (1) in the ICD-10-AM Fifth Edition Workshop incorrectly advised the procedure code for ‘administration of chemotherapy via portacath’ to be 96207-00 [1921].

The advice in Query 2131 stands - the correct code to assign for IV administration of chemotherapy for neoplasm via a portacath is 96204-00 [1920] Administration of pharmacological agent via external vascular catheter, antineoplastic agent.

There has been substantial revision of pharmacotherapy codes for ACHI Sixth Edition to update terminology and clarify code selection."


Query Title:
Urinary catheterisation in medical cases

Query Text:
The question of whether a code for urinary catheterisation should be assigned when performed for medical (not surgical) patients has arisen in our hospital network.

We note that the ACS 0042 Procedures normally not coded directs us not to assign a code for postprocedural urinary catheterisation unless the patient has been discharged with the catheter in situ.  Does this also apply to medical patients who have not had a procedure performed, as the standard states postprocedural catheterisation?

Query Q1358 on the NCCH database discusses urinary retention with IDC insertion in a medical patient who was discharged with the catheter still in situ.  In this situation we were instructed to assign a code for the insertion of the IDC.

However, what about when a medical patient has an IDC inserted, but it is removed before discharge?  Should a code for the insertion of an IDC be assigned in this case?  Not all medical patients have IDCs inserted.

We have been unable to find further direction on the NCCH database or in the VICC Newsletter, and fellow HIMs have differing opinions.  We look forward to clarification from VICC on this issue.

Response:
The VICC advises that in accordance with advice published in NCCH query Q1358 (02/11/2000) Second edition, a code for the urinary catherisation in medical patients is only assigned if the urinary catheter is present on discharge.


Query Title:
Blood clots following Transurethral resection of prostate (TURP)

Query Text:
Please refer to ICD Coding Newsletter July 1996 #1176.  Is this answer is still current?

A patient comes in to Casualty with haematuria, and urinary retention due to blood clots following a TURP which was performed 2 weeks ago.  A bladder washout was performed using an IDC.

In 1996, we were instructed to code this as:(I have converted the codes to ICD10)
T81.0 Haemorrhage complicating a procedure
N99.8 Other postprocedural disorders of genitourinary system
R33 Retention of urine
Y83.6 Removal of organ
Y92.22 Health service area

After reading the current ACS 1904 Procedural complications, under the "classification of transient conditions" section, I'm not sure if it still holds.

Response:
The Procedural complications Coding feature in the November 2001 ICD Coding newsletter specifically says that VICC #1176 is no longer applicable and coders should not be applying it.  Note index entry:  Clot, bladder N32.8 Other specified disorders of bladder. 

Coders should refer to ACS 1904 Procedural complications for guidance.


Query Text:
We note there is a new code for Radioablation of Liver, we now perform this procedure on Kidneys to treat renal tumours.  Following the instructions in NCCH query #1250 we are currently using Other procedures on kidney - 90354-00 [1064].  Could you please confirm if this is the correct code to use and also could you develop a new procedure code for this procedure as you did for the liver.


Search Details: NCCH #1250

Response:
The VICC agrees with the enquirer's code selection and will forward this query to the NCCH for consideration of creating a new code for radioablation of kidney.

Refer also to VICC query 2596 Radioablation of a kidney lesion.


Query Text:
ACS 1530 Premature Delivery and ACS 1515 Antepartum Condition with Delivery appear to provide conflicting advice with regards to the principal diagnosis for obstetric cases.

For example:
A 30 year old primigravida was admitted at 34 weeks gestation on 1.9.06 with severe pre-eclampsia. On 10.9.06 she underwent an emergency caesarean delivery due to fetal distress. 

ACS 1530 states if the reason for early delivery is documented in the clinical record, code this as the principal diagnosis, followed by O60.1.

ACS 1515 states if an episode of care includes delivery of a baby but the patient was admitted for an antepartum condition which required treatment for more than seven days before the birth, sequence the antepartum condition as the principal diagnosis.

According to ACS 1530 fetal distress should be the principal diagnosis. 

According to ACS 1515 severe pre-eclampsia should be the principal diagnosis.

Please advise which ACS takes preference in this example.

Search Details: ACS 1530 and ACS 1515

Response:
Draft response to enquirer:

The VICC advises to follow the advice published in Coding Matters Volume  13, Number 2 Frequently asked questions - part 1:
Q: Is there a rule regarding principal diagnosis selection for obstetric cases?
A: Chapter 15 of the ACS provides a number of standards which deal with principal diagnosis selection, in particular ACS 1515 Antepartum condition with delivery and ACS 1530 Premature delivery. If none of these standards apply, ACS 0001 Principal diagnosis should be followed. In obstetric cases, the reason for admission is for the safe delivery of the baby and, therefore, in most instances the principal diagnosis will be based on the sequence of events surrounding the delivery.  However, there may be some exceptions to this, therefore, coders should follow ACS 0001 Principal diagnosis for code assignment. This issue is currently under review.

The VICC will forward this query to NCCH as examples when reviewing ACS 0001 Principal diagnosis for obstetrics.


Query Text:
61469-00 [2205] Lymphoscintigraphy is referred to as a 'code also' directive in the tabular list in block [808]:
30335-00 [808] Regional excision of lymph nodes of axilla
Level I excision of lymph nodes of axilla
Limited excision of lymph nodes of axilla
Low axillary dissection or excision
Regional lymph node excision with excision of  lymphatic drainage area including fat
Sentinel node biopsy/excision
Note: Level I includes nodes of the lower axilla up to the lower border of pectoralis minor
Code also when performed:
• injection of radioisotope and mapping (lymphoscintigraphy) of nodal basin (61469-00 [2005])

Please advise whether the 'code also when performed' note above applies in a hospital that does not have a nuclear medicine department on site.  Some of our patients have lymphoscintigraphy and it is performed at another hospital across the border either the day prior or the morning of the axillary lymphatic procedure at our hospital.  Thus lymphoscintigraphy is performed but not during the episode of care we are coding, but as an outpatient of another hospital.  Do we code the lymphoscintigraphy?

Response:
The VICC advises that if the procedure is performed during the episode of care or the procedure is performed under contract, then it should be coded.


Query Text:
ACHI Index:

Rotation, forceps, with delivery 90468-04

Delivery, forceps, with rotation 90468-03

Delivery, forceps, with rotation, with extraction 90468-04

The code descriptions are:
90468-03 Forceps rotation of fetal head
90468-04 Forceps rotation of fetal head with delivery.

It seems that the index entry under Delivery, forceps, with rotation should give the code 90468-04, and that the essential modifier of 'with extraction' is unnecessary as 'with delivery' is already specified.

Search Details: 
Index entries; Tabular entries.
NCCH query Q899 (1/4/99) re specificity of type of forceps provides answer of: 90468-04 [1337] Forceps rotation of fetal head with delivery is provided for cases where the baby is rotated and delivered with the same forceps.  The specificity of forceps type is not essential in such circumstances.  Therefore in the case cited, only one code 90468-04 [1337] should be assigned.

Response:
The VICC referred this query to the NCCH who provided the following advice:
"The correct code to assign for forceps rotation with delivery is 90468-04 Forceps rotation of fetal head with delivery.

The current indexing under 'delivery' is misleading and will be reviewed for a future edition of ACHI."


Query Text:
Patient diagnosed with 'exertional angina'.

We have had ongoing discussions as to whether this should be coded to I20.9 angina, unspecified or I20.8 Other forms of angina.

In the Tabular volume, 
I20.8 Other forms of angina lists 'Angina of effort', however I20.0 Unstable Angina lists 'worsening effort'.  This is adding to coders confusion.

Which code does the Vic Coding Committee recommend be used for 'exertional angina'?

Response:
The VICC advises to follow index entry Angina, specified, to assign:
I20.8 Other forms of angina pectoris


Query Title:
Additional diagnoses for rehabilitation and GEM episodes

Query Text:
I am seeking clarification of the requirement by DHS to fully code out all conditions that a patient has whilst he or she is receiving either Rehabilitation or GEM care.  It has been brought to my attention that there is a large metropolitan network that apparently has instructed its coders to simply put in the appropriate “Z” code for rehab, and a principal diagnosis for GEM.  It takes many hours each month for my staff to fully code all the complications, co morbidities and other interventions for these patients.  It not used at all in for in house reporting.

Response:
The VICC advises that irrespective of Care Type conditions meeting additional diagnosis criteria in the episode of care must be coded.  In addition, rehabilitation and GEM episodes must be coded in accordance with ACS 2104 Rehabilitation and 2108 Assessment and applicable Victorian additions to the ACS.  This is mandated by the Victoria-Public hospitals and Mental Health Services Policy and Funding Guidelines 2006–07 - General Conditions of Funding, section 6.1 Supply of statistics and information which states:
“The hospital or SRHS will code patient episodes reported to the VAED in accordance with the current Australian Coding Standards and as amended from time to time, Victorian Additions to the Australian Coding Standards effective 1 July 2006 and ICD Coding Newsletters issued from time to time by the department”.


Query Text:
When coding EPS with radiofrequency ablation 38212-01 [665], should an additional code be used for the  EPS to indicate the number of catheters used?  I am advised by our cardiac cath. lab. that EPS can be performed using 2 or 3 catheters, then if an aberrant pathway is detected, an additional catheter is inserted for the ablation.  Other times, 4 catheters are inserted initially, 3 of which are used for the study and the 4th is then used for ablation.  Therefore, ablation can be performed using 3 or 4 catheters.  

Search details:
VICC query #1927 advises that radiofrequency ablation is always performed in conjunction with EPS and to code this to 38212-00 [665] Cardiac electrophysiological study >4 catheters in 4th edition.  In 5th  edition we can use 38212-01 [665] but there is no reference to the number of catheters used in the study.  Does the use of this code override the need for any specification of the number of catheters?  Using the index the look-up for EPS is: 
Study
-electrophysiological (EPS)
--cardiac
---with 
----ablation by radiofrequency 38212-01 [665]
---< 3 catheters 38209-00 [665]
---> 4 catheters 38212-00 [665]
This would lead me to believe that a code for both the ablation and the number of catheters could be used.  However the look-up for ablation is:
Ablation
-cardiac
 --by radiofrequency with electrophysiological study 38212-01 [665]

This would seem to indicate that only one coded is needed. Your advice would be appreciated.

Response:
The VICC advises that in accordance with ACS 0041 Conventions used in the alphabetical index of interventions when a procedure description includes terms listed under a prepositional subterm and an alphabetic subterm, the prepositional subterm takes precedence.  Therefore, in the case cited following the index entry:
Study
-electrophysiological (EPS)
--cardiac
---with 
----ablation by radiofrequency 38212-01 [665]

The correct code to assign is 38212-01 [665] Cardiac electrophysiological study with radiofrequency ablation.  There is no need to assign an additional code to identify the number of catheters.


Query Title:
Readmission for post abortion complications

Query Text:
This query relates to the article Fetal Death In Utero, Termination and Abortion published as a Coding Feature in ICD Coding Newsletter, August 2003, specifically the section �Readmission with other post abortion complications.  The advice is copied below:

Readmission with other post abortion complications:
If readmitted with other post abortion complications code:
O08.x Complications following abortion and ectopic and molar pregnancy
and
xxx.x Code for condition, if this adds specificity
and
O09.x Duration of pregnancy

We have noted that the advice to include code O09.x changed between 1st and 2nd editions of the ACS and this code is longer required as an additional code when using O08.x.

Coding Matters Volume 9 Number 3 (December 2002) page 13 also advises that O09.x Duration of Pregnancy should not be assigned with category O08.

We request that this article be updated to reflect the current coding advice in ACS 1518 Duration of Pregnancy which states O09 is required as an additional code in all cases of abortion in the code range O00-O07.


Search Details: References used in writing this query:

ACS 1518 Duration of Pregnancy (1st, 2nd and 5th editions)
ICD Coding Newsletter August 2003
Coding Matters Volume 9 Number 3 Page 13 (December 2002)

Response:
The VICC notes that the enquirer is correct and acknowledges that in the conversion of the article from ICD-9-CM to ICD-10-AM this detail was overlooked ,that is, O09.x is no longer required when assigning a code from O08.x.  At this stage the VICC has no plans to revise the article.

Coders are reminded that more recent advice may exist, when they are referring to advice published in previous editions of 
ICD-10-AM/ACHI and that they must code in accordance with the latest published advice.


Query Text:
We have a sameday patient with lymphoma admitted for CSF pathology to be collected from their Ommaya reservoir (inserted in a previous admission).  The NCCH query Q1994 advice suggested to use code 39015-01 [3] Insertion of ventricular reservoir, for the insertion of the reservoir. 

The most appropriate procedure code we could find for CSF collection is 13939-01 [766] Maintenance (alone) of implantable infusion device or pump. Please advise on code selection.

Response:
The VICC agrees with the enquirer's code selection following index entry Withdrawing, fluid, from, implantable infusion device or pump (reservoir) to assign:
13939-01 [766] Maintenance (alone) of implantable infusion device or pump.  

It should be noted that this procedure is on the Type C list of the Commonwealth's Day Only Procedures Manual therefore, unless the episode meets criteria for admission, the episode would not normally be reported to the VAED.


Query Text:
Please advise on the procedure code for excision of concha bullosa. Male patient 32 years with DNS (not corrected this admission) admitted for removal by FESS of nasal polyps and concha bullosa. Codes assigned: 
J33.0 Polyp of nasal cavity 
J34.3 Hypertrophy of nasal turbinates 
J34.2 Deviated nasal septum
41737-02[386]Ethmoidectomy, unilateral
41668-00[377]Removal of nasal polyp
41764-01[370]Sinoscopy GA [1910]

Search Details:
The index (page 81) excision, concha bullosa - see Ethmoidectomy.
However, in NCCH Casemix, DRGs & clinical coding (2000),that advises to assign disease code J34.3 Hypertrophy of nasal turbinates for concha bullosa, the advice is to assign for removal of concha bullosa 41689-00 [376] partial turbinectomy. If ethmoidectomy is also performed then the turbinectomy code is not assigned. This advice post-dates the NCCH query database #340 27/8/1998 1st edition which refers the enquirer to the index.

Ethmoidectomy was not performed in this case.

DRG with ethmoidectomy D06B other sinus & complex middle ear procedures.
DRG with turbinectomy D10Z Nasal procedures.

Response:
The NCCH was consulted with regards to this query and provided the following advice:

"The NCCH Casemix, DRGs and Clinical Coding Specialty Books are not relevant beyond ICD-10-AM/ACHI/ACS Third Edition. The Good Clinical Documentation Guide replaced these Specialty Booklets from Fourth Edition.

For excision/removal of concha bullosa follow the index and assign the appropriate ethmoidectomy code. If an ethmoidectomy is not performed assign only codes for the specific procedure(s) performed.

Please consider submitting a public submission with supporting clinical advice if you feel changes to the index are warranted."


Query Text:
How do you code a cyclops lesion of the knee?  Cyclops lesion is a complication of previous reconstruction surgery to the knee.   The codes I have come up with are:   
T84.4 Mechanical complication of other internal orthopaedic devices, implants and grafts
Y83.4 Other reconstructive surgery
Y92.22 Health service area
with perhaps M25.66 Stiffness of joint, not elsewhere classified, knee to further describe the manifestation (stiffness of the knee) (after T84.4).

Search Details:  Cyclops lesion
A cyclops lesion is a complication of anterior cruciate ligament surgery, where the new replacement ligament slowly strips away and bundles into a knot, jamming up the 'intercondylar notch' and preventing the knee from fully straightening. The lump sometimes looks like the central eye of a mythical 'cyclops' monster, hence the name.
http://www.kneeguru.co.uk/dictionary/doku.php/c/cyclops-lesion

Response:
The VICC agrees with enquirer's selection of principal diagnosis, T84.4 Mechanical complication of other internal orthopaedic devices, implants and grafts.  

An additional code, if required, should further specify the specific disorder and reflect the condition of the ligament, for example, ‘disorder of ligament’ rather than a symptom or manifestation. Therefore the assignment of M25.66 Stiffness of joint, not elsewhere classified, knee is not supported.

The correct external cause code to assign in this scenario is Y83.2 Surgical operation with anastomosis, bypass or graft as it is more specific than Y83.4 which is ‘other’ reconstructive surgery.


Query Text:
After reading the NCCH queries 1811, 1877, 1975, 2002 and 2023, the responses determine that R45.81 Suicidal ideation should be assigned as a principal diagnosis where documentation in the clinical record is incomplete and clinical advice is unavailable to confirm any underlying mental disorder (NCCH query 2023).

R45.81 coded as the principal diagnosis groups to DRG 961Z Unacceptable Principal diagnosis with 0 WIES.

NCCH state in query 1811 'It is therefore inappropriate for the NCCH to advise the use of an alternative code in order to 'fix' grouping problems.  This issue should be followed up with the Commonwealth Department of Health and Ageing and your local state health authority'.

I have heard from the DHS that for version 5.2 of the grouper there is a fix for this issue.

Can you please advise the correct code for 'Suicidal ideation' for the interim where documentation in the clinical record is incomplete and clinical advice is unavailable to confirm any underlying mental disorder?

Could Z03.2 Observation for suspected mental and behavioural disorders be possibility for the interim with R45.81 Suicidal ideation as an additional diagnosis?

Response:
The VICC advises to refer to ACS 0521 Admitted patient without sign of mental illness and be guided by the documentation in the medical record.  Several codes may be appropriate, and coders should look in particular at the following codes: 
Z03.2 Observation for suspected mental and behavioural disorders 
Z04.6 General psychiatric examination, requested by authority; or 
Z00.4 General psychiatric examination, not elsewhere classified.


Query Title:
Coding of manifestations of multiple sclerosis

Query Text:
Should all manifestations of MS be coded out when a patient is admitted with MS or are they considered to be part of the disease process and not coded?  Is this the same for other neurological disorders, for example,  Parkinsons disease?

We have noted that ACS 0625 Quadraplegia/Paraplegia instructs coders that MS can be coded as an underlying cause for the paraplegia.

We also note NCCH Q1064 on the NCCH database.  This instructs coders to follow ACS 1802 Signs and Symptoms 'certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right'.  This last point is of particular importance as some 'symptoms', because of their significance, require coding as well as the underlying cause.

Is allied health considered to be medical care for these patients so therefore allow certain symptoms to be coded?

Search Details:  
NCCH Q1064 Multiple sclerosis  
Q: When an MS patient is admitted, should we code the MS alone or should we also code out the symptoms/manifestations of the MS? For example neurogenic bladder, paralysis etc. How should these be sequenced? Is it similar to cancer? ie. code the problems then the underlying cause? (known cerebral metastases, patient presenting with seizures). Of course a lot of the problems are transient and do not always represent. In addition would the same apply to Parkinson's and other systemic neurological disorders?  
A: The NCCH cannot make hard and fast rules about the cases you have cited without reference to the clinical documentation. For correct code assignment, there are three standards which you need to bear in mind: 1. ACS 0002 ADDITIONAL DIAGNOSES 2. ACS 0001 PRINCIPAL DIAGNOSIS 3. ACS 1802 SIGNS & SYMPTOMS.  23/11/1999  1st  edition

Response:
The VICC advises that manifestations and symptoms of MS should not be automatically coded, they should be coded in accordance with ACS 0001 Principal diagnosis, ACS 0002 Additional diagnoses and ACS 1802 Signs and symptoms (if applicable).  This instruction applies to other neurological conditions such as Parkinson’s Disease.

ACS 0625 Quadriplegia and Paraplegia provides specific direction for the coding of MS as an underlying cause in that context.

Allied health intervention is considered to be medical care, therefore any specific condition documented as requiring allied health intervention will meet ACS 0002 Additional diagnoses criteria.


Query Text:
When using histology to code a record, should we only use information contained in the conclusion or can we obtain information from the body of the histological report as well?

For example, if the conclusion of the report says 'Basal Cell Carcinoma' but in the body of the report it states that 'the tumour has the appearance of a fibroepithelial BCC'; which morphology code should we be using?

My understanding from speaking to a histopathologist is that in some cases the body of the report is often a 'worksheet' completed sometimes by a junior histopathologist, but that the conclusion is usually the validated diagnosis by a more senior pathologist.

The example given is quite simplistic, but it is not always very straightforward.

Response:
The conclusion of the report should be used when confirming histopathological details for coding purposes.  Where the coder considers that there are discrepancies between the conclusion and the body of the report, ACS 0010 General abstraction guidelines should be followed and clarification from the clinician should be sought.

In the case cited, the VICC considers the appropriate morphology is M8090/3 Basal Cell Carcinoma.[End of original response].

This query is superseded by Coding Rule Q3147 Selection of morphology codes from pathology reports published 15 March 2017 reproduced below:
Q:
Should coders use the summary or the microscopic section of the pathology report to determine the correct morphology code?
A:
ACS 0010 Clinical documentation and general abstraction guidelines/Findings that provide more specificity about a diagnosis states:
 
Laboratory, x-ray, pathological and other diagnostic results should be coded where they clearly add specificity to already documented conditions that meet the criteria for a principal diagnosis (see ACS 0001 Principal diagnosis) or an additional diagnosis (see ACS 0002 Additional diagnoses).
 
A discharge summary is a summation of the whole episode of care; similarly the summary on a pathology report provides a brief summation of the body of the report. The entire pathology report must be used to abstract information for the purposes of clinical coding and therefore determine the correct morphology code.
 
This advice has a minor modification to correspond with an update in a subsequent edition of ICD-10-AM/ACHI/ACS.


Query Text:
Male patient 32 year of age presented with a perforated duodenal ulcer (not bleeding).  The operation report states suture of perforated peptic ulcer, omental patch fixed (operation report attached).

The current advice at our organisation is to code as repair of site being patched.  See Repair, intestine, small NEC 
30375-19 [901]  .   Another possible code would be Suture, ulcer, perforated (duodenal) (gastric) 30375-10 [887]  .

If both suture of ulcer and omental patch were performed, which is the more appropriate code to use?

Search details:
NCCH query Q43 applies to repair of a bleeding ulcer using an omental patch so is not relevant.

Response:
The VICC advises that if both the suture of the perforated ulcer and the omental patch are performed, that both procedures are coded.  The correct codes to assign for each procedure are:
30375-10 [887] Suture of perforated ulcer, for the suture of the ulcer
30375-19 [901] Other repair of small intestine, for the omental patch

For Ninth edition advice please refer to #3062 Repair of perforated ulcer.


Query Text:
ACS 1404 Admission for renal dialysis states that "Where the patient is discharged on the same date as the admission or on the next day after admission, code as principal diagnosis, either Z49.1 Extracorporeal dialysis for extracorporeal dialysis or Z49.2 Other dialysis for peritoneal dialysis."

Patient with ESRF is now ready to commence CAPD. The patient is admitted and discharged on the same day for specialised training and during the course of training the procedure of CAPD is also performed.  

Should the principal diagnosis be Z49.0 or Z49.2 as per ACS 1404?

Response:
The VICC notes that because the specialised training involves receiving supervised dialysis, the correct principal diagnosis code to assign is:
Z49.2 Other dialysis

Procedure code 13100-08 [1061] Continuous peritoneal dialysis, long term should be assigned and 90352-00 [1063] Education and training for home dialysis may also be assigned to indicate the training component of this episode of care.

Note: This query has been retired due to ACS and ACHI classification updates.


Query Text:
Can you please advise on the appropriate codes we should use for Uterine Fibroid Embolisation?

We have started doing these procedures and I have been unable to find an appropriate code.  Catheters are inserted into both uterine arteries, and particles are injected into the arteries to effectively cut off circulation to the fibroid, with the aim of shrinking the fibroid. This is done in the angio lab (not theatre).  There is a good description on femisa.org.au of this procedure.

I can't find any ACHI code that accurately reflects this procedure, as there are no index entries for Destruction, lesion, uterus. I have used 90436-00 [1273] Other procedures on uterus and 59924-00 [1989] Other arteriography as a last resort.

Do you have any better codes that other sites are using for this procedure?

Response:
The VICC advises that as this is a procedure where the blood supply to the lesion is disrupted, the correct index look up is Embolisation, artery, via surgical peripheral catheterisation.  Therefore the correct code to assign is:
35321-00 [767] Transcatheter embolisation of blood vessel

Coding Matters Volume 6 Number 2 September 1999 provides the following information in the article titled 'Transcather embolisation of blood vessel':

"Transcatheter embolisation of blood vessels is performed to therapeutically block or occlude blood vessels. This may be performed to arrest a haemorrhage, treat vascular anomalies such as arteriovenous malformations (AVM) or fistulas or to block blood supply to a tumour.  Embolisation can also be performed as a precursor to surgery, such as excision of tumour or clipping of AVM, as embolisation reduces the risk of haemorrhage or infarct. 

The technique involves the delivery of an agent or device through a small catheter and is generally performed in X-Ray departments or catheter laboratories. Many agents or devices can be used to occlude blood vessels: 
· Sponges - gelatin (Gelfoam) or plastic
· (polyvinyl alcohol)
· Balloons
· Wire coils (steel or platinum with or without
· polyester strands)
· Ethanol
· Glue
· Silastic pellets"

The VICC notes that the combination of diagnosis and procedure codes is all that is required to translate the medical statement into code.


Query Title:
Bile leakage following laparoscopic cholecystectomy

Query Text:
Victorian ICD Coding Newsletter February 2004 #1873 indicates to code bile leakage following laparoscopic cholecystectomy as it is a DHS performance indicator (CI-4). 

In this particular query, there is no indication that the bile leakage was treated, monitored (to meet ACS 0002).  Do we follow this advice because it is an indicator or does there have to be evidence of treatment ?

Search Details: 
Victorian Newsletter, NCCH queries (nothing for bile leakage)

Response:
The VICC notes that VICC query #1873 does not contain an instruction to always code bile leakage, but rather provides advice on how to code it if it meets criteria for coding.  The existence of DHS performance indicators should not be used as a criteria for coding.  Bile leakage would be coded if it is documented as being treated, monitored or actively evaluated, that is, meets ACS 0002 additional diagnosis criteria.


Query Text:
Patient is 78 years of age. Bronchiectasis first diagnosed at 6 months of age.  Patient has had multiple admissions over the years, and is on permanent daily antibiotic treatment.

Question 1:
Should this be coded as 'congenital bronchiectasis' even though the word congenital is never used?  I think that since the bronchiectasis was diagnosed as such a young age, without the aid of present day diagnostic resources it could be assumed that the bronchiectasis was congenital.    

Question 2:
How do you code 'infective exacerbation'?  Do you code the bronchiectasis code first  (either J47 or Q33.4) followed by J22 to indicate the LRTI?  or do you code the J22 first,  followed by the bronchiectasis code? 

Question 3:
Patient deceased - death certificate notes Respiratory Failure as the cause of death, with the infective exacerbation of bronchiectasis second.  Would you code the Respiratory Failure?  Wouldn't this be just a progression of the infective exacerbation of bronchiectasis?

Search Details: 
NCCH Q1977 (which gives the impression that the infection should be coded first, followed by the bronchiectasis to complete the clinical picture).

NCCH Q2125 (Should congenital bronchiectasis be considered in the same line as CF?  Should be code the Bronchiectasis first, with the specific manifestations second?)

Response:
The VICC advises the following in response to your specific questions:
Answer 1:
Conditions not present at birth are not considered to be congenital.   If information is not available to the coder regarding whether or not the condition was present at birth, the coder must seek further clarification before assigning a congenital code. Coding Matters Volume 13 Number 2, September 2006 article titled 'Assignment of Chapter 17 Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) as additional diagnoses' provides the following definition:
'A congenital condition is one that is present at or before birth. Congenital conditions may be inherited. For example, osteogenesis imperfecta is a genetic disorder that is present at birth'.

Answer 2:
Infective exacerbation of bronchiectasis with no documentation of the infective component is coded as J47 Bronchiectasis. In order to assign a code for the 'infective' component, documentation such as pneumonia or LRTI must be present.  The word 'infective' in infective exacerbation on its own is not sufficient to assign J22 Unspecified acute lower respiratory infection. 

Answer 3:
Respiratory failure is considered a condition in its own right and therefore can be coded if it meets criteria for coding outlined in ACS 0001 Principal diagnosis and ACS 0002 Additional diagnoses.  Bronchiectasis may be the underlying cause of respiratory failure.


Query Text:
A patient was admitted in labour at 16 weeks.  Membranes ruptured and a baby was born weighing 120g.  Baby had beating heart and took several  breaths.

Do we code this just as a spontaneous abortion?  Or are we able to code: 
O03.9 spontaneous abortion
O09.2  duration of pregnancy 14-19 weeks
O60.1  preterm labour with preterm delivery
Z37.0  single liveborn

as per the advice contained within ACS 1511 Termination of pregancy, if not why is a spontaneous abortion different?

Search Details: 
NCCH Q695 allows the addition of Z37- to indicate a live outcome.

Response:
The VICC referred this query to NCCH who provided the following advice:
"The correct code assignment for the scenario cited is:
O03.9 Spontaneous abortion, complete or unspecified without complication
O09.2 Duration of pregnancy, 14 - 19 completed weeks
Z37.0 Single live birth

It is incorrect to assign O60.1 Preterm spontaneous labour with preterm delivery.  ACS 1510 Pregnancy with abortive outcome states 'a livebirth in Australia is defined as at least 20 weeks gestation or at least 400g weight, an abortion is therefore defined as expulsion or extraction of the products of conception by any means, before fetal viability, that being less than the 20th week of pregnancy (140 days) and/or less than a fetal weight of 400g.'  Therefore the scenario cited is an abortion not a preterm delivery.

In the rare circumstance such as cited in the query where the fetus has a beating heartbeat and takes several breaths or lives for a period of time, assign an additional code from Z37 Outcome of delivery as per previous advice in Q695.

ACS 1510 Pregnancy with abortive outcome and ACS 1511 Termination of pregnancy have been revised for ACS Sixth Edition."


Query Text:
Due to being a small country hospital we will often send patients to larger hospitals for imaging (for example, CT scans, MRI's) while still an inpatient. They have the scan done as an outpatient and then return to us once completed. As they are an inpatient at the time the hospital pays for the scan and ambulance if one was required for transport of patient for the scan.  My query is if we should be coding the CT scan or not?

I do know of some hospitals in similar circumstances that do code them and some that don't.

According to VICC query #2237 we should be coding them but we never have.  Please clarify and would appreciate something in writing.

Response:
The VICC advises that currently medical imaging procedures performed in privately owned radiology departments or radiology departments at other hospitals are only coded if the hospital pays for the procedure.  

As the VICC has now received several queries about this matter, the issue is being further investigated.  It is proposed that updated advice will be issued for 1 July 2007 implementation.


Query Text:
Patient admitted to ED at 10.00am.  Patient intubated in ED at 11.00am and immediately commenced SIMV.  At 1.00pm decision is made to send the patient to the Cath Lab/Radiology/Theatre where the patient undergoes a procedure/surgery (still ventilated).  Procedure completed at 4.00pm and patient is transferred to ICU where they continue SIMV until 6.00am the next morning, at which point the patient is extubated.

Total MV hours is 19.  Should 13882-00 [569] Management of continuous ventilatory support <= 24 hours be assigned (as well as an initiation code)?  ACS 1006 point 5 states:
'Assign a code for continuous ventilatory support for periods <= 24 hours ONLY when the ventilation is not performed during a procedure. For example, ventilation for <= 24 hours in intensive care after head injury or burns should be coded.

The ventilatory support that is provided to a patient during surgery is associated with anaesthesia and is considered an integral part of the surgical procedure and therefore ventilation of <= 24 hours should not be coded in these cases. However, CVS initiated during surgery and continuing for greater than 24 hours should be coded with duration beginning at the time of intraoperative intubation.'

It seems that coders interpret this standard in two different ways:

1) That because the initial ventilation was not for the initiation of a procedure/surgery that point 5 does not apply and that 13882-00 could be assigned in the above example.

2) That even though the ventilation was initiated for a reason other than initiation of a procedure/surgery (for example decreasing conscious state) that 13882-00 cannot be assigned because the patient was ventilated during the procedure/surgery and total MV hrs was less than 24..

The ICD Coding Newsletter in August 2000 states 'For coding periods of CVS of less than 24 hours, there is a difference between episodes separated:
- before 1 July 2000, when periods of CVS of less than 24 hours were not coded; 
- on or after 1 July 2000, when periods of CVS of less than 24 hours are coded except when CVS is initiated for a surgical procedure'.

The confusion arises around the term 'during' in ACS 1006 ie 'Assign a code for continuous ventilatory support for periods <=  24 hours ONLY when the ventilation is not performed during a procedure'.  Should 'during' be interpreted to mean 'for initiation of' a procedure?


Q1 Can you advise whether 13882-00 [569] Management of continuous ventilatory support <= 24 hours should be assigned (as well as an initiation code) in the above situation (which is not uncommon)?  

Q2 Does the same advice apply regardless of the type of procedure/ where it is performed?  For example, coronary angiogram performed in the cath lab or coiling of an aneurysm performed in the Radiology department or surgery performed in theatre?


Search Details:
The ICD Coding Newsletter in August 2000 
ACS 1006

Response:
The VICC advises that in accordance with point 5 of ACS 1006 Respiratory support, in this scenario it is correct to assign 13882-00 [569] Management of continuous ventilatory support <= 24 hours and 13857-00 [569] Continuous ventilatory support, initiation outside of intensive care unit because the patient was not intubated for the purpose of the procedure being performed. 

In response to your second question, this advice applies to procedures performed both in and outside of theatre.

The VICC acknowledges that the term 'during' can be confusing and will forward this query to NCCH for consideration of clarifying the wording in point 5 of the ACS.


Query Text:
Please advise on a diagnosis code for tear/injury of the omentum; there is a procedure code for suture/repair of the omentum 90329-02 [1000].

Male patient 50 years with stabbing injury to abdomen causing omental tear and full thickness small bowel (ileum) tear, both of which were repaired.  Codes assigned (for the purposes of this query - other codes had no impact on the DRG):
S36.49 Injury of other and multiple parts of small intestine
S36.81 Injury of peritoneum (for omental tear)
S31.83 Open wound (of any part of abdomen) communicating with an intra-abdominal injury
X99.08 Assault by knife, other specified person
Y92.09 Other and unspecified place in home
U73.8  Other specified activity
30375-24 [901]  Suture of small intestine
90329-02 [1000] Other repair of omentum
GA [1910]

The online medical dictionary describes the omentum (greater) thus:- A peritoneal fold…hanging like an apron in front of the intestines.  Therefore as the omentum is part of the peritoneum, should S36.81 Injury of peritoneum be assigned in this case or should the less specific S36.88 be used?  There is a significant difference to the DRG depending on which code is used for omental tear. S36.88 groups to DRG G02B,  S36.81 groups to W03Z.

Search details:
Index entries at tear/torn (traumatic) (pg 399) and laceration (pg 238) for internal organ - see Injury, by site.  At injury by site (pg 223) omentum is not listed.  Next to injury intra-abdominal organ (pg 221),…specified site NEC S36.88.  There are no inclusion notes for the omentum in the tabular list at S36.8x injury of other intra-abdominal organs.

Response:
The VICC agrees the most appropriate code to assign for injury of the omentum is S36.81 Injury of peritoneum as per the enquirer's research.  The VICC has asked the NCCH to give consideration to creating an index entry for Injury, omentum.


Query Text:
Patient admitted with a diagnosis of Gastroenteritis with dehydration and given Gastrolyte via a nasogastric tube.

Should we be assigning a code for this, or is this an instance of a procedure not normally coded that may be assigned based on in house needs?

Two code options are: 
96202-07 [1920] Enteral administration of pharmacological agent, nutritional substance; or
96202-08 [1920] Enteral administration of pharmacological agent, electrolyte  

Search Details: 
ACS 0042 Procedures not normally coded
ACS 1615 Specific interventions for the sick neonate

Response:
The VICC advises that in accordance with ACS 0042 Procedures normally not coded point 5 Drug treatment, if the treatment is the principal treatment in a same day epsiode, the treatment should be coded.  If the episode is not a same day episode, the treatment may be coded if there is a local requirement to do so as per point a) in the same standard indicates.  If the episode is of a neonate, apply ACS 1615  Specific interventions for the sick neonate.

As gastrolyte corrects electrolyte imbalance rather than being a nutritional substance, the correct code to assign for gastrolyte via nasogastric tube is:
96202-08 [1920] Enteral administration of pharmacological agent, electrolyte.


Query Text:
We are submitting this query because according to HDSS there is a problem with the coding standard not matching with the DRG allocation.  Our communication with HDSS started because we had an episode group to un-groupable DRG (963Z).  

The patient was diagnosed with a cephalhaematoma at birth due to it being difficult.  The patient is now nearly 8 months old and was recently admitted to our hospital to have a CT with anaesthetic performed to investigate the cephalhaematoma further.  

The cephalhaematoma pathway only has two options: 
a) Fetus or Newborn (Birth Trauma), and
b) Traumatic

The birth trauma pathway was chosen due to the cephalhaematoma not being caused by an accident.  The codes assigned for this episode were:
P12.0 CEPHALHAEMATOMA DUE TO BIRTH TRAUMA
P03.9 FETUS NEWBORN AFF COMP LABOUR DELV UNSP
56007-00 [1952] CT OF BRAIN WITH IV CONTRAST MEDIUM       
92514-19 [1910]  GENERAL ANAESTHESIA, ASA 19               

This code assignment allocates the episode to DRG 963Z Neonatal Diagnosis not consistent with age/weight. 

HDSS recommended we assign a code from the S chapter rather than P12.0 to enable the episode to be assigned to another DRG. Can you please investigate the assignment of DRG 963Z from the birth trauma cephalhaematoma pathway for a patient that isn't a newborn, as it would appear from our example that a patient can present after the birth episode with a cephalhaematoma that was due to a traumatic birth.

Response:
As per recent advice in #2011 Neonate with melaena due to ingestion of maternal blood published in the 1st Quarter 2004-05 ICD Coding newsletter and #2258 Neonatal Abstinence Syndrome published in the December 2006 VICC queries database, the VICC recommends assigning a non-perinatal code as principal diagnosis and assigning P12.0 Cephalhaematoma due to birth trauma as an additional diagnosis.  The VICC suggests the assignment of the following codes for the case cited:
S09.8 Other specified injuries of head (following index entry Cephalhaematoma, traumatic)
P12.0 Cephalhaematoma due to birth trauma
X58 Exposure to other specified factors
Y92.22 Health service area
U73.9 Unspecified activity

The VICC has received advice from the Commonwealth that a review of the grouping of P codes is planned for a future version of the grouper and this query will be forwarded to the Commonwealth as a further example to assist them in their review.


Query Text:
We have recently begun admitting patients for insertion of insulin pumps in order to stabilse patient's unstable diabetes.  This involves subcutaneous catheterisation and connection of the pump as well as intensive education on the use and maintenance of the pump. 

We are coding these patients to E1x.65 Diabetes Mellitus with poor control, but are unsure as to what procedure code to use to indicate the insertion of the insulin pump. 

We have read NCCH query numbers Q1018, Q1548, Q1815 but have not been much help in coding this procedure.

Response:
The VICC advises not to assign a procedure code for the insertion of the insulin pump because it is a subcutaneous device that is not normally coded.  

The NCCH provided the following advice regarding the administration of insulin:
"Advice pertaining to the insertion of Insulin Pumps was published in Coding Matters Vol 14 No 2 Sept 07, as follows:
Administration of insulin via an insulin pump is not normally coded as per ACS 0042 Procedures normally not coded, point 5:
Drug treatment should not be coded unless the substance is given as the principal treatment in same-day episodes of care (for example, chemotherapy for neoplasm or HIV) or is specifically addressed in a coding standard…

However, where insulin is administered via an insulin pump as the principal treatment in same-day episodes of care, assign:
96200-06 [1920] Subcutaneous administration of pharmacological agent, insulin
96208-06 [1921] Loading of ambulatory drug delivery device, insulin

If the patient’s pump is loaded with insulin but they do not receive a dose during the episode of care, assign only:
96208-06 [1921] Loading of ambulatory drug delivery device, insulin.

Q1018, Q1548 and Q1815 have been amended to reflect this advice."


Query Text:
Can you please advise the correct code to assign for Colonic Manometry? There is no look up for this procedure. The pressure in the colon and the strength of the muscle contractions are measured during colonic manometry. Patients are sedated and a colonoscope is inserted into the colon through the rectum.  The doctor will then insert a motility tube which is left until the completion of the test. 

Suggested codes are:
Study
-intestinal
--colonic transit, radionuclide 61384-00 [2007]

OR

Colonoscopy 32090-00 [905]

Search details: 
http://www2.kumc.edu/kupedigi/ColoMano.htm

Response:
The VICC referred this query to the NCCH who provided the following advice:

'The NCCH advises that in addition to the code for colonoscopy assign 92204-00 [1866] Noninvasive diagnostic tests, measures or investigations, not elsewhere classified'. 

VICC notes the Index pathways are:

Investigation (of) NEC (see also Test, testing) 92204-00 [1866]
or
Test, testing (for) NEC (see also Investigation) 92204-00 [1866]

Please consider submitting a public submission with supporting clinical advice and statistics on how often colonic manometry is performed.


Query Title:
Permanent Neonatal Diabetes due to Kir6.2 mutation

Query Text:
Can you please clarify the correct code to use for a patient presenting with Permanent Neonatal Diabetes due to Kir6.2 mutation?
 
The documentation in ACS 0401 Diabetes mellitus and impaired glucose regulation on neonatal diabetes reads like you should assign P70.2  Neonatal diabetes mellitus for both transient and permanent neonatal diabetes. This patient is now older and the diabetes is documented as permanent neonatal diabetes due to Kir6.2 mutation.  

Following the index for diabetes, due to genetic defect leads you to E13.x Other specified diabetes mellitus.  

Is the correct code in this case P70.2 or E13?  If we code P70.2 should we continue to code this in subsequent admissions according to ACS 1605 Definition of conditions originating in the perinatal period?

Response:
Clinical advice obtained by VICC confirms that E13.x is the correct code to assign for the case cited, with an additional code assigned for the chromosomal abnormality (underlying condition).


Query Title:
Failed spinal anaesthesia (no anaesthetic injected)

Query Text:
How should we code failed spinal anaesthesia when the anaesthetist has gone on to use a regional block due to its failure?  The operation was for a total knee replacement and sedation anaesthesia was the type of cerebral anaesthesia:

Suggested codes as follows:
Example 1
92515 - xx [1910] sedation
92508 - xx [1909] neuraxial 
92512 - xx [1909] regional (not normally coded due to hierarchy of anaesthesia codes but coded in this case to reflect failed spinal)

Example 2
92515 - xx [1910]
92512 - xx [1909] (in keeping with hierarchy)

Would it be possible to use a lumbar puncture (39000 -00 [30]) to reflect these scenarios (in this case no spinal anaesthetic was injected).  Would NCCH consider a failed conduction anaesthesia code to cover these scenarios?

Search Details: 
ACS 0031 P. 42 Anaesthesia
ACS 0019 p. 36 Procedure not completed or interrupted
NCCH query 1175 Failed spinal anaesthesia
NCCH query 1407 Failed spinal anaesthesia

Response:
The VICC advises that if a spinal needle was inserted and no anaesthetic was injected then a lumbar puncture can be coded to reflect the extent of the procedure as per ACS 0019 Intervention abandoned, interrupted or not completed.

Therefore, for the case cited the correct codes to assign are:
92515-xx [1910] Sedation
92512-xx [1909] Regional block
39000-00 [30] Lumbar puncture


Query Text:
NCCH Q2158 directs us to use 50127-00 [1571] Arthroplasty of joint not elsewhere classified for insertion of KALIX implants. 

The KALIX implant must be removed:
- At the end of growth when used in paediatric patients
- After 15 to 18 months when used for adult patients.

We are seeking advice for codes to use for its removal.  Should the diagnosis codes be:
Z47.0 Follow up care involving removal of fracture plate and other internal fixation devices
or
Z47.8 Other specified orthopaedic follow-up care

Should procedure code be:
Removal
-implant
--leg (no entry for foot) 90606-01 [1661]

Are there any other suggestions?

Response:
After review of the operation report that states the KALIX implant is in the sinus tarsi which is the canal between the talus and calcaneum, the correct procedure code to assign for the case cited, following index entry Removal/implant/leg is:
90606-01 [1661] Removal of other implant

The correct diagnosis code to assign following index entry Aftercare, orthopaedic, specified NEC is Z47.8 Other specified orthopaedic follow-up care because the implant is not a fracture plate or a fixation device.


Query Text:
What is the most appropriate code for radial head excision and replacement?  Suggestions include:
1. Arthroplasty
   - elbow NEC 90536-00 [1418]'other repair of elbow'.
AND
Ostectomy
   -radius 48406-03 [1426] 'Ostectomy of radius'

2. Arthroplasty
   - elbow
   --for joint replacement 49115-00[1418]'Total arthroplasty of elbow'(to  reflect that a prosthesis was used)
AND
Ostectomy
   -radius 48406-03 [1426] 'Ostectomy of radius'

3. Implantation
   -prosthesis
   --arm NEC 90539-00[1409]'Implantation of prosthetic device of arm'
AND
Ostectomy
   -radius 48406-03 [1426] 'Ostectomy of radius'

4. 49112-00 [1418] Silastic replacement of radial head of elbow seems most appropriate but how do I tell if the prosthesis is 'silastic'?  Also I cannot find the look up in the index to get to this code. I have tried:
Arthroplasty

Insertion
  -prosthesis

Implant,Implantation
  -prosthesis

Response:
The VICC advises to follow the index entry:
Replacement
- radial head (silastic) 49112-00 [1418] 

to assign 49112-00 [1418] Silastic replacement of radial head of elbow, for radial head excision and replacement.  

As silastic in the index is a non-essential modifier, the prosthesis does not have to be silastic.


Query Text:
A patient has an AMI and IHD is suspected. The patient is then transferred for an angiogram at a hospital that provides higher level care.  Do we apply ACS 0012 Suspected conditions and code the IHD with a “transferred up” code or just the AMI?

Response:
The VICC has assumed the enquirer has documentation of AMI as principal diagnosis and ? IHD as an additional diagnosis.  

On that basis the VICC advises that I21.x would be the principal diagnosis and I25.9 Chronic ischaemic heart disease, unspecified and Z75.3 Unavailability and inaccessibility of health-care facilities could be assigned for the case cited, as per ACS 0012 Suspected conditions.


Query Text:
A patient is immunodeficient as a result of non-Hodgkin’s lymphoma and a subsequent bone marrow transplant. The patient is regularly given infusions of Intragam.  Should we code D84.8 Other specified  immunodeficiencies or the lymphoma as the principal diagnosis?

Response:
The VICC notes that Intragam is used to treat immunodeficiency and both a bone marrow transplant and lymphoma may result in the patient being immunosuppressed.  

Therefore the principal diagnosis should be assigned in accordance with the documented principal diagnosis for the episode.  The VICC also notes that D89.8 Other specified disorders involving the immune mechanism, not elsewhere classified is the more appropriate code to assign for immunodeficiency as per Index entry Immunodeficiency, acquired.


Query Text:
If a mother is GBS positive and the neonate is observed and given prophylactic treatment with no diagnosis of ‘Risk of Sepsis’, no documented condition and no symptoms, should we be assigning an appropriate code from category Z03 Medical Observation and evaluation for suspected diseases and conditions, together with an appropriate code from category Z29 Need for other prophylactic measures? Or can we only code an appropriate code from category Z29? 

ACS 1617 Neonatal Sepsis/Risk of Sepsis instructs us to code an appropriate code from category Z03 and Z29 only if the neonate was diagnosed with a ‘Risk of Sepsis’ and no documented condition and prophylactic treatment is initiated.
In the above situation, the neonate has no diagnosis of ‘Risk of Sepsis’. The GBS positive mother is only a risk factor. Should we be coding appropriately from category Z03 for all risk factors, even though no diagnosis of ‘Risk of Sepsis’ is documented?

Response:
The VICC advises that in accordance with ACS 1611 Observation and Evaluation of Newborn and Infants for Suspected Condition Not Found Z03.7- Observation and evaluation of newborn for suspected condition not found codes can be assigned when there is documentation of observation and evaluation of the suspected condition.  If there is no documentation of the suspected condition but the neonate is given prophylactic treatment, only assign a code from category Z29 Need for other prophylactic measures.


Query Title:
Coding of Conditions from Haematology reports.

Query Text:
We have been noticing that the pathologists are now documenting on the bottom of the Haematology reports comments such as 'post haemorrhagic anaemia- transfuse 1 unit RBC'.  Can we code from this documentation, or do we still need documentation of anaemia by a clinician in the progress notes?  If we have documentation of anaemia, can we use this information on the Haematology report to code posthaemorrhagic if this is not documented in the notes? 

We have noted query 1918 on the NCCH database. 

Search Details: 
QUERY 1918 NCCH Coding anaemia from haemoglobin (Hb) result 
I wish to clarify if anaemia can be coded in the following instances: 
1. Patient admitted for chemotherapy for Non-Hodgkin lymphoma (NHL). Summary specifies Hb was 90, so 2 units of red blood cells given. Pathology report for the date in question specifies Hb. 90L (L meaning low), but the word anaemia is not mentioned in the actual admission. Can I code anaemia on the basis of the pathology report specifying that the Hb was low? Index entry for low haemoglobin is D64.9 Anaemia, unspecified. 

2. When an Hb reading is specified in the progress notes, eg. Hb 90, and blood transfusion is given. Again, no reference is made to anaemia in the progress notes, but pathology report specifies that Hb is L (ie. Low). 

3. Can I code D62 Acute posthaemorrhagic anaemia when Hb is specified as low in pathology reports, having been normal prior to surgery, but only the Hb reading is specified in the progress notes with no mention of the word anaemia, and transfusion is given. During a coding workshop for 3rd edition revision of ICD-10-AM, I gave similar examples and was told I could code anaemia because the diagnosis had been made by the pathologist on the pathology report (ie when the pathologist states the reading is low) and not by me as the coder, but we would like confirmation of this. 

The Coding Committee has drafted a response to this query, but would like confirmation that the NCCH agrees with this response. The response is as follows: The vital point underlying this issue is documentation. Coders may be able to recognise a result, which potentially indicates a condition. Pathology results alone cannot be used as criteria for assigning a code, and the record should be further reviewed for evidence of clinical documentation which confirms a diagnosis. As in a similar query to this, published in Victorian Coding Newsletter Nov 2001, #1735 particularly in scenarios 4, 5 and 6, there is inadequate documentation to support  a case for anaemia to be coded. Documentation of a condition on a discharge summary can be confirmed by an abnormal result specified in the body of the record. However, if there is nothing more than a reading or result to indicate a condition, then this should be queried with the clinician and, if appropriate, it should then be documented by the clinician. Also, coders should be aware that arrows might indicate a trend, rather than a high/low reading. 

The NCCH supports the VCC's decision and response for this query. Pathology results should be documented in the medical record by the treating clinician to confirm a diagnosis and meet the criteria in ACS 0002 ADDITIONAL DIAGNOSIS before being assigned a code for an episode of care. 24/06/2004 3rd

Response:
The VICC advises that if the only documentation of post haemorrhagic anaemia is on the haematology report, then the anaemia would not be coded.  If there is documentation of anaemia in the body of the record and the haematology report specifies that it is post haemorrhagic anaemia, then it is reasonable to assign D62 because the haematology result supports the notes and provides further specificity.


Query Title:
Non-diagnostic coronary angiography with PTCA and stenting

Query Text:
We would appreciate clarification of responses given by the NCCH to queries 2115 (7/7/05 4th) and 2233 (17/7/06 4th) regarding the assignment of intraoperative arteriography 35200-00[719]. 

In response to query 2115 re intraoperative CT they also state “assign intraoperative arteriography where an arteriogram has been performed with another procedure”. 

At 2233 they advise “that whenever an angiogram is performed at the same operative episode as an angioplasty (with reference to PTCA) then the angiogram should also be coded” with no mention of using an intraoperative code. (This advice overrides previous coding practice that followed the HDSS/ICD Coding Newsletter August 2001 Clinical Feature about coronary angiography, “an angiogram performed as part of the angioplasty procedure is not coded separately (unless performed diagnostically before proceeding to PTCA or stent insertion, in the same operative episode)).

We have therefore (prior to 2233) been coding coronary angiography from block [668] page 95 that includes codes with or without cardiac catheterisation for diagnostic coronary angiography. 

ACS 0933 Cardiac catheterisation and coronary angiography (page 146) states that “cardiac catheterisation is an invasive procedure” and “cardiac catheterisation is usually performed in conjunction with coronary angiography.

If we are now to code coronary angiography in all episodes whether it is diagnostic or not, please advise if it is not diagnostic if we should use a code from block [668] or, if we code intraoperative arteriography, which would be consistent with 2115, should we also add a code for the cardiac catheterisation from block [667] page 95?


Search details: 
NCCH queries 2115, 2233. 
ACS 0933 Cardiac catheterisation and coronary angiography. 
Procedure blocks [668], [719] & [667].

Response:
The VICC referred this query to the NCCH who provided the following advice:
"The correct procedure code to assign for angiogram performed at the same operative episode as an angioplasty is the appropriate code from block [668] Coronary angiography.

It is incorrect to assign a code from block [719] Intraoperative arteriography as there is an excludes note on page 100 of the ACHI Tabular List, under the heading 'ARTERIES' which states:
'Excludes: coronary arteries (see blocks [667] to [681]).'

See also Q2233 and Q2442."


Query Title:
Procedure code for unsuccessful treatment of encrusted ureteric stent

Query Text:
Same day patient admitted with an encrusted (R) JJ stent.  An endoscopic lithotripsy was attempted but failed.  Codes assigned:

DRG  L04B  MDC 011 KDY,URT&MJR BLDR PR N-NPM+SMCC

PT83.8  Other complications of genitourinary prosthetic devices, implants and grafts
PN28.8  Other specified disorders of kidney and ureter
PY83.1  Surgical operation with implant of artificial internal device
PY92.22 Health service area
PE11.72 Type 2 diabetes mellitus with features of insulin resistance 
AI10      Essential (primary) hypertension

90358-00 [1088] Other procedures on ureter 
36803-00 [1065] Ureteroscopy
92514-29 [1910] General anaesthesia, ASA 29

'Other procedures on ureter' was used because the encrustation was caused by calcification of the stent and was not strictly a ureteric calculus.  However if the treatment is the same as for a calculus should we use 36803-02[1068] Endoscopic manipulation of ureteric calculus via ureteroscopy in this case? (DRG L07B Transurethral procs except prostatectomy no cc).

The successful treatment of this complication of JJ stents is discussed in the references listed below.

Search details:
International Journal of Urology 1986 Dec;136(6):1297-8 Lupu et al. Calcification of ureteral stent treated by ESWL. 
International Journal of Urology 2006 13, 1141-1143 Bhansali et al. Laparoscopic management of a retained heavily encrusted ureteral stent

Response:
The VICC referred this query to the NCCH who provided the following advice:

"Ureteral stents are an integral part of urological practice.  Stents can migrate, fragment or be forgotten and a portion of these will become calcified.  Treatment to render a patient stent-free in these circumstances includes ureteroscopy, percutaneous nephroscopy, cystoscopic electrohydraulic lithotripsy, extracorporeal shock wave lithotripsy, open cysto-litholapaxy and simple nephrectomy - or a combination of the above.

The NCCH agrees the correct code to assign for the scenario cited is 36809-00 [1074] Endoscopic fragmentation of ureteric calculus . Calcified encrustation is considered calculous material, therefore the correct pathway is 'Destruction, calculus, ureter.'  Assign also a code for removal of ureteric stent as appropriate.

The NCCH will consider improvements to the Alphabetic Index for a future edition of ACHI."

The VICC notes this advice was published in the March 2009 Volume 15 Number 4 10-AM Commandments.


Query Title:
Assignment of Z51.1 Pharmacotherapy session for neoplasm in endoscopy case

Query Text:
A patient has low rectal carcinoma and is admitted for a colonoscopy.  During the admission, chemotherapy is running through a PICC (initiated in a previous episode). Theatre was informed and cytotoxic precautions were adopted.

Do we add the code Z51.1 Pharmacotherapy session for neoplasm?

Response:
The VICC advises that because the chemotherapy was not initiated or managed in this episode, that is, does not meet ACS 0002 Additional diagnoses criteria, Z51.1 Pharmacotherapy session for neoplasm would not be assigned.

Refer to Coding Matters Volume 11 Number 2 September 2004 article Drug administration for further information on assignment of Z51.1.


Query Title:
Prefixing of Z92.22 Personal history of long-term (current) use of other medicaments, insulin

Query Text:
A patient has type 2 diabetes and is treated with insulin.

Should we prefix Z92.22 Personal history of long-term (current) use of other medicaments, insulin as a P or an A?

Response:
The VICC advises that Z92.22 Personal history of long-term (current) use of other medicaments should be prefixed with an 'A' as per the Victorian Addtions to the Australian Coding Standards effective 1 July 2006, Vic Prefixes A- Associated Condition dot point 3:
• Conditions that are coded because of 'use additional code...' or similar instructions in ICD-10-AM, or because of a specialty standard (listed in ACS 0002) directing the coder to assign additional code(s), if these conditions were present on admission but do not meet the definition of a primary condition.


Query Text:
Once diabetes meets criteria for coding, I know we can or should go back to previous admissions or correspondence to find all the diabetic complications to code.  My query is whether we can get information on other conditions that we code with diabetes (like hypertension, high cholesterol) from previous admissions. 

Search Details: 
ACS 0401 Diabetes mellitus and impaired glucose regulation

Response:
The VICC referred this query to the NCCH who provided the following advice:
"When it has been determined that diabetes has met the criteria in ACS 0001 Principal Diagnosis or ACS 0002 Additional Diagnoses previous episodes of care may be referred to cautiously, to provide further specificity to a diabetic associated condition."

VICC advises that coders need to be aware that information documented elsewhere in the record may relate to conditions that are no longer present.  For example, acute renal failure documented in a previous episode may not still be current.  Similarly obesity documented previously may now be resolved.


Query Text:
ACS 1404 Admission for renal dialysis includes the section: 
"Where a renal dialysis episode of care is multi-day, but the intent for admission was same-day, code as principal diagnosis the condition responsible for extending the patient's length of stay and Z49.1 or Z49.2 as an additional diagnosis."
 
I have a patient admitted for same-day dialysis who, towards the end of the dialysis, collapses and is then admitted to the ward. The standard seems to indicate that collapse should be the principal diagnosis and that whilst the admission started with the dialysis, I shouldn't code dialysis or ESRF as principal. 

Is this correct?  Why don't we apply principal diagnosis rules to this episode?

Search Details: 
ACS 1404 Admission for renal dialysis

Response:
The VICC referred this quey to the NCCH who provided the following advice:

"The NCCH advises that your interpretation of ACS 1404 Admission for renal dialysis is correct and the condition responsible for extending the patient's length of stay should be assigned as the principal diagnosis with either Z49.1 or Z49.2 as an additional diagnosis.

ACS 1404 Admission for renal dialysis will be reviewed for a future edition of ICD-10-AM/ACHI/ACS."


Query Text:
Patient admitted with diagnosis Streptococcal Pneumoniae Meningitis.  When you look up the index Meningitis, Streptococcal the code arrived at is G00.2 Streptococcal meningitis.  However, ACS 0103 Streptococcal Infection states that Strep Pneumoniae is considered Pneumococcal. If look up in the index Meningitis, pneumococcal you arrive at code G00.1 Pneumococcal meningitis.

Is G00.1 the correct code and if so should the index be altered to have an entry under Meningitis, strep, for strep pneumoniae? 

Internet search has found a site which states : Meningitis caused by Streptococcus pneumoniae is called PNEUMOCOCCAL MENINGITIS 

Search Details: 
ACS 0103 Streptococcal Infection http://www.dhpe.org/infect/Bacmeningitis.html

Response:
The VICC advises that the correct code to assign for streptococcal pneumoniae meningitis is:
G00.1 Pneumococcal meningitis

The VICC will forward this query to NCCH for review of this index entry and index entries for other infections caused by streptococcal pneumoniae.


Query Text:
Patients admitted as same day stay for botox injection - no summary.  Operation report has listed 'contracture', 'spasticity', 'CP' or 'spastic CP' as diagnosis, or nothing at all in which case correspondence is used - see examples.  What code should be used as principal diagnosis?   We have differing opinions as to which ACS or logic should be followed. We have asked an experienced external coder also who was not sure so as none of us are absolutely clear about the coding of these episodes, we felt it appropriate to ask the committees expert advice.

1.  One opinion is that the muscle contracture (or listed condition) is the problem, and that the CP is the underlying condition, not being treated, and so the muscle contracture (or listed condition) should be coded as principal diagnosis.  This is based on the fact that the contracture has developed many years after the initial diagnosis of CP and is not related to the paralysis or spasticity associated with CP.  This is following the logic in ACS 0001 Principal diagnosis - underlying condition.

2.  The other opinion is that the muscle contracture or listed condition is a symptom of CP and so the CP should be coded as principal diagnosis.  

If there is no other documentation apart from CP anywhere in the record, these cases are coded to CP, but it is when there is additional information that the issue is clouded somewhat.

Clinicians at our hospital have been asked for clinical advice, and their opinion is that the contracture (or listed condition) has developed as a consequence of the CP, but is not part of the spasticity associated with the initial diagnosis as CP itself does not worsen, and interestingly would prefer that CP is not coded as the principal diagnosis.  However, clinical advice and the classification are often at odds, and we are unsure as to what the principal diagnosis should be.  The patient age range is anything from young children to adults.

I have attached a brief summary of three different internet sites of clinical information.  

Search details:
What is Cerebral Palsy?
The term cerebral palsy refers to any one of a number of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination but don’t worsen over time. Even though cerebral palsy affects muscle movement, it isn’t caused by problems in the muscles or nerves.  It is caused by abnormalities in parts of the brain that control muscle movements.  The majority of children with cerebral palsy are born with it, although it may not be detected until months or years later. The early signs of cerebral palsy usually appear before a child reaches 3 years of age.  The most common are a lack of muscle coordination when performing voluntary movements (ataxia); stiff or tight muscles and exaggerated reflexes (spasticity); walking with one foot or leg dragging; walking on the toes, a crouched gait, or a “scissored” gait; and muscle tone that is either too stiff or too floppy. Ref: NINDS cerebral palsy page

TYPES OF CP 
There are three main types of CP: 

Spastic cerebral palsy:
This is the most common type of CP. Spasticity means stiffness or tightness of muscles. The muscles are stiff because the message to the muscles is sent incorrectly through the damaged part of the brain.

When people without CP perform a movement, some groups of muscles become tighter and some groups of muscles relax. In people with spastic CP, both groups of muscles may become tighter. This makes movement difficult or even impossible.

Athetoid cerebral palsy:
Athetosis is the word used for involuntary unpredictable movements that occur in this type of CP. This involuntary movement is present even at rest and is often most noticeable when the person moves. Children with athetoid cerebral palsy often have very weak muscles or feel floppy when carried.

Ataxic cerebral palsy: 
This is the least common type of CP. Ataxia is the word used for unsteady shaky movements or tremor. People with ataxia also have trouble keeping their balance.
Ref:  The spastic centre

The child usually will begin physical therapy soon after diagnosis. Therapy enhances motor skills (such as sitting and walking), improves muscle strength and helps prevent contractures (shortening of muscles that limits joint movement). Sometimes braces, splints or casts are used along with physical therapy to help prevent contractures and to improve function of the hands or legs. If contractures are severe, surgery may be recommended to lengthen affected muscles.
Medical Reference – Cerebral Palsy

Response:
The VICC advises that where the presenting problem and the underlying condition are documented in the same episode that in accordance with ACS 0001 Principal diagnosis - underlying condition, the presenting problem would be the principal diagnosis and the underlying condition would be the additional diagnosis.  Therefore, if contracture and cerebral palsy (CP) are documented in the same episode the contracture (presenting problem) would be the principal diagnosis and the CP (underlying condition) would be the additional diagnosis.  However, the documentation available may lead you to assign the cerebral palsy as the principal diagnosis, for example, if the only documentation is CP or if the documentation is spasticity in a child in which case the index actually leads you to CP.


Query Text:
Although it is clear from ACS 0246 Familial Adenomatous Polyposis that we always assign either Z83.7 Family history of disease of the digestive system or Z80.0 Family history of malignant neoplasm of digestive system, it is not clear whether we always use the FAP morphology code provided in the standard based on a clinical diagnosis alone.   It seems to be rare that the histopathology actually states FAP in the conclusion.

Two possible scenarios:
a) Patient with an indication of FAP has a polypectomy performed and the histology comes back as either hyperplastic polyps or adenomas. Do we code the morphology based on the histology report (for example, M8211/0 Tubular adenoma NOS), the FAP morphology code (M8220/0 Adenomatous polyposis coli), or follow the rule based on assigning the highest morphology?

b) Patient with an indication of FAP has hyperplastic polyps or adenomas identified on colonoscopy/gastroscopy, however no pathology is sent. Do we code the FAP morphology code (M8220/0 Adenomatous polyposis coli), or code to polyp as specified in the findings (eg hyperplastic polyp, or adenoma)?  

Search Details: 
ACS 0246 Familial Adenomatous Polyposis

Response:
The VICC advises that unless the morphology of FAP has been confirmed by the clinician, that the morphology code assigned should be that documented in the histology report.  Where no histology is taken, the specified findings should be coded.

Updated advice 20/11/2007:  The advice in this query has been superseded by query #2349 Mixed hereditary polyposis syndrome published in the December 2007 database.


Query Title:
Follow-up cerebral angiogram following coiling of aneurysm

Query Text:
Patients are admitted for follow-up cerebral angiograms following coiling of aneurysms.  Often the report indicates that there is still a residual aneurysm and we would code the principal diagnosis as the aneurysm with an additional diagnosis code for the follow-up (Z09.0 Follow-up examination after surgery for other conditions).

However, occasionally the report might indicate that the aneurysm has been completely occluded (please see supporting radiology report).  In this case do we code:
a) Principal diagnosis as Z09.0 Follow-up examination after surgery for other conditions with an additional diagnosis Z86.7 Personal history of disease of the circulatory system, or

b) Even though the aneurysm has been occluded is it considered that the condition still exists and we would code the principal diagnosis as the aneurysm with an additional diagnosis code for the follow-up (Z09.0 Follow-up examination after surgery for other conditions)?

Response:
The VICC advises that a completely occluded aneursym indicates that there is no residual condition therefore, in accordance with ACS 2113 Follow-up examinations for specific disorders Z09.0 Follow-up examination after surgery for other conditions is the correct principal diagnosis.


Query Title:
MRI brain, cerebral cell study and stereotactic localisation

Query Text:
I am writing in regards to query #2175 MRI brain and cerebral cell study.

The NCCH provided the advice: 
"The NCCH agrees that 40803-00 [1] Intracranial stereotactic localisation is the appropriate code for the case cited. There is an includes note for magnetic resonance imaging (MRI) at this code.  Please also refer to ACS 0629 Stereotactic Radiosurgery, Radiotherapy and Localisation for further information regarding intracranial stereotactic localisation.  The NCCH will investigate MBS item number 40800 Stereotactic anatomical localisation, which was not used in ACHI because it was mapped to 40801".

This MRI brain/ Cerebral Cell study is carried out the day before surgery.  It seems incorrect to code the 40803-00 [1] for this procedure and then again for the localisation performed in surgery the next day.  We spoke to a Neurosurgeon who stated the following:The MRI is not the localising device.  They put the MRI images on the stealth during surgery.  The fiducial markers are dots placed on patient's head to determine the shape of the patient's head in preparation for surgery.  The stealth MRI or CT is completed the day before the neurosurgery and the stereotactic localisation is carried out during the neurosurgery the next day.

According the advice above, we believe that 90901-00 [2015] MRI Brain should be coded for MRI brain/ Cerebral cell study when it is performed before the surgery.  If it is performed during the neurosurgery procedure, it would not be coded, as it is included in the stereotactic localisation code.Can you please confirm your response to this query?

Search Details: 
VICC query #2175

Response:
The VICC referred this query to the NCCH who provided the following advice:
"The NCCH agrees that if the magnetic resonance imaging (MRI) is performed prior to the surgery the correct code to assign is 90901-00 [2015] Magnetic resonance imaging of brain.  If the MRI is performed for localisation at the time of intracranial surgery then the correct code to assign is 40803-00 [1] Intracranial stereotactic localisation as there is an includes note for magnetic resonance imaging (MRI) at this code."


Query Text:
Can you please advise the code selection for procedures Fistulogram and angioplasty.  Please refer to the following report.

FISTULOGRAM AND ANGIOPLASTY - (RA)

CLINICAL NOTES
Right radiocephalic fistula.  Swollen right arm.  Previous stenting distal subclavian vein.

FINDINGS
The fistula was punctured at the upstream dialysis puncture site under local anaesthesia with an 18-gauge angio catheter.  Run off venography was performed.  This confirmed proximal to mid stent stenosis on a background of stent fracturing in the distal right subclavian vein.

A 5-french sheath was inserted over a guidewire.  The occlusion in the stent was passed with a stiff guidewire and the aid of a van Schie 1 catheter.  The stent was angioplastied with a 40 X 9mm diameter balloon.  Following angioplasty good flow was seen through the re-opened distal right subclavian vein with a residual stenosis of less than 50% in the mid-reaches of the fractured stent.  A pressure dressing was applied on removal of the sheath at the end of the procedure to control bleeding.

CONCLUSION
Fracturing and instant occlusion distal left subclavian vein. Good result following angioplasty with less than 50% residual stenosis.  

We have coded 35303-06 [754] Percutaneous transluminal balloon angioplasty as principal procedure.  Do we code Fistulogram 59739-03 [1988] and/or Diagnostic DSA as the additional procedure?

Also, should we code fistulogram and/or intraoperative angiography as the additional procedure code if the fistulogram is intraoperative (not diagnostic)?

Search Details: 
VICC query #2039 Intraoperative computerised tomography

Response:
This query was originally published in the 2007-08 September Database as follows:

The VICC advises that the correct codes to assign for the case cited are:
59739-03 [1988] Other sinography
for the fistulogram performed whether diagnostic or intraoperative; and
35303-06 [754] Percutaneous transluminal balloon angioplasty

From the information provided, VICC members would not assign a code for the DSA.


This query has been updated for clarity as follows:

The VICC advises that the correct codes to assign for the case cited are:
59739-03 [1988] Other sinography
for the fistulogram performed whether diagnostic or intraoperative; and
35303-06 [754] Percutaneous transluminal balloon angioplasty

From the information provided, VICC members would not assign a code for the DSA.

VICC advises a code for the fistulogram would only be coded if it meets the criteria for coding a per ACS 0042 Procedures not normally coded.


Query Title:
Pain management procedure for chronic back pain

Query Text:
We have a patient with chronic back pain who comes in once per month to have his intrathecal pump loaded with morphine.  Some coders are using a code from Block [37] as a pain management procedure, while other coders are using a code from Block [1921].

My concern is that there is an exclusion note on Block [1920] that excludes pain management procedures, this used to sit above Block [1920] but was moved as people were misinterpreting it as belonging to only the extension -09.  I would assume that the exclusions under Block [1920] should also apply to Block [1921] but the tabular does not reflect this.

Could you please advise whether the exclusions listed under Block [1920] should also apply to Block [1921]?

Response:
The excludes note at Block [1920] does not also apply to Block [1921].

A code from Block [1921] should be assigned for the case cited because the admission is only for loading of the device and not administration of the agent also.  This is in accordance with ACS 0045 Drug delivery devices under the heading Loading of a drug delivery device.


Query Text:
A 26 year old woman was admitted as a same day patient for Intra-Muscular Methotrexate for treatment of a Hydatidiform
Mole.  As this is a same day admission and the Hydatidiform Mole has a morphology code (M9100/0 Hydatidiform Mole NOS), does this mean that the Principal Diagnosis should be Z51.1 Pharmacotherapy session for neoplasm, rather than the Hydatidiform Mole code (O01.-) ?

Search Details: 
ICD Coding Newsletter June 2002 Coding Feature.
HDSS Bulletin 6-13 October 1999
Coding Matters Vol 6, Number 2

Response:
The VICC advises that as Hydatidiform mole is a (benign) neoplasm, in accordance with ACS 0044 Pharmacotherapy, same day episodes of care for chemotherapy for neoplasm, Z51.1 Pharmacotherapy session for neoplasm is assigned as principal diagnosis.

The VICC notes that intra-muscular injection is not on the Automatically Admitted Procedure List (AAPL), unless the episode meets criteria for admission, the episode would not normally be reported to the VAED.


Query Title:
I131 MIBG (metaiodobenzylguanidine) cardiac scan

Query Text:
We would appreciate your assistance with the following nuclear medicine diagnostic procedure code.

Patient being investigated for increasing gait disturbance, tremor and emotional lability with a final diagnosis of likely idiopathic Parkinson's disease.

Her diagnostic procedure was an I131 MIBG (metaiodobenzylguanidine) cardiac scan.

Response:
The VICC advises that although this is a cardiac nuclear medicine scan, because there is no default code for cardiac, the appropriate code to assign for this procedure is 90910-00 [2014] Nuclear medicine study of other region or organ by following index entry:
Nuclear medicine 
-imaging (study) 90910-00 [2014]


Query Text:
As per NCCH query Q2233 we assign a code for the angiogram as well as the angioplasty.

Our question is what code should be assigned for the angiogram component of the procedure.

Response:
This query was referred to the NCCH who provided the following advice:
"The NCCH agrees that the correct code to assign for the angiogram component of the procedure in the scenario cited is 38215-00 [668] Coronary angiography.

See also Q2233 and Q2429."


Query Text:
Baby investigated for prolonged jaundice since 11 days old.  Fifth admission at five weeks of age finally establishes that baby has breastmilk jaundice.  Baby was admitted with intent of having further phototherapy, but treatment plan changed after one hour of phototherapy, and trial of with-holding breast milk for 72 hours done instead.  Baby diagnosed with breastmilk jaundice.  

ACS 1615 Specific interventions for the sick neonate states jaundice of newborn is not to be coded unless treated with >12 hours phototherapy.

I feel that code P59.3 Neonatal jaundice from breast milk inhibitor should be used as principal diagnosis, as it meets the definition in ACS 0001 Principal diagnosis.  However, the episode groups to 963Z Neonatal diagnosis not consistent with age/weight.

In order to code the episode, I have used R17 Unspecified jaundice, with P59.3 as an additional diagnosis, even though there is an exclusion note at R17 excluding neonatal jaundice.

I would appreciate your advice.

Response:
This is a known grouping issue, therefore in keeping with previous advice in #1346 Jaundice in Newborn published in the April 1998 ICD Coding newsletter and more recent advice in #2011 Neonate with melaena due to ingestion of maternal blood published in the 1st Quarter 2004-05 ICD Coding newsletter and #2258 Neonatal Abstinence Syndrome published in the December 2006 VICC queries database, the VICC recommends assigning R17 Unspecified jaundice as the principal diagnosis and assigning P59.3 Neonatal jaundice from breast milk inhibitor as an additional diagnosis. 

The VICC has received advice from the Commonwealth that a review of the grouping of Perinatal codes is planned for a future version of the grouper and this query will be forwarded to the Commonwealth as a further example to assist them in their review.


Query Title:
Premature rupture of membranes and spontaneous abortion

Query Text:
Patient presented with SROM and PV bleeding.  Assessed and diagnosed with PROM at 19/40 weeks.  Progressed to a normal vaginal delivery, babe deceased shortly after birth.  Birth weight 300g.  Retained placenta required manual removal in theatre. Histopathology of the placenta revealed chorioamnionitis.

Discharge summary lists the principal diagnosis as Premature Rupture of Membranes and Spontaneous abortion.

Should this be coded as a pregnancy with abortive outcome because the babe does not meet criteria for a livebirth (ACS1510) or as a livebirth as per ACS1517?  ACS1511 does not appear to fit with this scenario, although the pregnancy did result in a live birth.

We have coded it as follows because PROM was listed first under PDX:
O42.11 PROM onset labour between 1-7 days later
O09.2  Duration of pregnancy 14-19 completed weeks
O60.1  Preterm labour with pre term delivery
Z37.0  Single live birth
O41.1  Infection of amniotic sac and membranes
O72.0  Third stage haemorrhage
plus relevant procedure codes

This coding does not fit any of the relevant standards, nor does it take into account the documentation of spontaneous abortion.

Search Details: 
Relevant coding standards in Chapter 15

Response:
In accordance with ACS 1510 Pregnancy with Abortive Outcome, because the babe is less than 20 weeks and less than 400 grams, the episode must be coded as an abortion.  Therefore VICC suggests the following codes be assigned for the case cited:
O03.3 Spontaneous abortion, incomplete, with other and unspecified complications (because the chorioamnionitis is a specified complication)
O09.2 Duration of pregnancy 14-19 completed weeks
O60.1 Preterm labour with pre term delivery
Z37.0 Single live birth
O41.1 Infection of amniotic sac and membranes
O42.1x PROM onset labour after 24 hours (assign the appropriate code depending on the documentation)

Codes O60.1 and Z37.0 have been assigned because there is a livebirth outcome, by applying the principles in ACS 1511 Termination of pregnancy and NCCH Q695 Liveborn infant at 17 weeks published 2/12/1998.

O72.0 Third stage haemorrhage is not required because the haemorrhage is included in the abortion code.


Query Text:
Can you please provide some advice on how to code Paravertebral abscess?  There is no specific look up for this code.  The codes for abscess of vertebra or spine seem inappropriate.  The definition of paravertebral is alongside a vertebra or the vertebral column.  We thought the only appropriate code for the interim is M79.88 Other specified soft tissue disorders.

Here is a copy of the MRI:

MRI FULL SPINE - (DL)

CLINICAL NOTES:
Further evaluation of spinal changes with contrast.

FINDINGS:
There is enhancement of the oedema within the vertebral bodies at L2 and L3 particularly on the right.  No definite abnormal enhancement within the intervening disc.

There is mild enhancement within the disc above, at L1/2.

Within the spinal canal there is enhancing tissue anteriorly, and to a lesser extent posteriorly.  This has a configuration of congested venous plexus.  There is no definite epidural phlegmonous change.

However, there is extension of inflammatory tissue into paravertebral tissues from the disc on the right.  There is enhancement and multiple fluid collections within and deep to the right psoas extending from L2 to L5.  Most of the fluid collections are poorly defined and small.  This enhancing tissue extends into the right L2/3 foramen around the exiting nerve.  Just at the inner aspect of this foramen in the spinal canal there could be a very small fluid collection (eg. Image 6, Series 7 and Image 8, Series 8).

CONCLUSION:
The enhancement confirms the presence of discitis and paravertebral abscess on the right at L1/2 and L2/3.  Possible very small fluid collection in the epidural space on the right at the inner aspect of the L2/3 foramen.

Response:
Based on the documentation of 'psoas' in the MRI report VICC considers M60.08 Infective myositis other is the appropriate code to assign for this paravertebral abscess, following index entry Abscess, psoas  nontuberculous.  The VICC will refer this query to the NCCH for consideration of creation of an index entry for Abscess, paravertebral for use when there is no documentation of a specified site.

The VICC does not consider M79.88 Other specified soft tissue disorders is appropriate to assign for this paravertebral abscess.


Query Text:
Lady admitted for excision of two breast lesions. This was done via a single incision. Should code 31500-00 [1744] Excision of lesion of breast be assigned twice to indicate two lesions were removed, or should it only be assigned once as there was only one incision made?

Response:
Although ACS 0020 Multiple/bilateral procedures states 'Generally, if a procedure or procedures involves two or more sites, or is performed under anaesthesia, the procedure should be coded as many times as it is performed', the VICC advises to follow the advice in NCCH Q2111 Multiple myomectomies published 23/06/2005 which advises to assign only one procedure code as multiple lesions are being excised from the one anatomical site.


Query Text:
Can you please provide advice on coding removal of nasal splints post repair of cleft lip/nose.

Patients will have the splints inserted at the time of cleft lip repair to maintain the corrected nostril contour and present some time later for either removal or replacement of the splints. This is performed under general anaesthetic. 

The following procedure codes are suggested, and our coders have varying opinions on which is appropriate to use. 
92030-00 [1887] Replacement of nasal packing
92031-00 [1887] Removal of nasal packing
OR
41659-00 [372] Removal of intranasal foreign body
OR
30055-00 [1601] Dressing of Wound
(Code includes replacement of wound packing)

Search Details: 
NCCH Query Q2226

Response:
Research undertaken by VICC indicates that the stents are held in place in bone and are therefore considered an implant.  The correct code to assign for removal of the stents is 90606-00 [1661] Removal of facial implant by following index entry Removal, implant, nose.  

For reinsertion or replacement of the stents, the VICC advises to assign 90133-00 [381] Other procedures on nose, following index entry Procedure, nose, NEC as there is no other index entry available, in addition to the code mentioned above (90606-00 [1661]).


Query Title:
MCAD - medium-chain acyl-CoA dehydrogenase (MCAD) deficiency.

Query Text:
Can you please provide advice on what code should be used for a diagnosis of MCAD - medium-chain acyl-CoA dehydrogenase (MCAD) deficiency.

MCAD deficiency is a genetic disorder caused by the deficiency for an enzyme which metabolises medium-chain fats.

Suggested code assignment by coders is E88.8 Other specified metabolic disorders but we would appreciate your advice.

Response:
The VICC advises that following index entry Deficiency, circulating enzymes, the correct code to assign for the case cited is:
E88.0 Disorders of plasma-protein metabolism, not elsewhere classified [end of original response].

The original response has been superseded by VICC query #3602  Medium chain acyl-coa dehydrogenase deficiency (MCADD)


Query Title:
Pharmacotherapy for prevention of neutropenia

Query Text:
We have patients admitted to our Oncology unit for injection of Neulasta to help prevent developing neutropenia post chemotherapy. Should we be coding these patients to Z51.1 Pharmacotherapy session for neoplasm or to Z29.2 Other prophylactic pharmacotherapy. In my view it should be coded to Z29.2 as the treatment is not for a neoplasm or neoplasm related condition (the neutropenia would result from the chemotherapy and not the neoplasm) however we can not seem to agree and would like clarification.

Response:
As this is is prophylactic treatment and not chemotherapy, the correct code to assign in this scenario is:
Z29.2 Other prophylactic pharmacotherapy

The VICC notes that injection of prophylactic pharmacotherapy is not on the Type B list of the Commonwealth's Day Only Procedures Manual, therefore, unless the episode meets one of the other criteria for admission as detailed in section 2 of the VAED manual under Criteria for Admission, the episode should not be reported to the VAED.


Query Text:
A patient was admitted with a fractured humerus sustained following a fall.  Several days after admission the patient was diagnosed with bony metastases and the fractured humerus was documented as pathological.  Clarification was sought from the clinician regarding whether the fracture was traumatic, pathological or both.  The clinician confirmed that both factors caused the fracture, that is, the fall and the neoplasm.  I feel that both circumstances need to be coded to accurately reflect the case.  Could you please comment on whether both the trauma and pathological fracture codes can be used to code this case.

Response:
The VICC advises that provided the fracture has been documented as both traumatic and pathological, follow the Guidance in the use of ICD-10-AM in the ICD-10-AM Tabular List.

As in the scenario cited the pathological fracture is due to neoplastic disease both sets of codes for the pathological and traumatic fracture and external cause codes should be assigned.  This is because the Excludes notes at Chapter 19 relate to pathological fractures NOS and osteoporotic pathological fractures; neoplastic fractures M90.7x are not listed in the Excludes notes. Sequencing of the codes will be in accordance with ACS 0001 Principal diagnosis.

See also IHPA Coding Rule Q3498 Fracture of femoral neck due to osteoporosis and fall published 22 June 2020, for implementation 1 July 2020.

Note: The response has been updated for clarity.


Query Title:
Charcot's arthropathy with diabetic foot

Query Text:
We are seeking clarification of the coding of Charcot's arthropathy with diabetic foot as referenced at ACS 0401 Diabetes mellitus and impaired glucose regulation. 

Coders assign E1_.73 Diabetes mellitus with foot ulcer due to multiple causes according to the documentation or the criteria listed. They are then instructed to assign additional codes for the specific complications for example, polyneuropathy G62.9. As this is multiple condition coding the exclusion note at M14.6* (see reference below) is treated as a Type 1 exclusion note (ACS 0033) and M14.6* is assigned with E1_.73 to add the specificity of Charcot's arthropathy.

Our issue is that we cannot get to an index entry for Charcot's arthropathy (an asterisk code) in the same way that we can for polyneuropathy. We are wondering if an ICD-10-AM index entry could be included and/or an amendment to ACS 0401 to clarify the code assignment of Charcot's arthropathy in diabetic foot?

Search Details: 
ICD-10-AM Disease Index (page 66)Charcot's arthropathy with diabetes = E1_.61. Diabetes with arthropathy (Charcot's)E1_.61, and with Charcot's arthropathy E1_.61. (page 109).
ICD-10-AM Tabular List (page 262)M14.6* Neuropathic arthropathy (Charcot's) Excludes: diabetic neuropathic arthropathy(E1-.61). 
ACS 0401 page 102 & 0033 pages 22 & 23.
There are no NCCH queries relevant to this issue.

Response:
The VICC advises to follow essential modifier nonsyphilitic as per the advice in NCCH Q1245 to assign G98† and M14.6* for Charcot's arthropathy.  The index entries to follow are:
Charcot's 
--nonsyphilitic NEC G98† M14.6* 

Arthropathy (see also Arthritis) M13.9- 
-Charcot's (tabetic) A52.1† M14.6* 
--nonsyphilitic NEC G98† M14.6*


Query Text:
What code should be assigned for a discharge diagnosis of 'thigh swelling'?  The index appears to lead you to two different codes depending on how it is looked up:
Swelling
-Localised (skin)
--limb
---lower R22.4
OR
Swelling
-thigh M79.85

Is this a problem with the index?  Should skin, which is a non-essential modifier following the word localised, be an essential modifier?  Please advise which of the above codes is the most appropriate and why.

Response:
The VICC advises that because you have documentation of a specific site, that is thigh, the correct index entry to follow is Swelling, thigh to assign code M79.85 Other specified soft tissue disorders, pelvic region and thigh.


Query Text:
With more obstetric patients electing to have LUSCS as purely personal preference, do we code the O82 Single delivery by caesarean section to denote the patient's choice if there are abnormalities (which are also coded) such as CPD or persistent POP documented at operation?  On admission these patients have no detectable complication.  There is no exclusion note for O82 Single delivery by caesarean section unlike O80 Single spontaneous delivery which specifies without abnormality/complication.

Response:
The VICC advises that it is appropriate to assign O82 Single delivery by caesarean section if there is no documented reason for the caesarean section in addition to codes for abnormalities such as CPD as described in ACS 1506 Malpresentation, disproportion and abnormality of maternal pelvic organs.

ACS 1505 Single spontaneous vaginal delivery only provides advice regarding O80 Single spontaneous delivery and coders should not refer to codes O80, O81 and O82 as a group as they are mutally exclusive.


Query Text:
Is there a sequencing order for anaesthetic codes?  It is clear there is a hierarchy within conduction and cerebral anaesthesia (only code the first in the hierarchy), but if you have one conduction and one cerebral anaesthetic, do they have to be in a particular order?

Response:
The VICC advises that because no sequencing order is specified in ACS 0031 Anaesthesia in regard to [1910] Cerebral anaesthesia and [1909] Conduction anaesthesia, they do not have to be assigned in a particular order.


Query Text:
Nursing home patient on long-term jejunostomy feeds via PEJ tube.  The tube became blocked and was removed by the nursing home staff and the patient was sent to hospital.  At hospital (the admission I am coding), the progress notes explain this history and state 'PEJ tube re-inserted'.  The patient was then sent back to the nursing home.  

What do I code as the principal diagnosis?  Blocked tube or attention to device.  Some coders say that because the tube has been removed before the patient has arrived here that it should be attention to device Z43.4 Attention to other artificial openings of digestive tract; others say because it was blocked, even though it was removed before the patient arrived, that you code mechanical complication T85.5 Mechanical complication of gastrointestinal prosthetic devices, implants and grafts.

Response:
The VICC advises that because the patient required hospital attention due to the tube becoming blocked, the correct code to assign is T85.5 Mechanical complication of gastrointestinal prosthetic devices, implants and grafts.

Z43.4 Attention to other artificial openings of digestive tract is not appropriate because the admission was related to a complication of the tube.


Query Text:
Could you please advise on circumstances where unconsciousness would be coded? 

If the underlying cause of the symptom (LOC) is known, can the LOC still be coded. We note that in Standard 1901 Poisoning, significant manifestations of a poisoning for example, coma, arrhythmia can be coded.

VICC query #1933 Unconscious collapse suggests that if the underlying cause of unconsciousness is known then the symptom would not be coded. We feel that if the LOC meets ACS 0002 then it should be coded. The patient may have investigations for their LOC even if they have regained full consciousness by the time of admission. Patients who are not fully conscious will require increased nursing care at the time of admission.

I have listed some coding scenarios where we are having trouble deciding if unconsciousness should be coded:

1. A Patient is admitted with a final diagnosis of UTI and an additional diagnosis of unconscious collapse. The patient had a LOC for a short time at home and was confused on arrival in Emergency. The patient had a CT brain done during the admission. 

2. A patient was admitted after an episode of collapse and LOC for 5 minutes at home. The final diagnosis was AMI. Would the LOC be coded it this instance?

Could the committee also comment on the 3 dot points raised in VICC#1933
-Patient's level of consciousness on admission. If the patient is conscious on admission is LOC coded?
-Documentation of loss of consciousness (and duration) associated with collapse. If the LOC is brief, is this coded?
-Other significant symptoms/conditions, such as respiratory arrest. How do we decide if LOC is coded in these scenarios?

Search Details: 
VICC #1933

Response:
The VICC advises that the three dot points raised in VICC #1933 Unconscious collapse were provided by the NCCH and they relate to unconsciousness as a separate condition which meets ACS 0002 Additional diagnosis criteria.

In scenario one, based on the information provided because the UTI is listed as the principal diagnosis and the unconscious collapse is listed as an additional diagnosis, if the unconscious collapse is clearly an unrelated condition codes for the LOC and collapse would be assigned in addition to the UTI.

In scenario two, as the LOC appears to be the presenting problem and the AMI is the final diagnosis 'after study', the LOC would not be coded as per ACS 0001 Principal diagnosis.


Query Text:
Patient is admitted for change of dressings for burns. Normally this procedure is not coded unless performed under anaesthesia. Point C ACS 0042 Procedures normally not coded.

In this case, the patient had their dressings changed under oral sedation.  According to ACS 0042 this procedure would then be coded because it is being performed under sedation. However according to ACS 0031 Anaesthesia oral sedation is not coded. Does this mean, the information in ACS 0031 would take precedence over ACS 0042 and both the change of dressings AND sedation would not be coded? Or do we code the dressings alone because they were done under sedation, but do not code the oral sedation code according to ACS 0031?

We often have this scenario also for nasogastric intubation.

Search Details:
ACS 0031 0042 1911

Response:
The VICC advises that in accordance with ACS 1911 Burns, the change of burns dressings would be coded as it was performed under anaesthesia.  The oral sedation would not be coded as per ACS 0031 Anaesthesia.  The fact that the anaesthesia does not meet criteria for coding does not preclude the change of burns dressings being coded.


Query Text:
My query is in regard to a condition called (mixed) hereditary polyposis syndrome.  I have queried our gastroenterologist and he consistently says that it it is not FAP or HNPCC specifically but it is of the same family.

I have looked up polyposis; polyp; syndrome and can find no specific entry for hereditary or mixed.

Should I be using the code specific to pathology results (if any).  Should this condition be accompanied by a Z83.7 or a Z80.0 code?

Response:
Following ACS 0010 Clinical documentation and general abstraction guidelines which says that in the event the investigation varies from the clinical documentation, to follow the clinical documentation, the VICC advises to follow Index entry Polyposis, intestinal (adenomatous) (juvenile) to assign:
D12.6 Colon, unspecified
M8220/0 Adenomatous polyposis coli
U91 Syndrome not elsewhere classified
for documentatation mixed hereditary polyposis syndrome

Assign a code for family history if the documentation supports the assigment of the code.

Please note this advice supersedes the advice in VICC #2321 Familial adenomatous polyposis published in the June 2007 VICC queries database.


Query Text:
63 y.o male, IDDM, admitted for hydrodilation, steroid injection and manipulation of frozen shoulder.  Doctor states on admission examination note 'IDDM with frozen right shoulder'.

Our question is whether there has to be a documented link between the diabetes and the frozen shoulder to code E10.61 as principal diagnosis or do you code M75.0 as principal with E10.9 as an additional code.

The DRG in both cases is I72B.

Search Details: 
No entry in index under:
Diabetes
--with

BUT

Diabetes
--periarthritis, shoulder = E1-.61

Response:
This query was originally published in the 2007-08 March Database as follows:

Clinical research suggests that frozen shoulder and periarthritis are the same condition.  However because in this scenario the frozen shoulder is not documented as 'diabetic frozen shoulder', Index entry Diabetes, diabetic, periarthritis, shoulder cannot be followed.  

As there is no Index entry for Diabetes with periarthritis, the conditions must be coded separately.  

Therefore for the case cited the following codes should be assigned:
M75.0 Adhesive capsulitis of shoulder
E10.9 Type 1 diabetes mellitus without complication


This query has been updated for clarity as follows:

Clinical research suggests that frozen shoulder and periarthritis are the same condition. However, because in this scenario the frozen shoulder is not documented as 'diabetic frozen shoulder', Index entry Diabetes, diabetic/ periarthritis, shoulder cannot be followed.

As there is no Index entry for Diabetes with periarthritis, the conditions must be coded separately.

Therefore for the case cited the following codes should be assigned:
M75.0 Adhesive capsulitis of shoulder
E10.9 Type 1 diabetes mellitus without complication
VICC notes that there is now Index entry Diabetes, diabetic (controlled) (mellitus) (without complication)/frozen shoulder. The original answer still applies as the frozen shoulder is not documented as 'diabetic frozen shoulder'.


Query Text:
Please clarify application/interpretation of the Note in category T78

T78 Adverse effects, not elsewhere classified
Note: This category is to be used to identify the effects, not elsewhere classifiable, of unknown, undetermined or ill-defined causes. For multiple coding purposes this category may be used as an additional code to identify the effects of conditions classified elsewhere.
 
Excludes: complications of surgical and medical care NEC (T80-T88)

Is it correct to interpret this note to mean that if the nature of the adverse effect is documented, that a code for the effect should be assigned, before a T78 code (specifically T78.0, T78.1, T78.2 and T78.3)?  Is it optional to assign T78 as an additional diagnosis?  

What does the reference to 'unknown, undetermined or ill-defined causes' mean?  Does this note only apply if the cause is unknown, undetermined or ill-defined?  For example, if the cause of the allergic reaction is known such as seafood, is it appropriate to assume this note does not apply?

Patient diagnosed with lip swelling as a result of an allergic reaction to seafood.  How should this be coded?

Patient presents with swelling of the lips, face and tongue.  Discharge summary states angioedema as the principal diagnosis.  Should T78.3 be assigned as principal diagnosis or R22.0 Localised swelling, mass and lump, head?

Search details:
NCCH Q286 the response advises that wherever the nature of the adverse effect is documented (ie rash) an appropriate code for that condition should be assigned (see Note under category T78)

Response:
In response to your questions, the VICC advises that it is correct to interpret the note at Category T78 to mean that if the nature of the adverse effect is documented, that a code for the effect should be assigned before a T78 code and that it is optional to assign T78 as an additional diagnosis code.

The reference to 'unknown, undetermined or ill-defined causes' is applicable to countries with single condition coding where for example, the effect was known but not the cause so only T78 would be assigned.  Therefore this note is not relevant in Australia.

Therefore, for scenario one where the patient diagnosed with lip swelling as a result of an allergic reaction to seafood assign:
R22.9 Localised swelling, mass and lump, unspecified
T78.1 Other adverse food reactions, not elsewhere classified
Y57.9 Drug or medicament, unspecified

For scenario two, the VICC considers that the only codes required are T78.3 Angioneurotic oedema and the external cause codes as the discharge summary states angioedema as the principal diagnosis. [end of response]

Refer to #2948 Allergy T78.4 for Eighth edition advice.


Query Text:
59 year old female underwent ultra-low anterior resection for Carcinoma rectum.

Third post operative day clinician documents B Blocker withdrawal syndrome when IV B Blocker withheld by nursing staff without asking clinician.  As a result patient went into AF.

How do you suggest we code the withdrawal?

Response:
The VICC advises to code the withholding of the B Blocker to Y63.6 Nonadministration of necessary drug, medicament or biological substance by following index entry:
Nonadministration (of) 
-drug or biological substance (necessary) Y63.6 

Therefore, for the case cited the following codes should be assigned:
I48 Atrial fibrillation and flutter
Y63.6 Nonadministration of necessary drug, medicament or biological substance
Y92.24 Place of occurrence, health service area, this facility


Query Text:
An email received in July 07 stated that the Victorian Additions to the Australian Coding Standards have been updated. 
Our main concern is the change in prefixing obstetric codes. (the special instructions for the prefixing of obstetric codes have been deleted. Obstetric codes should now be prefixed following the same guidelines as for other codes)

Our query is what do we classify as a 'complication' and how do we know what to prefix as a 'P' or 'C'.
Example 1:
Patient presents for delivery with Gestational Diabetes. She sustains a 2nd degree tear that is sutured. Can you please clarify that the tear should be prefixed with a 'c'? The previous Vic additions instructed us to prefix a tear with a 'P' but if we follow prefixing guidelines for other codes (as per July 07 update) we would prefix it with a 'C' as it is seen as a complication as it wasn't present on admission. 
P O24.42
P Z37.0
C O70.1

Example 2:
Patient presents post dates for induction of labour. Patient then develops fetal distress and failure to progress and requires an emergency LUSCS. Should the fetal distress and failure to progress be prefixed with a 'c' with post dates as the principal diagnosis?
P O48
P Z37.0
C O68.8
C O62.2

Can you please provide us with some examples of how certain cases should be prefixed as it is causing considerable confusion.

Response:
The VICC agrees with the enquirer's assignment of the C prefix in the examples cited.  The VICC will provide a coding feature in the future detailing examples of the assignment of the C prefix in obstetric cases and will also add examples into the Victorian Additions to the Australian Coding Standards for 1 July 2008.


Query Text:
Does H.Pylori need to be proven on histopathology before being coded.  We have a doctor who regularly writes 'Antibiotics for H. Pylori eradication' after a gastroscopy regardless of whether a biopsy was done or not.  

When asked, he says that the mucosa can sometimes be too fragile to cope with a biopsy and he makes a clinical judgement that the condition (gastritis, ulcer) may be due to or associated with H. Pylori.  Just in case, he orders antibiotic treatment.

It causes much discussion here whether the H. Pylori should be coded, or whether  Z29.2 should be coded.   

Search Details: 
ACS 0010
NCCH query 1887

Response:
The VICC advises that it is appropriate to assign a code for H Pylori if there is clinical documentation of the condition, that is, the condition does not have to be proven on histopathology.


Query Title:
Dehiscence associated with total hip joint replacement

Query Text:
Could you please review the operation report below and advise us on the correct coding for this scenario.

Patient had recent THR and was readmitted with a dehiscence described as: 
There was dehiscence of the distal one third of the gluteus medius repair, which did communicate through a synovialised cavity with the hip joint.  Because of her pain and tenderness pre-operatively in that region, we elected to repair the abductors.

Index entry for dehiscence post procedural or operation wound directs you to T81.3. 

T81 Complications of procedures, not elsewhere classified
Excludes: adverse effect of drug NOS (T88.7)
complication following:
  immunisation (T88.0-T88.1)
  infusion, transfusion and therapeutic injection (T80.-)
specified complications classified elsewhere, such as:
  complications of prosthetic devices, implants and grafts (T82-T85)
  dermatitis due to drugs and medicaments (L23.3, L24.4, L25.1, L27.0,L27.1)
  poisoning and toxic effects of drugs and chemicals (T36-T65) 

Because the dehiscence communicates with the (prosthetic) hip joint should this be classified as a complication of the prosthetic device, noting that the excludes note does not state 'due to'? Should this be coded to:

T84.8 Other complications of internal orthopaedic prosthetic devices, implants and grafts
Conditions listed in T82.8 due to internal orthopaedic prosthetic devices, implants and grafts (T82.8) 

The look up in the index under complication, prosthetic device, specified NEC directs coder to T84.8. Should this code be assigned or T81.3?


OPERATION REPORT

OPERATION:RIGHT HIP ABDUCTOR REPAIR, OPEN PSOAS RELEASE AND ARTHROTOMY, RIGHT HIP JOINT.

OPERATIVE DIAGNOSIS:
Right hip psoas tendinitis, abductor right hip abductor dehiscence.

OPERATIVE DETAIL:
Implants used:  The patient was placed in the lateral position on the operating table with the right hip uppermost.  2g Keflin were given I.V.  A further 1g Keflin was given at completion of the procedure.  The right hip and leg were prepared with aqueous and alcoholic Iodine and draped.  

The abductors were initially exposed utilising the previous lateral incision.  Flaps raised anteriorly and posteriorly.  Bursa and suture material within the bursa were excised.  There was dehiscence of the distal one third of the gluteus medius repair, which did communicate through a synovialised cavity with the hip joint.  Because of her pain and tenderness pre-operatively in that region, we elected to repair the abductors.  

A direct lateral approach was made to the hip joint, mobilising gluteus medius separate from gluteus minimus and the capsule, splitting between the anterior one third and the posterior two-thirds.  Vastus lateralis was raised as a continuous sheet.  The gluteus medius tendon was debrided back to its tendinous portion, and the bursa was excised and the synovium on the anterior surface of the greater trochanter was removed.  The tendon was tagged and then retracted.  The joint was entered.  There was normal synovial fluid within the joint.  The anterior rim of the cup was defined.  It was not prominent.  The psoas tendon was tight, tenting the capsule anteriorly and inferiorly down to the lesser trochanter.  The capsule was mobilised off the intertrochanteric line down to the lesser trochanter.  The soft tissue mobilisation off the femur was continued distally over the lesser trochanter, releasing the psoas tendon and its inferior extension.  The tight psoas tendon was then not palpable. 

The hip was dislocated and the liner and cup and head were inspected.  There was no abnormality detected apart from innocuous titanium marks on the head.  

The hip was reduced.  Range of motion checked.  Flexion was possible to well over 90 degrees without impingement.  The hip was stable in extension and external rotation to 30 degrees.  Thickened capsule anteriorly was resected to minimise the chance of any recurrent impingement or impingement-type symptoms.  

The wound was lavaged with a total of six litres of Ringer solution.  The capsule and gluteus minimus were repaired back to bone through drill holes using 5 Ticron.  The gluteus medius was also repaired back to bone using 5 Ticron.  The capsule and gluteus minimus superiorly were repaired with 1 Vicryl.  The remainder of the closure was with 1 Vicryl then 1 Ethibond, 1 Vicryl, 2/0 Vicryl and 3/0 Monocryl for skin.  

POST-OPERATIVELY:
Keflin, Clexane, analgesia.  TED stockings.  Mobilise, weight bearing as tolerated.  

Search Details: 
ACS 0033 - relating to exclusion notes in block T81 of the tabular list of diseases.

Response:
The VICC advises that dehiscence is a rupture of a surgical wound and although in the case cited the dehiscence communicates with the prosthetic hip joint, it is not documented as a complication of the prosthesis. 

Therefore the correct code to assign is:
T81.3 Disruption of operation wound, not elsewhere classified


Query Text:
A 33 year old female who is morbidly obese was admitted for gastric reduction surgery.  However instead of the usual banding or stapling, a laparoscopic sleeve gastrectomy was performed.  

We have used the code for laparoscopic gastric reduction 30511-01[889] but do not think that this adequately describes the procedure performed.  None of the gastrectomy codes seem appropriate.  Can another code be used in conjunction with the gastric reduction code to indicate that a gastrectomy was performed? Presumably this carries more risk and cannot be reversed.  

Could the NCCH consider creating  a new code to cover this surgery or add an includes note under the gastric reduction code.

Response:
This query was originally published in the December 2007 VICC queries database release as follows:
The VICC does not consider 30511-01 [889] Laparoscopic gastric reduction appropriate as the procedure performed is actually removal of the stomach, not a reduction.  

Therefore the VICC suggests the assignment of the following codes:
30523-00 [879] Subtotal gastrectomy
30390-00 [984] Laparoscopy 

Please note that the assignment of 30523-00 [879] Subtotal gastrectomy with a principal diagnosis of E66.8 Other obesity will result in DRG 901Z  Extensive O.R. Procedure Unrelated To PDX.  The VICC will refer this to the Commonwealth for investigation.

Following publication of Coding Matters Volume 17 Number 1 June 2010 the VICC response is superseded by the following advice titled Duodenal Switch:
The duodenal switch (DS) procedure is a modified biliopancreatic diversion, sometimes known as a biliopancreatic diversion with duodenal switch (BPD-DS).

Biliopancreatic diversion, or bypass procedures, are principally malabsorptive procedures, but may include an element of restrictive surgery to reduce the size of the stomach.
Both the unmodified biliopancreatic diversion and the BPD-DS include a partial gastrectomy.

In the unmodified biliopancreatic diversion, a distal gastrectomy is performed, while in the BPD-DS a ‘sleeve’ gastrectomy is performed along the vertical axis of the stomach, preserving the pylorus and initial segment of the duodenum, which is then anastomosed to a segment of the ileum.

The ‘sleeve’ gastrectomy keeps the pyloric valve intact and eliminates the possibility of dumping syndrome, marginal ulcers, stoma closures and blockages, all of which can occur with other bypass/diversion procedures. 
In addition, it keeps a portion of the duodenum in the food stream. The preservation of the pylorus/duodenum pathway means that food is digested normally in the stomach before being excreted by the pylorus into the small intestine. As a result, the DS procedure enables more ‘normal’ absorption of many nutrients than is seen after other bypass/diversion procedures. 

However, the basic principle of the DS procedure is the same as the unmodified biliopancreatic diversion i.e. producing selective malabsorption by limiting the food digestion and absorption to a short common ileal segment. 

Therefore, the correct procedure code to assign for the DS procedure is 30512-02 [889] Biliopancreatic diversion or 30512-01 [889] Laparoscopic biliopancreatic diversion as appropriate, following the index pathway:
Biliopancreatic diversion (open) 30512-02 [889]
- laparoscopic 30512-01 [889]

In addition, assign 30511-01 [889] Laparoscopic gastric reduction or 30511-00 [889] Gastric reduction as appropriate, to specify the gastrectomy (restrictive component of the procedure), following the index pathway:
Reduction
- gastric (for morbid obesity) 30511-00 [889]
- - laparoscopic 30511-01 [889]

This has been flagged for review in a future edition of
ACHI.


Query Text:
We are currently revising our Blood Glucose Record chart and I requested tick boxes under Diabetes Type 2 that say Long Term Insulin Yes/No.

Staff now want a definition of when to tick this option to put into the work instruction linked to the form, and I just can't seem to find it although I know I've read it a number of times.

Can you help me with the long term insulin definition and when to use it and not to use it.

Response:
The VICC advises that long term insulin refers to the patient having ongoing insulin therapy prior to this episode of care.  ACS 0401 Diabetes mellitus and impaired glucose regulation page 91 under insulin therapy provides guidance for the use of  Z92.22 Personal history of long term (current) use of other medicaments, insulin.

It should be noted that a tick box can't be used to assign a code unless there is supporting documentation in the medical record.


Query Text:
We had a patient admitted with fulminant hepatitis and transferred onto to a metropolitan tertiary hospital.  It was thought it might be due to ETOH and/or paracetamol.

Looking up the index if I select Hepatitis, fulminant - I am forced to use a viral hepatitis code. 

However, by definition 'fulminant hepatitis' is - Acute liver failure or fulminant hepatitis is a rare but potentially fatal disease. Mortality without supportive management and/or liver transplantation is in excess of 70%.  Adult definitions of fulminant hepatic failure, which include the development of hepatic necrosis and encephalopathy within 8 weeks of onset of liver disease do not apply to acute liver failure in children particularly if secondary to autoimmune or metabolic liver disease. (http://www.md.ucl.ac.be/pedihepa/ALF.htm )

When I then look up acute liver failure -  the inclusion note on K72 includes 'fulminant hepatitis'.

Can I bypass the index if the hepatitis is definitely not viral and use an acute liver failure code?  Can I use K70.4 if the link is made with alcohol, even though I can't get there through the index, or K71.1 for the paracetamol cause?

Response:
The VICC advises that fulminant means severe, moving quickly - it is not a type of hepatitis.  Unless there is documentation of other causes of the hepatitis, you must follow the index entry Hepatitis, fulminant (viral) NEC to assign B19.9 Unspecified viral hepatitis without hepatic coma.  This is an example of the classification making the assumption that the most likely cause of hepatitis is viral.  

While the definition of fulminant hepatitis in your query refers to acute liver failure, hepatic necrosis and encephalopathy unless these terms are documented in the medical record, codes for these conditions cannot be assigned.


Query Text:
8-year-old male admitted for excision of osteochondroma of femur.

Codes assigned:
D16.2 Benign neoplasm of long bones of lower limb
M9210/0 Osteochondroma
30241-00 [1563] Excision of lesion of bone, NEC
92514-19 [1910] GA.
Episode grouped to I23Z Local excision and removal of internal fixation device excluding hip and femur.

This DRG does not appear to be correct as it excludes the femur.  Unable to find any more suitable codes.

Search Details: 
Version 5.2 DRG Definitions Manuals: The above excision code is in the procedure list for grouping to this DRG.

Response:
The episode has grouped to ADRG I23 because there is no specific code for excision bone femur.  In addition there is no diagnosis code that describes the condition is of the femur.  The VICC has therefore referred this query to the Commonwealth for investigation.


Query Text:
Z49.0 Preparatory care for dialysis.

Our coding team is looking for some clarification on the use of code Z49.0 Preparatory care for dialysis [includes creation of an arteriovenous fistula (AVF)].

Reference is made to the section in the ICD Coding Newsletter, August, 1999 entitled Preparation for Dialysis.  It acknowledged the change to the ICD-10-AM Alphabetic Index of Diseases (Volume 2) for creation of an AVF.  Other renal dialysis information was included. 

Coders were directed to use the code Z49.0 for elective admissions for: 
(a) creation of an AVF
(b) insertion of a Tenckhoff (peritoneal) catheter
(c) insertion of a permacath (for dialysis)

The use of Z49.0 for admissions where patients have these access devices for dialysis created/inserted for the first time seems clear.

We have the following situations at our hospital that I would like the VICC to help clarify.  In each of the cases the patient already has a dialysis access device in situ and have been receiving haemodialysis.

(1) Because of complication of left arm AVF (therefore cannot be used properly), patient admitted for creation of new AVF in opposite arm.  Is the principal diagnosis:
Z49.0 as creation of AVF
or 
AVF Complication code as reason AVF cannot be used which necessitates creation of new AVF in opposite arm; also Z49.0 specifies Preparatory care for dialysis but the patient is already receiving dialysis.

(2) Because of complication of left arm AVF (therefore cannot be used properly), patient admitted for closure of AVF, and creation of new AVF in different location of same arm.  Is the principal diagnosis: 
Z49.0 as creation of new AVF even though on same arm 
or  
AVF Complication code as reason AVF cannot be used which necessitates creation of new AVF in same arm; also Z49.0 specifies Preparatory care for dialysis but the patient is already receiving dialysis

(3) Patient changes mode of dialysis - because of complication of arm AVF (ongoing problems with AVFs over time), patient admitted for insertion of Tenckhoff catheter to eventually start peritoneal dialysis.  Is the principal diagnosis:
Z49.0 as insertion of Tenchoff catheter 
or 
AVF Complication code as reason AVF cannot be used which necessitates the insertion of a peritoneal catheter

Search Details: 
ICD Coding Newsletter, August, 1999 entitled Preparation for Dialysis

Response:
The VICC referred this query to the NCCH who provided the following advice:

"The NCCH advises that Z49.0 Preparatory care for dialysis should be assigned for those admissions where the intention is for creation of a new fistula in preparation to commence dialysis treatment.  Where the reason for creation of a new fistula is due to a complication relating to an existing fistula (even when the new fistula is being created at a different site), then assign the appropriate complication code from category T82 Complications of cardiac and vascular prosthetic devices, implants and grafts with external cause codes Y84.1 Kidney dialysis and Y92.22 Health service area."

The VICC notes this advice was published in the March 2009 10-AM Volume 15 Number 4 Commandments.


Query Title:
External cause codes for renal dialysis coding

Query Text:
External cause codes for renal dialysis coding.

In particular we would like the VICC to clarify the use of the Y code associated with renal dialysis - Y84.1 Kidney dialysis.  The renal dialysis procedure seems to have two integral components: the presence of an access device to enable dialysis to take place (Permacath central venous & Tenckhoff catheters and an AVF) and the dialysis procedure itself. 

This idea is supported by the NCCH in responses to coding queries. In discussing localised infections of an IV site Coding Matters, September, 2001, Vol. 8 No. 2, pg 9 notes that these problems are associated with the access device (that is, insertion of the catheter) rather than the procedure of infusion, transfusion or injection.  Furthermore, in answering NCCH Q2075 on complications of dialysis, the NCCH acknowledge that dialysis can be seen as a medical procedure more like infusion/injection. Also, see NCCH query Q1606 on overaggressive dialysis for use of Y84.1.

Given this, could the VICC confirm or clarify the following use of Y codes:
1.  Complication/problem with/related to AVF  Y83.2 Surgical operation with anastomosis, bypass or graft

2.  Complication/problem with/related to Tenckhoff (peritoneal) catheter  Y83.1 Surgical operation with implant of artificial internal device

3.  Complication/problem with/related to permacath (central venous) catheter  Y84.8 Other medical procedures


4.  Complication/problem related to renal dialysis (infusion) procedure itself  Y84.1 Kidney dialysis

Search Details:
Coding Matters, September, 2001, Vol. 8 No. 2, pg 9
NCCH query Q2075 on complications of dialysis
NCCH query Q1606 on overaggressive dialysis

Response:
The VICC referred this query to the NCCH who provided the following advice:

"The correct external cause code to assign for a complication related to any mode of dialysis is Y84.1 Kidney dialysis irrespective of whether it is a complication of the fistula, catheter or the infusion. The T code assigned describes the type of complication and the external cause code identifies that it is due to kidney dialysis."

The VICC notes this advice was published in the March 2009 Volume 15 Number 4 10-AM Commandments.


Query Text:
24 year old patient, 25 weeks pregnant.  Has Type 2 diabetes which is being treated with insulin during pregnancy as had previous admission for unstable BSLs.  Now admitted with hypertension stated as ? pre-eclampsia.

My query is whether to code the hypertension solely as a complication of pregnancy, with O24.12 Pre-existing diabetes mellitus, Type 2, in pregnancy, insulin treated as additional diagnosis, or whether codes from chapter 4 should also be used in order to strictly follow the index and standards, that is:
Diabetes
-with
--hypertension E11.72

In this case, I have used O16 for the hypertension as patient was monitored but no treatment given for hypertension.  There is no evidence in the history that the patient has had pre-existing hypertension.

Response:
In accordance with ACS 0401 Diabetes mellitus and impaired glucose regulation under the section Diabetes mellitus complicating pregnancy which advises to assign appropriate additional code(s) from E09–E14, E11.72 Type 2 diabetes mellitus with features of insulin resistance should be assigned.  

Therefore, for the case cited the codes to assign are:
O16 Unspecified maternal hypertension
O24.12 Pre-existing diabetes mellitus, Type 2, in pregnancy, insulin treated
E11.72 Type 2 diabetes mellitus with features of insulin resistance

It is unneccesary to assign I10 Essential (primary) hypertension as it is covered by O16.


Query Title:
Initiation of CPAP sleep clinic patients

Query Text:
What codes should we use for initiation of CPAP for our sleep clinic patients?  They will usually present for an overnight stay for diagnostic polysomnography and then, if applicable, return for another overnight stay at the sleep clinic for initiation and monitoring of CPAP treatment.  We are unable to find a code for the second admission to distinguish its therapeutic purpose from the diagnostic purpose of the first admission.

Response:
The VICC considers 11503-16 [1849] Continuous monitoring of pulmonary function for >= 6 hours duration may be appropriate to assign for monitoring of CPAP treatment if you want to capture these episodes.


Query Title:
ACS 1521 Conditions complicating pregnancy

Query Text:
The recent VAED audit has highlighted some confusion with regard to conditions complicating versus commonly occurring in pregnancy.  Would the committee please clarify the intent of ACS 1521 Conditions complicating pregnancy with regard to conditions commonly occurring and predominantly related to pregnancy such as vomiting in pregnancy, urinary tract infections, carpal tunnel syndrome, pre-existing diabetes and vaginal bleeding.

Should we ever be coding an 'O code' for these conditions in pregnant woman if they are not documented as 'complicating' or 'complicated by' pregnancy.

On another note, please also refer to NCCH query Q2071, has this been superseded? Should the codes for these scenarios be void of obstetric chapter codes?

Response:
In accordance with Coding Matters Volume 12 Number 1 article titled Trauma during pregnancy, the following guidelines should be applied to determine how to code conditions occuring during pregnancy:
If there is documentation of obstetric care but the reason for admission is not complicating the pregnancy, assign Z34 Supervision of normal pregnancy to reflect the obstetric care.

If there is documentation that the condition is complicated by the pregnancy or complicating the pregnancy, follow the index and assign the appropriate 'O' code.

If there is no documentation that the condition is complicated by the pregnancy or complicating the pregnancy and no obstetric care is given, assign Z33 Pregnant state, incidental.

NCCH Q2071 has been superseded by the advice provided in Coding Matters as described above which is in line with the advice in ACS 1521 Conditions complicating pregnancy.


Query Text:
PRS/2 triggers a warning in regard to principal diagnosis Z00.6 Examination for normal comparison and control in clinical research programme which I assign when our oncology patients are admitted for blood tests etc. in relation to their clinical drug trial.

If this is not correct could you please advise the correct principal diagnosis to assign?

Response:
Provided the episodes meet one of the criteria for admission as detailed in section 2 of the VAED manual under Criteria for Admission, in accordance with ACS 0026 Admission for clinical trial, drug challenge or therapeutic drug monitoring,  it is appropriate to assign Z00.6 Examination for normal comparison and control in clinical research programme as the principal diagnosis.


Query Text:
Failure to progress is a common occurance in pregnant women during labour.  Often the doctors are not more specific in the documentation other than to document failure to progress.  Can you please advise of the correct code to assign for failure to progress? 

Presently, some hospitals are assigning O62.2 Other uterine inertia.  However, I am unable to find an index entry to support the assignment of this code (as there is no look up for failure to progress specifically).  It seems that the correct code might be in fact O62.9 Abnormality of forces of labour, unspecified or O62.8 Other abnormalities of forces of labour. 

NCCH query Q1112 supports the assignment of a code from O62 block, but does not specify the use of O62.2 for failure to progress.

Perhaps a specific index entry for failure to progress is necessary, especially if the correct code is O62.2?

Response:
This query was originally published in the 2008-09 June VICC queries database as follows:

The VICC referred this query to the NCCH who provided the following advice"

"The NCCH agrees that failure to progress in labour is a description rather than a diagnostic term, therefore coders should assign a code for the underlying condition resulting in failure to progress. Underlying causes may include cephalopelvic disproportion, malpresentation, inefficient uterine action (primary uterine inertia or secondary uterine inertia), cervical dystocia, maternal exhaustion etc.

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.

The NCCH will consider improvements to the Alphabetic Index for failure to progress in labour for a future edition of ICD-10-AM."

The VICC notes this advice was published in the March 2009 Volume 15 Number 4 10-AM Commandments.

The Coding Matters advice has been superseded.  For Eighth edition advice on coding of failure to progress refer to ACCD Coding rules released 15 March 2014 titled Failure to progress in first or second stage:

[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:
- 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)


Query Text:
Pathology from a recent case clearly stated this patient has Papillary Thyroid Carcinoma.

We followed the ICD-10-AM alphabetical index and came to:
Carcinoma
- papillary
- - thyroid (M8260/3)

But when we confirmed the definition in the ICD-10-AM tabular index we found that M8260/3 reads Papillary adenocarcinoma NOS.

We subsequently followed the Index entry: 
Carcinoma
- papillary M8050/3 (papillary carcinoma NOS)

but which is correct?

Response:
VICC research indicates that papillary adenocarcinoma of thyroid and papillary carcinoma of thyroid are the same condition, therefore it is correct to follow index entry Carcinoma, papillary, thyroid to assign morphology code M8260/3.


Query Text:
Operation Performed:  Fistula repair high anal fistula

Indication: Previous complex extrasphincteric fistula which was managed by an advancement flap repair which subsequently failed, now for re-exploration and Fibrin glue instillation to the fistula.

Procedure: The tract was curetted externally and Fibrin glue was then instilled to the external opening extending to the external component, a large Fibrin plus was matured and Steristrips were used to hold the plug in place.

Please advise correct procedure code.  Suggested code is 32162-02 [937] Insertion of seton and excision of anal fistula involving upper half of anal sphincter mechanism.

Response:
In accordance with the advice in NCCH Q1523 Injection of fibrin glue (13/02/2002 Second editon), the VICC advises to follow index entry Closure, fistula, anus to assign 90315-01 [933] Excision of other lesion or tissue of anus.  As the instillation of the glue is a component of the closure of the fistula, in accordance with ACS 0016 General procedure guidelines it would not be coded as a separate procedure.

Please note that there will be a code for administration of biological sealant to anorectal region in Block [929] in Sixth Edition.


Query Text:
We are having more and more patients admitted for induction of labour due to the closure of maternity services in country hospitals and the long distances women have to travel for their deliveries.  Our obstetrician is adamant that physical isolation is a valid reason for induction for these women and that these are not social inductions.  It reflects badly on our induction rates if we cannot flag these cases and he feels that our very low rate of low Apgar scores indicates this intervention is not detrimental to the patients.  The most appropriate descriptive code would be Z75.3 Unavailablity and inaccessibility of health-care facilities but is this acceptable?

Response:
The VICC considers it is appropriate to assign an additional code to identify these cases and agrees with the assignment of Z75.3 Unavailability and inaccessibility of health-care facilities by following index entry Unavailability (of) medical facility, due to remoteness from facility.


Query Text:
A female patient with significant excoriation under breast area was admitted for an unrelated condition.  A wound chart was commenced to record the treatment and progress of the excoriation.  No other terms were used to describe the condition and there was no infection.

Index entry for excoriation directs to T14.0x Superficial injury of unspecified body region.  A more site-specific code can be found under Injury, superficial eg S20.1x Other and unspecified superficial injuries of breast.

We are not sure injury and external cause codes are best applicable when excoriation is due to rubbing of skin against skin which is moist and warm.  Other possible codes include L98.8 Other specified disorders of skin and subcutaneous tissue and R23.4 Changes in skin texture

If S or T codes are to be used, could you please advise which is the best external cause code in this example.

Search Details: 
ACS 1916 Superficial Injuries

Response:
The VICC referred this query to the NCCH who provided the following advice:

"The NCCH agrees that L30.4 Erythema intertrigo is the correct code for non-traumatic excoriation of skin of breast.

The NCCH will consider improvements to the index for this condition for a future edition of ICD-10-AM."

The VICC advises that L30.4 Erythema intertrigo can be found under the index lead term Chafing.

The VICC notes the NCCH advice was published in the March 2009 Volume 15 Number 4 10-AM Commandments.


Query Text:
Patient admitted for DBE via a colonoscopy with argon plasma coagulation (APC) ablation of ileal AVM.

ACS 0024 Panendoscopy states that an endoscopy of the ileum can be performed via the upper or lower gastrointestinal tract.  The index entry under 'ileoscopy' will assist in assigning the correct code.

Following the index, Ileoscopy, with, coagulation, argon plasma you get 30478-21 [1007] Panendoscopy to ileum with other coagulation which is a gastroscopy code.

However, as the APC is done via a colonoscopy we feel the correct code should be 90308-00 [908].   In the index for Ileoscopy there is an entry for 'via colonoscopy - see Colonoscopy' however you first get to with coagulation.

What is the correct code to assign for the above procedure?  

Search Details: 
ACS 0024 Panendoscopy
ACS 0041 Conventions Used in the alphabetic Index of Interventions

Response:
The VICC agrees that for the case cited the correct code to assign is 90308-00 [908] Endoscopic destruction of lesion of large intestine following index entry Colonoscopy/with/destruction of lesion.  

The VICC acknowledges that there is a problem with the Index entry for Ileoscopy in that the entry 'via colonoscopy' comes after 'with coagulation' which leads you to assign 30478-21 [1007] which is a upper GI endoscopy code and will refer this to the NCCH for investigation.


Query Text:
This query relates to the coding and grouping of therapeutic plasmapheresis.  We have patients with neurological diagnoses such as peripheral neuropathy and myasthenia gravis admitted specifically for therapeutic plasmapheresis.  This procedure involves the removal of the patients plasma from the blood via apheresis and the reinfusion of remaining blood with the addition of a plasma product such as albumex.

Following the index 
Admission (for) 
-plasmapheresis Z51.81 
we would assign
Z51.81 Apheresis as principal diagnosis
an additional code for the condition 
plus procedure codes
13750-00 [1892] Therapeutic plasmapheresis
92062-00 [1893] Transfusion of other serum

This groups to B62Z Admit for Apheresis.

I notice there is an AR-DRG B40Z Plasmapheresis with Neurological Disease (same day DRG) which seems an appropriate DRG for this type of admission.  Removing code Z51.81 as principal would allow grouping to this DRG.

Under what circumstances would B40Z ever be assigned if not for this type of admission?

Queries and coding advice for assignment of Z51.81 refer more specifically to procurement of donor blood products rather than for therapeutic reasons.  

Search Details: 
VICC Query #2052
NCCH Queries  Q1375, Q2121
ICD-10-AM Commandments Vol 7 No 4 - Apheresis

Response:
This query was referred to the NCCH who provided the following advice:

"There are two types of patients admitted for donor apheresis. One type of donor is a patient with a known disease, such as a malignancy, admitted to donate cells for therapeutic reinfusion at a later date (autologous donation). In this scenario, assign a code for the condition that will be treated by the donated cells. 

The other type of donor is a healthy donor, admitted to donate cells for infusion into another person (allogeneic donation). In this scenario, assign as the principal diagnosis Z51.81 Apheresis.

For patients admitted for therapeutic apheresis (e.g. plasmapheresis, leukapheresis etc.) assign as the principal diagnosis a code for the condition requiring treatment.  It is unnecessary to also assign Z51.81 Apheresis as this information is specified by the procedure code.

See ACS 0301 Stem Cell Procurement and Transplantation."


Query Text:
A 38 year old female was admitted to hospital with R) Glaucoma and underwent R) Bleb needle revision with 5-FU.  We assigned the following procedure codes : 
42749-00 [191] Revision of scleral fistulisation procedure (includes revision of filtering bleb)
42824-01 [251] Subconjunctival administration of 5-FU (fluorouracil)

Would you please confirm that our codes are correct.

Response:
The VICC agrees that as per NCCH query Q343, it is appropriate to assign 42749-00 [191] Revision of scleral fistulisation procedure for the case cited.  It is also appropriate to assign 42824-01 [251] Subconjunctival administration of 5-FU (fluorouracil) as in this case the needle was used to inject 5-FU.


Query Title:
Medtronic Infuse Bone Morphogenic Protein 2 (BMP)

Query Text:
What code should be used for insertion of a Medtronic Infuse Bone Morphogenic Protein 2 (BMP)? It is being used in spinal fusions and also in the treatment of nonunited fractures. I have assigned code 47920-00 [1554] Insertion of bone growth stimulator.

Response:
The VICC advises that as per similar previous NCCH queries Q1445 Procedure code for removal and subsequent injection of Thrombin + A.G.F into Bone, Q1446 Autogenous bone marrow and OPI putty, Q2281 Injection of Bone Substitute Material (BSM) and Q2338 Osteoset implantation, BMP 2 is considered a bone graft and therefore should be coded as such.


Query Text:
If a patient has intra-thecal morphine as part of surgical anaesthesia, this is considered an on-going spinal anaesthetic with definite nursing observations required for 12-24 hours.  How should this be coded?   Should it be 92508-99 [1909] Neuraxial block, ASA 99 or as a continuous block?

Response:
The VICC advises that the intra-thecal morphine is considered an analgesic, not an anaesthetic and is therefore not coded.


Query Text:
What is the correct code to assign for traumatic epidural haemorrhages of the spinal column?

In the index:
Haemorrhage
-epidural (traumatic) S06.4

S06.4 Epidural haemorrhage is in the Intracranial Injuries category of codes.  This code does not seem correct for cases of spinal epidural haemorrhages especially given the index entry for Haematoma is:
Haematoma
-epidural (traumatic) S06.4
--spinal - see Injury, spinal cord, by region

Can the spinal cord injury codes also be used for a diagnosis of haemorrhage not haematoma?

Response:
The VICC advises that when it is known that the epidural haemorrhage is spinal, follow Index entries Injury, spinal cord or Haematoma, epidural, spinal.  

The VICC will refer this query to the NCCH suggesting index entry  'epidural, spinal - see Injury, spinal cord, by region' be added under lead term Haemorrhage as well as excludes note 'excludes spinal epidural haemorrhage' at S06.4 Epidural haemorrhage.


Query Title:
Presenting condition linked to previously diagnosed cancer

Query Text:
Could the committee please clarify the coding of patients with a previously diagnosed cancer presenting with a condition linked to the cancer.

1. Patient with previously diagnosed breast cancer with liver metastases presents with a subcapsular liver haematoma.  The principal diagnosis on discharge summary is 1. Liver haematoma 2. Pain secondary to cancer.  Multiple scans done and pain relief given.

2. Patient with previously diagnosed NHL transferred to our hospital with IVC obstruction.  Notes state IVC obstruction due to NHL disease progression.  Biopsy of mass surrounding IVC performed and histology showed NHL.  Patient was palliated.

It is clear in the notes from both cases the cancer is linked to the other conditions.

3. VICC query #1998 has a patient with a blocked biliary stent due to tumour advancement.  The stent is removed and patient palliated. The advice given is to code the cancer as the principal diagnosis not a complication of the stent.  

4. There are many patients admitted with bowel obstructions due to previously diagnosed bowel cancer.  VICC query #998 April 1995).

In the above examples should the principal diagnosis be the cancer or the presenting complaint for example, liver haematoma- case 1, IVC obstruction- case 2, biliary obstruction- case 3, bowel obstruction- case 4?  

Search Details: 
VICC Query #1998
VICC Query #998

Response:
Coders should be aware that previous queries may have been superseded and also that previous queries cannot be applied as a blanket rule.  

ACS 0001 Principal diagnosis provides guidance about the presenting problem and the underlying condition both being treated where the underlying condition is already known.  If you have a scenario where both the presenting problem and underlying condition are treated apply the two or more interrelated conditions, each potentially meeting the definition for principal diagnosis section of ACS 0001 Principal diagnosis in accordance with the documentation available.


Query Title:
Acute myeloid leukaemia secondary to myelodysplastic syndrome

Query Text:
Coding a patient who has Acute Myeloid Leukaemia (AML) documented as secondary to myelodysplastic syndrome.  Index look up leads to C92.0- and M9871/3  but index also leads to same code under AML without prior MDS, which would appear to be an index error:

Leukaemia:
-myeloid (M9860/3) C92.9- 
--acute NOS (M9861/3) C92.0- 
---with 
----abnormal marrow eosinophils (M9871/3) C92.0- 
----maturation (M9874/3) C92.0- 
----multilineage dysplasia (M9895/3) C92.0- 
----prior myelodysplastic syndrome (M9895/3) C92.0- *
---without 
----maturation (M9873/3) C92.0- 
----prior myelodysplastic syndrome (M9895/3) C92.0- *

Response:
The VICC referred this query to the NCCH who provided the following advice:
“In Third Edition revisions were made to ICD-10-AM which incorporated codes from WHO's International Classification of Diseases for Oncology (ICD-O), Third Edition. This classification formed the basis of the index pathways cited in your query.

The NCCH acknowledges that AML with myelodysplastic syndrome and AML without myelodysplastic syndrome are clinically different, however, the classification groups them together. 

Suggestions for changes to the morphology codes should be lodged as a formal suggestion to AIHWs National Cancer Statistics Clearing House (NCSCH).”


Query Title:
Supervision of primigravida with advanced maternal age

Query Text:
FAQ fromFifth Edition coding workshops, Coding Matters, December 2007: Z35.51 Supervision of primigravida with advanced maternal age.

Q: Should Z35.51 Supervision of primigravida with advanced maternal age be assigned in all instances based
on documentation of the age of the mother at the time of delivery?

A: The codes Z35.5- Supervision of pregnancy with advanced maternal age should only be assigned when applicable, ie if they meet ACS 0002 Additional diagnoses, and not routinely coded based on the patient's age.  ACS 0002 Additional diagnoses states '... a condition which is the subject of a standard in this volume must meet the criteria for an additional diagnosis before it can be coded, unless indicated otherwise.'  In ACS 0002 there is a list of specialty standards where the coder is instructed to code conditions which do not meet the additional diagnoses criteria ie exceptions to ACS 0002.

ACS 1524 Advanced maternal age provides guidelines for using Z35.5- indicating that these conditions should be coded when documented by an obstetrician/clinician/midwife and that if the criteria for the specific obstetric diagnosis is met, but the relevant diagnosis is not documented, consult the clinician before assigning a code.  However, this standard is not listed in ACS 0002 as a specialty standard that is exempt from following ACS 0002 criteria.

Is the above interpretation of ACS 1524 Advanced maternal age and ACS 0002 Additional diagnoses correct?  
ACS 0002 says the list are examples of specialty standards.  ACS 1524 says to code Z35.5- if documented.
I thought you should code Z35.5- if 'advanced maternal age' is documented by a obstetrician/clinician/midwife and that it doesn't need to meet ACS 0002 as it is a specialty standard that provides specific advice of what to code when.

Search Details: 
ACS 1524 Advanced maternal age
ACS 0002 Additional diagnoses

Response:
The VICC notes that as per the enquirer's interpretation, the list of specialty standards in ACS 0002 Additional diagnoses are examples of specialty standards that provide direction to assign codes for conditions that do not meet ACS 0002 criteria.

Therefore you are free to apply ACS 1524 Advanced maternal age for documentation of 'advanced maternal age' and assign Z35.51 Supervision of primigravida with advanced maternal age.


Query Text:
A 92 year old female was transferred from another acute hospital to the Palliative Care Unit of this hospital with pneumonia and lung cancer. The pneumonia was treated with antibiotics for greater than 24 hours.
Diagnoses as listed on discharge summary:
Right lung pneumonia -transferred to Palliative Care for further management/ assessment
Right lower lobe lung cancer -referred to Palliative Care in November 2007. Nil chemotherapy or radiotherapy.

In this scenario, should we follow ACS 0001 Principal Diagnosis and sequence pneumonia as the principal diagnosis, or follow ACS 0224 Palliative Care and sequence the lung cancer as the principal diagnosis?

Search Details: 
ACS 0001 Principal Diagnosis
ACS 0224 Palliative Care

Response:
The VICC advises that because the patient was admitted with a principal diagnosis of pneumonia not  'palliative care', assign a code for pneumonia as the principal diagnosis.  Coders should not base their coding decision on the unit and/or doctor to which the patient is admitted but rather the documentation in the medical record.


Query Text:
We are seeking advice with regard to routinely assigning codes for the insertion of arterial catheters.  We are aware that not all coders and not all hospitals assign the codes, so in the interests of uniformity could the Committee please provide some direction?

There are two arterial catheter codes that we refer to.  Both would be used when an artery is cannulated for the extraction of arterial blood for testing purposes.

1) 13842-00 [1858] Intra-arterial cannulation for blood gas analysis
and
2) 34524-00 [694]  Catheterisation/cannulation of other artery

We note that ACS 0042 Procedures normally not coded does not list arterial cannulation.

Search Details: 
ICD-10-AM ACHI
ACS 0042 Procedures normally not coded

Response:
The VICC notes that arterial catheterisation is a high risk procedure and that patients who have arterial catheters are managed intensively; would most likely be in ICU; and require one on one nursing.  Therefore, like CVC's, this procedure should be coded when performed.  

Please note that there are other codes for insertion of arterial catheters in addition to those mentioned in the query that may be applicable.


Query Text:
How do you code skin sparing mastectomy as there is no index entry for this type of mastectomy?

Response:
Research undertaken by VICC indicates that skin sparing mastectomy is a subcutaneous mastectomy.   Therefore follow index entry:
Mastectomy
-subcutaneous (unilateral) 31524-00 [1747] 
--bilateral 31524-01 [1747] 

to assign the appropriate code.

For Eighth edition advice, refer to VICC query #2884 Skin sparing mastectomy.


Query Title:
Intraductal carcinoma of breast with metastases

Query Text:
Using the PICQ software we have an episode that has triggered indicator 100038 which identifies records containing a secondary neoplasm code but no code for the primary site.  The coding for the episode in question is:
 
PD05.1       INTRADUCTAL CARCINOMA IN SITU OF BREAST
PM8500/2   INTRADUCTAL CA, NONINFILTRATING NOS
PC77.3       SEC / UNSP NEOPLM AXIL UPP LMB LYMPH NODES
PM8500/6   INFILTRATING DUCT CA NOS, MET

M8500/3 is for infiltrating duct carcinoma not non infiltrating.  So I was wondering if we should use M8500/3 in place of M8500/2 because the carcinoma has spread to the axilla lymph nodes.  Can you please advise what coding path should be taken?

Response:
VICC advises that the PICQ Indicator logic is correct.
1.  The Histopathology dated 26/7/07 states in the Pathologists Opinion, "…showing as invasive secretory ductal carcinoma (WHO Classification) of the breast with a metastatic deposit with in a sentinel lymph node".
2.  As per response to Query 2251 on the VICC queries database and advice published in Coding Matters Volume 4 Number 1 Page 7, if both in situ and invasive cancer are present in the same lesion, assign behaviour code /3. 

VICC would code this case to:
C50.9 Breast, unspecified
M8502/3 Secretory carcinoma of breast
C77.3 Axillary and upper limb lymph nodes
M8502/6 Secretory carcinoma of breast, metastatic


Query Title:
Intracranial haematoma due to a haemorrhagic disorder

Query Text:
Could the Committee please consider the following with regard to ACS 0303 Abnormal Coagulation Profile?

Patients admitted with an intracranial haematoma because of a haemorrhagic disorder due to a circulating anticoagulant are correctly coded with D68.3 Haemorrhagic disorder due to circulating anticoagulants as the principal diagnosis according to  ACS 0303.  When a craniotomy is performed to evacuate the haematoma these cases are grouping to either Q02A Oth OR pr bld & blood frm org + CSCC (inlier weight 3.5949) or Q02B Oth OR pr bld & blood frm org -CSCC (inlier weight 1.0296). 

If you assign the intracranial haemorrhage code first the episodes group to a craniotomy DRG B02A Craniotomy + CCC (inlier weight 8.4910), or B02B Craniotomy + SMCC (inlier weight 4.7759), or B02C (-cc inlier weight 3.1489).  We believe that the craniotomy DRGs correctly reflect the surgical resources used in these cases. 

We have contacted the Commonwealth Health-Casemix-Grouper department to ask if this anomaly has been addressed in AR-DRG version 6.0 however, a review of ACS 0303 may also assist with this issue.

Search Details: 
ACS 0303 Abnormal Coagulation Profile

Response:
The VICC acknowledges the current difficulty with ACS 0303 Abnormal Coagulation Profile and notes that the NCCH  has reviewed this standard for Sixth edition.  In the meantime coders should continue with their current practice.  The VICC also notes that for this scenario ACS 1902 Adverse effect of drugs and ACS 0001 Principal diagnosis - 'two or more diagnoses that equally meet the definition for principal diagnosis' may also provide direction.


Query Title:
Lateral release in total knee replacement

Query Text:
Is a lateral release performed during total knee replacement inherent in the procedure or coded out as a seperate procedure?

Response:
VICC research indicates that although lateral release is not performed for all patients undergoing total knee replacement, when it is performed it is a component of the total knee replacement.  Therefore in accordance with ACS 0016 General procedure guidelines under Procedure components, procedures which are individual components of another procedure are not coded.


Query Text:
An 84 year old patient admitted for L) CAT & IOL and LRI - Limbal Relaxing Incision.  I am not sure how to code the LRI procedure.

I checked the internet and found some information about the procedure at:
http://www.stlukeseye.com/professionals/lri_nomogram.htm

It states it is similar to the CRI - corneal relaxing incision.  The relevant ICD codes for CRI are: 
42672-00 [167] Incision of cornea, nonpenetrating, for correction of surgically induced astigmatism
and
426720-01 [167] Incision of cornea, nonpenetrating, with compression sutures for correction of surgically induced astigmatism

I am not sure if I should use one of these codes (which one), or should it go to a code more specific to the limbus?

Response:
The VICC advises that the correct code to assign for limbal relaxing incision without documentation of surgically induced astigmatism is 42644-00 [167] Incision of cornea by following index entry Incision, cornea.   It is appropriate to follow this index entry because the limbus is the far peripheral aspect of the cornea.


Query Title:
Laser ablation of tumour of the lower ureter

Query Text:
How would laser ablation of tumour of the lower ureter be coded?

We have currently coded it to 90358-00 [1088] Other procedures on ureter.

It is done in conjunction with a ureteroscopy and JJ stent insertion which are also coded.

Response:
The VICC referred this query to the NCCH who provided the following advice:
"The correct code to assign for laser ablation of tumour of the lower ureter is 90358-00 [1088] Other procedures on ureter.  Assign also the appropriate codes for endoscopy or stent insertion that may be performed.

The NCCH will review the codes in block [1074] for a future edition of ACHI."


Query Text:
If the look up  for:
Insertion
- drain
-- chest 
--- closed (endoscopic) 38409-00 [560]  
--- open 38415-00 [549] 

gives options for both open and closed drainage (for example US guided drainage of pleural effusions)

and the look up for:
Drainage
-- chest 
--- closed (endoscopic) 38409-00 [560]  
--- open 38415-00 [549] 

also gives the option for closed drainage.

Then should the look up for:
Drainage
- pleura (for empyema) (with resection of rib) 38415-00 [549]

Also include an option for a closed drainage?

Or should there be an excludes note under 38415-00 [549] Incision of pleura to indicate there is a code more suitable for a closed drainage?

Response:
In accordance with NCCH query Q1965 (17/06/04 Third edition), closed (endoscopic) drainage of the pleura should be coded to 38409-00 [560] Insertion of intercostal catheter for drainage.


Query Text:
What is the correct diagnosis code to assign for Femoro-acetabular impingement (FAI)?

Patients with FAI are now being admitted for an orthopaedic procedure to correct this.  

The procedure is documented as surgical hip dislocation with femoral head 'bumpectomy'and lateral tear debridement.  Can the VICC please advise on the correct codes to assign for this procedure?

Response:
From the operation reports provided, femoro-acetabular impingement is documented as labral tear, therefore the VICC suggests assigning diagnosis code M24.15 Other articular cartilage disorders, pelvic region and thigh by following Index entry:
Tear, torn
-articular cartilage, old M24.1-

For documentation of tear debridement, assign 90574-01[1561] Excision of joint, not elsewhere classified by following the index entry  Debridement, joint, specific joint NEC.

For documentation of bumpectomy, assign 48424-04 [1483] Ostectomy of proximal femur by following the index entry Ostectomy, femur, proximal.[end of response].

Refer to query #2882 Femoro-acetabular impingement (FAI).


Query Title:
Conditions occurring in the post partum period

Query Text:
Conditions which occur in the post partum period are creating much discussion at our hospital, particularly in light of ACS 1521 Conditions complicating pregnancy, in which conditions must be documented to be complicating pregnancy, or being aggravated by pregnancy or the main reason for obstetric care, and whether the logic applies to post partum conditions.  
Could the committee please advise correct coding, particularly of principal diagnosis (PDx), for the following cases:

1.  Multigravida, normal vaginal delivery (NVD), nil complications, but on day three develops dysuria, seen by RMO who advises Ural, and to see GP after discharge from Hospital if symptoms persist.  Is the PDx:
O99.8 Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium
or 
O80 Single spontaneous delivery
both followed by R30.0 Dysuria?

2.  Primigravida, NVD, small tear not requiring suturing, who develops acute appendicitis on day two post delivery (documentation states has had abdominal pain for five days, but attributed to irritable uterus by G.P.).  Went on to have laparoscopic appendicectomy, discharged on day six.  Is the PDx:
O99.8 Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium
or 
O80 Single spontaneous delivery
both followed by appendicitis code.

3.  Multigravida, NVD, has haemorrhoids noted on day two, and was given medication and advised to follow up with G.P. on discharge.  There is an index entry for Haemorrhoids, COMPLICATING puerperium.  Does this indicate it would be coded to:
O80 Single spontaneous delivery 
I84.9 Unspecified haemorrhoids without complication?

4.  Primigravida, NVD, no complications, but develops PE on day three (family history of PE).  There is an index entry Embolism, puerperal, see Embolism, obstetric  that would indicate this should be coded to O88.2 Obstetric blood clot embolism (and also ACS 1548 Postpartum condition or complication uses this scenario as an example).

These cases have all come up in internal audits, and we have no consistency of when we should be using an O99 code as PDx for these types of cases, and can find no clear guidelines in the ACS.

Response:
The VICC referred this query to the NCCH who provided the following advice:

"ACS 1521 Conditions Complicating Pregnancy does apply to the postpartum period unless 	otherwise stated in the code title or where an includes or excludes note directs the coder elsewhere.

O80 Single spontaneous delivery as per ACS 1505 Single Spontaneous Delivery - "is intended for single spontaneous vaginal deliveries:

without abnormality/complication classifiable elsewhere in Chapter 15 Pregnancy, childbirth and the puerperium and without manipulation or instrumentation."

Given the above, the correct codes for the scenarios cited are as follows:

1. O99.8 Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium
Conditions in C00–D48, H00–H95, M00–M99, N00–N99, Q00–Q99 and R00–R99
R30.0 Dysuria
Z37.- Outcome of Delivery

2. O99.6 Diseases of the digestive system complicating pregnancy, childbirth and the puerperium
Conditions in K00–K93
K35.9 Acute appendicitis, unspecified
Z37.- Outcome of delivery

and appropriate procedure codes.

3. O87.2 Haemorrhoids in the puerperium
Z37.- Outcome of Delivery

4. O88.2 Obstetric blood clot embolism
Z37.- Outcome of delivery"


Query Text:
If a patient is admitted for follow up of bladder cancer and no cancer is found, do you prefix the history code with a P or an A?  The follow up standards directs us to code an additional code from Z85-Z87 for the personal history. 

Can a history code be assigned as a P?

Response:
As two codes are required to describe the reason for admission, the VICC advises to prefix the personal history of cancer code with a (P).  The VICC also notes the following instruction in the prefix document of the Victorian Additions to the Australian Coding Standards:
'When a code potentially meets the definition for more than one prefix definition, assign the prefix according to the following hierarchy:
1. Primary condition (P)
2. Complication (C)
3. Associated condition (A)'


Query Text:
This query is about clinical coding of mental health day programs where the patient is admitted over 6 - 12 weeks x 1 or x 2 times per week for a session of therapy.  For example, principal diagnosis of bipolar depression.  Procedures would be for a therapy, or training such as any of the following:
-cognitive behaviour (CBT)
-art therapy
-music therapy
-relaxation therapy
-training - psychological (life skills)
-psychotherapy see procedure index, (page 194) and listing there Block [1873]
-counselling for substance addiction counselling or education (Drug & alcohol) for those facilities that do D&A

Having had some discussions with some other Psychiatric facilities it seems that some are and some are not coding the procedures.  I suspect the Private hospitals are balancing resources spent on coding for information that has no impact on the billing, therefore it is quicker to code these cases without the procedure codes.

ACS 0042 Procedures normally not coded does not include any of the above as listed above, therefore I would expect they must be coded.  What should I be coding?

Response:
The VICC notes that ACS 0042 Procedures normally not coded contains dot points providing direction for when these procedures can be coded, it doesn't state that these procedures may never be coded.

Also refer to ACS 0032 Allied Health Interventions for further guidance to assign a general or specific allied health intervention code.

Finally, VICC also notes that these patients may not meet admission criteria as set out in the DHS Admission Policy 2003-04 available at: http://www.health.vic.gov.au/hdss/vaed/admpol0304.pdf
and the VAED manual Section 3, page 69.


Query Text:
In mental health units, it is not uncommon to see 'homicidal ideation' documented with other mental health disorders.

We agree the Principal Diagnosis should be the specific mental health disorder (examples schizophrenia or depression), but feel the additional information warrants coding, in the same way as 'suicidal ideation' warrants coding where it exists.  Neither suicidal ideation nor homicidal ideation necessarily constitute part of the mental disorder, but are significant factors in the management of a mental disorder where either or both are present.

Where the condition exists, it is normally the trigger to commence a period of involuntary treatment.

The condition appears to meet ACS 0002 Additional Diagnoses in so far as the need for increased clinical care and/or monitoring and often alteration or adjustment of normal course of therapeutic treatment - both for the safety of the client, but also the safety of the staff, other clients and the public at large.

Our dilemma: There is no index entry for homicidal Ideation,  homicidal tendencies or any other adequate code to include which would allow the codes to be translated back to the medical statement.

Homicidal ideation is also a documented adverse effect of some (otherwise) therapeutic drugs; for example, the condition is a known and documented side effect of some antidepressant drugs, particularly the serotonin-norepinephrine reuptake inhibitors (SNRI) group such as Venlafaxine (Effexor), so needs to be able to be coded in the adverse effects sequence.
 
A client can present with both suicidal and homicidal ideation, or either one or the other, so to include 'homicidal ideation' in the same code as 'suicidal ideation' would not reflect the true clinical presentation, nor would such an inclusion allow accurate translation back to the medical statement.  To combine the two statements in one code would also be unacceptable from a research perspective.

We would appreciate your advice on this matter, both from a perspective of current coding, and future editions of the classification.

Response:
VICC agrees that there isn't an appropriate code for homicidal ideation.  If the enquirer wishes for a code to be developed, then a public submission should be sent to the NCCH.  However, NCCH Q1975 Homicidal ideation (09/08/04 Third edition) should be noted which states that it is unlikely that a specific code for homicidal ideation will be considered, as this is a less common occurrence and would therefore not be warranted.


Query Text:
Would VICC please advise on the diagnosis codes to assign for an ABO Incompatible Kidney transplant recipient admitted for same day Plasmapheresis for admissions both pre and post transplant?  The plasmapheresis is done to mimimise the risk of rejection.

Normally, a kidney donor has to have the same blood group as the recipient or a blood group that is acceptable.  Most people have natural antibodies against blood groups other than their own. Kidney transplants into patients with a different blood group have previously resulted in very rapid severe rejection and destruction of the kidney within hours or days by a process known as acute rejection. The process of 'plasmapheresis' removes specific antibodies from the recipients blood so that person won't reject the 'incompatible' kidney.

Response:
The VICC referred this query to the NCCH who provided the following advice:

"Plasmapheresis in the scenario cited is one component of an immunosuppressant protocol for ABO-incompatible kidney transplant. Immune suppression reduces a normal immune response to prevent rejection of transplanted organs or cells.

The NCCH agrees that the correct code to assign for same day prophylactic plasmapheresis for a kidney transplant using an incompatible blood group donor is Z29.1 Prophylactic immunotherapy.

Do not assign Z51.81 Apheresis as per the index entry Admission, plasmapheresis as this is the code for a patient admitted for allogeneic donor apheresis (that is, a healthy donor admitted to donate cells for transplant into another person).

See also ACS 0301 Stem Cell Procurement & Transplantation."

Based on the NCCH response, the VICC advises that if the plasmapheresis is prophylactic pre and post transplant, the correct principal diagnosis to assign is Z29.1 Prophylactic immunotherapy by following index entries Prophylactic, immunotherapy or Immunotherapy, prophylactic.  If the patient develops ABO incompatibility post transplant the principal diagnosis would be ABO incompatibility and not Z29.1.


Query Text:
ACS 1521  Conditions complicating pregnancy includes the following sentence:
'To code other conditions complicating pregnancy (or being aggravated by the pregnancy or that are the main reason for obstetric care), a code from ...

Could the committee please advise if the following case contains adequate documentation for a coder to assign a code from the Obstetrics chapter as principal diagnosis, as per the above sentence:
Pregnant female admitted with a diagnosis of Cholestasis.  There is no documentation that the cholestasis has complicated the pregnancy in any way, except for a note on discharge 'ANC review next week with repeat LFT's and increased CTG monitoring'.  Is 'increased CTG monitoring' adequate for a coder to determine that this condition has complicated the pregnancy?

Response:
For the case cited, VICC considers that increased CTG monitoring is sufficient evidence to support that this condition has complicated the pregnancy.


Query Text:
In mental health units, it is not uncommon to see intentional self-harm documented either as a precursor to admission or an event during an admitted episode.

Mental health clinicians make a clear distinction between intentional self-harm with suicidal intent and intentional self-harm with no suicidal intent (to relieve anguish, anxiety or stress, or to indicate distress a cry for help).  The latter is a common feature of Borderline Personality Disorder (BPD) clients and adolescent presentations.

The two types of intentional self-harm are clinically important; as both change the way a client is treated, however the treatment may be different, depending upon the purpose of the intentional self-harm.  When self harming changes the treatment regime it would meet the criteria for an additional diagnosis code, ie. intentional self-harm increases the need for special nursing and sometimes prompts admission to a high dependency unit (HDU).

Z91.5 Personal History of Self-Harm can be assigned where the intentional self-harm occurs prior to admission, or has occurred during a previous admission, but doesn't add the granularity needed to distinguish between suicidal intent and non-suicidal intent.

External cause codes (X60-X84) for Intentional self-harm do not distinguish between suicidal intent and non-suicidal intent, nor do they adequately cater for harm done by the client scratching or biting themselves.

When coding out the injury, the external cause, activity code U73.8 Other Specified Activity also makes no distinction between suicidal or non-suicidal intent.

Could you please provide advice on the appropriate way to code the following common scenarios when they meet the definition of additional diagnoses?

1. Client intentionally self-harms prior to admission with no suicidal intent.  For example, young adolescent female presents with increasing self-harming behaviour (scratching/cutting), mutism and disordered eating on a background of chaotic upbringing.  (Scratching/cutting superficial and don’t require review/intervention)

2. Client intentionally self-harms prior to admission with suicidal intent.  For example, young man with Borderline Personality disorder and depression transferred to the adult mental health inpatient unit from medical unit  (of another hospital) for ongoing care following an polypharmacy overdose (of lethal intent).  Medically cleared prior to transfer, and no ongoing monitoring of medical issues required.

3. Client intentionally self-harms during an admission with no suicidal intent.  For example, current inpatient (diagnosis of depression) intentionally self-harms - superficial scratching of arms and legs with a pen to indicate/express current/increasing  level of distress – no medical review/intervention required.  Client transferred to High Dependency Unit for ongoing monitoring of mental state.

Response:
The VICC understands that the enquirer is trying to distinguish between 'intentional self harm with suicidal intent' and 'intentional self harm without suicidal intent' which our coding currently does not identify.  

The VICC therefore suggests the enquirer submits a  public submission to NCCH for the creation of codes to meet this purpose.


Query Text:
Should O34.2 Maternal care due to uterine scar from previous surgery be used for all cases where a woman has had a previous delivery by caesarean section and is having an elective caesarean section for the current delivery? Or should O34.2 only be used for these cases if it is documented by a doctor/midwife that the uterine scar is the reason for the next caesarean section?  If the only reason documented for the next caesarean section is maternal choice, should O82 be used instead of O34.2?

I have always assigned O34.2 for these cases, but was wondering if differentiation should be made between those women who would be able to deliver vaginally after a previous caesarean section but choose not to, and those women who are unable to delivery vaginally.

Standard 1506 Malpresentation, Disproportion and Abnormality of Maternal Pelvic Organs states O34.2 should be assigned for all cases where a patient is admitted for an elective caesarean section due to previous caesarean section.  

O82 note states O82 is only to be used when there is no other code in chapter 15 to indicate reason for caesarean section.

Response:
VICC advises that O34.2 Maternal care due to uterine scar from previous surgery should not be routinely assigned for all cases where previous caesarean section is documented.  'O34.2 should only be assigned when the reason for caesarean section is documented, as outlined in ACS 1506  Malpresentation, Disproportion and Abnormality of Maternal Pelvic Organs, and in particular the three dot points:

-patient is admitted for an elective caesarean section due to previous caesarean section,

-trial of scar (eg caesarean or other operative uterine scar) proceeds to a caesarean delivery, or

-previous uterine scar requires care but delivery does not occur during the episode of care, for example, antepartum care for uterine pain due to previous scar.

If the above criteria has been satisfactorily met then assign O34.2 Maternal care due to uterine scar from previous surgery accordingly.

In answer to the second part of your query, code O82 Single delivery by caesarean section, would be the correct code to use if the only documented reason for caesarean section is maternal choice.


Query Text:
Often before a Stem Cell Transplant takes place a patient will receive several treatments of stem cell growth factor.  This has previously been a subcutaneous injection and therefore not admitted, however our Oncology Department has begun using the drug Palifermin which is given intravenously. 

The answer may be determined by deciding whether the Palifermin (stem cell factor) is related to the treatment of the neoplasm, a neoplasm-related condition, or is it treating the 'treatment-related' condition?  At a very broad level the drug is 'treating the neoplasm' by assisting with the successful collection of stem cells for future transplant.  On an episodic level, the drug is not 'treating the neoplasm', 'a neoplasm-related condition' or a 'treatment-related condition'.  Please advise.

Scenario 1:
Z51.1       Pharmacotherapy
C83.8       Other types of diffuse NHL
M9673/3   Mantle Cell Lymphoma
96199-00  IV administration of pharmacological agent, antineoplastic agent

or

Scenario 2:
C83.8        Other types of diffuse NHL
M9673/3    Mantle Cell Lymphoma
Z51.4        Preparatory care for subsequent treatment, not elsewhere classified
96199-09   IV administration of pharmacological agent, other and unspecified agent

Search Details: 
ICD 10AM Commandments Volume 11 Number 2, September 2004 - Drug Administration
ACS 0044 Pharmacotherapy

Response:
VICC advises that drugs can be used for a variety of purposes and coders should not draw conclusions on the use of a drug from the MIMs.  Coders need to be guided by the documentation in the record rather than interpreting the use of a drug.  

If the documentation states 'admitted for IV therapy for neoplasm'  Z51.1 Pharmacotherapy session for neoplasm
would be coded as principal diagnosis as per ACS 0044 Chemotherapy.  If the documenation states 'admitted for prophylactic administration of a drug' the principal diagnosis would be Z29.2 Other prophylactic pharmacotherapy.

It seems in the scenario described the patient has been admitted for administration of stem cell growth factor, therefore the documented condition will be coded as principal diagnosis.


Query Text:
Could you please confirm the correct codes for mucous plugging?

Following the index you are led to a code in T17-, Foreign body in respiratory tract but what should be used as the external cause code.  I have used W80 but is a mucous plug a foreign body?  Should T17- be used if it is not a foreign body?

Could you please assist with this as we are commonly coming across this terminology.

Search Details: 
VICC query #2217 indicates codes to be used, but the query was about the suctioning not the disease code assignment.

Response:
VICC agrees that the codes obtained by following the index, are the correct codes to assign:
T17.- Foreign body in respiratory tract 
W80 Inhalation and ingestion of other objects causing obstruction of respiratory tract 
 
Mucus plugging is classified as a foreign body as it is foreign to the respiratory tract.

Please note that in Sixth edition the external cause code for mucus plugging would be W80.8 Other specified object.


Query Title:
Anticoagulation therapy pre and post surgery

Query Text:
What is the correct way to code patients admitted prior and post surgery for anticoagulation therapy when the surgery is performed at another hospital? 

The examples given in ACS 0303 Abnormal coagulation profile due to anticoagulants assume that the surgery is performed at the same hospital, and Z92.1 Personal history of long term (current) use of anticoagulants is to be coded as an additional diagnosis, with the principal presumably being the condition that required surgery.

For example we have a patient admitted to HITH prior and post surgery for skin cancers to scalp.  The private hospital does not have a HITH program so the patient is admitted to our hospital for anticoagulant stabilisation.  The patient is on Warfarin for atrial filbrillation (AF).  These patients invariably had their usual Warfarin changed to Clexane.

The condition requiring the surgery is not treated, evaluated or otherwise dealt with at all by this hospital.  We would not have adequate documentation to follow ACS 0303 (for example, operation reports, histology reports).  Often we do not know what the condition requiring surgery is (the documentation may just indicate a specific procedure for example, colonoscopy).

Do we code the condition that requires the anticoagulant as the principal (for example, AF) as this condition requires therapeutic treatment (change in medication).  

Alternatively do we code Z51.4 Preparatory care for subsequent treatment, not elsewhere classified as the principal?.  Z92.1 is not considered an acceptable principal diagnosis.

This query assumes that the admission is justified in accordance with the DHS admission policy.

Search Details: 
ACS 0303 Abnormal coagulation profile due to anticoagulants
Coding matters Volume 7 number 2

Response:
The VICC referred this query to the NCCH who provided the following advice:
“The correct code assignment for a patient admitted for anticoagulant stabilisation prior to surgery to be performed at another hospital is:

Z51.4 Preparatory care for subsequent treatment, not elsewhere classified
Z92.1 Personal history of long term (current) use of anticoagulants

The correct code assignment for a patient admitted for anticoagulant stabilisation post surgery performed at another hospital is:

Z48.8 Other specified surgical follow-up care
Z92.1 Personal history of long term (current) use of anticoagulants

See also ACS 2103 Admission for Convalescence/Aftercare.

NB: If there is a contractual arrangement existing between the two hospitals in the scenario cited then the guidelines within ACS 0029 Coding of Contracted Procedures should also be followed.”


Query Text:
We have been coding large neurovascular island flap to 45563-01 [1673] Island flap with neurovascular pedicle.  However the definition in the Standards describes an island flap as being tunnelled under the skin.  In our case the Island flaps are not being tunnelled but simply advanced into position.  

A reference book Local Flap Reconstruction by Anthony Penington suggests that the tunneling is not essential for it to still be an island flap.  Are we using the correct code?

Response:
The documentation provided is sufficient to assign 45563-01 [1673] Island flap with neurovascular pedicle.  The "with/without tunnelling" aspect of the procedure has no bearing on code assignment.


Query Title:
Flap Lift for removal of epithelial ingrowth

Query Text:
Querying correct code for 45 year old male patient who has had a Flap Lift for removal of epithelial ingrowth. A flap lift is sometimes performed on patients who have very recently had a corneal flap created as part of their LASIK surgery. In some cases, due to wrinkling, striae or epithelial ingrowth, this flap needs to be relifted and then repositioned by the surgeon so that the patient can heal. I would like to confirm that codes H59.8 and 42656-01, or 42656-00 would be suitable.

Response:
Research undertaken by VICC indicates that striae are wrinkles that spontaneously develop in the corneal stromal flap after LASIK.  Therefore this is a complication of the eye, not the surgery.

Following ACS 1904 Procedural complications and Index entry Complication(s)/eye (see also Complication(s)/by site and type)/intraoperative or postprocedural/specified site NEC, the correct code to assign is H59.89 Other postprocedural disorders of eye and adnexa, not elsewhere classified.  

If there were documentation specifically about a graft complication, T85.88 Other complications of internal prosthetic device, implant and graft, NEC would be assigned by following Index entry Complication/graft/specified NEC as there is no look up for Complication, flap.

The procedure codes selected seem correct from the operation notes provided.


