# VICC queries

Query Text:
Could VICC please advise the correct diagnosis code to assign for documentation of angioectasia? 

We have seen documentation of angioectasia of the duodenum or jejunum treated with argon plasma coagulation. Research online indicates gastrointestinal angioectasia are the most common gastrointestinal tract vascular anomaly and are characterized by ectatic, dilated, thin-walled vessels in the submucosa or mucosa. Angiectoasias are often located in the colon, and are less often located in the upper gastrointestinal tract and small bowel. Small bowel angioectasias have been reported to be the source of obscure gastrointestinal bleeding.

Research online also indicates the term angiodysplasia has been used interchangeably with angioectasia, though there has been debate over these terms equivalence. There is no specific index pathway for ‘angioectasia’. Possible Index pathways which have been considered for small intestine angioectasia include:
• Angiectasis, angiectopia I99
• Disorder / intestine, intestinal / vascular / specified NEC K55.8 
• Angiodysplasia (caecum) (colon) K55.21
• For documentation of jejunal angioectasia: Disease, diseased / intestine / specified NEC K63.8 
• For documentation of duodenal angioectasia: Disease, diseased / duodenum / specified NEC K31.88 or Angiodysplasia (caecum) (colon) / duodenum K31.81 

Please advise:
1) The code to assign for jejunal angioectasia?
2) The code to assign for duodenal angioectasia?
3) The index pathway to assign for angioectasia of other sites?

Response:
VICC sought clinical advice which indicated that angioectasia and angiodysplasia can be considered as synonymous terms. Therefore, in answer to the specific questions in the query, in Eleventh Edition, follow the Index lead term Angiodysplasia (caecum) (colon) (intestine) and:

For duodenal or jejunal angioectasia, assign either:
K55.31 Angiodysplasia of small intestine, without mention of haemorrhage, or
K55.32 Angiodysplaysia of small intestine, with haemorrhage as appropriate.

For angioectasia of stomach, assign either:
K31.81 Angiodysplasia of stomach without mention of haemorrhage, or
K31.82 Angiodysplasia of stomach with haemorrhage as appropriate.

For angioectasia of other sites or not further specified, assign either:
K55.21 Angiodysplasia of colon without mention of haemorrhage, or
K55.22 Angiodysplasia of colon with haemorrhage as appropriate.

VICC notes that the Index was updated for Eleventh Edition as the previous entries for angiodysplasia did not include modifiers for small intestine other than duodenum. Sites other than duodenum or stomach were classified to K55.2- Angiodysplasia of colon in Tenth Edition.


Query Title:
Intravenous therapy for Postural orthostatic tachycardia syndrome (POTS)

Query Text:
We have a patient who presents every few days for IV saline infusion to treat POTS. There is discussion as to whether this is coded to 96199-08 [1920] IV administration of pharmacological agent, electrolyte or 96199-19 [1920] IV administration of pharmacological agent, other and unspecified pharmacological agent. Could you please clarify?

Response:
VICC research indicates that IV saline is an isotonic solution primarily given for volume maintenance in patients with POTS. As per ACS 0042 Procedures normally not coded, provided this is a planned same day episode for IV administration of saline, assign 96199-19 [1920] Intravenous administration of pharmacological agent, other and unspecified pharmacological agent.


Query Text:
What is the correct procedure code to assign for a pelvic lymph node dissection not specified as radical, regional or simple?

Response:
VICC advises that for Tenth Edition (separations up until and including 30 June 2019), for documentation of pelvic lymph node dissection, assign 90282-00 [811] Excision of lymph node of other site by following ACHI Index lead term Dissection/lymph node - see Excision/lymph node/specified site NEC.

For Eleventh Edition (separations from 1 July 2019), assign 96244-05 [806] Excision of lymphatic structure, pelvic by following ACHI Index lead term Dissection/lymph node - see Excision/lymphatic structure (node)/by site - Excision/lymphatic structure/pelvic (limited) (regional) (simple) (total).


Query Title:
Methotrexate injection for ectopic pregnancy

Query Text:
A 29 year old woman was admitted to hospital for intramuscular injection of methotrexate due to a cornual ectopic pregnancy. Duration of pregnancy 6 weeks. Abortion is not documented in the record but clearly the reason for the methotrexate was to terminate the ectopic pregnancy. I am not sure if ACS 1511 Termination of pregnancy should be applied for this admission.

1) Can the committee please advise what codes should be assigned for the above scenario?

2) Can the committee also please advise what codes should be assigned for an ectopic pregnancy (duration 6 weeks) that is removed via a unilateral, laparoscopic salpingectomy (under GA)?

Response:
VICC advises that the correct diagnosis codes for the scenario cited are:
O00.8 Other ectopic pregnancy
O09.1 Duration of pregnancy 5-13 completed weeks

Follow the Alphabetic Index entry Pregnancy/ectopic (ruptured)/specified NEC O00.8, and the Use additional code instruction in the Tabular list.

For intramuscular injection of methotrexate for a 6 week cornual ectopic pregnancy assign:
35677-03 [1256] Fetotoxic management for removal of ectopic pregnancy.

Follow the ACHI Index entry Administration/type of agent/methotrexate, intramuscular/for ectopic pregnancy 35677-03 [1256].

When unilateral laparoscopic salpingectomy is performed for ectopic pregnancy, assign:
35678-01 Laparoscopic salpingectomy with removal of pregnancy

Follow the ACHI Index entry Salpingectomy/unilateral/laparoscopic (total)/for removal of ectopic pregnancy (tubal) 35678-01 [1256].


Query Title:
Peri-umbilical cellulitis – postoperative wound infection

Query Text:
Can the Committee please advise the correct coding and sequencing of the following scenario?

Principal diagnosis on the discharge summary states:
Periumbilical cellulitis

Documentation in the progress notes state “wound infection post-op”, “patient presents with 1/7 of increased abdominal pain at umbilical incision site”, “erythema and tender around umbilical incision site”, “Imp: surgical site superficial infection, Plan: Analgesia, IV Abx”, “wound infection post lap appendicectomy”.

Does the coder apply ACS 0001 Principal diagnosis and assign:
L03.3 Cellulitis of trunk
T81.4 Wound infection following a procedure
Y83.6 Removal of other organ
Y92.23 POO, health service area

Or does the coder apply ACS 1904 Procedural complications and assign:
T81.4 Wound infection following a procedure
L03.3 Cellulitis of trunk
Y83.6 Removal of other organ
Y92.23 POO, health service area

Response:
VICC advises that the correct sequencing of diagnoses codes for the scenario cited is:

T81.4 Wound infection following a procedure, not elsewhere classified
L03.3 Cellulitis of trunk
(and appropriate external cause codes)

Where the cause of a condition is documented as a procedural complication, following the classification advice in ACS 1904 Procedural complications, a code for the complication is sequenced first, followed by a code for the condition where it provides further specificity.

Note that, as per ACE Coding Rule TN1504 Eleventh Edition ACS 1904 Procedural complications – additional code to add specificity, the cellulitis qualifies for coding as further specificity of the condition, rather than the infection site.


Query Title:
Functional decline and deconditioning post acute admission

Query Text:
We have patients who are treated in our acute hospital and then transferred to our sub-acute hospital for continuing sub-acute care. Some are classified as GEM admissions while others are Rehabilitation.

Many of the discharge summaries for these sub-acute patients have a final diagnosis of “deconditioning” following …. (CVA, # NOF, CCF etc). In both the GEM and rehab admissions there is usually a rehabilitation plan within the notes and evidence of physio, OT, social work and other allied health involvement. Whatever the reason for the acute admission has been, “deconditioning” is generally mentioned as one of the main problems in the notes for the sub-acute admission.

Some coders simply follow the doctor’s final diagnosis and code “Deconditioning” to M62.50 Muscle wasting and atrophy, not elsewhere classified, multiple sites as per the June 2017 ACCD advice. This advice also says when there is documentation of the underlying cause, apply guidelines in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.

Others feel these should generally be coded according to ACS 2104 Rehabilitation. The principal diagnosis would be the main condition that was treated in the preceding acute admission. A code for deconditioning could be added as an additional diagnosis. 

Would you please give some guidance on which advice we should be following?

Search Details
ACCD advice "Deconditioning" June 2017
ACS 2104 Rehabilitation

Response:
VICC considers that this is primarily a documentation issue, and makes the following observations:
ACS 2104 Rehabilitation requires the principal diagnosis to be the underlying condition requiring rehabilitation, and references ACS 0001 Principal diagnosis. The principal diagnosis of the rehabilitation episode may not be the same condition that was assigned as principal diagnosis in the preceding acute episode of care.

As per ACS 0604 Cerebrovascular accident (CVA), if rehabilitation is undertaken at a second facility immediately following an acute episode of care at another facility for the CVA as a continuum of care, the principal diagnosis at the rehabilitation facility is the CVA.

As noted in ACE Coding Rule Q3064 Deconditioning, if there is documentation of the underlying cause of deconditioning, apply the guidelines in ACS 0001 Principal diagnosis, section titled Problems and underlying conditions or ACS 0002 Additional diagnoses, section titled Problems and underlying conditions.

VICC also notes that as per VICC queries #3207 Conditions noted to be "on a background of …." and #3210 Underlying condition (both published September 2018), documentation of "deconditioning following [a condition]" does not necessarily support that deconditioning is due to that condition, and that the causal relationship may need to be clarified by the clinician.


Query Text:
A patient has presented to our hospital for an elective laparoscopic small bowel resection and stricturoplasty for a diagnosis of stricturing small bowel Crohn’s disease. In the body of the handwritten operation report findings, there is documentation of 'stricturing terminal ileum secondary to Crohn’s'.

Can you please advise as to whether the small bowel stricture is a component of the Crohn’s disease, or a condition in its own right and therefore should be coded separately?

If they should be coded separately, (in this case) would the Crohn’s or the stricture be assigned as principal diagnosis?

Response:
VICC research indicates that stricture is a common complication of Crohn's disease and can lead to partial or complete obstruction of the bowel, often requiring surgical resection.

VICC advises that coders should firstly be guided by what is documented as the principal diagnosis.

For a principal diagnosis of 'stricturing Crohn's disease', VICC advises to follow ACS 0001 Principal diagnosis section title Problems and underlying conditions. If Crohn's disease is not a previously known condition, code Crohn's disease as the principal diagnosis. This does not prevent the assignment of a code for the stricture as an additional diagnosis if documentation supports that the stricture meets ACS 0002 Additional diagnoses in its own right, for example dilatation of the stricture. If Crohn's disease is a known condition, and only the stricture is being treated, assign a code for the stricture as principal diagnosis, and Crohn's disease as an additional diagnosis.


Query Title:
TAMIS (Transanal minimally invasive surgery) excision of rectal lesion

Query Text:
The ACHI Index does not appear to provide a pathway leading directly to a code to classify the procedure of TAMIS excision of a rectal lesion

Possible Index pathway which has been considered is:
Excision/tumour – see also Excision lesion(s)/rectum (perirectal) (trans-sphincteric) NEC /per anal (rectoscopy) 32099-00 [933]

Please advise the correct ACHI Index pathway to follow and code to assign to classify the procedure of TAMIS excision of rectal lesion.

Response:
VICC advises that when transanal minimally invasive surgery (TAMIS) is performed to excise a lesion of the rectum, follow ACHI Index lead term Excision/lesion(s)/rectum/per anal and assign 32099-00 [933] Per anal excision of lesion or tissue of rectum.


Query Text:
Please confirm the correct procedure code for excision of a dentigerous cyst?

Dentigerous cysts are the second most common type of odontogenic cyst, which is a fluid-filled sac that develops in the jawbone and soft tissue. They form over the top of an unerupted tooth or partially erupted tooth. For coding purposes is a dentigerous cyst considered a cyst of the bone or the tooth? 

Please confirm the correct procedure code is either:

Excision
-Cyst
- - mouth 30283-00[403]

or
Excision
- Lesion
-- Bone NEC 30241-00 [1563]

We note VICC query #3082 Enucleation of mandibular cyst, however this does not include the dentigerous cyst. Dentigerous cysts can occur in the mandible and maxilla.

Response:
VICC research also indicates that a dentigerous cyst is associated with unerupted or partially erupted teeth and develops in the maxilla or mandible.

In the absence of a more specific Index entry for excision of dentigerous cyst, and providing that documentation does not indicate that the cyst is in a site other than bone, VICC advises to follow the ACHI Index entry Excision/lesion(s)/bone NEC to assign 30241-00 [1563] Excision of lesion of bone, not elsewhere classified.


Query Text:
We often get documentation of insertion, removal or replacement of mushrooms, mushroom catheters or mushroom drains. The ACHI index does not appear to provide a pathway leading directly to a code to classify the procedures for insertion, removal or replacement of mushrooms, mushroom catheters or mushroom drains. Research online indicates mushroom catheters /drains are essentially a drainage device, in most cases they are placed to drain fistulas or abscesses (anal or rectal).
Possible index pathways (dependent on site) which have been considered include:
Insertion
- Procedure/Anus NEC 90316-00 [942] Other procedures on anus
- Procedure/Rectum NEC 90314-00 [942] Other procedures on rectum
Removal
- Removal/device/gastrointestinal tract NEC 92086-00 [1896] Removal of other device from gastrointestinal tract

No appropriate pathway for replacement therefore would code the insertion and removal.

Please advise the correct ACHI index pathways and procedure code to assign for:
1. Insertion of mushroom /mushroom catheter/mushroom drain of anus or rectum
2. Removal of mushroom /mushroom catheter/mushroom drain of anus or rectum
3. Replacement of mushroom /mushroom catheter/mushroom drain of anus or rectum

Search Details
https://www.hindawi.com/journals/tswj/2014/146281/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140329/

Response:
VICC obtained clinical advice that generally mushroom catheters are used as a type of drainage catheter in operations to drain sepsis in the perineum. Mushroom catheters are used as an adjunct to simple drainage of perianal or ischiorectal abscess, or to drain abscess associated with complex anal fistulas, and the use of a mushroom catheter is usually a marker that more complex disease is being dealt with, however they do not represent a separate procedure.

Regarding the operation reports provided with the query,VICC advises that the mushroom drain should be regarded as a procedural component. This is because in one operation, a fistulectomy was performed and in the other operation a sigmoidoscopy was performed.

However, if a patient was admitted solely for insertion, replacement or removal of a mushroom drain, (providing the episode meets criteria for admission):

For insertion of mushroom drain of rectum, assign 92066-00 [1894] Insertion of rectal tube following the ACHI Index entry Insertion/tube/rectum.

For replacement of mushroom drain of rectum, assign 92066-00 [1894] Insertion of rectal tube following the ACHI Index entry Replacement/tube/rectum.

For removal of mushroom drain of rectum or anus, assign 92086-00 [1896] Removal of other device from gastrointestinal tract following the ACHI Index entry Removal/device/gastrointestinal tract NEC.

VICC notes that there is no ACHI code for insertion of mushroom catheter of anus when this is the only procedure performed. If you see such cases, we suggest you submit a query to VICC for us to forward onto IHPA.


Query Text:
What is the most accurate way to code 'Fall with headstrike' when there is no mention of any head injury? Specific head injury obs are not always ordered and CT brain is not always ordered. There are sometimes other injuries we can code.
Should this be 'unspecified head injury' or 'Observation following a fall'?

Response:
VICC advises that as per ACS 1905 Closed head injury/loss of consciousness/concussion, if ‘head injury’ or ‘closed head injury’ is documented, S09.9 Unspecified injury of head can be assigned as ‘head injury’ is a state or condition in its own right. However, VICC does not consider that the term ‘headstrike’ is synonymous with the state or condition of ‘head injury’ as it describes the mechanism of injury.

Therefore, if headstrike is documented, without further clarification, S09.9 Unspecified injury of head cannot be assigned. In the absence of other codeable injuries (for example, facial bruise or abrasion), a code from Z04 Examination and observation for other reasons should be assigned if it meets ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.


Query Text:
Misoprostol (bucally, sublingually or vaginally) and osmotic dilators are used to prepare the cervix prior to late term abortion (17-23 weeks). Dilapan-S is used which is a synthetic osmotic dilator and is applied under light sedation. Laminaria can also be used which is dehydrated stems of seaweed manufactured into rods 2-10 mm in diameter but Dilapan-S is the preferred method to cervical dilation.

What code would you suggest for the Dilapan-S? We are currently using 35500-00 [1296] Gynaecological examination but this is not correct.

Response:
VICC research indicates that Dilapan-S® is a rigid gel rod inserted into the cervix that increases in volume by absorbing fluids, gradually dilating the cervix. It can be used for cervical ripening prior to the induction of labour, or for cervical softening prior to instrumentation of the uterine cavity for termination of pregnancy.
https://www.dilapans.us.com/

Where Dilipan-S® is applied and is the only procedure performed under cerebral anaesthesia, VICC advises to follow ACHI Index lead term Dilation/cervix and assign 35640-02 [1277] Dilation of cervix with an appropriate code for cerebral anaesthesia.

If Dilipan-S® is applied without cerebral anaesthesia and induction of labour for termination of pregnancy occurs in the same episode of care, VICC advises that only a code for induction of labour from block [1334] Medical or surgical induction of labour is assigned as VICC considers that dilation of cervix is a procedural component of the induction of labour to terminate the pregnancy.

If Dilipan-S® is applied without cerebral anaesthesia and termination of pregnancy occurs in the same episode of care by curettage or evacuation of uterus, an additional code for dilation of cervix is not assigned. Follow the ACHI Index lead term Dilation/with to assign an appropriate code from block [1265] Curettage and evacuation of uterus.

For example, patient admitted for termination of pregnancy, and has Dilipan-S® applied under IV sedation. Later in the day, prostaglandin induction of labour is performed. Assign:
Appropriate diagnosis codes for termination of pregnancy
90465-01 [1334] Medical induction of labour, prostaglandin
35640-02 [1277] Dilation of cervix
92515-xx [1910] Sedation

90465-01 [1334] 01 [1334] Medical induction of labour, prostaglandin is assigned as the first procedure because it is the procedure that best reflects the 'procedure performed for treatment of the principal diagnosis' as per the hierarchy in ACS 0016 General procedure guidelines.


Query Text:
The procedure of choice at this site for termination of pregnancy up to 10 weeks is manual vacuum aspiration (MVA). MVA is a type of STOP and we have been using this code (35640-03) however we would like to be able to differentiate the different ways that termination are performed (MVA, suction curettage and D&E). Do you agree with the use of 35640-03 for MVA?

Response:
VICC considers that manual vacuum aspiration is an example of a surgical method of terminating pregnancy, and ACS 1511 Termination of pregnancy (Abortion), section titled ACHI codes for termination of pregnancy (Abortion) directs to assign an appropriate code from block [1265] Curettage and evacuation of uterus for surgical methods of termination of pregnancy.

VICC considers that vacuum is synonymous with suction, therefore VICC advises that in the absence of a more specific ACHI code, 35640-03 [1265] Suction curettage of uterus should be assigned for documentation of termination of pregnancy by manual vacuum aspiration.

You may wish to submit a public submission to IHPA for a specific code for manual vacuum aspiration for termination of pregnancy.


Query Title:
Termination of pregnancy after fetal viability

Query Text:
Could the VICC please advise regarding the coding of the following scenario:

Principal diagnosis: Pregnancy termination on psychosocial grounds
Gestation: Gestation 20 weeks +
Procedures: Dilation and evacuation of the uterus
(as per direct wording on discharge summary)

Instructions within ACS 1511 Termination of pregnancy require us to code not only a reason for the abortion as principal diagnosis, but also delivery, preterm labour and outcome of delivery codes even though they are not applicable in such episodes.

Response:
VICC confirms that for termination of pregnancy after fetal viability, codes for delivery, preterm delivery and outcome of delivery are required regardless of the method of termination.

As per ACS 1511 Termination of pregnancy, section titled ICD-10-AM codes for medical abortion/after fetal viability, the codes for the scenario cited in Tenth Edition (separations up to and including 30 June, 2019) are sequenced in the following order:
Z65.9 Problem related to unspecified psychosocial circumstances
O04.9 Medical abortion, complete or unspecified, without complication
O83 Other assisted single delivery
O60.3 Preterm delivery without spontaneous labour
O09.3 Duration of pregnancy, 20-25 completed weeks
Z37.- Outcome of delivery
35643-03 [1265] Dilation and evacuation of uterus

For Eleventh Edition (separations from 1 July 2019), as per ACS 1511 Termination of pregnancy (Abortion), section titled ICD-10-AM codes for medical abortion, codes for the delivery, the codes for the scenario cited are sequenced in the following order:
O04.9 Medical abortion, complete or unspecified, without complication
O09.3 Duration of pregnancy, 20-25 completed weeks
Z65.9 Problem related to unspecified psychosocial circumstances
O83 Other assisted single delivery
O60.3 Preterm delivery without spontaneous labour
Z37.- Outcome of delivery
35643-03 [1265] Dilation and evacuation of uterus
90477-01 [1343]  Assisted vertex delivery


Query Title:
Tender/graze following fall or other accident

Query Text:
Can the committee please advise how a diagnosis of tender following a fall or other accident is coded. When an injury is described as pain, we can follow the pathway pain, due to current trauma and assign the appropriate chapter code. However there is no pathway of tender, due to current trauma.

In addition to the above, if graze is documented as a result of a trauma, can this be coded to abrasion? Or other specified injury?

Response:
VICC research notes that tenderness can be considered a form of pain in the traumatic setting and advises that if tenderness of a site is caused by a fall, or other trauma, to follow the advice in ACE Coding Rule TN210 Pain versus injury post trauma and assign a code for unspecified injury of that site.

VICC considers that graze is synonymous with abrasion, therefore if graze is documented at a site due to trauma, the Index lead term Abrasion should be followed.

If the tenderness or graze is associated with a more severe injury of the same site, the tenderness/graze is not coded as per ACS 1916 Superficial and soft tissue injuries.


Query Text:
Can the committee please advise if the advice in VICC query #2462 Decreased conscious state (retired 30/06/2015) is still valid?

See also retired VICC query #1532 Decreased conscious state.

Response:
For ICD-10-AM Tenth Edition (separations up to and including 30 June, 2019), VICC advises that the advice in VICC query #2462 Decreased conscious state is still applicable, which is that clarification should be sought from the clinician to ascertain if there is an underlying cause for the decreased conscious state. If however, there is no other documentation available it is appropriate to assign R41.8 Other and unspecified symptoms and signs involving cognitive functions and awareness. Coders should be careful not to confuse documentation of decreased conscious state with loss of consciousness.

For ICD-10-AM Eleventh Edition (separations from 1 July 2019), VICC advises that there is a new Alphabetic Index entry Decrease(d)/consciousness (cause unknown)(level) which allows a coder to assign a code from R40 Somnolence, stupor and coma if decreased conscious state meets the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses and no underlying cause is identified.


Query Text:
A patient with necrotic pancreatitis was admitted to our facility for a necrosectomy. 

The gastroscopy report documents: ‘Metallic stent in situ with necrotic tissue blocking stent. Necrotic tissue removed from within the stent and necrotic cavity using snare. Normal pancreatic tissue noted with minimal bleeding. A repeat gastroscopy and necrosectomy is recommended in 1 week'.

Our research indicates that a necrosectomy is an endoscopic means of removing necrotic pancreatic tissue. It avoids the need for an open or laparoscopic procedure.

https://www.medscape.com/viewarticle/809196_6 
https://www.nice.org.uk/guidance/ipg567/chapter/3-The-procedure 

Can the committee please advise what procedure codes should be assigned for a necrosectomy?

Search Details
ACCD Q2939 Endoscopic ultrasound

Response:
VICC advises provided there is evidence that the necrotic tissue removed was pancreatic tissue (for example on the procedure report or histopathology report), to follow the Index entry Excision/lesion(s)/pancreas (pancreatic duct)/endoscopic and assign 90294-01 [979] Endoscopic excision of lesion of pancreas or pancreatic duct for the scenario cited.


Query Text:
Leptomeningeal disease (LMD) is a late-stage complication of systemic cancers caused by multifocal metastases to the leptomeninges, which consist of the pia mater, arachnoid, and subarachnoid space. 

Common neoplastic aetiologies of LMD include breast, lung (mainly non-small-cell lung cancer [NSCLC]), gastro-intestinal, melanoma, primary central nervous system (CNS) cancers (such as medulloblastoma, ependymoma, pineoblastoma, primitive neuroectodermal, or primary CNS lymphoma), lymphoma (mainly non-Hodgkin's Lymphoma [NHL]), leukemia (mainly acute lymphoblastic leukemia [ALL]), and multiple myeloma.

Can VICC please confirm the correct codes to assign for Leptomeningeal disease?

Search Details
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5641214/

Response:
VICC research confirms that the meninges are the membranes that surround the central nervous system, consisting of three layers: dura mater, arachnoid mater and pia mater. The leptomeninges are the two innermost layers being the arachnoid mater and the pia mater.
https://www.britannica.com/science/meninges 

VICC advises that when a patient has a solid tumour, such as breast, lung, gastro-intestinal tract, skin, which has metastasised to the leptomeninges, to follow the Alphabetic Index at Neoplasm, neoplastic/meninges, and if the LMD site is documented as brain, cerebral, cranial or intracranial, assign:
C79.3 Secondary malignant neoplasm of brain and cerebral meninges

If the LMD site is documented as spinal, spinal cord or unspecified, assign:
C79.4 Secondary malignant neoplasm of other and unspecified parts of nervous system.

If LMD is a complication of a systemic cancer (such as lymphoma, leukaemia or multiple myeloma), VICC advises that an additional code for LMD is not assigned, as metastatic sites classified to C77-C79 are reserved for metastases of neoplasms of sites classified to C00-C76 and C80, as per the Alphabetic Index at lead term Neoplasm, neoplastic.


Query Text:
Can VICC please confirm the correct principal diagnosis and procedure code to assign for same-day immunotherapy for treatment of neoplasms?

Response:
VICC advises that same-day immunotherapy for treatment of neoplasms is chemotherapy/pharmacotherapy. Assign codes as per ACS 0044 Chemotherapy (Tenth Edition) or ACS 0044 Pharmacotherapy (Eleventh Edition), classification section for same day episodes of care for pharmacotherapy for neoplasm:

Z51.1 Pharmacotherapy session for neoplasm as principal diagnosis
Codes for the neoplasm as per ACS 0236 Neoplasm coding and sequencing
An appropriate code from block [1920] Administration of pharmacotherapy with extension -00 Antineoplastic agent

The information in the ACHI Tabular at -00 Antineoplastic agent confirms this:
Tenth Edition:
Agents used in the treatment of neoplasms and/or neoplasm related conditions

Eleventh Edition:
Note: This extension is assigned for any agent (eg anti-infective, electrolytes, nutritional substances, steroids) classified to block [1920] that is used in the treatment of neoplasms and/or neoplasm related conditions


Query Text:
For nonobstetric conditions not complicating pregnancy, there is no clear rule to apply when the pregnancy only meets one of the criteria in ACS 1521 Conditions and injuries in pregnancy (e.g. CTG performed only).

Example: Pregnant patient admitted to a surgical ward with a principal diagnosis of Gastritis. A CTG is performed during the admission to monitor the pregnancy. No other obstetric care is provided.

Should Z34.9 be assigned over Z33 given the pregnancy was supervised?

ACS 1521 states, in the absence of specific documentation, a nonobstetric condition is classified as complicating pregnancy as indicated by two or more of the following criteria:
- Patient is admitted to an obstetric unit
- Patient is supervised/evaluated by an obstetrician, midwife and/or neonatologist (Note: evaluation may be performed remotely. That is, the clinician is located in another facility and consults via electronic methods (eg video/telephone conferencing))
- Fetal evaluation and/or monitoring is performed
- Patient is transferred to another facility for obstetric and/or neonatal care (see also ACS 1550 Discharge/transfer in labour). 

ACS 1521 is silent on how to code pregnancy episodes when one of the above applies to the case.

There are instructions for assigning Z34.9 in nonobstetric injuries/poisonings, however in these cases two of the obstetric criteria are met. 

Search Details
VICC 3452 - Conditions complicating pregnancy
VICC 3177 - Urinary tract infection in pregnancy
ACS 1521 - Conditions and injuries in pregnancy

Response:
VICC advises that codes from Block Z34.- Supervision of normal pregnancy are reserved for assignment in episodes where a pregnant patient is admitted for treatment of an injury or poisoning that meets the criteria for a pregnancy complication but there is no condition that qualifies for assignment of a code from Chapter 15 Pregnancy, childbirth and the puerperium.

As per ACS 1521 Conditions and injuries in pregnancy, section titled Nonobstetric conditions not complicating pregnancy (incidental pregnant state), Z33 Pregnant state, incidental is assigned as an additional diagnosis when the nonobstetric condition does not meet two or more of the criteria for classification as a pregnancy complication, and there is no documentation that the condition is complicating the pregnancy. For the purposes of classification, when only one of the criteria for complication of pregnancy is met, the pregnancy is incidental to the reason for hospitalisation.

Therefore, in the scenario cited, the correct codes are K29.70 Gastritis, unspecified, without mention of haemorrhage and Z33 Pregnant state, incidental as only one of the criteria (fetal monitoring) for a nonobstetric condition complicating pregnancy is met.


Query Title:
CPAP titration and coding of duration of NIV

Query Text:
Can you please clarify, following VICC query #2823 CPAP titration, the advice to assign 11503-16 [1849] Continuous monitoring of pulmonary function for = 6 hours duration.

Can you please confirm, as the patient is also receiving a period of NIV ventilation, following ACS 1006 Ventilatory support, is it correct to also assign a code from 92209-xx?

CPAP titration: 11503-16 and 92209-xx?

There are no exclude notes at either codes

Search Details
VICC 2823
VICC 2364
ACS 1006

Response:
VICC confirms that it is correct to assign a code for CPAP titration and a code for CPAP when CPAP levels are being titrated.

Therefore, for documentation of CPAP titration or monitoring of CPAP for >= 6 hours, assign:
11503-16 [1849] Continuous monitoring of pulmonary function for >= 6 hours duration, and
an appropriate code from block [570] Noninvasive ventilatory support.

VICC notes that Classification point 1 e. in ACS 1006 Ventilatory Support states, 'Do not code ventilation when the patient brings their own ventilatory support devices (eg CPAP machine) into hospital AND the patient operates the device'.

VICC also notes that when these are the only interventions performed, the episode may not meet criteria for reporting to the VAED because 11503-16 [1849] Continuous monitoring of pulmonary function for >= 6 hours duration and 92209-00 [570] Management of noninvasive ventilatory support, <= 24 hours are on the Not Automatically Qualified for Admission List (NAQAL). Refer to the VAED Criteria for reporting document on the HDSS website for further information.


Query Title:
Principal diagnosis selection for revision of continuous glucose monitoring (CGM) device

Query Text:
Patients at our hospital are being admitted for removal and re-insertion of a subcutaneous continuous glucose monitoring device. This procedure is sometimes documented by the clinician as revision of CGM. These patients all have unstable type 1 diabetes documented in the procedure notes. 

We are unsure whether the principal diagnosis should be adjustment/management of the device or the patient’s diabetes.

Codes that we have considered are:
• E10.65 Type 1 diabetes mellitus with poor control 
• Z45.89 Adjustment and management of other implanted devices

Can VICC please advise what code should be assigned as the principal diagnosis for a same day admission for removal/insertion (revision) of a continuous glucose monitoring device?

Search Details
VICC #3439 Principal diagnosis selection for insertion of continuous glucose monitoring (CGM) device

Response:
VICC advises that if unstable type 1 diabetes is documented as the reason for revision of the continuous glucose monitoring (CGM) device, it is correct to assign E10.65 Type 1 diabetes mellitus with poor control as the principal diagnosis.

Z45.89 Adjustment and management of other implanted devices should be assigned as principal diagnosis if the reason for revision of the CGM device was for end of battery life, or for removal/re-insertion/revision of CGM without further specificity.


Query Title:
Open wound with artery, nerve and/or tendon injury

Query Text:
ACS 1908 Open wound with artery, nerve and/or tendon damage states “for open wounds involving artery, nerve and/or tendon damage, sequencing of codes is determined by following the guidelines in ACS 0001 Principal diagnosis.

Where the principal diagnosis cannot be determined after referring to ACS 0001 Principal diagnosis and ACS 1907 Multiple injuries, the clinician should be consulted as to the correct sequencing. Where this is not possible sequence the diagnosis using the following hierarchy:
• artery injury 
• nerve injury
• tendon injury
• open wound”

In each of the examples in ACS 1908 the patient was admitted with a deep laceration and injuries to the underlying structures have been sequenced as PDx (as per the hierarchy) rather than laceration of skin. 

ACS 1917 Open Wounds states “an open wound is generally defined as a wound that penetrates the skin and directly communicates with the tissues beneath … The open wound should be coded in addition to the injury”. 

Does this mean that injuries to the underlying structures should be sequenced ahead of the open wound code?

Can the VICC please clarify which condition should be sequenced as PDx in the following scenarios?

Scenario one
Discharge Summary: PDx - Left distal palm laceration with radial index nerve damage. Procedure - Nerve repair and wound washout.

As there is no Index entry for Laceration/ palm is it correct to follow Index Laceration /nerve in preference to Laceration NEC (see also Wound, open) and assign injury of nerve as principal diagnosis and open wound of palm as an additional diagnosis? 

Index
Laceration NEC (see also Wound, open) T14.1
-nerve — see Injury/nerve 

Scenario two
Discharge Summary: PDx – Right MF, RF, LF lacerations. Procedure - Middle finger 100% FDP/FDS repair, ring finger – 100% FDP/FDS repair, RDN/UDN repair & RDA/UDA repair. Little finger – 100% FDP/FDS & RDN/UDN repair.

In this scenario, as the PDx cannot be determined after referring to ACS 0001 and ACS 1907 is it correct to follow the hierarchy in ACS 1908 and code injury of artery as PDx?

Scenario three
Discharge Summary: PDx – left palm laceration. Procedure – explore, washout, repair of FDP tendon (partial). 

As there is no Index entry for Laceration/ palm is it correct to follow Index Laceration / tendon in preference to Laceration NEC (see also Wound, open) and assign injury of tendon as principal diagnosis and open wound of palm as an additional diagnosis? 

Scenario four
Discharge Summary: PDx – Right ring / little finger laceration. Procedure – right RF/LF FDP repair & UDN/UDA repair.

In this scenario, as the PDx cannot be determined after referring to ACS 0001 and ACS 1907 is it correct to follow the hierarchy in ACS 1908 and code injury of artery as PDx?

Response:
VICC referred this query to IHPA, who provided the following response:

ACS 1908 Open wound with artery, nerve and/ or tendon damage provides guidelines about how to capture the severity of a laceration where surgery may be required. Injury details such as the type, depth and underlying structures damaged or repaired is often found in the operation report.

ACS 0010 Clinical documentation and general abstraction guidelines states:
Before classifying any documented clinical concept, the clinical coder must verify information on the front sheet and/or the discharge summary (or equivalent) by reviewing pertinent documents/ data within the body of the current episode of care.

The discharge summary and the body of the clinical notes should be used together to identify the specificity or severity of the laceration and inform code assignment. Classification decisions are not based solely on the discharge summary. 
[End of IHPA response].

VICC notes IHPA has published this response as IHPA Coding Rule Q3548 Open wound with artery, nerve and/or tendon injury for implementation 01 October 2020.

Further to the IHPA response, VICC ‘s interpretation of the advice in IHPA Coding Rule Q3548 Open wound with artery, nerve and/or tendon injury and ACS 1908 Open wound with artery, nerve and/or tendon damage is: 

If there is a documented principal diagnosis (which can be verified in the body of the record), do not follow the hierarchy in ACS 1908 Open wound with artery, nerve and/or tendon damage. 

In the instance where the principal diagnosis is documented as ‘open wound’ or ‘laceration’ look for further information of the structures injured within the body of the record. Where multiple underlying structures are damaged and repaired, and no one structure has been identified as the principal diagnosis by the clinician, coders should apply the hierarchy in ACS 1908 Open wound with artery, nerve and/or tendon damage to inform the principal diagnosis. If a specific structure, such as an artery or tendon, is documented as damaged but there is no evidence it was repaired, the hierarchy does not apply to that specific structure and it would not be assigned as principal diagnosis (as supported by Example 1 in ACS 1908 Open wound with artery, nerve and/or tendon damage). 

VICC therefore, advises the following code assignment for each of the scenarios provided.

Scenario one: 
VICC notes for this scenario the injury described on the operation report provided to VICC was ‘volar laceration left middle and little finger’ with documentation that the volar middle finger laceration did not involve tendons and nerves, but that for the volar little finger injury the ulnar digital nerve was fully cut. (Note that volar means ‘of the palm’). VICC also notes that the documentation of the site of the nerve injury on the discharge summary (radial digital nerve) is in conflict with the operation report (ulnar digital nerve). If radial digital nerve cannot be verified in the body of the record (as per ACS 0010), then the code for ulnar digital nerve should be assigned instead.

Therefore, as the principal diagnosis has been documented as ‘laceration’ and there is evidence of a nerve injury which has been repaired, VICC advises to apply the hierarchy in ACS 1908 Open wound with artery, nerve and/or tendon damage and assign a code for the ulnar digital nerve injury as the principal diagnosis.

Scenario two:
As the principal diagnosis has been documented as ‘lacerations’ and there is evidence of injury to multiple underlying structures that have been repaired, VICC advises to apply the hierarchy in ACS 1908 Open wound with artery, nerve and/or tendon damage and assign a code for injury of artery as the principal diagnosis.

Scenario three:
As the principal diagnosis has been documented as ‘laceration’ and there is evidence of a tendon injury that has been repaired, VICC advises to apply the hierarchy in ACS 1908 Open wound with artery, nerve and/or tendon damage and assign a code for the tendon injury as the principal diagnosis.

Scenario four:
As the principal diagnosis has been documented as ‘lacerations’ and there is evidence of injury to multiple underlying structures that have been repaired, VICC advises to apply the hierarchy in ACS 1908 Open wound with artery, nerve and/or tendon damage and assign a code for injury of artery as the principal diagnosis.

Note: VICC has published this response because the committee has added further information to respond to the specific questions in the original query. This information does not alter the IHPA Coding Rule.


Query Title:
Ankle syndesmosis injury and Maisonneuve fracture

Query Text:
This year we have seen an increasing number of footballers admitted to our hospital with a diagnosis of ankle syndesmosis injury. Some of the patients were treated conservatively and some of the others required surgical fixation to treat the injury.

We have also had a patient with the diagnosis of Maisonneuve fracture and he underwent an ORIF of ankle syndesmosis. 

Our research indicates that an ankle syndesmosis injury is a sprain of the syndesmotic ligaments that connect the tibia and fibula in the lower leg.
https://physioworks.com.au/injuries-conditions-1/high-ankle-sprain 

We also researched a Maisonneuve fracture and it refers to a combination of a fracture of the proximal fibula together with an unstable ankle injury (widening of the ankle mortise on x-ray), often comprising ligamentous injury (distal tibiofibular syndesmosis, deltoid ligament) and/or fracture of the medial malleolus.
https://radiopaedia.org/articles/maisonneuve-fracture 

Can the committee please what codes should be assigned for:
1) Ankle syndesmosis injury?
2) Maisonneuve fracture?

Response:
VICC research also confirms that ankle syndesmosis injury is a sprain of the ligaments in the ankle, therefore VICC advises to follow the Index entry Sprain, strain (joint) (ligament)/ankle to assign a code from S93.4- Sprain and strain of ankle.

Further research by VICC confirms that Maisonneuve fracture is defined as a spiral fracture of the proximal third of the fibula with unstable ankle injury and that the unstable ankle injury may involve fracture of the distal fibula. Therefore, as there is no Index entry for Maisonneuve fracture, the documented components of the injury must be coded separately. 

For the fibula fracture VICC advises to use radiology or review other parts of the clinical record to verify the specific site(s) of fibula fracture and then follow appropriate Index entries under lead term Fracture/fibula to assign the correct code. To code the unstable ankle injury, if there is no further specificity of the type of unstable ankle injury (eg sprain), assign S99.8 Other specified injuries of ankle and foot following the Index entry Injury (traumatic) (see also specified injury type)/ankle/specified NEC.

Please note that as per ACS 1907 Multiple injuries, in the initial admission all documented injuries must be coded. For a subsequent admission, only code the injuries that meet the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.


Query Text:
There does not appear to be a specific ACHI index pathway to classify the Body Lift procedure. This appears to be the case in both Tenth and Eleventh edition.

ACHI index pathways considered have been based on the documentation of the components of the Body Lift procedure on the operation record. For some episodes there has been no details of the components documented.

When clinical clarification cannot be obtained please advise the correct ACHI index pathway/s and procedure code/s to assign for Body Lift.

Search Details
https://plasticsurgery.org.au/procedures/surgical-procedures/body-lift/

Response:
VICC referred this query to IHPA who provided the following response in Coding Rule Q3424 Body lift procedure published 20 March 2020:

“A body lift is a form of body contouring surgery that involves removing loose skin folds and extra fat, which results in improved shape and tone of the underlying tissue (Better Health Channel 2019). This procedure is also known as a lipectomy (Merriam-Webster n.d.).
Assign multiple ACHI codes when body lift procedures are performed on multiple body regions.
Follow the ACHI Alphabetic Index at Lipectomy/by site.
For example, brachioplasty is classified in ACHI to Lipectomy/arm.
Follow the ACHI Alphabetic Index entry:
Brachioplasty — see Lipectomy/arm
Lipectomy
- arm (circumferential) (wedge)
- - 1 excision 30168-00 [1666]
- - 2 excisions 30171-00 [1666]
- - suction 45584-00 [1666]

Where there is no documentation of the number of excisions performed, follow the guidelines in ACS 0038 Procedures distinguished on the basis of size, time, number of lesions or sites; default to Lipectomy/arm/1 excision:
Where there is no documentation in the clinical record, no further information can be obtained from the clinician and there is no default in the index, assign the code for the smallest size, the least duration, the least number of lesions or sites, as appropriate.
Amendments will be considered for a future edition. [end of IHPA response]

Further to the IHPA response, the operation report provided with the query cited shows the following procedures performed: abdominal lift, brachioplasty (bilateral) and bilateral buttock lift.

Therefore, following the IHPA advice, for the case cited assign the following codes:

For abdominal lift, assign 30165-00 [1666] Lipectomy of abdominal apron, following Index entry Lipectomy/abdominal

For bilateral brachioplasty assign 30171-00 [1666] Lipectomy, 2 or more excisions following Index entry Lipectomy/arm/ 2 excisions

This code represents two excisions; one per arm.  See also Index entry lift/ arm/>= 2 excisions (bilateral) 30171-00 [1666]

For bilateral buttock lift, assign 30171-00 [1666] Lipectomy, 2 or more excisions following Index entry Lipectomy/ buttock/ 2 excisions

This code represents two excisions; one per buttock.

VICC notes this results in the same code being assigned twice; one for the arm and one for the buttock, to represent two different anatomical sites. This is in accordance with ACS 0020 Bilateral/ multiple procedures.

Note: VICC has published this response because the committee has added further information to the IHPA Coding Rule response. This information does not alter the IHPA Coding Rule.


Query Text:
Can VICC please provide advice on the coding of FAP (familial adenomatous polyposis)? 
Research online indicates FAP is an inherited condition caused by a mutation in the APC (Adenomatous Polyposis Coli) gene, where people develop multiple colorectal adenomas. Other manifestations in people with FAP are duodenal adenomas and gastric fundic gland and adenomatous polyps. Polyps in the duodenum can sometimes develop into cancer. Without colectomy, the risk of colorectal carcinoma is almost 100%. 

The Tenth and Eleventh edition of the ICD-10-AM, ACHI and ACS have been reviewed. 

In the ICD-10-AM index, the index pathway for FAP is:
FAP (familial adenomatous polyposis) – see Polyposis / 
Polyposis – see also Polyp / 
familial adenomatous (M8220/0) (see also Polyposis/colon) D12.-. 
The sites classified in D12 are: caecum, appendix, ascending colon, transverse colon, descending colon, sigmoid colon, colon unspecified, rectosigmoid junction, rectum and anus and anal canal. 

There was previous NCCC and VICC advice relating to FAP which has now been retired. 
The Ninth Edition ACS 0246 Familial Adenomatous Polyposis has not been included in Tenth or Eleventh Edition. 

For a patient admitted for a same day gastroscopy and colonoscopy, please advise the diagnosis code/s to assign in the following scenarios: 

1. Indication is FAP and a sigmoid colon polyp is found and removed. 
The doctor documented on the operation record the polyp is expected with FAP. 
The histopathology results reported hyperplastic polyp. 
Is it correct to assign: D12.6 Benign neoplasm of colon, rectum, anus and anal canal, Colon, unspecified, M8220/0 Adenomatous polyposis coli as the principal diagnosis as there is no documentation the FAP was a past history, with K63.58 Other polyp of colon assigned as an additional diagnosis code? 

2. Indication is personal history of FAP and a stomach polyp is found and removed. 
The histopathology results reported FAP polyp of the stomach.
Is it correct to assign D13.1 Benign neoplasm of other and ill-defined parts of digestive system, Stomach, M8220/0 Adenomatous polyposis coli?

3. Indication is personal history of FAP. 
There is no documentation FAP polyps were previously found. 
No polyps were found in the current admission. 
A biopsy was performed for a duodenal lesion. 
Histopathology reported duodenal adenocarcinoma. 
Is it correct to assign Z09.9 Follow up examination after unspecified treatment for other conditions, Z86.0 Personal history of other neoplasms, C17.0 Malignant neoplasm of small intestine, Duodenum, M8140/3 Adenocarcinoma NOS? 

4. Indication is FAP gene mutation. 
There is no documentation FAP polyps were previously found. 
No polyps were found in the current admission. 
Is it correct to assign Z13.83 Special screening examination for digestive tract disorder?

5. Indication is family history of FAP. 
There is no documentation the patient’s family members have a previous history of FAP polyps or cancer. 
No polyps were found in the current admission. 
Is it correct to assign Z13.83 Special screening examination for digestive tract disorder and Z83.7 Family history of diseases of the digestive system? 


Search Details
Australian Coding Standard, 10th and 11th Edition, 0052 Same-Day Endoscopy – Surveillance 
Australian Coding Standard, 9th Edition 0246 Familial Adenomatous Polyposis
NCCH, Volume 13, Number 2, September 2006, Updated 1 July 2017, Assignment of Chapter 17 Congenital malformations, deformations and chromosomal abnormalities codes (Q00 – Q99) as additional diagnoses 
VICC Queries 2321, Retired 30 June 2013, Familial Adenomatous Polyposis
VICC Queries 2126, Retired 30 June 2010, Familial adenomatous polyposis (FAP)
NCCH, Coding Matters advice, September 2006, Retired 30 June 2013, Personal history of familial adenomatous polyposis (FAP)
https://gut.bmj.com/content/gutjnl/54/7/1034.full.pdf
https://www.cancer.nsw.gov.au/getattachment/understanding-cancer/cancer-in-nsw/hereditary-cancers/familial-adenomatous-polyposis-(fap)/fap-guide.pdf?lang=en-AU

Response:
In all scenarios cited VICC advises that the correct standard to follow is ACS 0052 Same-day endoscopy - surveillance.

In scenario 1, as the indication is documented as FAP, VICC agrees to assign D12.6 Benign neoplasm of colon, unspecified and M8220/0 Adenomatous polyposis coli as principal diagnosis. K63.58 Other polyp of colon can be assigned as an additional diagnosis because a hyperplastic polyp of the colon was identified and removed.

In scenario 2, assign as principal diagnosis D13.1 Benign neoplasm of other and ill-defined parts of digestive system, Stomach with M8220/0 Adenomatous polyposis coli as there is personal history of FAP and the histopathology result indicated FAP of the stomach.

In scenario 3, assign as principal diagnosis C17.0 Malignant neoplasm of small intestine, duodenum with M8140/3 Adenocarcinoma NOS as the biopsy result showed duodenal adenocarcinoma and FAP is a known pre-cancerous condition which can be found in both the duodenum and stomach. 

In scenario 4, assign as principal diagnosis Z13.83 Special screening examination for digestive tract disorder as the documented indication for the procedure is FAP gene mutation and there was no mention of personal or family history of FAP.

In scenario 5, assign as principal diagnosis Z13.83 Special screening examination for digestive tract disorder followed by Z83.7 Family history of diseases of the digestive system as no polyps were found during the procedure and the documented indication is a family history of FAP.


Query Text:
Could VICC please advise the correct diagnosis code to assign for documentation of prominent internal fixation devices?

We often see prominent internal fixation device / metalware documented as the indication for removal of internal fixation devices. Research online indicates the term prominent is synonymous with protrusion, though there has been debate over these terms equivalence. There is no specific index pathway for ‘prominent’. The index pathway for protrusion leads to a code for a mechanical complication.

Can prominent internal fixation devices be classified to a mechanical complication code or should they be classified to a code for Other complication of device?

Response:
VICC agrees that ‘prominent’ is synonymous with ‘protrusion’ and therefore documentation of a prominent internal fixation device is classified as a mechanical complication of a device.

VICC advises to follow Index entry Protrusion, protrusion/device, implant or graft/fixation, internal (orthopaedic) NEC to assign T84.1 Mechanical complication of internal fixation device of bones of limb or T84.2 Mechanical complication of internal fixation device of other bones.


Query Text:
I would like to know how to code an injection into the fetal heart with potassium to facilitate fetal demise (abortion). Currently there is only an intra-amniotic injection code but this is not the latest practice. 
  
I will continue to code intra-amniotic injection until a more suitable code is available or unless directed otherwise.

Response:
For intra-fetal cardiac injection, if there is documentation of fetal reduction, (defined as reducing multiple pregnancy) VICC advises to assign 90463-00 [1330] Fetal reduction by following ACHI Index entry Administration/type of agent/fetotoxic/for/fetal reduction (gas) (potassium chloride).

If fetal reduction is not documented, follow the ACHI Index entry Termination of pregnancy (administration of pharmacological agent) (medical) NEC to assign 90462-01 [1330] Termination of pregnancy [abortion procedure], not elsewhere classified.


Query Text:
A patient is admitted for termination of pregnancy at 6 weeks. Patient goes to theatre and suction D&C performed under IV sedation. Patient has ongoing pain and haemorrhage post operatively and ultrasound performed. Patient found to have retained clot and returned to theatre where aspiration of uterus performed.

Is the abortion coded to O04.9 or O04.1. If coded to O04.1 then would the prefix be 'C' as there was no complication on admission. Also there was no complication on admission, the complication of haemorrhage arose after the suction D&C. No documentation that the haemorrhage was a complication of the procedure apart from the procedure being incomplete with retained products and haemorrhage.

Response:
VICC advises that for the scenario cited, the correct principal diagnosis code (and only code) to assign is O04.4 Medical abortion, incomplete, without complication. This is because the documentation states that the procedure was incomplete with retained products and haemorrhage, therefore there is a documented link between the haemorrhage and the retained products.

If the haemorrhage had not been linked to retained products, the correct principal diagnosis would have been O04.1 Medical abortion, incomplete, complicated by delayed or excessive haemorrhage.

The Prefix must be P Primary condition as per ACS 0048 Condition onset flag Guide for use point 7. Where multiple conditions/sites are classifiable to a single ICD-10-AM code that meets the criteria for different condition onset flag values, assign COF 1 (see Example 12). The exception to this is when the condition is sequenced as the principal diagnosis and must be assigned COF 2 (see Example 15).


Query Title:
Clarification of VICC query #3256 Diverticular disease and chronic incurable disease

Query Text:
There have been different interpretations of Q2 of VICC query #3256 Diverticular disease and chronic disease and the response. The response states that ‘VICC research indicates that diverticulosis is considered to be chronic and incurable, whereas diverticulitis is an acute condition. Where diverticular disease is documented without documentation of diverticulitis, a code for diverticulosis should be assigned. Follow the guidelines in ACS 0052 Same day endoscopy — surveillance to assign diagnosis codes according to the documentation available’.

Where there is an indication for a colonoscopy of ‘Surveillance of diverticulitis. Pain has now settled’, under findings there is documentation of ‘Mild diverticulosis was evident in ascending colon and the sigmoid colon’, conclusion documents ‘colonic polyps, diverticular disease, haemorrhoids’.

There is no documentation of diverticulitis, there is external correspondence from another health care facility where the patient was previously treated for diverticulitis with antibiotics.

Is it correct to code this scenario as? 
a) As ‘diverticulitis’ was not found, code the principal diagnosis to Z09 following ACS 0052 Same day endoscopy — Surveillance Classification ‘an appropriate code from categories Z08 or Z09 Follow-up examination after treatment for…if the condition under surveillance has been previously treated and no recurrence or residual condition is detected.’ An additional diagnosis code for the diverticulosis found is not required in this case as this condition does not meet ACS 0002 Additional diagnoses. 

b) Code the principal diagnosis to Diverticulosis as ‘diverticulosis’ was found and the conclusion was ‘diverticular disease’, following ACS 0052 Same-day endoscopy surveillance Classification ‘the pre-existing condition under surveillance (including chronic incurable conditions)’ and following VICC 3256 ‘where diverticular disease is documented without diverticulitis, a code for diverticulosis should be assigned’. An additional diagnosis code for personal history of specified digestive system disease is not required to capture the history of diverticulitis. 


Search Details:
VICC Query #3256 Diverticular disease and chronic disease

Response:
VICC confirms that diverticulitis is an acute form of a chronic incurable condition. When the indication for a colonoscopy is 'surveillance of diverticulitis', VICC considers this is endoscopic surveillance for review of a chronic incurable condition.

When only diverticulosis is found (ie the acute form of the condition has resolved), it is correct to assign a code for diverticulosis (the chronic condition) as principal diagnosis because the first dot point in the Classification section of ACS 0052 Same-day endoscopy - surveillance directs coders to assign the pre-existing condition under surveillance as principal diagnosis (including chronic incurable conditions).


Query Text:
What is the correct code for cryptogenic organising pneumonia?

Response:
VICC research indicates that cryptogenic organising pneumonia (COP) is a rare lung condition affecting the small airways (bronchioles) and alveoli (tiny air sacs). It was previously known as idiopathic bronchiolitis obliterans with organising pneumonia (BOOP).

VICC acknowledges that the ICD-10-AM/ACHI/ACS classification is not in keeping with the changing clinical terminology for cryptogenic organising pneumonia. VICC consulted with a respiratory physician who confirmed that cryptogenic organising pneumonia (COP) is the current clinical terminology for idiopathic bronchiolitis obliterans with organising pneumonia (BOOP).

Therefore as COP and BOOP are the same condition, VICC advises to follow Index entry Pneumonia/bronchiolitis obliterans organising (BOOP) and assign J84.8 Other specified interstitial pulmonary diseases for documentation of cryptogenic organising pneumonia.


Query Title:
Wound management charts and pressure injuries

Query Text:
In Eleventh Edition, ACS 0002 Additional diagnoses specifies that pressure injuries meet criteria for coding when diagnosed by a registered nurse and a wound care treatment plan is commenced (Example 12).

1. Does the establishment of a wound chart that includes treatment goals and space for nurses to complete type and frequency of dressing changes, constitute a wound care treatment plan?

2. If not, please advise what needs to be included in a wound chart in order for it to be classified as a wound care treatment plan.

Search Details	: 
Eleventh Edition ACS 0002 Additional Diagnoses

Response:
VICC advises that the document Eleventh Edition ICD-10-AM/ACHI/ACS Victorian education updated for ACS 0002 effective 1 January 2020 contains two examples which address the coding of pressure injuries, and are reproduced below:

Example 20
Patient has new small pressure area on sacrum. Cleaned and dressed. Patient provided with an air mattress.

In this example the small pressure area is not coded because no care plan for the condition is documented; the care provided for the pressure area was a routine intervention.

Example 23
Patient has a new stage 2 pressure injury near sacral region. Aquacel soft is applied and patient is changed to a pressure mattress. A wound management chart is completed detailing a plan for ongoing care with a dressing regime.

In this example the pressure injury is coded because there is documentation of the condition, assessment of the pressure injury and a documented plan of care to support the management of the pressure injury. 

Note: A documented plan may be in the progress notes or on a wound management chart. A wound specialist or a general nurse may formulate and document a plan to manage the pressure injury.

[end of examples]

Therefore, VICC advises that if a wound management chart contains assessment of a pressure injury and a documented plan of care (ie a dressing regime) for the pressure injury, then the pressure injury should be coded.

(access the document at https://www.bettersafercare.vic.gov.au/our-work/information-management-and-standards/clinical-coding-and-classifications/education).


Query Text:
When coding a surveillance colonoscopy for past history of rectal polyp, which past history code should be used? 

1. Z87.18 Personal history of other digestive system disorder or 
2. Z87.12 Personal history of colonic polyps

We are debating whether we can use the ACHI Index entry History/colonic polyps for documentation of a rectal polyp.

Search details:
Alphabetic index
Includes/excludes notes
Codefinder Anatomy plates and numerous other definitions of colon.
ACS Eleventh Edition

Response:
Although the rectum is considered part of the large intestine, it is a different anatomic site to the colon, and is classified separately in ICD-10-AM Chapter 11 Diseases of the digestive system, therefore VICC considers that it is incorrect to follow the Index entry History (of) (personal)/colonic polyps. 

For history of rectal polyps, VICC advises to follow the Index entry History (of) (personal)/disease or disorder(of)/digestive system/specified disease or disorder NEC and assign Z87.18 Personal history of other digestive system disease.


Query Title:
Lactation consultant intervention in newborn episode

Query Text:
The ACHI code 95550-16 [1916] Allied health intervention, lactation consultant has a sex edit in the Codefinder which makes this code only valid for female patients.

ACS 0032 Allied health interventions does not specify that this code is to be used exclusively for coding the mother’s record. Can the VICC please clarify whether this code can be assigned where there is documentation of a lactation consultant intervention in a newborn’s record? 

Search Details
ACS 0032 Allied health interventions

Response:
VICC advises that IHPA have published the following advice in ACE as TN1502: Eleventh Edition FAQs Part 2: Lactation consultation in newborn episode:

Q:
Can the new allied health code for lactation consultant be used on a newborn/neonate episode when the lactation consultant sees the neonate and documents in the progress notes, or is it for use in the obstetric (mothers) episode of care only?

A:
The new intervention code 95550-16 [1916] Allied health intervention, lactation consultant is intended for use on the mother’s episode of care, not on the newborn’s episode of care (male or female). This is confirmed by the presence of the clinical (sex) edit on this code which prohibits its assignment on the episode of care of a male. 

Where a newborn is reviewed for feeding problems by a lactation consultant (eg review of tongue tie), coders should assign a diagnosis code to indicate the neonatal condition causing the breastfeeding (attachment) difficulty, if applicable or a code from category P92 Feeding problems of newborn. 

Published 16 September 2019, 
for implementation 01 October 2019.
[end of IHPA response]


Query Title:
Coding of metastases from previous episodes

Query Text:
Can metastatic cancer sites be coded in an episode where there is only documentation of the primary cancer?

For example, an episode has documentation of "Adenocarcinoma of the rectum" but correspondence and other episodes indicate the patient has mets to the lung and brain. Is the entire record allowed to be used in this instance to add further specificity to the documented condition, or does the term "Metastatic" Adenocarcinoma of the rectum need to be documented?

Search Details
ACS 0010 Clinical documentation and general abstraction guidelines
ACCD FAQ June 2019

Response:
VICC advises that Victorian coders should continue to follow the advice in the document Eleventh Edition ICD-10-AM/ACHI/ACS Victorian education updated for ACS 0002 effective 1 January 2020 until such time that IHPA reviews the inconsistencies created by the FAQs.

The Victorian education states:

'Notwithstanding the advice in the IHPA ACE Eleventh Edition Education Frequently Asked Questions Part 1 Coding Rules for implementation 1 October 2019 , specialty standards ACS 0401 Diabetes mellitus and intermediate hyperglycaemia and ACS 0236 Neoplasm coding and sequencing should be applied to code the severity of the condition provided diabetes or a neoplasm is documented in the current episode, to maintain consistency of data'.

(access the document at https://www.bettersafercare.vic.gov.au/our-work/information-management-and-standards/clinical-coding-and-classifications/education).


Query Text:
We often have patients who have been referred to OT specifically for cognitive testing. This results in a finding of mild cognitive impairment - there is no other mental or behavioural component. There is often an infective or cerebral comorbidity. An example is a new finding of meningioma/viral URTI with mild cognitive impairment - is this the same thing as mild cognitive disorder? Are we able to use F06.7 (MCI) or do we stay with R41.8 Cognitive symptoms?

Response:
VICC advises that mild cognitive impairment and mild cognitive disorder are not necessarily the same condition. For documentation of mild cognitive impairment, the correct code to assign is R41.8 Other and unspecified symptoms and signs involving cognitive functions and awareness following the Index entry Impairment/cognitive NEC. This Index entry was added for Eleventh Edition to reflect the information in ACS 0532 Cognitive impairment which was deleted for Eleventh Edition.

F06.7 Mild cognitive disorder should only be assigned when documentation supports the Index pathways required for this code.


Query Title:
Complications of neoplasm treatment arising during an admission

Query Text:
Eleventh Edition ACS 0236 Neoplasm Coding and Sequencing states that: A primary neoplasm is classified as a current condition if the episode of care is for:
• diagnosis or treatment of the primary neoplasm, in any of the following circumstances:
• initial diagnosis of the primary neoplasm
• treatment of complications of the primary neoplasm or neoplasm treatment.

If the episode of care is for treatment of another non-malignant condition, the malignancy may be classified as a current condition only if it meets the criteria for code assignment as per ACS 0002 Additional diagnoses.

The Eleventh Edition FAQs - Amended appear to reiterate the point if the patient is admitted for treatment/management of a complication of neoplasm treatment then the neoplasm can be coded, however does not provide instruction about coding a complication of neoplasm treatment that arises during the episode of care.

If a patient is admitted for a non-malignant condition, and develops a complication of neoplasm treatment during the episode of care – can the cancer be coded even if the cancer doesn’t meet ACS 0002 in its own right?
 
For example: a patient is admitted with OA hip for hip replacement. They have a history of ca breast and had chemo 2 days prior to the admission. On Day 2 of this admission, the patient develops diarrhoea which meets ACS 0002, and the diarrhoea is documented to be due to the recent chemotherapy. Can we assign a code for the breast cancer?

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

ACS 0236 Neoplasm coding and sequencing/Primary neoplasm as a current condition states:
A primary neoplasm is classified as a current condition if the episode of care is for:
• 	diagnosis or treatment of the primary neoplasm, in any of the following circumstances: 
-  	initial diagnosis of the primary neoplasm
-  	treatment of complications of the primary neoplasm or neoplasm treatment
-  	operative intervention to remove the primary neoplasm
-  	medical care related to the primary neoplasm, including palliative care (see also ACS 2116 Palliative care)
- 	recurrence of the primary neoplasm previously eradicated from the same organ or tissue (see also ACS 0237 Recurrence of malignancy)
…

If the episode of care is for treatment of another nonmalignant condition, the malignancy may be classified as a current condition only if it meets the criteria for code assignment as per ACS 0002 Additional diagnoses.

The term ‘neoplasm treatment’ in ACS 0236 (above) relates to interventions specifically targeting the neoplasm, such as pharmacotherapy or radiotherapy. Complications of surgical interventions performed for treatment of a neoplasm are assigned in accordance with the guidelines in ACS 1904 Procedural complications.

Therefore, a primary neoplasm code is assigned in an episode of care when there is treatment of a primary neoplasm, neoplasm related condition, or a pharmacotherapy or radiotherapy related complication.

When a nonmalignant condition is the principal diagnosis in an episode of care, a primary neoplasm code is assigned as an additional diagnosis when:
• 	it meets the criteria in ACS 0002 Additional diagnoses; or
• 	a neoplasm related condition, or pharmacotherapy or radiotherapy related complication, meets the criteria in ACS 0002 Additional diagnoses.

Where documentation confirms a neoplasm is completely resolved and none of the above points applies, and the history is relevant to the current episode of care, assign a code from category Z85 Personal history of malignant neoplasm. 

[End of IHPA response]

VICC notes IHPA published this response as IHPA Coding Rule Q3498 Clarification of ACS 0236 Neoplasm coding and sequencing for implementation 01 January 2021.

VICC interprets the IHPA response to mean that the same instructions apply if the complication of neoplasm treatment (excluding surgical complications) occurs during the episode of care. That is, if a patient is admitted for a non-malignant condition, and develops a complication of neoplasm treatment during the episode of care, the cancer is coded even if the cancer does not meet ACS 0002 Additional diagnoses in its own right. 

Note: A complication of a surgical intervention for a neoplasm is not considered a complication of ‘neoplasm treatment’. Therefore the primary neoplasm is not coded unless it meets ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses and another dot point of ACS 0236 Neoplasm coding and sequencing.

Therefore the scenario cited would be coded as:
Principal Diagnosis – OA hip
Additional Diagnosis – diarrhoea due to recent chemotherapy
Additional Diagnosis – breast primary neoplasm as the diarrhoea due to chemotherapy is a ‘pharmacotherapy related complication’ that meets the criteria in ACS 0236 Neoplasm coding and sequencing for coding of the neoplasm.

Note: VICC has published this response because the committee has added further information to the IHPA Coding Rule response. This information does not alter the IHPA Coding Rule.


Query Text:
We are seeking clarification of stroke deficits and associated conditions as per ACS 0604 Cerebrovascular accident (CVA).

Eleventh Edition ACS 0604 provides an example of a stroke deficit as hemiplegia, and some examples of conditions associated with CVAs. However the standard does not seem to provide a definition of deficit or information on how a coder can know whether a condition is considered to be a deficit or an associated condition and the difference between the two.

Q1. Does the condition need to be documented specifically as a deficit or a sequelae of stroke?
Q2. Is there a list of conditions that can be classed as deficits? If there is no list of conditions, can you please provide advice on how we can determine if a condition is a deficit or an associated condition?

Response:
VICC advises that regardless of whether a condition is documented as a deficit or is one of the certain associated conditions that indicate severity of stroke described in ACS 0604 Cerebrovascular accident (CVA), the condition needs to meet ACS 0002 Additional diagnoses.

This is supported by the steps described in the Guidance in the use of ICD-10-AM in the Introduction to the Tabular List, in particular, point 4 which states (after verifying the suitability of the code selected) to first refer to the General standards for diseases, then refer to any specialty standard. As ACS 0002 Additional diagnoses is a general standard for diseases, a deficit or associated condition must first meet ACS 0002.


Query Title:
Assignment of cancer site codes based on clock positions or diagrams

Query Text:
In the Eleventh Edition Education slides Neoplasms, there is a diagram with clock positions with an example of documentation of a breast lesion at 6 o’clock coded to C50.8 Overlapping lesion of breast.

VICC #3107 Breast Quadrants and neoplasm codes advises to use a diagram as a reference to assist in determining the site of the neoplasm, however code assignment must be based on documentation in the medical record and by following the index to arrive at the appropriate code.

We note that there are no index options for clock positions, therefore can you please clarify if it is acceptable to use the diagram from the Eleventh Edition education slides Neoplasms to assign breast cancer site codes based on documentation of clock positions? We also note that this is similar to the example in ACS 0234, Example 2. 

Search details:
ACS 0234 Contiguous sites
Eleventh Edition Education slides – Neoplasms
VICC Q3107 Breast quadrants and neoplasm codes

Response:
VICC acknowledges that documentation of breast lesions often utilises shorthand in the form of a clock position, however the Indexing of malignant breast lesions refers to quadrants, halves, central portion and specific anatomy of the breast, and some sites are not indexed at all, such as 'subareolar'.

VICC advises that as ACCD used the diagram titled "Contiguous site of the breast - breast quadrants" in the Eleventh Edition education material for Neoplasms, and the clock position is used to assign a code in example 2 of ACS 0234 Contiguous sites, for consistency of data it is acceptable for coders to use the diagram to assign a code for the site of a breast lesion.


Query Text:
There is a new code, Z32.2 Initiation of medical abortion. This is to be used for supervision of the initial episode of care for a staged medical abortion. Our site usually performs staged abortions for late cases over two days, however, I have just coded one that was over 3 days. Can I assign Z32.2 on day 2 at which time the cervix was still tight so they inserted more dilapam to dilate the cervix. Patient returned on day 3 to have more dilation and D&E.

Response:
VICC notes that in Victoria, an intended same day episode for administration of medication to initiate the termination of pregnancy is not reported to the VAED unless the episode meets one of the criteria for reporting as per the document Victorian Admitted Episodes Dataset: Criteria for Reporting.

Provided the episode in the scenario cited meets criteria for reporting to the VAED, it is correct to assign as principal diagnosis Z32.2 Initiation of medical abortion as per ACS 1511 Termination of pregnancy (abortion), section titled  ICD-10-AM codes for staged medical abortion.


Query Title:
Medium chain acyl-coa dehydrogenase deficiency (MCADD)

Query Text:
What is the appropriate code for Medium chain acyl-coa dehydrogenase deficiency (MCADD)? 

MCADD is a rare genetic condition where a person has problems breaking down fat to use as an energy source. This means that someone with MCADD can become very ill if their body's energy demands exceed their energy intake, such as during infections or vomiting illnesses when they're unable to eat.

The best fit code I can find is:
Deficiency
-enzyme, circulating NEC E88.0
or
Disorder
-fatty acid metabolism E71.3

E71.3 incorporates very long chain acyl-coa dehydrogenase deficiency (VLCAD) which I believe would be very similar to the MCADD.

Response:
VICC obtained clinical advice that indicates there are different types of disorders of fatty acid metabolism, such as Long-chain 3-hydroxy acyl-CoA dehydrogenase (LCHAD) deficiency;  Very long chain acyl-CoA dehydrogenase (VLCAD) deficiency; Medium-chain acyl-CoA dehydrogenase (MCAD) deficiency; Short-chain acyl-CoA dehydrogenase (SCAD) deficiency. 

As MCADD is a type of fatty acid metabolism disorder, VICC advises to follow the Index lead term Disorder/fatty acid metabolism to assign E71.3 Disorders of fatty-acid metabolism.


Query Title:
Complication of primary neoplasm or neoplasm treatment

Query Text:
The Western Australian Clinical Coding Authority has released a Coding Guideline: Guide to Major Eleventh Edition Changes. This guideline states the following:

Primary neoplasm is automatically coded in an episode involving treatment of complications of the primary neoplasm or neoplasm treatment i.e. the neoplasm itself does not need to meet ACS 0002 Additional diagnoses. See Example 11 in ACS 0002 Additional diagnoses. Primary neoplasm is automatically coded in an episode for management of a complication of neoplasm surgical site, such as wound infection or haematoma following recent surgery. However, concern has been raised about late complications of neoplasm treatment such as cystitis/proctitis/osteonecrosis due to radiotherapy, where the primary neoplasm has been cured and is no longer current. This issue will be raised with the Independent Hospital Pricing Authority (IHPA). In the meantime, do not code cured primary neoplasm as a current condition in these circumstances. 

Can VICC please advise if a neoplasm code should be assigned in episodes where the patient is admitted for ‘late’ complications of the neoplasm treatment such as: Radiation enteritis, Radiation fibrosis, Osteonecrosis, Incontinence (either due to radiotherapy or surgery such as prostatectomy for neoplasm), Cystitis, Proctitis?

Response:
VICC referred this query to IHPA who provided the following response:

ACS 0236 Neoplasm coding and sequencing/Primary neoplasm as a current condition states:
A primary neoplasm is classified as a current condition if the episode of care is for:
• 	diagnosis or treatment of the primary neoplasm, in any of the following circumstances: 
-  	initial diagnosis of the primary neoplasm
-  	treatment of complications of the primary neoplasm or neoplasm treatment
-  	operative intervention to remove the primary neoplasm
-  	medical care related to the primary neoplasm, including palliative care (see also ACS 2116 Palliative care)
- 	recurrence of the primary neoplasm previously eradicated from the same organ or tissue (see also ACS 0237 Recurrence of malignancy)
…
If the episode of care is for treatment of another nonmalignant condition, the malignancy may be classified as a current condition only if it meets the criteria for code assignment as per ACS 0002 Additional diagnoses.

The term ‘neoplasm treatment’ in ACS 0236 (above) relates to interventions specifically targeting the neoplasm, such as pharmacotherapy or radiotherapy. Complications of surgical interventions performed for treatment of a neoplasm are assigned in accordance with the guidelines in ACS 1904 Procedural complications.
Therefore, a primary neoplasm code is assigned in an episode of care when there is treatment of a primary neoplasm, neoplasm related condition, or a pharmacotherapy or radiotherapy related complication.

When a nonmalignant condition is the principal diagnosis in an episode of care, a primary neoplasm code is assigned as an additional diagnosis when:
• 	it meets the criteria in ACS 0002 Additional diagnoses; or
• 	a neoplasm related condition, or pharmacotherapy or radiotherapy related complication, meets the criteria in ACS 0002 Additional diagnoses.

Where documentation confirms a neoplasm is completely resolved and none of the above points applies, and the history is relevant to the current episode of care, assign a code from category Z85 Personal history of malignant neoplasm. 

[End of IHPA response].

VICC notes IHPA published this response as IHPA Coding Rule Q3498 Clarification of ACS 0236 Neoplasm coding and sequencing for implementation 01 January 2021.

VICC interprets the IHPA response to mean that where there is a complication of ‘neoplasm treatment’, the cancer is coded as a current condition. This is regardless of the timeframe or whether the cancer is considered ‘cured’. However, this excludes complications of a surgical intervention as a complication of a surgical intervention for a neoplasm is not considered a complication of ‘neoplasm treatment’. Therefore the primary neoplasm is not coded unless it meets ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses and another dot point of ACS 0236 Neoplasm coding and sequencing.

Example 1:
Principal diagnosis - radiation-induced cystitis (documented as a complication of previous radiotherapy for cured prostate cancer)
Additional diagnosis – prostate primary neoplasm as the radiation-induced cystitis is a ‘radiotherapy related complication’ that meets the criteria in ACS 0236 Neoplasm coding and sequencing for coding of the neoplasm. 

Example 2:
Principal diagnosis - Incontinence due to radiotherapy for prostate neoplasm
Additional diagnosis – prostate primary neoplasm as the incontinence is a ‘radiotherapy related complication’ that meets the criteria in ACS 0236 Neoplasm coding and sequencing for coding of the neoplasm.

Example 3:
Principal diagnosis – Incontinence due to prostatectomy for prostate neoplasm
Prostate primary neoplasm is not coded as an additional diagnosis as incontinence is a surgical complication in this example (unless the cancer meets ACS 0002 Additional diagnoses in its own right).

Note: VICC has published this response because the committee has added further information to the IHPA Coding Rule response. This information does not alter the IHPA Coding Rule.


Query Text:
We have a scenario where a baby is documented as having 'presumed sepsis', is receiving IV antibiotics and is then transferred to another hospital with 'presumed sepsis and significant vomiting'.

Applying the ACCD advice Q3259 we have to code this to 'risk of sepsis' as the term 'presumed' has been used. This is inconsistent with how we code other suspected conditions and given that the baby was transferred for higher level care it seems wrong to code it as 'risk of sepsis'. Could you please advise on how this should be coded? Thanks for your assistance.

Search Details
Q3259 Neonatal Sepsis/ Risk of Sepsis
ACS 1617 Neonatal Sepsis/ Risk of Sepsis

Response:
VICC advises that it is correct to assign Z03.71 Observation of newborn for suspected infectious condition with Z75.6 Transfer for suspected condition for an unwell baby who is commenced on IV antibiotics and transferred from a regional to a tertiary hospital with a diagnosis of ‘presumed sepsis'.

This is supported by ACE Coding Rule Q3259 Neonatal Sepsis/Risk of Sepsis, third dot point which states: "for classification purposes, a diagnosis of ‘risk of sepsis’ or ‘suspected sepsis’ (ie probable, possible, likely, queried sepsis) are synonymous in neonates. Assign Z03.71 Observation of newborn for suspected infectious condition regardless of whether the neonate has signs or symptoms, or coexisting conditions documented".


Query Title:
Blastic plasmacytoid dendritic cell neoplasm (BPDCN)

Query Text:
Blastic Plasmacytoid Dendritic Cell Neoplasm (BPDCN) is a rare, clinically aggressive hematologic malignancy that most commonly manifests as cutaneous lesions with or without bone marrow involvement and leukemic dissemination. Morphology in this case was described as 'features consistent with acute leukaemia'.

I used leukaemia as my lead term and assigned C94.70 other specified leukaemia without remission and M9800/3 Leukaemia NOS (or perhaps should have used M9801/3 for acute leukaemia?). There was no direct pathway for these codes. Previously BPDCN was known as natural killer cell leukaemia. The pathway for this is leukaemia, NK-cell, aggressive which leads to C94.70 Other specified leukaemia M9948/3. I have since found further patient care conference notes that describe the cancer as 'BPDCN Myeloid". I would appreciate your assistance to identify the most appropriate codes.

Search Details
https://www.hematology.org/Thehematologist/Ask/8927.aspx

Response:
VICC advises that the correct codes to assign for Blastic plasmacytoid dendritic cell neoplasm (BPDCN) are:
C86.4 Blastic NK-cell lymphoma
M9727/3 precursor cell lymphoblastic lymphoma NOS
by following the Index entry Tumour/dendritic cell/blastic plasmacytoid C86.4 M9727/3.

VICC notes that the Index entry at neoplasm is for anatomic site, and that there are no suitable Index entries for any of the other morphological descriptors. Therefore VICC considers it is appropriate to consider Tumour a synonymous lead term for Neoplasm. This is supported by the advice in ACE Coding Rule Q3301 Intraductal Papillary Mucinous Neoplasm (IPMN).


Query Text:
We are seeking to clarify whether robotically-assisted interventions should always be classified as laparoscopic/endoscopic in the absence of evidence to suggest open approach.
ACS 0053 Robotic-Assisted Intervention states: ‘…Where a procedure is performed with the assistance of robotic technology, code first the procedure(s) performed, followed by 96233-00 [1923] Robotic-assisted intervention’.

Our facility performs robotic assisted procedures often without documentation that the procedure is ‘laparoscopic’, such as that for robotic assisted radical prostatectomy (documented as ‘RARP’), robotic assisted hysterectomy and robotic nephrectomy. When we have sought further documentation, our clinicians have advised us that robotic-assisted surgery is inherently laparoscopic. Advice from an Urologist whom performs RARP indicates this procedure is always laparoscopic. Similar advice was received from a gynaecologist who advised that for a hysterectomy with BSO, any robotic component of the surgery is always laparoscopic. In the ACHI Index, there is:
• Prostatectomy/robotic-assisted laparoscopic radical (RALRP) — see Prostatectomy/radical(total)/laparoscopic AND Robotic-assisted intervention. 
• Hysterectomy (abdominal) (total) NEC/laparoscopic NEC
Can you please advise if documentation indicates that a procedure is ‘robotic-assisted’ without mention of being ‘laparoscopic’ (or ‘endoscopic’) and there is no evidence of open approach, are we able to code the procedure as laparoscopic (or endoscopic) when the index pathway has a provision to do so? 

Search Details
ACS 0053 Robotic-assisted interventions
VICC 2897 Robotic assisted surgery (June 2014)

Response:
As per ACS 0053 Robotic-assisted intervention, minimally invasive surgery is being performed across a wide range of specialties with the assistance of robotic technology. However VICC research indicates that it is sometimes used in traditionally open procedures, therefore it cannot be assumed that the procedure is laparoscopic.

If a robotic-assisted procedure is performed without documentation that the procedure was laparoscopic and clarification with the clinician is not possible, assign the procedure code as directed by the ACHI Index, even if it results in a code for an open procedure. Also assign 96233-00 [1923] Robotic-assisted intervention as per ACS 0503 Robotic-assisted intervention.


Query Text:
We are seeking clarification to classify the Nanoknife procedure which we have seen being used to treat prostate cancer at our facility. Our research indicates that Nanoknife is the brand name for the machine used to deliver irreversible electroporation (IRE) which uses short, repetitive, non-thermal high-energy pulses of electricity to destroy cancer. These pulses of electricity destroy the tumour leaving the surrounding tissue, veins, nerves and ducts unaffected.

One of the surgeons at our facility who performs Nanoknife of the prostate for prostate cancer has advised that this procedure is synonymous with IRE and is always performed transperineally. We note that in the ACHI Index there is the lead term: 
Electroporation, irreversible (IRE) — see Destruction/by site

1. Can you please advise if Electroporation, irreversible (IRE) — see Destruction/by site is the correct index pathway to classify Nanoknife procedure.
2. Can you please advise as to the correct index pathway and code to classify documentation of ‘Nanoknife’ of the prostate when no further documentation can be sought.

Search Details
https://vitusprostate.com/en/science/treatment/nanoknife/
https://pancreaticcanceraction.org/about-pancreatic-cancer/treatment/radiotherapy/irreversible-electroporation-nanoknife/

Response:
VICC agrees with your research that Nanoknife® is an irreversible electroporation (IRE) system, therefore it is appropriate to follow the ACHI Index lead term Electroporation, irreversible (IRE) — see Destruction/by site.

When there is Nanoknife (IRE) of prostate, coders must review the operation report and other parts of the episode of care to make a classification decision as there is no default code. Assign 90408-02 [1162] Other closed destruction procedures on prostate provided documentation supports that the operative approach was not endoscopic or open.


Query Text:
Could you please specify how a diagnosis of "Thunderstorm Asthma" should be coded. Should an additional code be assigned to J45.9 Asthma, unspecified to indicate the exacerbation is related to the storm, if so, what code should that be?

Response:
VICC advises that the term ‘thunderstorm asthma’ is used to describe asthma that can happen suddenly to people in spring or summer when there is a lot of pollen in the air and the weather is hot, dry, windy and stormy. (see https://www.nationalasthma.org.au/living-with-asthma/resources/patients-carers/factsheets/thunderstorm-asthma)

VICC advises to assign J45.9 Asthma, unspecified for documentation of ‘thunderstorm asthma’.

As per ACS 2001 External cause code use and sequencing, external cause codes may be used as additional codes with conditions classified outside of Chapter 19 Injury, poisoning and certain other consequences of external causes that have an external cause. However, as there are multiple factors that can cause ‘thunderstorm asthma’ VICC considers that there is no appropriate external cause code to assign.


Query Title:
Endoscopy for history of familial adenomatous polyposis

Query Text:
We have had an increasing number of patients admitted for same day endoscopies with the indication of "personal history of familial adenomatous polyposis." We are unsure which rules within ACS 0052 Same day endoscopy – surveillance should be applied in these scenarios. 

We would appreciate it if the committee could please clarify:

1. Should we treat these endoscopy admissions for “personal history of familial adenomatous polyposis” as a follow up endoscopy or as a chronic incurable condition?

2. If these episodes are considered a follow up endoscopy, would the findings of a tubular adenoma be treated as a reoccurrence of the condition?


Search Details
ACS 0052 Same day endoscopy - surveillance

Response:
VICC advises that the correct part of ACS 0052 Same-day Endoscopy – Surveillance to follow is “For classification purposes, endoscopic surveillance refers to: screening of diseases that have the potential for malignant transformation (eg pre-malignant conditions such as Barrett’s oesophagus, hyperplastic polyps and familial adenomatous polyposis (FAP)”.

VICC advises that for a same-day endoscopy for personal history of familial adenomatous polyposis (FAP), with a tubular adenoma found on endoscopy, to assign a code for tubular adenoma as principal diagnosis as the condition under surveillance has been detected at screening.


Query Text:
ACCD Advice 15 December 2018 'Neonatal sepsis/risk of Sepsis' states terms such as risk of, suspected, probable, possible, query, likely sepsis are synonymous in neonates. Does this include the term 'presumed?' Therefore, should a diagnosis of 'presumed sepsis' in a neonate who is treated with IV antibiotics be coded as the neonate having sepsis, or having risk of sepsis?

Response:
VICC considers that ‘presumed sepsis’ is synonymous with terms such as risk of, suspected, probably, possible, query, likely sepsis.

Therefore it is correct to follow ACE Coding Rule Q3259 Neonatal Sepsis/Risk of Sepsis, third dot point which states: "for classification purposes, a diagnosis of ‘risk of sepsis’ or ‘suspected sepsis’ (ie probable, possible, likely, queried sepsis) are synonymous in neonates. Assign Z03.71 Observation of newborn for suspected infectious condition regardless of whether the neonate has signs or symptoms, or coexisting conditions documented".


Query Title:
Principal diagnosis assignment for syndromes

Query Text:
Coding Rule Q2669 Principal diagnosis assignment for syndromes has been retired presumably due to updates to ACS 0005 Syndrome for Eleventh Edition.

The advice was that where a patient presents for management of a component of a previously diagnosed syndrome, a code for the component should be assigned as the principal diagnosis. 

Can we still follow this advice?

For example, if a patient is admitted for cleft palate repair and the cleft palate is documented as due to Pierre Robin Syndrome, should cleft palate be sequenced as principal diagnosis?


Search Details
ACS 0005 Syndromes
Q2669 Principal diagnosis assignment for syndromes: retired 30/6/19

Response:
VICC advises that as the ACE Coding Rule Q2669 Principal diagnosis assignment for syndromes has been retired, it can no longer be referenced to determine the principal diagnosis when a patient presents for management of a component of a previously diagnosed syndrome.

VICC considers that although ACS 0005 Syndromes was reworded for Eleventh Edition the intent has not changed, in that it still informs how to code a syndrome when there is no single code, rather than how to select the principal diagnosis.

Therefore, when a patient presents for management of a component of a previously diagnosed syndrome, coders should be guided by documentation of the principal diagnosis, and follow ACS 0001 Principal diagnosis accordingly.

For the scenario of cleft palate due to Pierre Robin Sequence, if cleft palate is documented as the principal diagnosis, assign a code for cleft palate as principal diagnosis. Assign Q87.06 Pierre Robin Sequence as an additional diagnosis as per ACS 0002 Additional diagnoses, section titled Problems and underlying conditions.


Query Title:
Designation requirements on clinician documentation queries

Query Text:
Can you please clarify the level of detail required for clinician designation on documentation queries?

Q1. Is it acceptable for a clinician to specify their designation as VMO / HMO / surgeon or do they need to specify their clinical specialty eg orthopaedic surgeon / physician/ geriatrician etc?

Q2. If documentation queries are generated via an electronic system, is it acceptable for the clinician’s designation to be allocated by the system and preprinted on the form? For example: Dr Mouse is an anaesthetist and is entered onto the electronic system as such. If a documentation query is generated to Dr Mouse, is it acceptable for his designation to be preprinted on the form so that he only has to complete his signature (as well as other required information on the query)?

Response:
In answer to question one, the designation of a clinician in a health service is governed by the credentialling of that clinician for that health service.

In answer to question two, for classification purposes, ACS 0010 Clinical documentation and general abstraction guidelines requires that the designation is present on a documentation query but does not provide instruction for how the designation is documented. VICC considers that it is acceptable for the clinician's designation to be populated electronically prior to (or at the time of) the clinician answering and signing the query.

VICC notes that Action 6.11 Documentation of information in Standard 11 Communicating for Safety Standard of the National Safety and Quality Health Services (NSQHS) Standards states that:
- All electronic and written documentation adheres to the standards and procedures of the health services and professional bodies concerned; this includes the use of approved abbreviations, and rules for clinician and patient identification.


Query Title:
Coding convention for 'other' procedures

Query Text:
Can you please advise if the advice provided in VICC query #3067 Coding convention for procedures, 2016 – 2017 March Database is still current for Eleventh Edition and ACS 0010 Clinical documentation and general abstraction guidelines.

VICC query #3067 advises that when there are no specific Index entries listed in the ACHI index for a specific procedure, coders should in the first instance seek clinical advice to inform their assignment of a ‘best fit’ code. The introduction to the ACS states that ‘…Sometimes reference to the appropriate section of ICD-10-AM and ACHI will be enough to explain to a clinician what is required for both diagnosis and intervention descriptions (see ACS 0010 Clinical documentation and general abstraction guidelines)..’

Can VICC please provide an example of how a documentation query could be phrased that would not be considered leading as per ACS 0010, but also would allow an appropriate code to be assigned? We often find that if we do not provide options to select, that the clinicians will not respond or will reply with further terminology that cannot be assigned a code. 

In the absence of further documentation that can be assigned a procedure code, can we default to following the index Procedure / anatomical site and assign ‘other procedure’ for the site of the procedure? 

VICC query #3067 also states that a query to VICC must then be submitted to have the code selection ratified by referral to ACCD, as the ACCD is the authority to provide ‘best fit’ code advice. However we note that these are often rarely occurring procedures and/or we are required to complete coding prior to published advice.

Search Details
ACS 0010 Clinical documentation and general abstraction guidelines.
VICC query #3067 Coding convention for procedures
Australian Coding Standards, Introduction, Documentation within the health care record

Response:
VICC advises that query #3067 Coding convention for procedures is still current. That is, when there are no specific Index entries in ACHI for a specific procedure, the procedure must be clarified with the clinician in order to inform assignment of a ‘best fit’ code. A query to VICC must then be submitted to have the code selection ratified by referral to IHPA.

To write the query please follow the guidelines in the Eleventh Edition ICD-10-AM/ACHI/ACS Victorian education document, section titled Guidelines for generating appropriate queries to clinicians, which states:

•	The query references the documentation in the record that has prompted the query 
•	The query enhances the clinical truth of the existing documentation 
•	The query allows the clinician to add context to their response 
•	The query is not leading to a particular response 
•	The query does not indicate potential financial impact (including indication to move from one DRG to another) 
•	The query is signed, named, dated and designated by the person creating the query 
•	The query response is signed, named, dated and designated by the person answering the query 
•	The query is an open or multiple-choice format, except in circumstances where a yes/no format is appropriate

Therefore, in writing the query, the coder should determine what code(s) might be reasonably used to classify the procedure and construct the query in a way that gives the clinician the opportunity to add context to their response. For example:

This patient had X procedure as per the operation report dated …/…/…. We are unable to match this description with a specific code in the ACHI classification.

Can you provide any alternative terminology for this procedure that may assist us to assign the correct code?

In the event that there is no other terminology for this procedure, could you please clarify whether any of the following codes might be considered a ‘best fit’ for this procedure?

a. (code title as per Tabular List)
b. (add as many options as appropriate)
c. None of the above
d. Other comments/information

If the query results in provision of terminology that allows a specific code to be assigned, this should not become a ‘blanket’ rule for that procedure. Each instance should be queried if the documentation does not support code assignment.

If a specific procedure code still cannot be assigned, coders are advised to make a reasonable decision as to the best fit code in accordance with the documentation and the ACHI classification. Coders should not default to following the Index lead term Procedure/anatomical site and assign 'other procedure' for the site of the procedure.

In all circumstances where a code has been selected as 'best fit', a query must be submitted to VICC to have the code selection ratified by referral to IHPA, as IHPA is the authority to provide ‘best fit’ code advice.


Query Title:
Same-day chemotherapy and patient stays overnight

Query Text:
Eleventh Edition ACS 0011 Intervention not performed or cancelled, point 2 advises: 
If a patient is admitted to a facility for an intervention that was not undertaken (or initiated) due to another condition or complication, and the patient requires ongoing inpatient care for that other condition assign:
• a code for the condition responsible for the cancellation of the intervention, as principal diagnosis
• a code for the condition that required the cancelled intervention, or appropriate Z code for the reason for admission, as an additional diagnosis
• Z53.0 Procedure not carried out because of contraindication, as an additional diagnosis.

We note Example 5 from ACS 0011 Intervention not performed or cancelled:
EXAMPLE 5:
Patient with breast cancer was admitted for same-day chemotherapy. The chemotherapy session was cancelled as the patient was anaemic. The patient was transfused with two units of packed cells and discharged home that afternoon.
Codes: D64.9 Anaemia, unspecified
Z51.1 Pharmacotherapy session for neoplasm
C50.9 Breast, unspecified
M8000/3 Neoplasm, malignant
Z53.0 Procedure not carried out because of contraindication
13706-02 [1893] Administration of packed cells

ACS 0044 Pharmacotherapy advises: Where pharmacotherapy is administered for a neoplasm or neoplasm (treatment) related condition during multi-day episodes of care:
• assign a code for the condition requiring treatment 
• do not assign Z51.1 Pharmacotherapy session for neoplasm.

Can VICC please clarify, if a patient was admitted for same day chemotherapy and the chemotherapy was cancelled as the patient was anaemic and the patient stayed overnight for a blood transfusion to treat the anaemia, should Z51.1 Pharmacotherapy session for neoplasm be assigned as an additional diagnosis code to capture the original intention for the admission (same-day chemotherapy)?

Response:
VICC advises that because the patient stayed overnight in the scenario cited, it is not appropriate to assign Z51.1 Pharmacotherapy session for neoplasm. This is in accordance with ACS 0044 Pharmacotherapy, section titled Multi-day episodes of care for pharmacotherapy for neoplasm, which states do not assign Z51.1 Pharmacotherapy session for neoplasm in multi-day episodes of care. 

Therefore, in accordance with ACS 0011 Intervention not performed or cancelled, point 2, for the scenario cited, assign:

D64.9 Anaemia, unspecified
Appropriate codes for the neoplasm
Z53.0 Procedure not carried out because of contraindication
13706-02 [1892] Administration of packed cells


Query Text:
We often see spurious labour documented in our medical records. Recently a patient was admitted to our hospital for induction of labour. The indication for the induction was ‘spurious labour - greater than 48 hours’.

There is no index entry for ‘spurious labour’. 

We note that there is an index entry: Pain/labour, false or spurious - See labour/false.
There is also an index entry: Pregnancy/complicated by/spurious labour pains 
However as we do not have pain/pains documented we cannot follow these index entries.
We also note that ACS 1550 Discharge/transfer in labour lists spurious labour pains as a synonym for false labour.

Our research indicates that spurious labour is also known as false labour (Spurious Labour - Does it Matter? Aust. N.Z.J Obstet. Gynaec. (1981) 21:167).

The Western Australian Clinical Coding Authority (WACCA) published a query in 2011 (WA 0711/07) that advised to assign a code from block O47 False labour for spurious labour.

Can the committee please advise what code should be assigned for a diagnosis of ‘spurious labour’ when there is no documentation of spurious labour pain/s?

Response:
Clinical advice obtained by VICC confirms that spurious labour is a synonymous term for false labour.

Therefore, for documentation of spurious labour it is appropriate to follow Index entry Labour/ false to assign a code from O47 False labour or labour without delivery.


Query Title:
First carpometacarpal joint (CMCJ) hemi FCR suspensionplasty

Query Text:
Patient admitted with post-traumatic 1st CMCJ osteoarthritis for 1st CMCJ hemi FCR suspensionplasty. 

Currently within the index classification there are no codes for 1st CMCJ hemi FCR suspensionplasty.

Could VICC please advise what procedure code(s) should be used for 1st CMCJ hemi FCR suspensionplasty?

Response:
VICC notes the scenario cited is similar to IHPA Coding Rule Q3467 Trapeziectomy with abductor pollicis longus (APL) suspensionplasty, as a suspensionplasty for the CMC joint uses part of the flexor carpi radialis or APL tendons. 

Following the logic in IHPA Coding Rule as reproduced below, VICC considers the suspensionplasty to be an inherent component of arthroplasty and therefore only 46324-00 [1468] Arthroplasty of carpal bone is required.

Q:
What code is assigned for trapeziectomy with abductor pollicis longus (APL) suspensionplasty?

A:
Trapeziectomy is indicated for painful osteoarthritis of the carpometacarpal (CMC) joint of the thumb (Healthdirect Australia 2019). It involves removal of the trapezium, which is a cube-shaped bone in the wrist that sits beneath the base of the thumb (Healthdirect Australia 2019).

An abductor pollicis longus (APL) suspensionplasty is performed to stop the CMC joint from deforming and preserve thumb function. It uses a part of the flexor carpi radialis or APL tendons and binding it to strong suture material to suspend the base of the first metacarpal bone to the second metacarpal bone (Leclerq 2015; Renfree et al. 2017; Soejima et al. 2006).

For classification purposes, trapeziectomy with APL suspensionplasty are inherent components of arthroplasty. Therefore, assign 46324-00 [1468] Arthroplasty of carpal bone alone.
Follow the ACHI Alphabetic Index:
Arthroplasty
- wrist
- - carpal bone
- - - for joint replacement (with resection) 46324-00 [1468]

Amendments will be considered for a future edition. [end of IHPA response]


Query Title:
ACS 0002 and Eleventh Edition Victorian Education

Query Text:
ACS 0002 states the following:
“Documentation of a consultation does not have to be a formal consultation report. Documentation of assessment of a condition in the progress notes or elsewhere (eg a care plan) is sufficient. Telephone or electronic consultation with clear documentation of the information exchange is also regarded as a clinical consultation.”

1. Can you please further clarify other forms of ‘Clinical Consultation’ as mentioned in ACS 0002? Are the following forms of documentation also regarded as ‘Clinical Consultation’?
a. Medications prescribed on the medication chart by doctor with documentation of the condition and treatment in the same nursing progress note. For example, a nurse documents stat dose of magnesium for Mg 0.65 in the progress notes, test results verify that Mg 0.65 is abnormal and the doctor has signed off on the magnesium order on the medication chart. “
b. Nursing documented “Doctor aware” in progress notes.

ACS 0002 also states the following:
For the purposes of classification, a clinical consultation refers to documentation provided by the:
• treating clinician/team who is primarily responsible for managing a patient's condition during the episode of care
• specialist who provides advice/opinion, to the referring clinician/team, regarding a patient's management
• nurses, midwives and allied health professionals who are engaged in a patient's management within their scope of practice.

2. Can you please further clarify if the following conditions documented by a Dietitian are within a Dietetics scope of practice? 
a. Electrolyte imbalances. For example, a Dietitian documents in progress notes or Dietitian Assessment form Mg 0.65 or (down arrow)Mg0.65 with a plan to replace Magnesium in the same note and test results verify that Mg 0.65 is abnormal. Magnesium is signed off on the medication chart.
b. Dietitian documents Neutropenia with a plan for Neutropenic diet.
c. Dietitian documents Hypoalbuminaemia with a plan to replace Albumin.

Response:
For scenario 1a, VICC advises that medication prescribed on the medication chart by a doctor is considered clinical consultation, in response to the nurse’s documentation of “stat dose magnesium for abnormal mg of 0.65”.

As well as the clinical consultation, code assignment must be based on meeting one of the three criteria in ACS 0002 Additional diagnoses. 

Therefore, in addition to the clinical consultation, the coding of hypomagnesaemia is based on the administration of therapeutic treatment as per dot point one of ACS 0002 Additional diagnoses. This is in accordance with example three of Eleventh Edition ICD-10-AM/ACHI/ACS Victorian education and ACE Coding Rule TN1035 Low magnesium, which instructs to follow the lead term Hypomagnesaemia to assign E83.4 Disorders of magnesium metabolism, for low magnesium without further specification.

For scenario 1b, VICC does not consider the nurse's documentation of 'doctor aware' alone is clear evidence of clinical consultation. Therefore the criteria in ACS 0002 Additional diagnoses is not met for the purpose of code assignment. 

For the examples in scenario 2, VICC considers  if a clinician has documented a condition, coders should trust that the clinician has documented appropriately to their scope of practice. See also VICC query #3290 titled VICC query #2752 Coding from nursing documentation.


Query Title:
ACS 0010 Clinical documentation and general abstraction guidelines documented descriptions

Query Text:
ACS 0010 Clinical documentation and general abstraction guidelines states the following:
Do not use test result values, descriptions, medication charts, symbols and abbreviations in isolation to inform code assignment. For example:
• a documented description (eg low blood sugar level) does not necessarily mean that the patient has a particular condition (eg hypoglycaemia).

If the documentation does not sufficiently describe a disease/condition, clinical coders should clarify the significance of the documented shorthand (test result, values, abbreviations and symbols) with the clinician to inform accurate code assignment.
Where this is not possible, assign a code for the condition represented in shorthand (as described above) only if:
• test results (pathology report) verify that a result is abnormal AND
• there is appropriate ICD-10-AM indexing AND
• it meets the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.

1. While following the above guidelines in ACS 0010, can we code hypotension from the “documented description” in the following scenario?

Doctor documents “low BP” or “(down arrow) BP” with a plan to withhold their antihypertensive medications. Antihypertensive medications are withheld on the medication chart.

We have noted the following:
• There is no pathology report that can verify the BP result is abnormal
• There is an appropriate index for low, blood pressure (see also hypotension) I95.9
• ACS 0010 states “If the ICD-10-AM Alphabetic Index does not provide appropriate indexing, or there is uncertainty or ambiguity in relation to abbreviated forms or descriptions in the documentation, confirm with the clinician prior to code assignment.”
• ACS 0010 states “low blood sugar level” does not necessarily mean that the patient has hypoglycaemia

Response:
VICC notes that a blood pressure (BP) reading is a test result and therefore when there is documentation of “(down arrow) BP”, the following advice in ACS 0010 Clinical documentation and general abstraction guidelines under section Test results and medication charts should be applied: 

'…assign a code for the condition represented in shorthand…only if:

• test results (pathology report) verify that a result is abnormal AND 
• there is appropriate ICD-10-AM indexing AND 
• it meets the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses'

For documentation of 'Low BP', for which the medication has been withheld, VICC considers the Index entry Low/  blood pressure (see also Hypotension) should be followed and the default code I95.9 Hypotension, unspecified assigned.

VICC acknowledges the sentence in ACS 0010 Clinical documentation and general abstraction guidelines section titled Test results and medication charts, which states 'Do not use test result values, descriptions, medication charts, symbols and abbreviations in isolation to inform code assignment' and considers that low blood sugar level has been provided as an example only in this section of the standard, where a documented description cannot be used in isolation to inform code assignment. 

As with all documented descriptions, refer to ACS 0002 Additional diagnoses to ensure the condition meets criteria for coding. Therefore for documentation of low blood sugar levels, provided the criteria in ACS 0002 Additional diagnoses has been met, follow Index entry Sugar/blood/low to assign E16.2 Hypoglycaemia, unspecified.


Query Text:
ACS 0010 Clinical documentation and general abstraction guidelines states we are unable to code resistance to an antibiotic documented solely on a discharge summary including that by copy and paste from the pathology system, it must be documented in the body of the record. 

Could VICC please clarify whether coders are able to send a query to a clinician to confirm drug resistance to organisms if it’s only documented on the discharge summary and not documented in the body of the notes? 

Given this is just getting the clinician to document something that is directly copied by the pathology system, could VICC also clarify whether we are able to query a clinician to confirm resistance if it is only documented on the pathology results within the pathology system and not within the body of the record at all (i.e. including being absent from the discharge summary)?

Search Details
ACS 0010
VICC Query 3240

Response:
In answer to the first question, VICC considers that it is appropriate to submit a query to confirm drug resistance to organisms if the only documentation is on the discharge summary. This is in accordance with ACS 0010 Clinical documentation and general abstraction guidelines, section titled Guidelines for generating appropriate queries to clinicians, which states:

'When a diagnosis or test result is recorded on the front sheet and/or discharge summary (or equivalent) for which there is no supporting documentation in the body of the current episode of care (including documentation/information contained within other systems pertaining to the current episode of care), it may be necessary to consult with the clinician before assigning a code. For example, documentation of the administration of a drug from the medication chart, or a microbiology test result which is not qualified within the current episode of care, is not sufficient for clinical coders to perform the classification function. In these instances, documentation issues must be clarified with the clinician'.

In answer to the second question, VICC considers that it is appropriate to query the resistance, when it is only documented on the pathology result, provided an infection and associated organism is documented as per ACS 0112 Infection with drug resistant microorganisms, and the infection meets ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.


Query Text:
We ask VICC to please advise how to apply ACS 0002 Additional diagnoses to the following scenario:

Nurse documents magnesium level of 0.65 (confirmed to be abnormal on test results) within a progress note entry. Immediately following this statement, a stat dose of magnesium has been noted as being administered. Doctor has signed off on the magnesium stat dose order on the medication chart.

No written consultation with doctor has been documented, however the doctor has signed off this specific medication to be administered.

The above scenario logic applies to multiple different medications, to treat various condition. We would not like to limit this question to electrolyte treatment only. 

If the doctor has signed off on the medication, can this be interpreted as the condition requiring further assessment by a clinician and a care plan has been prescribed in the absence of a written clinical consultation?

Response:
VICC advises that medication prescribed on the medication chart by a doctor is considered a clinical consultation in response to the nurses documentation of stat dose magnesium (for) abnormal mg of 0.65. This logic may be applied to scenarios other than those for the treatment of electrolyte imbalances.

In the scenario cited, VICC considers the low magnesium can be coded based on ACS 0002 Additional Diagnoses, dot point one; Commencement, alteration or adjustment of therapeutic treatment.

VICC acknowledges there is no index entry for low magnesium, using lead term Low, however as per ACE Coding Rule TN1035 Low magnesium, follow the lead term Hypomagnesaemia to assign E83.4 Disorders of magnesium metabolism.


Query Text:
Elective admission for removal of left DIEP flap due to fat necrosis of left breast. There is no ACHI Index entry for removal of DIEP flap. Clinical advice has clarified that the most appropriate code is excision of soft tissue.

Can the VICC please advise whether they agree with this code as a best fit?

Search Details
VICC # 3067 Coding convention for procedures

Response:
VICC research indicates that a DIEP flap is a type of breast reconstruction in which blood vessels called deep inferior epigastric perforators (DIEP), as well as the skin and fat connected to them, are removed from the lower abdomen and transferred to the chest to reconstruct a breast after mastectomy.

Histopathology received for the case cited showed fibrofatty tissue had been excised for removal of the DIEP flap. Therefore, VICC agrees to assign code 90575-00 [1566] Excision of soft tissue, not elsewhere classified following Index entry Excision/ soft tissue NEC.


Query Title:
Electrohydraulic lithotripsy (EHL) of gallstone impacted at pyloric /duodenal junction

Query Text:
Patient admitted with gastric outlet obstruction secondary to migrated / impacted gallstone and underwent gastroscopy with attempted lithotripsy / extraction of calculus.

Gastroscopy procedural note:
Stomach - large gallstone impacted at pylorus / D1 junction. Attempted EHL / lithotripsy to break up stone incomplete … attempted balloon and basket extraction with big force … still won’t budge. NG left in situ for drainage. 
Duodenum – unable to pass obstruction.

There is no ACHI procedure code for EHL/ lithotripsy/ destruction of calculus at pylorus or duodenum.

Can the VICC please advise the most appropriate procedure code?

Search Details
VICC 3067 Coding conventions for procedures

Response:
VICC considers that as there is no code for lithotripsy/destruction of calculus of pylorus or duodenum not performed by extracorporeal shockwave lithotripsy (EWSL), only a code for the gastroscopy can be assigned. This is in accordance with the fourth dot point of ACS 0019 Intervention abandoned, interrupted or not completed. 

Z53.3 Procedure abandoned after initiation can also be assigned to identify the lithotripsy was started but not completed.

VICC suggests submitting a public submission to IHPA for addition of codes for lithotripsy not performed by EWSL.


Query Title:
ACS 0002 – Documented plan for routine care

Query Text:
In ACS 0002 example 11 the patient was advised by a nurse to drink more fluids as slightly hypotensive. In this example, the hypotension was not a significant condition in the episode of care, as the patient was only advised to drink more fluids; therefore it does not meet the criteria in ACS 0002.

If, following clinical consultation, a doctor documents a plan which would be considered routine care such as ‘encourage oral fluids’ would the condition still be considered clinically significant thus meeting the criteria in ACS 0002?

For example
Progress note
ATSP re ↓ BP
- BP 95/65 ATOR
- SOB comfortable
- Nil symptoms
- Drinking ++, IL jug this AM
- Feels well, nil dizziness
- TOV at 10:30 am
- Nil urine passed yet
- Not uncomfortable
Plan 1. Encourage oral fluids
2. Monitor TOV & urine

Discharge Summary
#Elective laparoscopic right hemicolectomy
-recovered well
-passed TOV
-discharged home

#Hypotension
-low BP at times throughout admission: asymptomatic
-Treated with oral fluids
-for GP R/V in 1 week please to ensure return to usual BP

If this example, does hypotension meet criteria for coding in ACS 0002 as the condition has been documented following clinical consultation and there is a prescribed plan of care?

Would the answer be different if the clinical consultation was not specifically for the hypotension (eg. hypotension noted during consultation for another condition with plan for oral fluids)?



Search Details
ACS 0002 Additional diagnoses examples 2, 3 and 11

VAHI Eleventh Edition Victorian education ACS 0002 Additional diagnoses

Response:
When considering whether a condition meets ACS 0002 Additional diagnoses, one of the following three criteria must be met:

• commencement, alteration or adjustment of therapeutic treatment 
• diagnostic procedures 
• increased clinical care

In example eleven of ACS 0002 Additional Diagnoses, drinking more fluids is not considered therapeutic treatment and there was no care plan or diagnostic procedure performed. However, in the case cited, VICC considers the hypotension meets ACS 0002 Additional diagnoses, as there was a clinical consultation, with documentation of a clinical assessment and a diagnosis and care plan for the condition. Therefore the criteria in dot point three of ACS 0002 Additional Diagnoses section titled Increased clinical care is met .

In answer to the final question, VICC considers that regardless of the reason the clinical consultation was initiated, there needs to be clear evidence that there was a clinical assessment completed for the documented diagnosis, in addition to a plan of care for the condition.


Query Title:
Same morphology code twice for different neoplasm site codes

Query Text:
I refer to VICC query 3151 Skin Lesions about how the same morphology code M8070/3 can be assigned twice for two different codes from the C44 block. Is this advice still current? 

And should we be applying this advice for example to other types of neoplasms such as tubular adenomas in different sites of the colon? For example: a patient has tubular adenomas in the descending and ascending colon – should we assign the morphology code M8211/0 once or twice? In 3M if you assign two different neoplasm side codes that both have the same morphology, the morphology code only appears once.

Response:
VICC notes that the intent of VICC #3151 Skin Lesions was not to imply that coders should assign the same morphology code more than once, but rather to illustrate the morphology codes associated with each site, in that scenario.

For the case cited, only one morphology code should be assigned for the tubular adenomas of the descending and ascending colon.


Query Title:
Myelodysplastic Syndrome 5q Minus Syndrome and anaemia

Query Text:
Principal Diagnosis: Myelodysplastic Syndrome
Presenting Complaint: Anaemia for blood transfusion
The myelodysplasia is further specified as deletion 5q which codes to D46.6 Myelodysplastic Syndrome with isolated del (5q) chromosomal abnormality.

Information provided on the leukaemia.org.au website advises deletion 5q MDS is very rare and can cause refractory anaemia, refractory thrombocytopaenia and refractory neutropaenia.

There is no includes note for anaemia at code D46.6.

Can the committee please advise if anaemia should be an include for this code.

What is the principal diagnosis?
D46.6 MDS 5q or
D64.9 Anaemia unspecified

Search Details
https://www.leukaemia.org.au/disease-information/myelodysplastic-syndromes/types-mds/mds-deletion-5q/

Response:
Clinical advice obtained by VICC indicates that anaemia is regarded as a symptom of myelodysplastic syndrome (MDS).

VICC considers where anaemia without further specification is documented with any type of MDS, an additional code for the anaemia is not required.

VICC acknowledges there is no includes note for anaemia at code D46.6 Myelodysplastic syndrome with isolated del (5q) chromosomal abnormality and suggests you may wish to submit a public submission to IHPA asking for consideration of the addition of an includes note at D46.6.


Query Text:
Can VICC please provide clarification on the coding of atrial septal defect (ASD) balloon sizing undertaken as a separate procedure during a full heart study/coronary angiography?

Our clinicians have advised that the balloon sizing of the atrial septal defect was not a procedural component of the full heart study/cardiac catheterization. 

Could VICC please advise the correct ACHI code for atrial septal defect balloon sizing?

Response:
VICC research indicates that atrial septal balloon sizing is an assessment of the size of the device required for ASD repair, so as not to oversize the ASD. Clinical advice received from the enquirer indicates balloon sizing of the atrial septal defect is not a procedural component of the full heart study/cardiac catheterisation.

In the case cited, this was performed as a catheter based technique. As there is no ACHI procedure code to distinguish this technique, only a code for the angiography/catheterisation can be assigned. This is in accordance with the logic in ACE Coding Rule Q2679 Coronary Optical Coherence Tomography (OCT) and Intravascular ultrasound (IVUS).

You may wish to submit a public submission to IHPA suggesting the creation of a code.


Query Text:
VICC #3045 Anaemia and myelofibrosis queries code assignment for a patient receiving packed red blood cells with a documented diagnosis of myelofibrosis, and anaemia listed as a ‘presenting complaint.’ The query advises to only assign a code for the myelofibrosis ‘based on the information provided.’

Can VICC please clarify if the advice to code only the myelofibrosis is specific to the documentation in the query, or if this applies to all cases of anaemia with myelofibrosis? For a patient given packed red blood cells for an additional diagnosis of ‘anaemia secondary to myelofibrosis’, can ACS0002 Additional diagnoses/Problems and underlying conditions be applied to assign codes for both the anaemia and myelofibrosis?

We note there is no includes note for anaemia on D47.4 Osteomyelofibrosis.

Response:
VICC notes that in VICC #3045 Anaemia and myelofibrosis, the final diagnosis was documented as myelofibrosis, therefore the advice is specific to the documentation in that query and should not be applied to all cases of myelofibrosis with anaemia. The advice published was not intended to convey that anaemia would never be coded in these cases.

As per ACS 0001 Principal diagnosis, for cases of myelofibrosis with anaemia, code assignment is based on the documentation within each individual episode of care. VICC acknowledges this may result in a variation of the principal diagnosis selection.

For documentation of an additional diagnosis of 'packed cells given for anaemia secondary to myelofibrosis' follow ACS 0002 Additional diagnoses, section titled Problems and underlying conditions and assign a code for both conditions.


Query Text:
A patient with relapsed B cell Acute Lymphoblastic Leukaemia was admitted for Blinatumomab. Day 1 following infusion pt had MET call for hypotension, tachycardia and being febrile. This has been documented as a "presumed drug induced inflammatory response" with discharge summary calling it "cytokine release syndrome". Our haematologist has advised this is an adverse drug reaction to monoclonal antibodies, such as Blinatumomab and Moxetumomab and described it a form of systemic inflammatory response. She said it will become more common with increasing use of these drugs.

We have coded this to:
R65.2 Systemic inflammatory response, non infectious
and added a code to identify the drug Blinatumomab, a type of immunotherapy.

As there is no index entry for "cytokine release syndrome", would you please advise if this is correct. Should we also add U91 code to identify the syndrome component of the diagnosis?

Search Details
Google - "cytokine release syndrome" AKA an infusion reaction, is a form of systemic inflammatory response syndrome that is an adverse effect of some monoclonal antibody drugs". Also, "a condition that may occur after treatment with some types of immunotherapy, such as monoclonal antibodies"

Response:
For documentation of cytokine release syndrome, VICC advises to follow ACS 0005 Sydromes. As there is no one code for this syndrome assign codes for the manifestations as per ACS 0001 Principal diagnosis and ACS 0002 Additional diagnoses, followed by the external cause codes to identify the drug and U91 Syndrome, not elsewhere classified. 

As there is no documentation of systemic inflammatory response syndrome (SIRS), a code from category R65 Systemic inflammatory response syndrome [SIRS] cannot be assigned.


Query Text:
Patient with acute promyelocytic leukaemia admitted for chemotherapy. Treated with Tretinoin and arsenic, following which he developed hypertension, pulmonary infilatates, respiratory distress, fever and tachycardia. The diagnosis for this was "differentiation syndrome secondary to treatment with tretinoin". Our haematologist has described this as being like a systemic inflammatory response.

NCI Dictionary of Cancer Terms describes it as "a serious side effect that may occur in patients with acute promyelocytic leukaemia or other types of acute myeloid leukaemia who have been treated with certain types of drugs". It is caused by a large, rapid release of inflammatory cytokines (immune substances) from leukaemia cells that are affected by the anticancer cells. It is also known as ATRA syndrome.

Would this be coded as:
R65.2 inflammatory response syndrome
with addition of code to identify the causative drug?
Would U91 be added to identify the syndrome part of the diagnostic statement?

Response:
For documentation of differentiation syndrome, VICC advises to follow ACS 0005 Syndromes. As there is no one code for this syndrome, assign codes for the manifestations as per ACS 0001 Principal diagnosis and ACS 0002 Additional diagnoses, followed by the external cause codes to identify the drug and U91 Syndrome, not elsewhere classified. 

As there is no documentation of systemic inflammatory response syndrome (SIRS), a code from category R65 Systemic inflammatory response syndrome [SIRS] cannot be assigned.


Query Text:
How should a single non-traumatic intracerebral haemorrhage with extension into multiple sites be coded? 

For example, a large right parieto-occipital lobar haemorrhage with extension into the subdural & subarachnoid spaces and both lateral ventricles.

Response:
VICC advises that in accordance with ACS 0605 Stroke extension, each extension site should be coded as another stroke (cerebral haemorrhage).

A code for each extension site should be assigned when there is documentation of extension into multiple sites.


Query Title:
ACS 0002 Additional diagnoses and discharge medication

Query Text:
This patient was admitted with a traumatic subdural haematoma following a fall with headstrike. On the day of discharge U&Es were performed which showed potassium 3.1 mmol/L.

The discharge summary records the following:
# Hypokalaemia 
– likely in the setting of poor oral intake whilst in hospital
- Prescribed Slow K and for GP to repeat U&Es in 3-4 days (slip given)
The discharge prescription confirms that the patient was discharged with a course of Slow K.

We note the following in ACS 0002 Additional diagnoses:

However, where these findings or conditions are incidental to the episode of care and are only flagged for follow-up or referral post discharge they do not qualify for code assignment under ACS 0002 Additional diagnoses.

As per this instruction, the request for the GP to repeat U&Es does not qualify the hypokalaemia to be coded under ACS 0002 Additional diagnoses.

However, the patient was not only referred to the GP for follow up, they were also provided with the medication to treat the hypokalaemia. 

Can the committee please advise whether hypokalaemia should be coded in this scenario?

Does the provision of discharge medication (or a discharge prescription) for a documented condition qualify the condition for code assignment under ACS 0002 Additional diagnoses?

Response:
VICC notes in the scenario cited, hypokalaemia is documented on the discharge summary. As per ACS 0010 Clinical documentation and general abstraction guidelines, 'before classifying any documented clinical concept the clinical coder must verify the information on the front sheet and or the discharge summary (or equivalent) by reviewing pertinent documents/data within the body of the current episode of care'.

If the hypokalaemia is verified, VICC considers the hypokalaemia meets ACS 0002 Additional diagnoses dot point three; Increased clinical care, as a clinical consultation was provided for the condition with documentation of a clinical assessment (provision of a discharge prescription) and a diagnosis (hypokalaemia) and a care plan for the condition (repeat U&Es and prescription of slow K). 

VICC does not consider the section titled Incidental findings and conditions in ACS 0002 Additional diagnoses applicable in this scenario, as this section of the standard refers to findings or conditions that are only flagged for follow-up or referral post discharge.


Query Title:
Hypokalaemia - pathology result within the normal range

Query Text:
I recently encountered the following documentation in the ward round notes of an admission.

Cardiology: patient able to mobilise and shower; replace K+ for hypokalaemia (3.8). Aim home Sun/Mon.

The medication chart confirms that the patient was commenced on Chlorvescent (signed by doctor). 
The normal range for potassium levels as per the pathology provider is 3.5 – 5.0 mmol/L.
As such, the potassium level for this patient falls within the normal range; yet a diagnosis of hypokalaemia was made by the doctor.

Can the committee please advise whether a code for hypokalaemia should be assigned in cases such as these?

Would this advice also apply to other electrolyte disturbances or blood disorders (e.g. anaemia) where the doctor makes a diagnosis, yet the lab result for the condition falls within the normal range?

Response:
VICC advises that test results are not required to verify a documented diagnosis by a clinician. 

Therefore in the scenario cited, hypokalaemia is coded based on the doctor’s diagnosis and ACS 0002 Additional diagnoses dot point one; commencement, alteration or adjustment of therapeutic treatment, as the patient has been commenced on Chlorvescent for treatment of hypokalaemia.


Query Text:
A patient presented to our hospital for a surgical procedure.
After the procedure she was diagnosed with Streptococcus pneumoniae bacteraemia and was treated with intravenous antibiotics.

Following the documented terms:
Index: Bacteraemia (see also Infection/by type), Infection, Streptococcus, pneumoniae (pneumococcus)- B95.3

However, this code is assigned to add further specificity to an infection, not to actually classify a condition. See note at B95-B97: a code from these categories must be assigned if it provides more specificity about the infectious agent. 

There is an alternative index entry: Index: Bacteraemia (see also Infection/by type), Infection, Pneumococcus, pneumococcal NEC - A49.1

Can the committee please advise how Streptococcus pneumoniae bacteraemia should be coded?

Response:
VICC considers for documentation of Streptococcus pneumoniae bacteraemia, it is correct to assign two codes to identify both the condition and infectious agent. 

Therefore, VICC advises to assign A49.1 Streptococcal and enterococcal infection, unspecified site to identify the condition, following Index entry Bacteraemia (see also Infection/by type) Infection, infected (opportunistic)/Streptococcus, streptococcal NEC. B95.3 Streptococcus pneumoniae as the cause of diseases classified to other chapters, should also be assigned to further specify the infectious agent (pneumoniae). This is in accordance with the note at B95–B97 Bacterial, viral and other infectious agents, which instructs coders to assign a code from these categories if it provides more specificity about the infectious agent.

Note: This query has been superseded by IHPA Coding Rule Q3522 B95–B97 Bacterial, viral and other infectious agents, published 18 Dec 2020, for implementation 1 January 2021.


Query Text:
VICC query #3082 details how enucleation of a mandibular cyst should be coded.

Can this advice also be applied to enucleation of a maxillary cyst or a jaw cyst?

Response:
VICC advises that the advice in VICC #3082 Enucleation of mandibular cyst may be applied to enucleation of a maxillary cyst or jaw cyst. 

Therefore, unless histopathology indicates that the cyst is not of the bone, VICC advises to follow Index entries Excision/cyst - see also Excision/lesion(s) and Excision/lesion(s)/bone NEC to assign 30241-00 [1563] Excision of lesion of bone, not elsewhere classified for documentation of enucleation of maxillary cyst or jaw cyst.


Query Text:
A patient was admitted to this hospital for closure of an oro-antral communication. The oro-antral communication was closed using a buccal advancement flap. 

I note the following ACHI index entries:
Flap, advancement - see Flap/skin
Flap, buccinator - see Flap/myocutaneous
Flap, mouth 
Flap, mucosa, mucosal - see also Flap/skin
Flap, oronasal fistula

There is no ACHI index entry under flap for buccal.
We also note that in the ACHI Tabular Chapter 16, skin and subcutaneous tissue includes mucous membranes.

Can the committee please advise:
What code should be assigned for a buccal advancement flap for closure of an oro-antral communication?
What code should be assigned for a buccal flap/buccal advancement, not otherwise specified? (i.e. not used for closure of an oro-antral communication).

Response:
VICC considers oro-antral communication to be synonymous with oro-antral fistula, based on IHPA Coding Rule Q3344 Intraoperative oroantral fistula resulting from tooth removal, which defines oroantral fistula as “a persistent open communication”.

Therefore, for a buccal advancement flap for closure of an oro-antral communication, VICC advises to assign 41722-00 [388] Closure of oro-antral fistula only, following ACHI Index entry Closure/ fistula /oro-antral (closure) (plastic). 

For buccal flap or buccal advancement flap without further specification of the type or site, VICC advises that as the term buccal refers to the cheeks or mouth cavity, 45206-02 [1651] Local skin flap of lip should be assigned following ACHI Index entry Flap/skin (local) (single stage) NEC/mouth. Notwithstanding the code descriptor of ‘lip’ in the code title, VICC considers this the correct code to assign as per the Index entry and the includes note of ‘mouth’.


Query Title:
Infection due to suprapubic catheter (SPC)/cystostomy

Query Text:
What is the correct code to assign for infection due to a suprapubic catheter/cystostomy?

Infection/due to or resulting from/ device, implant or graft/catheter/urinary codes to T83.5 Infection and inflammatory reaction due to prosthetic device, implant and graft in urinary system.

Complication/cystostomy (catheter)(stoma)(tube)/infection codes to N99.52 Infection of stoma of urinary tract

T83.0 Mechanical complication of urinary (indwelling) catheter excludes complications of cystostomy (N99.5-), however there is no excludes note on T83.5 Infection and inflammatory reaction due to prosthetic device, implant and graft in urinary system.

Response:
VICC’s research indicates that cystostomy and suprapubic catheter (SPC) are synonymous terms and are considered a urinary stoma in ICD-10-AM. 

Therefore, VICC does not consider it is correct to follow Index entries Complication(s) (from) (of)/catheter (device) NEC/urinary (indwelling) – see Complication(s)/urethral catheter (indwelling) 
or Complication(s) (from) (of)/urethral catheter (indwelling) NEC/infection or inflammation T83.5 for documentation of infection due to suprapubic catheter (SPC)/cystostomy.

The correct code to assign is N99.52 Infection of stoma of urinary tract, following the Index entry Complication(s) (from) (of)/cystostomy (catheter) (stoma) (tube) NEC/infection. VICC notes that catheter, stoma and tube are non-essential modifiers at this Index entry. 

This is in accordance with ACS 1904 Procedural complications which states 'where a condition is not related to a prosthetic device, implant or graft and it is related to a body system, assign an appropriate code from the body system chapter' and is consistent with Example 13 in ACS 1904 Procedural complications where a gastrostomy tube is noted to be a digestive system stoma and not a prosthetic device, implant or graft.


Query Text:
We have been questioned by our Gen Medical, Gen Surgical and Haematology units re: queries pertaining to drug resistance. We have had many of these recently due to an audit team finding pathology evidence of drug resistance and then querying with the clinician to have it confirmed. The clinical heads of these units state that most organisms are resistant to all sorts of drugs and that, unless it is VRE or MRSA, the impact on care is minimal. If the organism is resistant to one drug, they simply and routinely select another.

ACS 0112 directs "if the clinician has documented in the record that the organism causing the infection is resistant to an antibiotic or other antimicrobial drugs, then the appropriate code from Z06 must be assigned as an additional code ...."

1. Would you please confirm that ACS 0112, being a specialty standard, overrides the requirements of:
- ACS 0002 (treated, diagnostic procedure, increased clinical care). The "diagnostic care" part of ACS 0002 mentions 'do not assign an additional diagnosis code based on the performance of routine tests alone such as routine ARO (antibiotic resistance organism) screening.' It is routine pathology practice that organisms causing infection are tested for drug resistance. Example 16 of ACS 0002 shows that MRSA meets ACS 0002 due to increased care
- ACS 0010, which mentions "unless the clinician can indicate that a test result is significant ...the result should not be coded.
2. Would you also please confirm that it is ethical and legitimate to query drug resistance when an infection has been appropriately documented in the record, the organism has been coded from the pathology as per ACS 0010 but the only mention of drug resistance is to be found on pathology reports?

Search Details
ACS 0002
ACS 0112
ACS 0010

Response:
Regarding question one, ACS 0112 Infection with drug resistant microorganisms does not override the requirements of ACS 0002 Additional diagnoses. Both standards must be used in conjunction with one another as documented in ACS 0112 Infection with drug resistant microorganisms, which states 'The presence of an infection (wound infection, urinary tract infection, pneumonia, etc) must be documented and coded in accordance with ACS 0002 Additional diagnoses before additional codes can be assigned for the organism, or the condition coded as being due to the organism'.

VICC notes example 16 from ACS 0002 Additional diagnoses is specific to a carrier status only and not in relation to an infection with a drug resistance.

For question two, VICC considers that it is appropriate to query the resistance, when it is only documented on the pathology result, provided an associated infection is documented as per ACS 0112 Infection with drug resistant microorganisms, and the infection meets ACS 0001 Principal Diagnosis or ACS 0002 Additional diagnoses.


Query Text:
We are clear on assigning codes for postprocedural pain when the pain is the reason for a pain service or associated consultation, and a plan for pain medication adjustment meets ACS 0002. However, we are unclear on when postprocedural pain meets ACS 0002, in terms of medication adjustment, when the treating or on-call team alters the pain medication regime with resolution of the pain. Often simple changes in a postprocedural pain management medication regime would be considered a “routine” occurrence.
Therefore, we are conflicted on whether the postprocedural pain meets ACS 002 in these scenarios, based on these points in:

ACS 1904 Routine postoperative care
Routine postoperative care includes:
• prescribing analgesic medication (eg. for pain in the operative site)
vs.
ACS 1904 Care beyond routine intraoperative/postoperative care
Care that is in excess of routine in the postoperative period (ie meeting the criteria in ACS 0002 Additional diagnoses) may include:
• consultation/treatment by a clinician resulting in a change of management

AND

ACS 0002 Additional diagnoses Increased Clinical Care
Conditions are significant in an episode of care when:
• receiving clinical consultation for a condition with documentation of:
o a clinical assessment, and
o a diagnosis, and
o a care plan for the condition…
• pre and postoperative management in excess of routine care (see also ACS 1904 Procedural complications) (see Examples 18 & 20)
Examples 18 and 20 in ACS 0002 are clear as not only has the treating team been consulted regarding the pain, but investigations were also undertaken. No further investigations are undertaken in our example below.

We acknowledge also that ACS 0002 states: “For the purposes of classification, a clinical consultation refers to documentation provided by the “treating clinician/team who is primarily responsible for managing a patient’s condition during the episode of care”. 
For Example: A single treating team or on-call clinician note with resolution of pain (at operative site) after plan carried out

ATSP: re right sided lower quadrant pain
Patient reporting sharp stabbing pain in right lower quadrant since this afternoon.
Worse on lying down. Reports has been drinking today. Not feeling otherwise unwell. Some nausea after taking tramadol
Day 1 post appendicectomy
O/E, Patient able to lie flat for examination, Abdomen not visibly distended, Abdomen soft throughout, pain on palpation in right lower quadrant, Nil guarding, Nil rigidity, Murphy's negative, Bowel sounds present
Obs stable, afebrile
Impression- likely post operative related pain
Plan: 1. Stat 5mg endone now, 2. To continue monitoring, page if further concerns, 3. Home team to review tomorrow


Search Details
ACS 0002 Additional diagnoses
ACS 1904 Postprocedural complications
VAHI Eleventh Edition ICD-10-AM/ACHI/ACS Victorian Education document

Response:
In order to assign the appropriate codes for procedural, postprocedural and intraoperative complications, ACS 0002 Additional diagnoses and ACS 1904 Procedural complications must be used in conjunction with one another and the criteria in both standards met.

ACS 0002 Additional diagnoses section titled Increased clinical care is specific to conditions where clinical care provided is beyond routine in nature. Whilst in the scenario cited, the patient received a clinical consultation with clinical assessment for a documented diagnosis and a plan of care, coders must note the final dot point in ACS 0002 Additional diagnoses section titled Increased clinical care, which instructs coders to see also ACS 1904 Procedural complications for pre and postoperative management in determining what is considered beyond routine care. 

ACS 1904 Procedural complications section titled Routine post operative care considers prescribing analgesic medication (eg for pain in the operative site) an example of routine postoperative care.

As there is no further evidence in the scenario cited that the condition received beyond routine intraoperative/postoperative care, VICC considers codes for postprocedural pain must not be assigned.


Query Text:
Many thanks for considering these issues for us.

Firstly:

1.Is the VAHI 11th Edition ICD-10-AM/ACHI/ACS Victorian Education document still to be used by Victorian Coders as a supplement to ACS 0002, since the release of Errata 3 amendments to ACS 0002 (for implementation 1st January 2020)?

If so, we would like clarification in regards to this particular point regarding the Increased Clinical Care section and condition significance; where the VAHI document differs slightly to the ACS 0002 update.

Conditions are significant in an episode of care when clinical care provided for a condition is beyond routine (i.e. increased clinical care). Examples of increased clinical care include: 

• providing care for a condition that is in excess of the routine care that would normally be provided by medical officer/nursing/allied health for that condition (e.g. documented evidence that the patient with dementia requires increased observation due to fluctuation in behaviour, cognition and physical condition) 
• receiving clinical consultation for a condition with documentation of a clinical assessment, a diagnostic statement, or a care plan for the condition (e.g. patient referral to an oncologist for cancer assessment with documentation of advice received; wound specialist/nurse assessment of pressure injury with documentation of staging of pressure injury and care plan). Note that a care plan may include an adjustment to, or continuation of, the current treatment plan, or transfer to another facility with documentation of the reason(s) for transfer 
• performance of a therapeutic intervention for a condition (e.g. dialysis for end-stage renal failure, pharmacotherapy for multiple sclerosis) 
• pre and postoperative management in excess of routine care (see also ACS 1904 Procedural complications) 
The sentence in the above point “receiving clinical consultation for a condition with documentation of assessment, a diagnostic statement OR a care plan for the condition”, implies a condition can be coded if it meets ANY of the criteria listed in the sentence (clinical assessment, a diagnosis, care plan).

However, the update to 0002 has been reworded, and though similar, the associated sentence here has been extrapolated out to dot-points that are followed by “AND”, implying that ALL three documentation points must be met (assessment + diagnosis+ care plan).

Conditions are significant in an episode of care when clinical care provided for a condition is beyond routine (i.e. increased clinical care). Examples of increased clinical care include:

•providing care for a condition that is in excess of the routine care that would normally be provided by medical officer/nursing/allied health for that condition (eg documented evidence that the patient with dementia requires increased observation due to fluctuation in behaviour, cognition and physical condition)
•receiving clinical consultation for a condition with documentation of:

o a clinical assessment, and 
o a diagnosis, and, 
o a care plan for the condition (eg patient referral to an oncologist for cancer assessment with documentation of advice received; wound specialist/nurse assessment of pressure injury with documentation of staging of pressure injury and care 

2.Should we apply the AND logic in the ACS 0002? Or for example, where there is consultation from another specialty or discipline, is this alone enough to meet criteria for Increased Clinical Care (assessment only)? 
Examples:

•Methadone dependent patient seen by APS with documentation of ‘usually on meth 25mg daily go back to normal meth dose in a few weeks (20mg)’ 
•Medical patient seen by Cardiology for PFO & atrial septal aneurysm with documentation of ‘no specific f/up’ next to PFO & atrial septal aneurysm.
•Medical patient with documentation of ATA occluded at fracture site on CTangio, Vascular aware will discuss at ORTH meeting. On 13/8 & 10/8 Vasc review of CTangio, ATA occludes, no further vascular intervention required.
•Patient reviewed by psych medical team for low blood pressure with Assessment/Plan 1. Given low fluid intake – encourage oral intake. 

3.Also, in regards to care plans, does there need to be evidence that the advice received or care plan has been carried out?

VAHI Examples 21 and 22 only state that there is a plan documented/formulated.Does there need to be documentation of OT and PT reviewing and monitoring chest and mobility (as per example 21), and documentation of the frequent checks being carried out as per example 22?

In example 24, the formulation and documented plan is for the exercises to be completed at home (for DRAM). There would not be documentation of the patient completing these exercises. This is a common scenario in short stay cases.




Episode Identification
945521 Discharge Date 23.7.19 (increase oral intake)

Search Details
VAHI 11th Edition ICD-10-AM/ACHI/ACS Victorian Education
ACS 0002 - Errata 3

Response:
Question 1 – VICC advises the Eleventh Edition ICD-10-AM/ACHI/ACS Victorian education document, effective 1 January 2020 has been updated to align with the amendments to ACS 0002 Additional diagnoses.

Question 2 – In order to meet ACS 0002 Additional diagnoses, Increased clinical care, a condition must receive a clinical consultation with documentation of all three of the following requirements: a clinical assessment and a diagnosis and an associated care plan, for the condition.

Question 3 – VICC acknowledges ACS 0002 Additional diagnoses is silent on scenarios where the documented care plan for a condition is not carried out. A query addressing this gap in the standard has been submitted to IHPA. In the interim, Victorian coders are advised to continue to follow the advice provided in the updated Eleventh Edition ICD-10-AM/ACHI/ACS Victorian education document, which instructs coders to assign a code for the condition, if the condition has received a clinical consultation with documentation of a clinical assessment and a diagnosis with an associated care plan, regardless if the care plan was carried out. Future amendments will be made to the advice in the Eleventh Edition ICD-10-AM/ACHI/ACS Victorian education document when IHPA advice becomes available.


Query Title:
Insertion of Malyugin ring during cataract extraction

Query Text:
In our cataract extraction via phacoemulsification operation reports (see attached), insertion of a Malyugin ring is often documented both within the body of the report, or in an “addition to routine surgery” section. Research and clinical advice indicates that the ring is introduced to enable better access in those with small pupils, floppy iris syndrome and other conditions. It is removed at the end of the surgery.

We note that insertion of iris hooks is an Includes note at Block 200 Extraction of crystalline lens, as is insertion of capsular tension rings at Block 193 Insertion of intraocular lens prosthesis. 

Our Ophthalmologist has advised the insertion of the ring is not routine and feels that 90076-00 [192] Other procedures on iris, is a “best-fit” code.

Should we code the insertion of such rings in addition to the cataract extraction, and if so, is the code we have provided appropriate?


Search Details
https://www.reviewofophthalmology.com/article/four-new-ways-to-manage-small-pupils
https://www.escrs.org/publications/eurotimes/13april/the-malyugin-ring.pdf
https://timroot.com/malyugin-ring/

Response:
VICC agrees with the clinical research in the query cited. A Malyugin ring was developed as a safe alternative to traditional pupil expansion techniques and provides the room needed for a surgeon to complete phacoemulsification and fragment removal in patients with small pupils.

Whilst this expansion technique is not routine for all cataract extractions via phacoemulsification, it is routine in cases for patients with small pupils.

VICC therefore considers insertion of Malyugin ring a component of a cataract extraction via phacoemulsifcation and as per ACS 0016 General procedure guidelines, section titled Procedure components an additional ACHI code is not required to capture this expansion technique.


Query Title:
IHPA Clarification of code assignment for procedures assisting delivery

Query Text:
IHPA Coding Rule P462 states that when O83 Other assisted single delivery or O84.81 Multiple delivery, all assisted, not elsewhere classified are assigned this MUST be followed by a procedure code indicating the relevant procedure code. 

For late term abortions we code:
O04.9 Medical abortion, complete or unspecified, without complication
O09.3 Duration of pregnancy 20–25 completed weeks 
O83 Other assisted single delivery
O60.3 Preterm delivery without spontaneous labour
Z37.1 Single stillbirth
90461-00 [1330] Intra-amniotic injection
35643-03 [1265] Dilation and evacuation of uterus
92515-x9 [1910] Sedatiion

If I do not assign O83 Other assisted single delivery, I get an error message as statutory reporting is also seeking a procedure code. In this instance wouldn't the Dilation and evacuation be the way the stillborn was delivered?

Response:
In accordance with ACS 1505 Delivery and delivery codes and IHPA Coding Rule P462 Clarification of code assignment for procedures assisting delivery, when O83 Other assisted single delivery or O84.81 Multiple delivery, all assisted, not elsewhere classified are assigned, one of the following ACHI codes must be assigned: 90470-01 [1339] Assisted breech delivery OR 90470-03 [1339] Breech extraction OR 90477-01 [1343] Assisted vertex delivery’. 

Therefore, as O83 Other assisted single delivery has been assigned in the scenario cited, one of the above ACHI delivery codes must be assigned. 

VICC considers the appropriate delivery code for the scenario cited to be 90477-01 [1343] Assisted vertex delivery, followed by the ACHI code for the dilataton and evacuation 35643-03 [1265] Dilation and evacuation of uterus. 

You may wish to submit a public submission for IHPA to consider amending ACS 1505 Delivery and assisted delivery codes to address these types of scenario.


Query Text:
Patient admitted with hereditary angioedema and was treated with a Berinert infusion. The infusion was administered intravenously and documented on a blood prescription transfusion form. 

Internet research indicates Berinert is a complement esterase inhibitor, a man-made form of a naturally occurring protein in the blood.

It is unclear whether the infusion should be coded as a transfusion of a blood product or an intravenous pharmalogical infusion. 

Could VICC please advise:
1. What procedure code should be used for the Berinert infusion?

Response:
VICC agrees with the research cited in the query, that Berinert is a complement C1 esterase inhibitor, which is derived from pooled human plasma. Berinert is included in a national government list of blood products (see  https://www.blood.gov.au/national-product-list).

Therefore, for a Berinert infusion assign 92062-00 [1893] Administration of other serum, following Index entry Administration/type of agent/plasma.


Query Title:
Previously symptomatic patient, now asymptomatic on presentation, confirmed COVID-19 episode

Query Text:
Our organisation is receiving patients transferred from interstate treatment areas (in cruise ship docking locations for example), that were clinically symptomatic and tested positive for COVID-19 at the transferring service. 
They are then transferred to our service directly as we are the treatment centre in their home state/area. They are asymptomatic on arrival and do not develop symptoms/manifestations during their stay.
We are assuming the VAHI and IHPA coding directives are to assist in clearly delineating symptomatic (at any stage) vs. true asymptomatic COVID-19 cases (that never progress to a symptomatic state in the admitted patient)? 
Therefore, would we follow the logic in Presentation Scenario 1:
Symptoms = Yes, Confirmed Case, and assign any clinically verified symptoms from the transferring service + B97.2 + U07.1
OR
As the patients are not symptomatic at our service, should we follow the 3rd Presentation Scenario:
Symptoms = No, Exposure = Yes, Confirmed Case. Assign B34.2 and U07.1.
Can you please advise on the coding scenario logic we should apply in these cases?


Search Details
VAHI - COVID-19 scenarios in admitted patient care
IHPA - Coronavirus disease 2019 - Updated 20.3.20

Response:
VICC referred this query along with several other Victorian queries to IHPA for advice.  IHPA has advised that the query submissions have been considered in the publication for COVID-19 Frequently asked questions (FAQs) - admitted care part 3. Queries that are frequently asked or appear to be common to the majority of jurisdictions are progressed for publication. IHPA also advised that the IHPA website ‘How to classify COVID-19’ remains the primary source of information on how to classify COVID-19. 

In response to this query, VICC advises that in accordance with COVID-19 Frequently asked questions - admitted care part 3,  as in the scenario cited, the patient is asymptomatic on admission and remains so during the entire episode, VICC advises to follow the IHPA Supplementary guidelines for classifying COVID-19 scenarios in admitted patient care, Symptoms = No, Exposure = Yes to assign:
B34.2 Coronavirus infection, unspecified site as principal diagnosis and 
U07.1 Emergency use of U07.1 [COVID-19, virus identified].


Query Text:
Please provide further advice RE: the coding of suspected COVID-19 cases ruled out. Are these codes only to be used when there is clear documentation of "suspected Covid" or simply when a patient has any symptoms of the virus and is tested as a precaution?

Search Details
March 27 Coding Rule published 7/02/2020 on COVID 19 - Where suspected COVID-19 is documented with symptoms

Response:
VICC referred this query along with several other Victorian queries to IHPA for advice.  IHPA has advised that the query submissions have been considered in the publication for COVID-19 Frequently Asked Questions (FAQs) admitted care part 3. Queries that are frequently asked or appear to be common to the majority of jurisdictions are progressed for publication. IHPA also advised that the IHPA website ‘How to classify  COVID-19’ remains the primary source of information on how to classify COVID-19.

VICC advises that the documentation must support that COVID-19 was suspected and ruled out in order for Z03.8 Observation for other suspected diseases and conditions or Z03.71 Observation of newborn for suspected infectious condition to be assigned, along with U06.0 Emergency use of U06.0 [COVID-19, ruled out].

For example, documentation of ‘Fever, for COVID swab’ would be sufficient to support the addition of Z03.8 Observation for other suspected diseases and conditions or Z03.71 Observation of newborn for suspected infectious condition as a link between the symptom and the plan to perform a test is documented.

Note that from 1 January 2020, IHPA made an exception to ACS 0012 Suspected conditions to identify symptomatic presentations where COVID-19 has been suspected but then ruled out.

Also note that as per Frequently asked questions – admitted care part 1 do not assign U06.0 Emergency use of U06.0 [COVID-19, ruled out] where COVID-19 is clinically ruled out alone (i.e. not verified by a negative laboratory test result for SARS-CoV-2).


Query Title:
Oesophageal varices and chronic incurable diseases

Query Text:
Can VICC please advise if oesophageal varices are considered a chronic and incurable condition, even if healed or previously treated? 

We need to know this in order to make a decision as to how to apply ACS 0052 Same-day Endoscopy – Surveillance and the VICC document, Same-day endoscopy – which Australian Coding Standard do I follow (Follow-up vs. Screening sections), in regards to assigning principal diagnosis? 

Literature review and advice supports that oesophageal varices can be treated and eradicated, but also that patients with certain clinical markers, will go on to have variceal recurrence. Also, that true eradication can only occur with resolution of the underlying portal hypertension/liver disease by liver transplant etc. This is also supported by advice that suggests banding treats variceal bleeding but does not remove the varices. We often see varices are still present on screening, but do not require treatment.
Common scenario:
Surveillance/screening of oesophageal varices documented as the Indication on gastroscopy report (no discharge summary), with a past history of oesophageal varices and underlying liver disease. 
Conclusion/body of scope report documentation such as “no residual varices seen” or “successful eradication with scarring consistent with previous banding”. No interventions undertaken.

• Do we assign I98.2 as PDx, as per ACS 0052, Classification dot-point 1:
“the pre-existing condition under survellance (including chronic incurable conditions)”? i.e the varices are pre-existing and considered a chronic incurable condition. Such as with Barrett’s oesophagus in ACS 0052, Example 8.
OR
• Assign the underlying liver disease as PDx, as per ACS 0052, Classification dot-point 1 above? i.e. the varices are not a chronic incurable condition but the underlying liver disease is. As per Example 9 in ACS 0052.
OR
• Do we assign Z09.X as PDx, as per ACS 0052, Classification dot-point 3:
“an appropriate code from categories Z08 or Z09 Follow-up examination after treatment for... if the condition under surveillance has been previously treated and no recurrence or residual condition is detected”? i.e. the varices are not a chronic incurable condition and were not seen, therefore, this is considered follow-up of the varices alone (not the underlying CLD). As per Example 2 in ACS 0052.

ACS 0052 Example 9 does not reflect our example completely, as there is no mention of the patient ever having varices previously.

Response:
Clinical advice obtained by VICC confirms that varices are not considered to be an incurable condition as oesophageal varices can resolve, however the underlying cause such as liver cirrhosis or chronic liver disease, are considered to be incurable conditions. 

For the scenario cited, the liver disease has been identified as the underlying cause of the oesophageal varices. As the varices were not found, VICC advises to assign a code for the underlying liver disease as the principal diagnosis. This is in accordance with ACS 0052 Same-day endoscopy – surveillance, which classifies endoscopic surveillance as screening of other diseases and pre-cursors (risk factors) (eg liver cirrhosis as a risk factor for gastro-oesophageal varices) and instructs coders to assign as principal diagnosis the pre-existing condition under surveillance (including chronic incurable conditions). This is highlighted in Example 9 which instructs coders to assign a code for the liver cirrhosis when no varices were found at endoscopy. 
 


Query Title:
Lymphatic Malformation and Venous Malformation

Query Text:
Can VICC please advise on the correct code for a lymphatic malformation and a venous malformation?

Our research indicates that these are a type of vascular malformation.

Is the correct code, Q27.9 Congenital malformation of peripheral vascular system, unspecified?

Following index:
Malformation (congenital) – see also Anomaly
Anomaly
- Vascular NEC Q27.9

Response:
VICC sought clinical advice which supports the enquirer’s research that venous and lymphatic malformations are both considered vascular malformations, as venous and lymphatic systems are both part of the circulatory system. 

Therefore VICC considers it correct to assign Q27.9 Congenital malformation of peripheral vascular system, unspecified following Index entry Anomaly,anomalous/vascular NEC.


Query Text:
A patient was admitted to our hospital for microlaryngoscopy and biopsy of left vocal cord for Reinke’s oedema. 

There is no index entry for Reinke’s oedema.
Our research indicates that Reinke’s oedema occurs where the surface of the vocal folds fill with fluid, becoming swollen and distended. The vocal cords are located within the larynx.

Index: Oedema, oedematous, larynx (see also Oedema/glottis) J38.4 Oedema of larynx
Index: Oedema, oedematous R60.9 Oedema unspecified

It does not seem logical to assign R60.9 Oedema unspecified for Reinke’s oedema, when Reinke’s oedema is a condition specific to the larynx.

Can the committee please advise what code to assign for Reinke’s oedema?

Response:
VICC research indicates that Reinke’s space is immediately inferior to the mucosal squamous layer of the vocal cords and it is this space that allows the vocal cords to have vibratory movement. 

As Reinke’s space is not part of the vocal cord/ fold itself, VICC considers this space to be part of the larynx. Therefore, for documentation of Reinke’s oedema assign J38.4 Oedema of larynx, following Index entry Oedema, oedematous/ larynx (see also Oedema/glottis).


Query Text:
Under lead term ‘anastomosis’ in the ACHI Index, there does not appear to be any modifier for ‘lymphovenous’. There are options for lymphatic (channel) (peripheral) and also for vein. 

We note IHPA Coding Rule Q3049 Vascularised Lymph Node Transfer. 

Could VICC please advise the correct ACHI Index pathway to follow and code/s to assign to classify the procedure of Lymphovenous anastomosis.

Search Details
Q3049 Vascularised Lymph Node Transfer

https://www.mqhealth.org.au/hospital-clinics/lymphoedema-clinic/procedures/lymphovenous-anastomosis-lva

Response:
VICC research indicates that a lymphovenous anastomosis is a procedure on the lymphatic system which connects lymph vessels to nearby veins in order to restore the flow of lymph fluid back to the venous system.

VICC advises, for documentation of lymphovenous anastomosis, to follow Index entry Anastomosis/lymphatic (channel) (peripheral) to assign 90283-00 [812] Other procedures on lymphatic structures.


Query Text:
Is Fetal Scalp Electrode (FSE) monitoring considered an instrumental or surgical intervention?

Fetal Scalp Electrode (FSE) monitoring is often undertaken to assess documented issues such as variable decelerations, reduced variability.

Examples of documentation include:
"Variable decelerations - for FSE"
"Reduced variability. Plan: continue to monitor, FSE"

In order to assign a code for decelerations, an essential modifier of either fetal distress or surgical or instrumental intervention must be documented.

Deceleration(s) (early) (late) (variable)
- fetal heart rate
-- requiring instrumentation or surgical intervention in 
labour and delivery O68.0

ACE Clarification of code assignment for procedures assisting delivery (20/3/2020) lists fetal monitoring as an "intervention" that may be performed with SVD. This in in reference to ACS 1505 which describes fetal monitoring as an “assistance procedure”

Is fetal scalp electrode (FSE) monitoring considered a surgical or medical intervention in order to assign a code from O68 Labour and delivery complicated by fetal stress [distress]?

Response:
VICC advises that fetal scalp electrode (FSE) monitoring is an assistance procedure rather than a surgical or medical intervention, so described by  ACS 1505 Delivery and assisted delivery codes 

Therefore Index entry Deceleration(s) (early) (late) (variable)/fetal heart rate/requiring instrumentation or surgical intervention in labour and delivery, cannot be followed as instrumentation or surgical intervention is an essential modifier for this Index entry. 

A code from O68 Labour and delivery complicated by fetal stress [distress] cannot therefore be assigned for documentation of decelerations when only fetal scalp electrode monitoring has occurred.


Query Title:
Same day pharmacotherapy with surgical procedures

Query Text:
We are interested in your opinion for coding the Pdx in the following scenario, which happens occasionally.

Patient admitted same day followup for cystoscopy with +/- TURBT for previous TCC bladder. No re-occurence is noted.

Mitomycin C is instilled in the bladder.

There is confusion over the assignment of the Pdx either Z51.1, or C67.9 as the main intent of the admission was not chemotherapy?

Search Details
VICC 2313 - retired 2013
VICC 2708 - retired 2017
Principal Diagnosis for Prophylactic PEG insertion prior to oropharyngeal radiation therapy (NCCC)

Response:
For the scenario cited, VICC interprets the intent of the admission is for follow up of the previously treated cancer. Therefore follow ACS 0052 Same-day endoscopy – surveillance, and assign a code from Z08 Follow-up examination after treatment for malignant neoplasms as the principal diagnosis, followed by a history code as no recurrence was noted. VICC advises, that without documentation that the mitomycin was for treatment of the neoplasm or neoplasm (treatment) related conditions, Z51.1 Pharmacotherapy session for neoplasm and 96201-00 [1920] Intracavitary administration of pharmacological agent, antineoplastic agent cannot be assigned.  

If clarification confirms that the mitomycin is for treatment of the neoplasm or neoplasm (treatment) related conditions then VICC advises to apply ACS 0044 Pharmacotherapy, section titled Same-day episodes of care for pharmacotherapy for neoplasm and neoplasm (treatment) related conditions, and assign Z51.1 Pharmacotherapy session for neoplasm as the principal diagnosis followed by the appropriate cancer codes.


Query Text:
1.Can VICC please advise if the following scenarios meet ACS 0002 Additional diagnoses criteria and ACS 1904 Procedural complications, in order to assign codes for a blocked catheter complication to codes T82.51, Y84.8, Y92.2*?

Scenario a):
Documented by nursing team in the nursing progress notes: “ordered Alteplase to relieve a blocked PICC catheter”, “Stat alteplase administered, left for two hours”

Scenario b):
Documented by nursing team in the nursing progress notes and there is reference to the gastroenterology team: “ordered Alteplase to relieve a blocked PICC catheter” and there is evidence treatment was given. 

2. 
a) For documentation of a blocked catheter (requiring thrombolytic therapy) are we able to follow the index classification:

- Block, blocked, blockage – see also Obstruction
- Obstruction, obstructed, obstructive
-- device, implant or graft
--- Catheter NEC
---- Vascular infusion
----- Central vascular (infusion port) (PICC) (Port-A-Cath) T82.51

b) Is there a requirement for documentation to specify that the blocked catheter is a complication in order to assign complication codes? 

3.Can you please confirm the index classification to follow and the correct diagnosis codes to assign for a blocked PICC catheter?

Search Details
ACS 0002 Additional diagnoses criteria and ACS 1904 Procedural complications

Response:
For scenarios 1a) and b) VICC advises it is correct to code the blocked catheter as a complication, as it meets ACS 0002 Additional diagnoses dot point one; commencement, alteration or adjustment of therapeutic treatment and ACS 1904 Procedural complications section titled Care beyond routine intraoperative/postoperative care, dot point one. In both scenarios the patient received a clinical consultation (where the clinician has prescribed alteplase) and commencement of treatment, resulting in a change of management of the condition.

For questions 2a) and 3 VICC agrees with the enquirer’s suggested Lead term of Block, blocked, blockage, which instructs to see also Obstruction. Following Index entry Obstruction/device, implant or graft/catheter NEC/vascular infusion/central vascular (infusion port) (PICC) (Port-A-Cath) assign T82.51 Mechanical complication of central vascular catheter.

For question 2b) VICC advises it is not a requirement of ACS 1904 Procedural complications for the documentation to specify that the blocked catheter is a complication. VICC considers documentation of a blocked catheter an example of a condition where the relationship is inherent in the diagnosis as per ACS 1904 Procedural complications section titled Overview dot point 2.


Query Text:
Can VICC please advise how to code conditions described as “extensions”. Are extensions part of the same (original) condition or are they part of another condition therefore require an additional code? For example:

1) Tumour/ cancer extensions
a. TCC bladder with extensions to prostate
i. Does this mean patient had a primary TCC of bladder with metastasis to the prostate
ii. Does this mean patient had a primary TCC of bladder that extends/ invades to the prostate but there are no metastasis to the prostate

2) Traumatic and non-traumatic brain haemorrhages (Haemorrhagic transformations) that extend to other parts of the brain, for example, intracerebral haemorrhages (i.e. frontal lobe) with intraventricular extension
a. Does this mean patient had one brain haemorrhage in the intracerebral region
b. Does this mean patient had two brain haemorrhages, one in the intracerebral region and one in the intraventricular region

3) Fracture extensions. Examples include; Fracture of Femur mid-shaft with extension to distal end and frontal bone fracture extending into the frontal sinus 
a. Does the patient have separate fractures or are the fractures part of one continuous fracture

4) Thrombosis of veins. For example, DVT extending inferiorly into the popliteal and posterior tibial veins
a. Does the patient have thrombosis of popliteal and posterior tibial veins? 

Please note current ACE Coding Rule: Portal Vein Thrombosis (Published 15.12.13 for implementation 1.1.14) for coding advice on a single portal vein thrombus extending into additional vessels. 


Search Details
ACE Coding Rule: Portal Vein Thrombosis (Published 15.12.13 for implementation 1.1.14)

Response:
1. VICC research indicates that a tumour extension is the progressive increase in tumour size which eventually leads to a breach in the barriers between tissues. As per ACS 0234 Contiguous sites, if a neoplasm spreads from a known primary site to an adjacent organ or site, assign a code for the primary neoplasm (site) only. The spread into the adjacent site is neither primary nor secondary at that site, but an expansion of the primary neoplasm. 

2. VICC advises, for brain haemorrhages that extend to other parts of the brain, to follow ACS 0605 Stroke extension, and code each extension site as another stroke haemorrhage. A code for each extension site should be coded when you have documentation of extension into multiple sites.

3. For the scenario cited, VICC does not consider there is sufficient information to assign a code for each fracture site described as an extension, that is the distal end of a mid shaft femur fracture may still be of the shaft of the femur. Unless documentation specifically states this is of a different bone or site, the fracture extension location should be queried with the clinician to provide confirmation.

4. VICC considers IHPA Coding Rule Q2822 Portal Vein Thrombosis is specific to portal vein thrombosis and should not be applied to thrombosis of other veins. VICC advises there is nothing precluding assignment of multiple codes from category I80 Phlebitis and thrombophlebitis, and the Index provides separate codes for each specified site. Therefore, for the example provided, it is correct to assign a code for both the popliteal and posterior tibial veins.


Query Title:
Documentation of excision of subcutaneous lesions on operation report when histology reveals fibroma

Query Text:
1. Can VICC please advise the correct index classification to follow and codes (diagnosis and procedure where applicable) to assign for the following scenarios?

Scenario a) Please confirm diagnosis code for Subcutaneous fibroma

Scenario b) Please confirm diagnosis and procedure codes for:
Diagnosis: Subcutaneous lesion ?cyst. Further specified on pathology as Fibroma
Procedure: Excision of subcutaneous lesion of right little finger and histopathology results confirm benign fibroma. 

Scenario c) Please confirm diagnosis and procedure codes for:
Diagnosis: Subcutaneous lesion ?cyst. Further specified on pathology as Fibroma
Procedure: Excision of fibroma of right little finger and histopathology results confirm benign fibroma.

2.When following the ACHI Alphabetic Index for excision of lesions, is there a precedence for location or for the type of lesion?

Please note the following references when reviewing this query:

VICC Query 3333 Excision biopsy of nodule in axilla, and states: “Where the operation report only contains non-specific diagnoses such as lesion, nodule, lump or mass and the histology is used by the coder to determine the diagnosis, VICC considers that the procedure code should correspond to the diagnosis code.”

ICD-10-AM ACS 0010 Clinical documentation and general abstraction guidelines

ICD-10-AM Alphabetic Index Neoplasm, note for connective tissue page 254

ACHI Tabular list, procedure code 31350-00[1566] Excision of lesion of soft tissue, NEC, Includes: Fibromatosis. 


Search Details
VICC Query 3333 Excision biopsy of nodule in axilla

ICD-10-AM ACS 0010 Clinical documentation and general abstraction guidelines

ICD-10-AM Alphabetic index Neoplasm, note for connective tissue page 254

ACHI Tabular list, procedure code 31350-00[1566] Excision of lesion of soft tissue, NEC, Includes: Fibromatosis.

Response:
The classification categorises fibroma as a connective tissue neoplasm, which is considered soft tissue. Therefore for scenario 1a, for documentation of subcutaneous fibroma, without further specification of site, VICC advises to assign D21.9 Other benign neoplasms of connective and other soft tissue, unspecified and M8810/0 Fibroma NOS, following Index entry Fibroma (M8810/0) - see also Neoplasm/connective tissue/benign. 

For scenario 1b) and c) VICC considers the final diagnosis to be fibroma, as per the histology report. The histology report is providing further specificity to a clinical diagnosis. Therefore follow Index entry Fibroma (M8810/0) - see also Neoplasm/connective tissue/benign; Neoplasm, neoplastic/connective tissue NEC/finger/benign to assign D21.1 Other benign neoplasms of connective and other soft tissue of upper limb, including shoulder.

In regards to the ACHI code, the Index entry at Excision/fibroma has essential modifiers of ossifying and soft tissue. By selecting soft tissue, the instruction see Excision/tumour/soft tissue/by en bloc resection cannot be followed as there is no documentation of the term en bloc resection in this scenario. VICC therefore advises to follow Index entry Excision/tumour/soft tissue NEC or Excision/lesion(s)/soft tissue NEC and assign ACHI code 31350-00 [1566] Excision of lesion of soft tissue, not elsewhere classified.

In response to question two, when following the ACHI Alphabetic Index for excision of lesions, if the operation report contains non-specific diagnoses such as lesion, nodule, lump or mass and the histology provides specificity, VICC advises it is appropriate to assign a procedure code that corresponds to the diagnosis code (in accordance with VICC #3333). In answer to your specific question regarding precedence for location or type of lesion, there is no precedence for either location or type of lesion as code assignment is dependent on the documentation and review of the Index entries appropriate to each scenario. For example, as fibroma is classified as a benign neoplasm of connective and other soft tissue, VICC has followed the above Index entry to assign 31350-00 [1566] Excision of lesion of soft tissue, not elsewhere classified.


Query Text:
We seek clarification on the advice regarding transfer of patients with confirmed, suspected or ruled out COVID-19.

Coding Rule TN1530 Coronavirus disease 2019 (COVID-19) updated 27 March 2020 states “for individuals transferred with suspected COVID-19, meeting the criteria in ACS 0012 Suspected conditions, do not assign the emergency use codes U07.1, U07.2 or U06.0.”

The Supplementary guidance for classifying admitted care table on the IHPA website (updated 9th April 2020) includes the sentence DO NOT assign U07.2 for individuals transferred with suspected COVID-19 that has not been ruled out. There is no mention of U06.0 or U07.1.

Does this advice apply to the transferring episode or receiving episode or both?

If COVID-19 is suspected at the time of transfer, but subsequently ruled out, do these guidelines still apply?

Scenario:
Patient admitted for same day chemotherapy. Noted to be febrile on admission so chemotherapy cancelled and COVID testing performed. Transferred to another health service with diagnosis of suspected COVID (result not available at the time of transfer). Result subsequently came back negative.

What codes would be assigned by hospital one in this scenario? 

Should this be coded as a clinically diagnosed / probable case (testing inconclusive, unavailable or not specified) as the test result was not available at the time of transfer?

R50.9 fever unspecified, 
B97.2 Coronavirus as the cause of diseases classified to other chapters to identify the infectious agent,
AND
Z75.6 transfer for suspected condition.

*U07.2 Emergency use of U07.1 [COVID-19, virus not identified] is NOT assigned as per Coding Rule TN1530.

Or

Should this be coded as a ruled out case as the test came back negative (even though the result was unavailable at the time of transfer) 
R50.9 fever unspecified, 
Z03.8 Observation for other suspected diseases and conditions AND
U06.0 Emergency use of U06.0 [COVID-19, ruled out]
*Z75.6 transfer for suspected condition is NOT assigned as suspected condition was ruled out

There is no direction about transfers of confirmed cases or ruled out cases. Does this mean that codes U07.1 and U06.0 can be assigned for transferred patients where COVID-19 is either confirmed or ruled out? This appears to be the case based on the Supplementary guidance for classifying admitted care table on the IHPA website (updated 9th April 2020), but Coding Rule TN1530 has not been updated to reflect this.

How would the transfer of a confirmed case be coded? 
For example, in the scenario above, if the result had come back positive prior to transfer are the correct codes to assign
R50.9 fever unspecified,
B97.2 Coronavirus as the cause of diseases classified to other chapters to identify the infectious agent AND
U07.1 Emergency use of U07.1 [COVID-19, virus identified]

Search Details
ACS 0012 Suspected conditions - where clinical documentation clearly indicates uncertainty about the final diagnosis at discharge, assign a code based on the following criteria …if a single condition is suspected, assign a code for the suspected condition.

Supplementary guidance for classifying admitted care table on the IHPA website (updated 9th April 2020)

Coding Rule TN1530 Coronavirus disease 2019 (COVID-19) updated 27 March 2020

Response:
VICC referred this query along with several other Victorian queries to IHPA for advice.  IHPA has advised that the query submissions have been considered in the publication for COVID-19 Frequently asked questions (FAQs) - admitted care part 3. 

Queries that are frequently asked or appear to be common to the majority of jurisdictions are progressed for publication. IHPA also advised that the IHPA website ‘How to classify  COVID-19’ remains the primary source of information on how to classify COVID-19.

In response to question one, VICC considers that the advice in the Supplementary guidance for classifying admitted care table on the IHPA website (updated 9 April 2020) which includes the sentence ‘DO NOT assign U07.2 for individuals transferred with suspected COVID-19 that has not been ruled out’ applies to the transferring hospital (Hospital A). This is supported by COVID-19 Frequently asked questions – admitted care part 1, FAQ titled Transfer for suspected COVID-19 example 2 whereby a U07 emergency use code is not assigned as COVID-19 has not been confirmed by laboratory testing or clinically diagnosed.

In response to scenario one, as the laboratory test for SARS-CoV-2 was performed at the transferring hospital and returned a negative result (even though the result was unavailable at the time of transfer), in accordance with COVID-19 Frequently asked questions – admitted care part 3 the correct codes to assign are:
R50.9 fever unspecified, 
Z03.8 Observation for other suspected diseases and conditions 
U06.0 Emergency use of U06.0 [COVID-19, ruled out]
Additional codes for cancelled chemotherapy are assigned in accordance with ACS 0011 Intervention not performed or cancelled

In response to the second question, in accordance with COVID-19 Frequently asked questions – admitted care part 3, codes U07.1 Emergency use of U07.1 [COVID-19, virus identified] or U06.0 Emergency use of U06.0 [COVID-19, ruled out] can be assigned for transferred patients where COVID-19 is either confirmed or ruled out. 

VICC therefore agrees that had the laboratory test for SARS-CoV-2 been positive prior to transfer or the test was later confirmed as positive, the correct codes to assign are:
R50.9 Fever unspecified,
B97.2 Coronavirus as the cause of diseases classified to other chapters to identify the infectious agent 
U07.1 Emergency use of U07.1 [COVID-19, virus identified]
Additional codes for cancelled chemotherapy are assigned in accordance with ACS 0011 Intervention not performed or cancelled.


Query Text:
Could you please advise what codes should be assigned by the transferring site when a patient is transferred specifically for COVID-19 testing in the following scenarios:
1.For a symptomatic patient 
a.when there is documentation of ‘suspected COVID’ ‘query’, ‘possible’ or similar terminology
b.when there is no documentation of ‘suspected’, query’, ‘possible’ COVID or similar terminology. See 
attached documentation for an example of this 
scenario. 
2.For an asymptomatic patient
a.when there is documentation of ‘suspected’, ‘query’, ‘possible’ COVID or similar terminology
b.when there is no documentation of ‘suspected’, ‘query’, ‘possible’ COVID or similar terminology

We note TN1530 Coronavirus disease 2019 (COVID-19) advises for patients transferred with suspected COVID-19 that the emergency use codes should not be assigned. However the advice does not explicitly instruct what other codes should be assigned. 

Search Details
TN1530 Coronavirus disease 2019 (COVID-19) Effective from 1 January 2020; Updated 27 March 2020*
IHPA Supplementary guidelines for classifying covid-19 scenarios in admitted patient care 
TN1037 Zika virus; use of WHO code for emergency use

Response:
VICC referred this query along with several other Victorian queries to IHPA for advice.  IHPA has advised that the query submissions have been considered in the publication for COVID-19 Frequently Asked Questions (FAQs) admitted care part 3. Queries that are frequently asked or appear to be common to the majority of jurisdictions are progressed for publication. IHPA also advised that the IHPA website ‘How to classify  COVID-19’ remains the primary source of information on how to classify COVID-19.

For episodes where the patient is transferred for COVID-19 testing, VICC advises to apply Frequently asked questions – admitted care part 1 FAQ titled Transfer for suspected COVID-19.  

For questions 1a and 1b where a symptomatic patient is transferred out for COVID-19 testing apply the guidelines in ACS 0012 Suspected conditions and COVID-19 Frequently asked questions – admitted care part 1 FAQ titled Transfer for suspected COVID-19 example 1 as per hospital A.  Therefore, assign a code for the symptom(s), followed by Z03.8 Observation for other suspected diseases and conditions and Z75.6 Transfer for suspected condition.

For question 2a and 2b where an asymptomatic patient is transferred out for COVID-19 testing apply the guidelines in COVID-19 Frequently asked questions – admitted care part 1 FAQ titled Transfer for suspected COVID-19 example 1 as per hospital A. As the patient is asymptomatic, assign Z03.8 Observation for other suspected diseases and conditions and Z75.6 Transfer for suspected condition.

Note that from 1 January 2020, IHPA has made an exception to ACS 0012 Suspected conditions regarding the assignment of codes from category Z03.- for coding of symptomatic presentations with suspected COVID-19, ruled out.


Query Title:
COVID transfers – tested at transferring facility, result not known at time of transfer

Query Text:
We have cases of suspected COVID-19 that are tested at our other campuses (as we use the same lab) and then sent to us to keep those facilities “COVID-free”. Though this question could equally apply to inter-hospital transfers.

If the patient is tested for COVID-19 BEFORE transfer at the transferring facility, but the result is not known at the time of transfer, and is found to be positive after transfer, do we code the first episode as per ACS 0010 Test Results and Medication Charts, Findings that provide more specificity about a diagnosis and Table 1a. for Laboratory confirmed cases? 

Or do we code as per ACS 0012 Suspected conditions and “Transfer for suspected COVID-19” in the COVID-19 Response, Rules for coding and reporting COVID 19 episodes of care, 4. Admitted care classification, as the result was not known at the time of transfer.

The Examples 1 & 2 in the FAQ - Transfer for suspected COVID-19 do not assist, as in neither Examples is the patient tested at the transferring facility (or yields a positive result). 


Search Details
IHPA COVID-19 Response - Rules for coding and reporting COVID-19 episodes of care 1.5.20
FAQ Transfer for suspected COVID-19, Examples 1 and 2

Response:
VICC referred this query along with several other Victorian queries to IHPA for advice.  IHPA has advised that the query submissions have been considered in the publication for COVID-19 Frequently Asked Questions (FAQs) admitted care part 3. Queries that are frequently asked or appear to be common to the majority of jurisdictions are progressed for publication. IHPA also advised that the IHPA website ‘How to classify  COVID-19’ remains the primary source of information on how to classify COVID-19.

VICC advises that where a patient undergoes laboratory testing for SARS-CoV-2 before transfer to another facility, the transferring hospital should apply ACS 0010 Clinical documentation and general abstraction guidelines section Test Results and Medication Charts. Therefore, when the result is found to be positive after transfer, it is correct for the transferring facility to assign emergency use code U07.1 Emergency use of U07.1 [COVID-19, virus identified] as per COVID-19 Frequently asked questions – admitted care part 3 FAQ titled Assignment of COVID-19 emergency use codes in admitted episodes of care for transferred patients.


Query Text:
We often see documentation of the terms anaemia and iron deficiency within a patient’s episode, but not always written together. For example: Colonoscopy report indications: ‘Iron deficiency. Anaemia.’ Sometimes we will also see separate progress notes entries where there will be documentation of iron deficiency, and then another progress note with anaemia without mention of iron deficiency.
Can the index pathway Anaemia/iron deficiency be followed when iron deficiency and anaemia are documented as separate conditions without a clear link/causal relationship? 
Or should we assign individual codes for iron deficiency and anaemia, and if possible seek further documentation from the clinician as to whether the patient has ‘iron deficiency anaemia’.

Response:
VICC advises that a causal link is required between anaemia and iron deficiency in order to assign a code for iron deficiency anaemia. 

For the scenario cited, VICC advises Index entry Anaemia/ deficiency/ iron cannot be followed, as there is no causal relationship documented between the anaemia and iron deficiency. Therefore assign a separate code for each condition where they meet ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.

VICC considers this may be a documentation issue and considers it appropriate to send a documentation query to the clinician to clarify if the anaemia is due to the iron deficiency.


Query Title:
Procedure cancelled due to another condition or complication

Query Text:
ACS 0011 Intervention not performed or cancelled/section two states that ‘…if a patient is admitted to a facility for an intervention that was not undertaken (or initiated) due to another condition or complication and the patient requires ongoing inpatient care for that other condition, assign a code for the condition responsible for the cancellation of the intervention as principal diagnosis.’

Can the Committee please clarify what ‘ongoing inpatient care’ includes? Is there any distinction between monitoring of a condition, performance of diagnostic investigations, or active treatment of a condition?

Can the Committee please advise on the correct principal diagnosis selection in the following scenarios?

1. Patient presents for same-day chemotherapy, but complains of cough on admission. The chemotherapy is cancelled and a chest x-ray and nasopharyngeal swab are performed to investigate the cough. No cause is found, and the patient is sent home later that day.

2. Patient presents for hysteroscopy, dilation and curettage for post-menopausal bleeding. The patient has a history of epilepsy, and has an epileptic seizure shortly after admission and the procedure is cancelled. The patient is monitored for further seizures for several hours then is sent home.

3. Patient is admitted for a knee replacement for OA. The patient has a drop in blood pressure after admission, and a MET is called for hypotension. The surgery is cancelled, the patient receives IV fluids for their low blood pressure, and then is sent home that day.

Response:
VICC advises that ACS 0011 Intervention not performed or cancelled does not make a distinction of what constitutes ongoing inpatient care. 

VICC considers the care given in the scenarios cited to be examples of ongoing clinical care, as the patient has required monitoring, therapy or investigation of the condition that caused the cancellation of their intervention.

VICC therefore advises the following principal diagnosis codes for each of the scenarios as per ACS 0011 Intervention not performed or cancelled are:

1. 	R05 Cough, as a chest x-ray and nasopharyngeal swab are performed to investigate the cough before being sent home.

2.	 A code from category G40 Epilepsy as the patient  received several hours of monitoring for further seizures prior to being sent home.

3. 	I95.9 Hypotension, unspecified as the patient received IV fluids for low blood pressure before being sent home.


Query Text:
In the last six months we have seen the diagnosis of hypovolemic hyponatraemia being increasingly documented in the medical record.
Previously national coding advice was released for hepatic encephalopathy (Q3058) which stated:

In classifying a condition with an underlying cause, if the Alphabetic Index or Excludes note… results in a code for one of the clinical concepts not being assigned, follow the guidelines in ACS 0001 Principal diagnosis/Problems and underlying conditions and assign codes for both the condition and the underlying cause. 

This advice is now retired however the advice has been incorporated into the index. As such, when hepatic encephalopathy is documented both of the above codes are assigned.

Can the committee please advise for a diagnosis of hypovolaemia hyponatraemia, whether hypovolaemia should be considered the underlying cause of the hyponatraemia?

Can the committee please advise what code/s should be assigned for the diagnosis of hypovolemic hyponatraemia?

Search Details:
Hepatic encephalopathy and alcoholic hepatic encephalopathy
Ref No: Q3058 | Published On: 15-Jun-2017 | Status: Retired | Retired On: 30-Jun-2019

Response:
VICC research indicates that hyponatraemic disorders are divided into euvolaemic, hypervolaemic and hypovolaemic, where hypovolaemic hyponatramia is a state in which the total body water and sodium content are decreased.

For documentation of hypovolaemic hyponatraemia which meets criteria for coding, VICC considers hypovolaemia is the type of hyponatraemia, therefore follow ACS 0001 Principal diagnosis and ACS 0002 Additional diagnoses section titled Problems and underlying conditions to assign E87.1 Hypo-osmolality and hyponatraemia as principal diagnosis with E86 Volume depletion as additional diagnosis.


Query Title:
Condition onset flag for COVID-19 symptoms not present on admission (ruled out cases)

Query Text:
COVID-19 FAQs Part 1 (published 1 May 2020) Condition onset flag for COVID-19 states to assign COF 2 Condition not noted as arising during the episode of admitted patient care where a patient is admitted for known or suspected COVID-19 or when it is uncertain whether the condition was present at admission or arose during the episode. In the specific circumstance where exposure to COVID-19 is documented as occurring during the episode of admitted care, assign COF 1 (e.g. where a patient contracts COVID-19 through exposure to an individual in a health care setting, who has tested positive to SARS-CoV-2).

Is COF 1 Condition with onset during the episode of admitted patient care only assigned when there is clear documentation that COVID-19 was contracted during the episode of care?

Can you please clarify whether COF 1 can be assigned when the symptoms clearly developed during the episode of care but there is no documented history of exposure occurring during the admission?

Scenario one: Newborn develops symptoms of cough and fever on day 10 of admission. No documented history of exposure to COVID-19. COVID-19 test result negative.

Which COF should be assigned in this scenario?

Scenario two: Long stay patient develops symptoms and/or tests positive four weeks into the episode of care with no documented exposure to COVID-19. This is outside the incubation period as we understand it. At what point could we assume that the COVID-19 was contracted during the episode of care?

Search Details
COVID-19 FAQs Part 1 (published 1 May 2020) Condition onset flag for COVID-19 
ACS 0048 Condition Onset Flag

Response:
VICC referred this query along with several other Victorian queries to IHPA for advice. IHPA has advised that the query submissions have been considered in the publication for COVID-19 Frequently asked questions (FAQs) - admitted care part 3. Queries that are frequently asked or appear to be common to the majority of jurisdictions are progressed for publication. IHPA also advised that the IHPA website ‘How to classify  COVID-19’ remains the primary source of information on how to classify COVID-19.

VICC advises that in accordance with ACS 0048 Condition onset flag and COVID-19 Frequently asked questions – admitted care part 1 Condition onset flag for COVID-19,  COF 1 Condition with onset during the episode of admitted patient care (Prefix C) should only be assigned where documentation supports the condition arose during the episode of admitted patient care and would not have been present or suspected on admission.

For scenario 1, VICC advises that the codes for cough and fever and the code U06.0 Emergency use of U06.0 [COVID-19, ruled out] would be assigned COF 1 (prefix C) as they have developed on day 10 of the admitted episode, i.e. the symptoms clearly developed during the episode of care.

For scenario 2, VICC advises that U07.1 Emergency use of U07.1 [COVID-19, virus identified] would be assigned COF 1 (prefix C) provided the documentation clearly supports that COVID-19 (or its symptoms) were not present or suspected on admission. Where symptoms develop during the episode of care these too would be assigned COF 1 (prefix C).

VICC is unable to comment on incubation periods and advises that where the documentation is unclear to seek clinical clarification.


Query Title:
Assignment of Z03.8 when COVID-19 ruled out with symptoms due to other condition

Query Text:
COVID-19 FAQs Part 1 (published 1 May 2020) Application of U06. Emergency use of U06.0 [COVID-19 ruled out] states that “health care facilities may test inpatients for SARS-CoV-2 where COVID-19 is a differential diagnosis or there is a decision to rule out COVID-19 for other reasons. COVID-19 may be a differential diagnosis in conditions such as influenza, pneumonia and heart failure. Where laboratory testing for SARS-CoV-2 is negative and COVID-19 has not been clinically diagnosed, assign U06.0 Emergency use of U06.0 [COVID-19, ruled out] as an additional diagnosis. Additional codes for observation for suspected conditions or exposure to communicable diseases may be assigned if applicable.”

In COVID-19 FAQs Part 1 (published 1 May 2020) Transfer for suspected COVID-19 examples 1 & 2 Z03.8 observation for other suspected disease and conditions is not assigned at hospital B as the symptoms were confirmed to be due to other conditions (influenza / viral pneumonia).

However, Coding Rule TN1530 – Coronavirus disease (COVID-19) (effective 1 January 2020; Updated 27 March 2020) and IHPA Supplementary guidance for classifying admitted care (updated 9 April 2020) advise to code Z03.8 in addition to the condition / symptoms.

Can you please clarify under what circumstances additional codes for observation for suspected conditions or exposure to communicable diseases would be assigned?

Can you please clarify whether Z03.8 should be assigned when the symptoms are determined to be due to another condition?

Scenario: Patient admitted with fever, shortness of breath and tachycardia. COVID-19 testing performed due to these symptoms, result negative. Diagnosis after study is chest infection. 

Are the correct codes for this scenario?
J22 unspecified acute lower respiratory tract infection
Z03.8 observation for other suspected disease and conditions
U06.0 emergency use of U06.0 [COVID-19 ruled out]

Search Details
COVID-19 FAQs Part 1 (published 1 May 2020) Application of U06. Emergency use of U06.0 [COVID-19 ruled out] and Transfer for suspected COVID-19 examples 1 & 2 
Coding Rule TN1530 – Coronavirus disease (COVID-19) (effective 1 January 2020; Updated 27 March 2020) 
IHPA Supplementary guidance for classifying admitted care (updated 9 April 2020)

Response:
VICC referred this query along with several other Victorian queries to IHPA for advice.  IHPA has advised that the query submissions have been considered in the publication for COVID-19 Frequently Asked Questions (FAQs) admitted care part 3. Queries that are frequently asked or appear to be common to the majority of jurisdictions are progressed for publication. IHPA also advised that the IHPA website ‘How to classify  COVID-19’ remains the primary source of information on how to classify COVID-19.

COVID-19 Response Rules for coding and reporting COVID-19 episodes Table 1c Suspected COVID-19 as reason for presentation, ruled out cases of COVID-19 provides guidance for the assignment of codes for observation for suspected conditions or exposure to communicable diseases.

COVID-19 Frequently asked questions - admitted care part 1 FAQ titled Transfer for suspected COVID-19 examples one and two only apply to patients who have been transferred. 

For the scenario cited, VICC advises to follow the advice in Table 1c Suspected COVID-19 as reason for presentation, ruled out cases of COVID-19 reason for presentation symptoms = yes, exposure = no to assign:
J22 unspecified acute lower respiratory tract infection
Z03.8 Observation for other suspected disease and conditions
U06.0 Emergency use of U06.0 [COVID-19, ruled out].

Note that from 1 January 2020, IHPA have made an exception to ACS 0012 Suspected conditions regarding assignment of codes from category Z03.- for coding of symptomatic presentations with suspected COVID-19, ruled out.


Query Title:
Non mandated screening for COVID-19, ruled out cases

Query Text:
IHPA COVID-19 FAQs Part 1 (published 1 May 2020) Assignment of Z11.5 special screening examination for other viral diseases to rule out COVID-19 states to assign Z11.5 special screening examination for other viral diseases as principal diagnosis where screening mandated by an authority is performed (i.e. in rare circumstances where the only reason for admission is to screen for COVID). Screening should not be confused with a decision to routinely test for COVID-19 during an admission. 

Can Z11.5 special screening examination for other viral diseases be assigned as an additional diagnosis where testing is performed during the admission on an asymptomatic patient with no history of exposure (e.g. reason for testing ‘pre surgery’, ‘patient unable to give history’ or not documented) where screening for COVID-19 is not the reason for admission and not mandated by authority?

Scenario one: Patient admitted with leg cellulitis. COVID-19 test performed due to recent overseas travel. Pt asymptomatic. Result negative.

Are these the correct codes in this scenario?
L03.13 cellulitis of lower limb
Z11.5 special screening examination for other viral diseases
U06.0 emergency use of U06.0 [COVID-19 ruled out]

Scenario two: Patient admitted with biliary colic and ERCP performed. Reason for COVID-19 testing on pathology clinical notes: ERCP tomorrow testing as per Gastroenterology. COVID -19 test result was negative.

Are these the correct codes in this scenario?
K80.50 calculus of bile duct without cholangitis or cholecystitis 
Z11.5 special screening examination for other viral diseases
U06.0 emergency use of U06.0 [COVID-19 ruled out]

Scenario three: Patient admitted with acute confusional state. No symptoms of COVID-19 but test performed as patient unable to give history. Result negative.

Are these the correct codes in this scenario?
F05.9 delirium unspecified
Z11.5 special screening examination for other viral diseases
U06.0 emergency use of U06.0 [COVID-19 ruled out]

Can you please clarify what is considered to be routine screening? Does routine screening refer to when a health service tests all patients and not where there is a specific reason for testing documented as in the scenarios above? 

Search Details
IHPA COVID-19 FAQs Part 1 (published 1 May 2020) Assignment of Z11.5 special screening examination for other viral diseases to rule out COVID-19

Response:
VICC referred this query along with several other Victorian queries to IHPA for advice.  IHPA has advised that the query submissions have been considered in the publication for COVID-19 Frequently Asked Questions (FAQs) admitted care part 3. Queries that are frequently asked or appear to be common to the majority of jurisdictions are progressed for publication. IHPA also advised that the IHPA website ‘How to classify  COVID-19’ remains the primary source of information on how to classify COVID-19.

In answer to this query IHPA advised that as per COVID-19 Frequently asked questions – admitted care part 1 FAQ titled Assignment of Z11.5 Special screening examination for other viral diseases to rule out COVID-19, Z11.5 is not assigned when a decision is made to routinely test for COVID-19 during an admission. 

VICC notes that routine testing would include the examples in your scenarios: test performed in asymptomatic patient due to recent overseas travel, testing prior to surgery and test performed as patient unable to give history.

Therefore, as in each of the scenarios cited screening has not been mandated by an authority as defined by the FAQ, VICC considers it is not appropriate to assign Z11.5 Special screening examination for other viral diseases.

As noted in the query, routine screening refers to the testing of patients when it is not mandated by an authority.


Query Title:
Excision of aneurysm of radiocephalic AVF with reconstruction of AVF

Query Text:
Can VICC please confirm the correct ACHI procedure code and index classification for ‘excision of aneurysm of radiocephalic AVF with reconstruction of AVF’. 

Please note operation report documents ‘reconstruction of AVF is by residual aneurysm wall and 5.0 prolene suture’. 

Please note the procedure codes below that we think may be appropriate to assign for this procedure:

33070-00 [714] Repair of aneurysm in extremity
Or
34518-00 [765] Repair of surgically created arteriovenous fistula
Or
33070-00 [714] Repair of aneurysm in extremity AND
34518-00 [765] Repair of surgically created arteriovenous fistula

Response:
For the scenario cited as two separate procedures have been performed, a code for each procedure should be assigned. VICC agrees with the codes suggested in the third option by the enquirer.

For repair of the aneurysm, assign 33070-00 [714] Repair of aneurysm in extremity by following Index entry Excision/aneurysm/extremity (limb). 

For the reconstruction of AVF, assign 34518-00 [765] Repair of surgically created arteriovenous fistula following Index entry Correction/arteriovenous/fistula, surgically created (for stenosis). VICC considers the lead term Correction appropriate to follow in this instance, as there is no appropriate Index entry using lead term Reconstruction.


Query Text:
This patient was admitted with concussion secondary to fall. The doctor has written that the fall was due to alcohol intoxication.

ACS 0503 Drug, alcohol and tobacco use disorder states:
Where the clinician has clearly documented a relationship between a particular condition(s) and alcohol/drug use, assign a code for the specific condition (see Alphabetic Index), with the appropriate code from F10–F19. Such documentation includes qualifying statements such as alcohol-induced or drug-related, or CAL (chronic airway limitation)/smoker indicating evidence that the substance use was responsible for (or substantially contributed to) physical or psychological harm. Sequencing should be determined by following the classification guidelines in ACS 0001 Principal diagnosis and ACS 0002 Additional diagnoses.

I cannot decide whether this advice from ACS 0503 is applicable as the alcohol use did not actually cause the injury. It was the cause of the external cause (i.e. fall) that then led to the injury.

Should the above advice from ACS 0503 be applied when alcohol/drug use is responsible for an external cause (e.g. fall, MVA) which then causes physical harm or injury (e.g. fracture, concussion)?

Can the committee please advise whether F10.0 Mental and behavioural disorders due to use of alcohol, alcohol intoxication should be assigned in the above scenario?

Search Details
ACS 0503 Drug, alcohol and tobacco use disorder

Response:
For the scenario cited, VICC considers the alcohol intoxication provides further specificity to the documented condition (concussion due to fall). 

As the clinician has documented a link between the condition and the alcohol use, VICC considers it appropriate to assign F10.0 Mental and behavioural disorders due to use of alcohol, alcohol intoxication, following ACS 0503 Drug, alcohol and tobacco use disorders General classification rule dot point one which states 'where the clinician has clearly documented a relationship between a particular condition(s) and alcohol/drug use, assign a code for the specific condition (see Alphabetic Index), with the appropriate code from F10-F19'.


Query Title:
Spinal meningioma documented as causing spinal cord compression

Query Text:
1. In the scenario where a neoplasm (e.g. spinal meningioma) is documented as causing spinal cord compression and in the episode of care, there was only treatment of the meningioma (by excision) without treatment of the cord compression, what are the correct codes? Please see coding options a)- c) below:

a)
1. D32.1 Benign neoplasm of spinal meninges
M9530/0 Meningioma NOS
OR
b)
D32.1+ Benign neoplasm of spinal meninges 
G99.2* Myelopathy in diseases classified elsewhere
M9530/0 Meningioma NOS
OR
c)
D32.1 Benign neoplasm of spinal meninges
M9530/0 Meningioma NOS
G95.2 Cord compression, unspecified

2.If option b or c is correct, is VICC able to provide the reasoning for assignment of additional diagnoses of cord compression/myelopathy?

3.Given the meningioma is being treated, does VICC consider that the compression is also being treated?

Response:
Where there is documentation that the neoplasm was the cause of the spinal cord compression but the treatment was only for the neoplasm, VICC advises that the codes for spinal cord compression would not be assigned as there was no documentation that the spinal cord compression met ACS 0002 Additional diagnoses. 

However, VICC notes that surgery to remove the neoplasm could also be treating the spinal cord compression. If there is documentation that the surgery was treating both the neoplasm and the spinal cord compression, both conditions should be coded as per IHPA Coding Rule Q3489 Spinal cord compression secondary to neoplasm:
D32.1 Benign neoplasm of spinal meninges
M9530/0 Meningioma NOS 
G99.2* Myelopathy in diseases classified elsewhere 
G95.2 Cord compression, unspecified.

The sequencing will be dependent on the documentation in the episode.

An example of documentation that indicates the surgery is treating both the neoplasm and the spinal cord compression is an indication on the operation report of ‘excision of meningioma for spinal meningioma with spinal cord compression’. 


Query Title:
Focal seizure in setting of known metastatic breast Cancer

Query Text:
Can VICC please confirm the principal diagnosis for the below episode?
a) Seizure 
OR
b) Brain metastasis

Principal diagnosis is Focal seizure in setting of known metastatic breast Ca.
Patient has PMHX of status epilepticus post stereotactic craniotomy & resection of right–sided parietal metastases Jan 2019.
Post lunch, patient had onset of cramping in L hand as in 3x previous focal seizures and spreading of cramping sensation up left arm and into R, followed by jerking of upper limbs and nodding of head.
It is unclear from the notes and correspondence if known brain tumour was the underlying cause of the seizures. This was supported by entry in the ED notes by a registered nurse on 30/07/19 “Problem: H/O: PHx brain tumour - R) motor cortex - going to remove in 1/52 time. 3x seizures in last ?1/12 due to tumour”.
Progress
- Discussed with Neurology BPT, case discussed with Neurology registrar
- Plan for increased Keppra dosing as per previous admission
- Increased Keppra to 1g BD and continue to monitor for ongoing seizure activity
- Keppra can be increased by 250mg PO BD per week if ongoing seizures
- Nil further investigations required
Patient reviewed by Neurosurgery registrar 
- For discharge home
- Not for CT-Brain in ED
- For pre-operative imaging and elective surgery as planned

Please see below the clinician query that was submitted for this episode:
Patient presented to EMER with focal seizure in setting of known metastatic breast cancer. The patient is known to have 2x brain tumours/ metastases of the r) motor cortex from primary invasive ductal breast carcinoma.
1. Can you please confirm the underlying cause of the focal seizures:
a) Brain tumour, metastases of the r) motor cortex from primary invasive ductal carcinoma
b) Other, please specify
c) Unable to determine
Clinician response:
1.a)

Response:
VICC considers the scenario cited to be similar to that in ACS 0001 Principal diagnosis section titled Problems and underlying cause, Example three. As the patient has presented with seizures and the underlying brain metastases were known at the time of admission, VICC advises to assign the seizure as the principal diagnosis as the patient was admitted for treatment of the seizures, followed by the appropriate codes for the metastatic breast cancer.

VICC notes the documentation query is clarifying the underlying cause of the seizures, not the principal diagnosis, and is also clarifying the documentation of 'in the setting of'. See also VICC query #3210 Underlying condition which confirms that VICC does not consider the phrases ‘on a background of’, ‘in context of’, ‘in a setting of’ or any other similar wording to indicate a link for coding underlying causes.


Query Title:
Insertion of nasojejunal tube via gastroscopy

Query Text:
Can VICC please advise the correct procedure code for the insertion of a nasojejunal tube via gastroscopy? 

Please note the endoscope was inserted to the fourth part of the duodenum. 

Please note the following index classification below:

Insertion
- tube
- - Intestine
- - - small
- - - - jejunum – see Insertion, tube, jejunostomy 

Insertion,
- tube
- - jejunostomy (feeding) (open) 31462-00 [892]

Gastroscopy 300473-00 [1005]

OR

Duodenoscopy
- with
- - insertion of jejunal tube 30478-05 [892]

Response:
For the case cited, as the scope was inserted into the fourth part of the duodenum, VICC agrees with the use of the lead term Duodenoscopy and the suggested Index entry Duodenoscopy/with/insertion of jejunal tube to assign ACHI code 30478-05 [892] Percutaneous endoscopic jejunostomy [PEJ].

Although the ACHI code title is not reflective of the intervention performed, the documentation has been accounted for using the Index entry above. 

You may wish to submit a public submission for improvements to the ACHI Interventions Tabular List.


Query Title:
Excision and drainage of infected sebaceous cyst on the posterior neck

Query Text:
Patient admitted for excision and drainage of infected sebaceous cyst on the posterior neck. Operation report notes “excision of cyst elements”. 

No histopathology to support that skin was removed. Contents noted on the operation report include pus + sebaceous material. 

There is no index classification for excision of cyst of skin and there are essential modifiers of “benign” or “malignant”, which we don’t have documented. 

Therefore can the committee please advise the index classification to follow and ACHI procedure code to assign for excision and drainage of infected sebaceous cyst of neck?

Response:
As there are two separate interventions performed in the scenario cited, VICC advises two ACHI codes should be assigned, one for the excision of the cyst and one for the drainage.

As stated by the enquirer, the Index entry Excision/cyst/skin (subcutaneous tissue) provides  essential modifiers of ‘Benign’ and ‘Malignant’ only. As neither have been documented, VICC advises to follow the ‘see also’ note at Excision/cyst and follow Index entry Excision/lesion(s)/skin and subcutaneous tissue/specified site NEC/neck to assign ACHI code 31235-01 [1620] Excision of lesion of skin and subcutaneous tissue of neck. 

For drainage of the cyst, VICC advises to follow Index entry Drainage/Cyst - see also Drainage by site; Drainage/skin (subcutaneous tissue) to assign ACHI code 30223-02 [1606] Other incision and drainage of skin and subcutaneous tissue.


Query Text:
Patient admitted with small bowel obstruction that required laparotomy and adhesiolysis.
During the procedure a single serosal tear was documented to be ‘oversewn with pds’. A coding query was written to clarify the nature of the tear. The clinician confirmed the tear was an accidental laceration during surgery of the small bowel. 
Currently there is no index classification for ‘oversewn’.
Could VICC please advise the:
1. ACHI procedure code for oversewn small bowel?
2. ACHI procedure code for oversewn serosa?

Response:
VICC considers the term ‘oversewn’ to mean suture. 

If the clinician has confirmed that the tear is of the small bowel serosa, VICC advises to assign 30375-24 [901] Suture of small intestine following Index entry Suture (laceration)/intestine/small.

If the only documentation is oversewing of serosa, VICC advises coders should first confirm the specific site of the serosal tear and then follow lead term Suture and select the specific site.

 


Query Text:
Can VICC please advise if both the abscess and cyst should be coded or just the sebaceous cyst in the following scenario and why?
Background:
- The terms cyst and abscess of elbow are used interchangeably throughout the episode and are referring to the same lesion
- The discharge summary documents the patient was admitted with sebaceous cyst and states “incision and drainage of cyst” was performed
- The operative diagnosis is “L posterior arm abscess, Incision and drainage”. Findings on operation report is “Lesion. ?Cyst present… 2yrs”. 
- Tissue Culture description: Left Elbow abscess, no growth after 2 days
- The principal diagnosis was initially documented as distal radius fracture. The below coding query sent to clinician to clarify principal diagnosis:
“Patient initially admitted under plastics for incision and drainage of sebaceous cyst of left elbow. Prior to discharge, patient had a mechanical fall sustaining a distal radius fracture and care was transferred to orthopaedics.
Please note, conditions which arise during the episode of admitted patient care and would not be present or suspected on admission are not to be sequenced as the principal diagnosis.”
1. Can you please confirm the principal diagnosis for this admission?
A) Sebaceous cyst of elbow
b) Other, please specify:
c) Unknown, unable to determine
Clinician response: a) sebaceous cyst of elbow

Response:
VICC notes this is a specific scenario, and as such the coding of cyst and/or abscess is dependent on the documentation within the episode of care.

From the documentation provided with the query, VICC considers there is one lesion with conflicting documentation between cyst and abscess. As it is unclear if there is an abscess and/or cyst in the one lesion, VICC advises to assign a code for the cyst as per the diagnosis on the discharge summary and documentation query. VICC considers that it would be appropriate to seek further clarification of the diagnosis to determine if the lesion is just a cyst or could be ‘an abscess with an underlying cyst’, ‘thought to be a cyst but after study was determined to be an abscess’ or ‘both a cyst and abscess’.

VICC agrees with the enquirer that the fracture did not meet the definition of principal diagnosis, as the fracture arose during the admission. As such, a query was not required to rule out the fracture as the principal diagnosis.


Query Text:
Whilst following ACS 0303 Abnormal coagulation profile due to anticoagulants, can you please clarify if the term “Bridging Anticoagulant Therapy” needs to be specifically documented in order to code Bridging Anticoagulant Therapy to Z92.1? Or, can you code Z92.1 for Bridging Anticoagulant Therapy when the definition in ACS 0303 is met as per documentation in the episode?

For example, can you code Z92.1 when a patient’s usual oral anticoagulant (eg warfarin) is replaced with a short action agent (eg clexane) prior to a planned procedure, until the patient can resume their usual anticoagulant therapy? Note, there is no documentation of “Bridging Therapy” in the current episode of care.

Search Details:
ACS 0303 Abnormal coagulation profile due to anticoagulants
VICC Query #3495

Response:
VICC does not consider that the term 'bridging anticoagulant therapy' must be specifically documented to assign Z92.1 Personal history of long term (current) use of anticoagulants as long as there is evidence in the episode of care that the usual oral anticoagulant was replaced with a short action agent prior to a planned procedure.


Query Text:
What terms are considered synonymous with isolation?

Can VICC please confirm if other terms such as "negative pressure room" or "contact precautions" is considered synonymous with isolation?

Response:
VICC advises that the term ‘isolation’ must be documented in order to assign a code for isolation. 

Documentation of ‘contact precautions’ and ‘negative pressure room’ may indicate a patient is requiring isolation, however VICC does not consider these to be synonymous terms for isolation.


Query Text:
Could VICC please clarify how to code inhalation of gastric contents during the anaesthetic/intubation process when there is documentation of aspiration but not of pneumonia or Mendelson’s syndrome. 

One example is 'bile viewed on oropharynx and ETT suctioned to a NIL aspirate from ETT'. It was '?bile so NGT inserted and bile draining'. Patient was sent to ICU post op as 'soiled airway on direct laryngoscopy’, ?bile > suctioned' and 't/f intubated due to ?aspiration on induction, pO2 91 on FiO02 60%'.

We feel the correct code to use is J95.4 Mendelson's syndrome but cannot find a look up for this.

Response:
VICC notes documentation of Mendelson’s syndrome or aspiration pneumonitis due to anaesthesia is required to assign J95.4 Mendelson's syndrome, as per the Index entries:
Mendelson’s syndrome (due to anaesthesia) J95.4
Pneumonitis/aspiration/due to anaesthesia J95.4
Syndrome/Mendelson’s (due to anaesthesia) J95.4

Therefore, for documentation of inhalation or aspiration of gastric contents, as there is no documentation to support following the above Index entries, VICC advises to assign T17.9 Foreign body in respiratory tract, part unspecified, by following Index entry Inhalation/stomach contents or secretions. Also assign appropriate external cause codes.

VICC advises, if documentation supports that the inhalation of gastric contents is due to anaesthesia, assign T88.59 Complications of anaesthesia, not elsewhere classified following Index entry Inhalation/stomach contents or secretions/due to anaesthesia (general) (local) or other sedation. Also assign T17.9 Foreign body in respiratory tract, part unspecified to give further specificity of the type of complication of anaesthesia, and appropriate external cause codes.


Query Title:
Posterolateral versus posterior spinal fusion and spinal fixations

Query Text:
We require advice on classification of spinal fusions when these are not documented as either posterior or posterolateral or anterior. We also seek advice on classification of new types of spinal fixations.

At our hospital we find that anterior spinal fusions are easily identifiable by documentation of anterior. However, often spinal fusions are not specified as either posterior or posterolateral (or both). Compounding this problem is the use of new and emerging spinal fixations and we are unable to differentiate posterior from posterolateral fusions as they are commonly referenced by the name of the fixation used rather than whether the fusion is ‘posterior’ or ‘posterolateral’.

The ACCD Clinical Update: The Spine Part B (Dec 2015) seems to suggest that code classification is based on whether the access is anterior, posterior or posterolateral.

However clinical and other jurisdictional coding advice that we have sought seems to suggest that posterior access can be used to achieve both posterior and posterolateral spinal fusion. 

1. Can the VICC please provide classification guidelines on how to classify spinal fusions not documented as either anterior, posterior or posterolateral such as ELIF, XLIF, AXLE fusion, TLIF, DLIF, LLIF and where no clarification can be sought.

2. Where a posterior fusion is documented (for example PLIF) and there is also evidence of graft placed in the posterolateral gutters, should codes be assigned for both a posterior fusion and posterolateral fusion? 

3. Can the VICC please provide classification guidelines on how to classify spinal fixations used in spinal fusion surgery that are not described as per those listed in ACS 1348 Spinal Fusion, for example AXLE clamp, Universal clamp, and interspinous clamp. 

4. Also, can you please clarify whether spinal fixations should be classified as segmental or non-segmental for a one-level fusion involving insertion of a plate with screws into adjacent vertebra, for example C5/6. The example attached contains documentation of ‘intersegmental’. 

Search Details
ACCD Clinical Update: The Spine Part B (Dec 2015)

ACS 1348 Spinal Fusion 

Clinical Coding Guidelines: Spinal Fusion and Fixation, WA Clinical Coding Authority

Axle Interspinous Fusion System/internal fixation device
https://xtantmedical.com/product/axle/

Universal Clamp spinal fixation system
https://www.zimmerbiomet.com/content/dam/zimmer-biomet/medical-professionals/000-surgical-techniques/spine/universal-clamp-surgical-technique.pdf

Interspinous fusion device
https://www.spineart.com/products/romeo2-pad/

Response:
In response to question one, VICC advises that code classification for spinal fusion is based on whether the approach/access is anterior, posterior or posterolateral.

In response to question two, as spinal fusions are classified based on approach/access, VICC does not consider documentation of ’graft placed in posterolateral gutters’ alone sufficient to assign a code for posterolateral fusion. Therefore, where posterior fusion is performed with evidence of graft placed in the posterolateral gutters only assign a code for posterior fusion, unless there is also evidence of posterolateral access.

In response to question three in regards to spinal fixation, VICC advises to apply ACS 0038 Procedures distinguished on the basis of size, time, number of lesions or sites which states ‘Where there is no documentation in the clinical record, no further information can be obtained from the clinician and there is no default in the Index, assign the code for the smallest size, the least duration, the least number of lesions or sites, as appropriate’.

In response to question four, VICC considers a one-level fusion involving insertion of a plate with screws into adjacent vertebra to best meet the definition of nonsegmental implant in ACS 1348 Spinal fusion. VICC therefore advises to assign 48681-00 [1390] Nonsegmental internal fixation of spine following Index entry Fixation/bone/internal/spine (screws) (simple) (wire loop)/nonsegmental for the scenario cited. 

In answer to your specific examples regarding approach, fixation and position of bone grafts, from the operation reports provided, VICC advises:

For the example provided which stated Lateral Lumbar Interbody Fusion (LLIF) with documentation on the operation report of ‘Lateral position’ and ‘4cm right flank incision’ and ‘right retroperitoneal transpsoas approach’, VICC considers this to be a posterolateral access. Therefore, assign an appropriate code following Index entry Fusion/spinal/posterolateral (interbody) (with bone graft).

For the example provided which stated Transforaminal Lumbar Interbody Fusion (TLIF), VICC considers this to be a posterior fusion as per the IHPA Clinical Update: The spine - Part B which describes transforaminal access as ‘posterior access but through the side of the foramen’. VICC therefore advises to assign an appropriate code following Index entry Fusion/spinal/posterior (interbody) (with bone graft).

For the example provided which stated AXLE fusion, with documentation on the operation report of ‘prone position’ and ‘an incision was made and dissection was carried out down to the posterior elements’, VICC considers this to be posterior access. Therefore assign an appropriate code following Index entry Fusion/spinal/posterior (interbody) (with bone graft).

For the example with documentation of insertion of a ‘L4/L5 axle clamp’ and the example with documentation of insertion of an ‘interspinous clamp’ at L5/S1, VICC considers these fixation types to be a nonsegmental implant as two levels were involved, with no evidence of intervening fixation. VICC therefore advises to assign 48681-00 [1390] Nonsegmental internal fixation of spine following Index entry Fixation/bone/internal/spine (screws) (simple) (wire loop)/nonsegmental. 

For the example with documentation of insertion of universal clamps at T7/8/9, VICC considers this to be segmental fixation as the clamps have been inserted at three levels and there is also documentation of rods and screws on the operation report provided. 

VICC notes that there are proposed changes to the classification of spinal fusion and fixation for ACHI Twelfth Edition.


Query Title:
Incision and drainage of submandibular abscess

Query Text:
At our hospital we frequently have patients who undergo incision and drainage of a submandibular abscess. The drainage is usually performed via an intraoral approach, however, sometimes it is performed extraorally. On some occasions a combination of these techniques is employed.

The ICD-10-AM code for submandibular abscess is K12.2 Cellulitis and abscess of mouth. 

Can the committee please advise what code should be assigned for incision and drainage of a submandibular abscess?

Does the approach taken (intraoral versus extraoral) affect the code assignment for this procedure?

Response:
As a submandibular abscess is an infection of the tissues (submandibular space) in the floor of the mouth, VICC advises the correct code to assign for incision and drainage of a submandibular abscess is 96215-00 [401] Incision and drainage of lesion in oral cavity. Follow Index entry Drainage/abscess/oral cavity.

VICC notes the approach taken does not affect code assignment as the ACHI classification does not differentiate between intraoral and extraoral approaches for drainage of abscess of oral cavity.


Query Text:
The IHPA COVID-19 Response v1.1 states, ‘Emergency use code U06.0 Emergency use of U06.0 [COVID-19, ruled out] is to be assigned when laboratory testing for COVID-19 has been performed, but ruled out (ie negative test result).’

If a patient presents to the emergency department and is swabbed in ED for suspected COVID-19 and then transferred to a COVID-specific ward until they later return a negative result, is it appropriate to assign U06.0?

Response:
IHPA has advised that the IHPA website ‘How to classify COVID-19’ remains the primary source of information on how to classify COVID-19. Queries that are frequently asked or appear to be common to the majority of jurisdictions are progressed for publication.

VICC advises that it is appropriate to assign U06.0 Emergency use of U06.0 [COVID-19 ruled out] as an additional diagnosis in the scenario cited as on admission the patient was suspected of COVID-19. This is in accordance with VICC query #2866 Clarification of coding for 2013-14 Victorian Admission Policy. Although sections of the Victorian Admission Policy, now titled VAED Criteria for reporting document, have been revised since the release of this query, point one of the response is still current. 

Point one of the response is reproduced below:  

Emergency department notes are to be regarded like any other documentation outside the admission (for example, GP referring letters, outpatient notes or transfer documentation) to provide further specificity to a documented condition in the admitted episode or to support the coding of conditions requiring ongoing treatment on the ward.


Query Title:
Callus reduction performed by a podiatrist

Query Text:
ACCD published advice in March 2017 regarding callus reduction performed on the ward by a podiatrist.  The advice was that this should be coded to the general allied health code for podiatry 95550-04 [1916]. Would you please advise if this advice still applies?

If so, does the documentation have to specify "reduction of callus"? Would it apply to documentation of "sharps removal of hyperkeratosis and corns"?

We have been discussing whether we should be clarifying these procedures with the podiatrist (ie asking if they are "debridement"). If confirmed as debridement, the default code would be "excisional debridement".


Search Detail:
ACCD March 2017 - callus reduction performed by a podiatrist
Eleventh edition FAQ - wound management
Foot debridement of diabetic patient VICC 2215 - retired

Response:
VICC advises that IHPA Coding Rule Q3059 Callus reduction performed by Podiatrist is current and therefore still applies.

VICC notes that the IHPA advice states ‘Callus reduction by a podiatrist involves progressively reducing the thickness of the callus using either lateral cutting strokes from a scalpel blade, or the abrasive action of a diamond electro-deposition file, until callus removal is complete’. VICC sought clinical advice which confirmed documentation of ‘sharps removal of hyperkeratosis and corns’ to be synonymous with ‘cutting strokes from a scalpel blade’. VICC therefore advises to assign 95550-04 [1916] Allied health intervention, podiatry for documentation of ‘sharps removal of hyperkeratosis and corns’ by the podiatrist.

VICC does not consider documentation of ‘sharps removal of hyperkeratosis and corns’ by the podiatrist a basis to query debridement.


Query Text:
Patients who are admitted with congenital laryngeal web for division via microlaryngoscopy often undergo an insertion of a laryngeal keel and return to hospital for the removal of the keel. Clinical advice obtained noted that “A keel is inserted into the anterior part of the larynx after the web has been divided. The premise is to stop the web from re-scarring over and once the original division has occurred, the keel can be removed”. There are no specific index entries listed in the ACHI Index for this procedure. 

1. Could VICC please advise the correct ACHI code for the insertion of a laryngeal keel via microlaryngoscopy?

2. Could VICC please advise the correct ACHI code for the removal of a laryngeal keel via microlaryngoscopy?

3. Could VICC please advise the appropriate principal diagnosis selection in cases where a patient is admitted for the removal of a laryngeal keel via microlaryngoscopy with no residual webbing documented?

Response:
VICC research indicates a laryngeal keel to be similar to a laryngeal stent, but softer than a stent and sometimes inserted after a stent.
VICC notes that ACHI does not currently have specific codes for insertion or removal of a laryngeal keel and advises the most appropriate option would be to code as a laryngeal stent as these are similar devices.

VICC therefore advises:
For insertion of a laryngeal keel via microlaryngoscopy assign 41905-02 [521] Insertion of laryngeal stent following Index entry Insertion/stent/larynx (endoscopic). No additional microlaryngoscopy code is required as the endoscopic component is captured with the non-essential modifier of ‘endoscopic’ in the Index.  

For removal of a laryngeal keel via microlaryngoscopy assign 41886-01 [521] Removal of laryngeal stent following Index entry Removal/stent/laryngeal and 41855-00 [520] Microlaryngoscopy as an additional code as per ACS 0023 Laparoscopic/arthroscopic/endoscopic surgery.

In answer to the last question, VICC advises, the correct principal diagnosis code in cases where a patient is admitted for the removal of a laryngeal keel via microlaryngoscopy with no residual webbing documented is Z45.89 Adjustment and management of other implanted devices. Follow Index entry Management (of)/implanted device NEC/specified NEC.

You may wish to make a public submission to IHPA to incorporate laryngeal keel procedures into the ACHI classification.


Query Text:
How should a limbal biopsy of the eye be coded? Should it be coded to cornea or sclera or both? Or something else?

There is no combined anatomy code under biopsy but there is under excision, lesion.

Response:
From the limited information provided VICC considers 42692-01 [169] Biopsy of cornea the appropriate code to assign for limbal biopsy of the eye not futher specified, following Index entry Biopsy (brush) (with brushing(s)) (with washing(s) for specimen collection)/cornea. VICC notes that other limbal procedures are classified to cornea in ACHI. 

However, VICC research indicates that limbal biopsy may be performed for transplantation into the other eye but clarification with the clinician would be required before assigning codes for transplantation. If clinical clarification confirms the procedure is for transplantation, see ACS 0030 Organ, tissue and cell procurement and transplantation.


Query Text:
How should aqueous misdirection be coded? 

A google search of aqueous misdirection says that this is a secondary angle closure with elevated IOP and shallowing of the anterior chamber of the eye. 

Is an appropriate code Elevated IOP H40.0 and/or Disease anterior chamber H21.9?

Response:
Clinical advice obtained by VICC indicates that aqueous misdirection pathophysiology is poorly understood. It results from an abnormal anatomical relationship between the lens, ciliary body and anterior hyaloid. Fluid accumulates in the posterior chamber pushing the lens forward, shallowing the anterior chamber and increasing the intraocular pressure.

As there is no specific code for aqueous misdirection of the eye, VICC advises to assign H21.9 Disorder of iris and ciliary body, unspecified following Index entry Disease, diseased/aqueous (chamber).


Query Text:
If FESS is documented as bilateral should it be coded twice?

Response:
VICC considers FESS to be an inherently bilateral procedure and therefore advises to apply ACS 0020 Bilateral/Multiple Procedures, section titled Bilateral procedures dot point 2 Inherently bilateral procedures and only assign 96257-01 [389] Functional endoscopic sinus surgery [FESS] once. 

This is also supported by the note in the ACHI Tabular List at code 96257-01 [389] Functional endoscopic sinus surgery [FESS] which indicates that FESS includes specific sinus procedures, both bilateral and unilateral. 


Query Title:
Endoscopic stenting from stomach to an intra-abdominal abscess

Query Text:
Patient was admitted for drainage of a post vascular procedure abscess located in the left upper quadrant of the abdomen. The Endoscopic Ultrasound Report documents the passing of the endoscope into the antrum of the stomach and the finding of a fluid collection beneath the left diaphragm. A needle was used to aspirate a small amount of pus for diagnostic assessment (microbiology). Then a hot stent was inserted into the collection with good drainage noted. The stent was left in situ.

The patient had two subsequent gastroscopy procedures with both noting the pre-existing placement of the stent in the upper body of the stomach, and then debris was removed from the stent lumen and peritoneal cavity. The stent was left in-situ post discharge for later removal.

There are no specific index entries listed in the ACHI index classification for these procedures. 

Could VICC please advise:
1. What is/are the procedure code(s) for the endoscopic placing of a stent from the stomach into an intra-abdominal abscess?

2. What is the correct procedure code for endoscopic (diagnostic) aspiration of an intra-abdominal collection from the stomach?

Response:
VICC notes there is no specific ACHI code for insertion of an endoscopic stent into an intra-abdominal abscess. VICC therefore advises that the most appropriate code to assign for endoscopic placement of a stent from the stomach into an intra-abdominal abscess for drainage is 30394-02 [987] Other closed drainage of intra-abdominal abscess, haematoma or cyst following Index entry Drainage/abscess/intra-abdominal (laparotomy) (open) NEC/closed NEC. 

A code for the endoscopy should also be assigned as per ACS 0023 Laparoscopic/arthroscopic/endoscopic surgery. VICC acknowledges that the stent component of the procedure is unable to be captured. In the scenario sited a code for the endoscopic ultrasound would also be assigned.

For endoscopic (diagnostic) aspiration of an intra-abdominal abscess from the stomach VICC advises to assign 30224-01 [987] Percutaneous drainage of intra-abdominal abscess, haematoma or cyst following Index entry Aspiration/abscess/intra-abdominal NEC. Notwithstanding the code descriptor of ‘percutaneous’ in the code title, VICC considers this the correct code to assign as per the Index entry.  A code for the endoscopy should also be assigned. 

VICC notes the term 'collection' has been used in question 2, however the query otherwise refers to 'abscess' and therefore VICC has responded as if the collection is an abscess. However, if in the scenario the only documentation is collection, clarify the type of collection with the clinician. 

If you consider these are frequently occuring interventions you may wish to make a public submission to IHPA to improve the ACHI classification of endoscopic drainage by stent and endoscopic aspiration of intra-abdominal abscesses.


Query Text:
Patients that present with rib/sternal fractures will sometimes have documentation such as ‘flail ribs’, ‘flail 4-7’, ‘flail’ without documentation of ‘flail chest.’ 

Currently following the Index when assigning a code for flail, we need documentation of ‘flail chest.’

- Flail
-- chest

Can VICC please advise the correct clinical code to assign for an intrathoracic injury documented as ‘flail’ such as examples above without documentation of ‘flail chest?’

Response:
VICC sought clinical advice which defined flail chest as ‘either a radiological or clinical diagnosis. It requires at least two consecutive ribs being fractured in two separate locations, resulting in a section of the chest wall that moves paradoxically with respiration’. 

The clinical advice also confirmed that terms such as ‘flail’, ‘flail ribs’ or ‘flail 4-7’, are all considered synonymous with flail chest. Therefore, for documentation of an intrathoracic injury described as ’flail’, follow Index entry Flail/chest and assign S22.5 Flail chest.

 


Query Title:
COVID-19 Patient presenting to hospital with condition unrelated to COVID-19

Query Text:
What codes are assigned for a patient who presents to hospital for a condition unrelated or unsuspected as being due to COVID-19, however undergoes a test which returns a negative result?

E.g. Patient presents to hospital with a fractured ankle following fall. The patient is not expressing any COVID-19 symptoms, is not suspected as having COVID-19, or has not been exposed to COVID-19, but whilst an inpatient is tested for COVID-19 and returns a negative result.

Response:
IHPA has advised that the IHPA website ‘How to classify COVID-19’ remains the primary source of information on how to classify COVID-19. Queries that are frequently asked or appear to be common to the majority of jurisdictions are progressed for publication.

VICC advises to apply the advice in COVID-19 Frequently asked questions – admitted care part 2 FAQ titled Application of U06.0 Emergency use of U06.0 [COVID-19 ruled out] for admitted patients with a negative test result for SARS-CoV-2 (COVID-19). 

Therefore, for the scenario cited, assign U06.0 Emergency use of U06.0 [COVID-19, ruled out] as an additional code.  

As per COVID-19 Frequently asked questions – admitted care part 3 FAQ titled Clinical documentation to support assignment of U06.0 Emergency use of U06.0 [COVID 19, ruled out], U06.0 Emergency use of U06.0 [COVID 19, ruled out] can be assigned where clinical documentation indicates that laboratory testing for SARS-CoV-2 has occurred but the presence of COVID-19 has been ruled out by virtue of a negative test result for SARS-CoV-2. The specific terminology of ‘ruled out’ is not required in order to assign this code.


Query Title:
Conditions further specified from imaging results

Query Text:
Our health service has noted some confusion regarding the use of imaging reports to further specify the coding of conditions where the classification assumes a causal link to another condition.

ACS 0010 section Findings that provide more specificity about a diagnosis states that '...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).' Example 10 includes documentation of cholecystitis with ultrasound confirming the presence of gallstones, and advises to assign K80.10 Calculus of gallbladder with other cholecystitis, without mention of obstruction.

'Coding from test results and findings on radiological reports' (ACCD 2015 Coding Rule Q2974) is not retired, and states 'Conditions/manifestations (where the classification assumes a causal link), that are listed in test results but not documented or confirmed by the clinician, are not to be used to inform code assignment.’ The example provided notes that '...although the classification links ureteric calculus and hydronephrosis, both conditions must be documented or confirmed by the clinician to inform code assignment.’ This advice appears to be contrary to the example in the Standard.

Can the Committee please clarify whether imaging results can be used to further specify documented conditions where the where the classification assumes a causal link to another condition?

What is the correct code to assign in the following examples?
1. Documented cholecystitis with gallbladder calculi noted on imaging
2. Documented ureteric calculi with hydronephrosis noted on imaging

Response:
VICC advises IHPA has confirmed that Coding Rule Q2974 Coding from test results and findings on radiological reports is retired as the advice has been incorporated into the Eleventh Edition of ACS 0010 Clinical documentation and general abstraction guidelines. 

VICC therefore advises, as per Example 10 of ACS 0010 Clinical documentation and general abstraction guidelines:

For documentation of cholecystitis with gallbladder calculi noted on imaging only, the correct code to assign is K80.10 Calculus of gallbladder with other cholecystitis, without mention of obstruction. Follow Index entry Cholecystitis/with/calculus, stones in/gallbladder.

For documentation of ureteric calculi with hydronephrosis noted on imaging only, the correct code to assign is N13.2 Hydronephrosis with renal and ureteral calculus obstruction following Index entry Calculus, calculi, calculous (impacted) (recurrent)/ureter NEC/with/hydronephrosis.
 

  


Query Text:
Our health service has identified during auditing that many of our endoscopic biliary procedures (e.g. sphincterotomy, calculus extraction, biliary stenting, etc.) are being performed via endoscopic retrograde cholangiography (ERC) only, i.e. without imaging of the pancreatic duct.

ACHI provides a number of pathways that index endoscopic biliary procedures via the ‘ERCP’ lead term (e.g. ‘ERCP/with/sphincterotomy’); however, these are not indexed via the ‘ERC’ lead term. Most of these procedures can alternatively be coded using the lead term of the interventional procedure (e.g. ‘sphincterotomy/sphincter of Oddi/endoscopic’).

For endoscopic extraction of CBD calculus via ERCP, the lookup ‘ERCP/with/extraction of calculus from common bile duct’ can be followed to assign 30485-01 Endoscopic sphincterotomy with extraction of calculus from common bile duct. However, using the lead term ‘extraction’, the essential modifier of ‘by endoscopic sphincterotomy’ is required to reach the same code.

Some of our patients are admitted for CBD calculus extraction following a previous endoscopic sphincterotomy. In these cases, a repeat sphincterotomy is not required. These patients undergo ERC with extraction of calculus only.

Can the Committee please advise the correct coding for an ERC with extraction of calculus when a sphincterotomy is not performed in the same procedure?

Response:
VICC notes that 30485-01 [963] Endoscopic sphincterotomy with extraction of calculus from common bile duct is assigned for extraction of calculus from common bile duct via ERCP whether a sphincterotomy is performed or not, as per the following Index entries:
ERCP (endoscopic retrograde cholangiopancreatography)/with/extraction of calculus from common bile duct 
ERCP (endoscopic retrograde cholangiopancreatography/with/sphincterotomy/with extraction of calculus from common bile duct. 

VICC agrees there are no suitable Index entries under lead term ERC for extraction of calculus of common bile duct, however VICC considers that it is the same procedure as extraction of calculus of common bile duct via ERCP but without the pancreatography component. Therefore, VICC advises the most appropriate code to assign is 30485-01 [963] Endoscopic sphincterotomy with extraction of calculus from common bile duct following Index entry ERCP/with/extraction of calculus from common bile duct. 

You may wish to make a public submission to IHPA to improve the ACHI classification of endoscopic retrograde cholangiography with extraction of calculus. 


Query Text:
We often see documentation of ‘nonunion of fusion’ as the diagnosis on the discharge summary or operation report. Sometimes there is documentation available describing the type of previous surgery eg past history of ankle joint fusion or past history of joint arthrodesis. 

We have sought clinical advice regarding this documentation and have been advised that ‘nonunion fusion’ is the correct surgical term for pseudoarthosis following fusion.

We note the index pathway: Pseudoarthrosis – see Pseudarthrosis/Pseudarthrosis, pseudoarthrosis (bone)/joint, following fusion or arthrodesis M96.0. 

As there are no index options under the lead term for nonunion fusion or nonunion arthrodesis, can VICC please advise if nonunion fusion or nonunion arthrodesis and pseudoarthosis are considered to be synonymous terms, and what code should be assigned for documentation of ‘nonunion of fusion’ or ‘non-union of arthrodesis’?

Response:
VICC research indicates that nonunion and pseudarthrosis are synonymous terms which is supported by the enquirer’s clinical advice that ‘nonunion fusion’ is the same as pseudarthosis following fusion. As arthrodesis is a form of fusion, ‘nonunion of arthrodesis’ is also considered to be the same as pseudarthrosis.

Therefore, VICC advises for documentation of nonunion of fusion or nonunion of arthrodesis to assign M96.0 Pseudarthrosis after fusion or arthrodesis following the Index entry Pseudarthrosis, pseudoarthrosis (bone)/joint, following fusion or arthrodesis.

VICC also notes the category title M84.1 Nonunion of fracture [pseudarthrosis] includes the term pseudarthrosis in square brackets. As the Conventions used in the Tabular List of Diseases section titled Square Brackets [ ] dot point one advises square brackets are used to enclose synonyms or alternative terms, therefore VICC considers this to support that the terms nonunion and pseudarthrosis/pseudoarthrosis are synonymous within the ICD classification.


Query Text:
ACS 0051 – Same-day endoscopy - Diagnostic says “assign codes for all other findings as additional diagnoses”.

On our colonoscopy operation reports, some of our clinicians’ document “moderate looping difficulties” or “scope inserted with moderate looping difficulties”. 

We are trying to determine:
1. Whether we need to code looping difficulties as additional diagnosis because it is a finding on the op report and does not need to meet the criteria in ACS 0002?
2. If we are coding looping difficulties, would K63.8, other specified disorders of intestine, be the correct code to use?

Search details:

Disease
-Intestine
- - specified NEC

Response:
VICC research indicates that looping difficulties can be due to multiple causes including patient anatomy, patient position, or procedure technique. Therefore VICC does not consider looping difficulties to be a condition and as such no code should be assigned unless there is documentation of a pathological condition or disease process for which a code can be assigned. VICC acknowledges the Index entry Loop/intestine K56.2 however, this Index entry cannot be followed for documentation of ‘looping difficulties’ alone.  

VICC advises that in the instance ‘looping difficulties’ result in the colonoscopy being abandoned, apply ACS 0019 Intervention abandoned, interrupted or not completed and assign Z53.3 Procedure abandoned after initiation, as an additional diagnosis. If there is documentation of a condition resulting in the abandonment also assign a code for this condition as an additional diagnosis. The nature of the looping difficulties may be queried with the clinician.


Query Text:
We often see documentation of plastic surgery for conditions that are not recognised by ICD-10-AM e.g. excess size breasts. ACS 1204 Plastic Surgery states that when the condition is not specified, or is a term not recognised by ICD-10-AM (e.g. ageing face), assign Z41.1 Other plastic surgery for unacceptable cosmetic appearance or Z42.- Follow-up care involving plastic surgery as the principal diagnosis, as appropriate.

The Conventions used in the Tabular List of Diseases states that “when a clinician uses terminology that is not listed in the ICD-10-AM Alphabetic Index, seek clarification for alternative terms that are listed in ICD-10-AM. If no alternate description is provided, to utilise one of the following strategies” with Example 44 instructing to follow index pathway for Disease/site.
 
ACS 0001 Principal diagnosis also states: “In determining principal diagnosis, the coding directives in the ICD-10-AM manuals take precedence over all other guidelines (see ICD-10-AM Tabular List: Conventions used in the ICD-10-AM Tabular List and ICD-10-AM Alphabetic Index: Conventions and general arrangement of the ICD-10-AM Alphabetic Index)”.

1. Can VICC please clarify, does the specialty standard ACS 1204 Plastic surgery override the instructions in the Conventions used in the Tabular List of Diseases and ACS 0001 Principal diagnosis? 

2. Can we seek further documentation from the clinician of alternative terminology which best reflects the condition in these circumstances?

3. In the absence of further documentation, can we follow the Conventions used in the ICD-10-AM Tabular List (Example 44) to assign a code for disease of the specified site e.g. disease breast? Or does the instruction in ACS 1204 require that either Z41.1 / Z42.- be assigned?

Response:
VICC notes the Introduction to the Australian Coding Standards which states:
‘The level of detail in the ACS reflects the assumption that users of the document will have had training in abstracting relevant information from health care records and in the use of ICD-10-AM and ACHI. It is assumed that clinical coders are aware of, and follow, ICD-10-AM and ACHI conventions in the first instance.’

VICC also notes the Guidance in the use of ICD-10-AM of the ICD-10-AM Diseases Tabular which states:
‘In order to classify accurately, it is essential to have a working knowledge of medical science and to understand the characteristics, terminology and conventions of ICD-10-AM. The ICD-10-AM Alphabetic Index contains many terms not included in the ICD-10-AM Tabular List, and clinical classification requires that the Alphabetic Index, the Tabular List and the Australian Coding Standards are all consulted before a code is assigned.’

Guidance in the use of ICD-10-AM in the ICD-10-AM Diseases Tabular Introduction lists the steps to follow when classifying diseases:
1. Identify in the current episode of admitted care, the clinical concept requiring classification (see also ACS 0001 Principal diagnosis and ACS 0002 Additional diagnoses).
Avoid indiscriminate coding of irrelevant information, such as symptoms or signs characteristic of the diagnosis (see also General standards for diseases).
Note: Certain symptoms represent important problems in medical care in their own right and may at times require code assignment (see also the Instructional note at the beginning of Chapter 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified).
2. Locate the lead term in the appropriate section of the ICD-10-AM Alphabetic Index. The lead term is usually a noun, but may be an adjective or eponym, identifying the pathological condition or injury.
• Follow any Instructional note(s) that appear under the lead term
  •	 Note any terms enclosed in parentheses (i.e. nonessential modifiers; they do not affect code assignment), as well as any terms indented under the lead term (i.e. subterms; these essential modifiers may affect code assignment), until the clinical concept has been accounted for
  •	 Follow carefully any cross references (see and see also).
Note: A code in the ICD-10-AM Alphabetic Index with a dash in the fourth or fifth position identifies that a fourth or fifth character is required for a valid code. The additional characters are located in the ICD-10-AM Tabular List.
3. Refer to the ICD-10-AM Tabular List to verify the suitability of the code selected:
• Be guided by any Instructional notes (e.g. 'Inclusion' terms, 'Includes' and 'Excludes' notes, 'Code also', 'Use additional code') at the selected code, or at the chapter, block or category.
4. Refer to the Australian Coding Standards:
• First, refer to the General standards for diseases
•	 Refer to any specialty standards, as indicated by an ACS symbol in the ICD-10-AM Tabular List
5. Refer to national Coding Rules, as appropriate
6. Assign the code.

Therefore, VICC advises the Australian Coding Standards and ICD-10-AM Coding Conventions should be used in conjunction with each other. In this instance ACS 1204 Plastic Surgery would be applied following the steps to classifying diseases in the Guidance in the use of ICD-10-AM in the ICD-10-AM Diseases Tabular Introduction as it is the next step after the conventions.

For example, when the documented principal diagnosis is ‘’excess size breasts’’, in the absence of further documentation that allows a condition of the breast to be coded, VICC advises to assign Z41.1 Other plastic surgery for unacceptable cosmetic appearance or Z42.- Follow-up care involving plastic surgery following ACS 1204 Plastic surgery. 

When a documented condition is not indexed, Conventions used in the ICD-10-AM Tabular List example 44 cannot be applied to assign a code for disease of a specified site e.g. disease breast as referring to Australian Coding Standards is the next step in the Guidance in the use of ICD-10-AM.

VICC does however consider it is appropriate to seek further documentation from the clinician regarding alternative terminology which reflects the medical condition as per ACS 0010 Clinical documentation and general abstraction guidelines.


Query Text:
When a patient is transferred from another hospital or another care type with an infection that is still being treated and with documentation in the preceeding episodes indicating the infection had antibiotic resistance, are we able to code the resistance?

Please note, it is not uncommon for regional sites to get patients who have been in metropolitan hospitals for weeks and come to them for step down care.

Response:
For the scenario cited, providing the infection meets ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses, VICC considers it appropriate to assign a code for the infection, the infectious agent and the drug resistance provided the resistance is documented in supporting clinical notes from the referring hospital or within the current episode.

This is in accordance with ACS 0112 Infection with drug resistant microorganisms, Classification section which states ‘If the clinician has documented in the record that the organism causing the infection is resistant to an antibiotic or other antimicrobial drugs, then the appropriate code from Z06.- Resistance to antimicrobial drugs must be assigned as an additional code to identify the antibiotic or other antimicrobial agent to which the organism is resistant’. ACS 0010 Clinical documentation and general abstraction guidelines, section titled Roles and responsibilities in the documentation and abstraction process states ‘information from the health care record outside of that directly relating to the current episode of care can help to inform code assignment, and such sources can be used to gain further specificity on documentation contained within the current episode of care’.

As per VICC #3628 Drug resistance VICC considers that it is appropriate to query the resistance, when it is only documented on the pathology result, provided an infection and associated organism is documented as per ACS 0112 Infection with drug resistant microorganisms, and the infection meets ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.


Query Title:
Carrier of drug resistant microorganisms

Query Text:
Coding Rule Q3173 Carrier of drug resistant microorganisms was retired on 30/06/2019. 

Could VICC please review this query and advise if the information is still current?

Whilst this query asks what codes are assigned for carrier of/colonisation with drug resistant microorganisms, the answer only mentions how to code carrier of a drug resistant microorganism. Does the answer also apply when there is documentation of colonisation? 

ACS 0112 Infection with drug resistant microorganism distinguishes between 'infection' caused by an organism and 'colonisation' with an organism. It states that the presence of an infection (wound infection, urinary tract infection, pneumonia, etc.) must be documented and coded in accordance with ACS 0002 Additional diagnoses before additional codes can be assigned for the organism, or the condition coded as being due to the organism. If the clinician has documented in the record that the organism causing the infection is resistant to an antibiotic or other antimicrobial drugs, then the appropriate code from Z06.- Resistance to antimicrobial drugs must be assigned as an additional code to identify the antibiotic or other antimicrobial agent to which the organism is resistant.

Where colonisation of an organism is documented and meets ACS 0002 (e.g. documented clinical assessment, diagnosis and plan of care) should this be coded to Z22 Carrier of infectious disease, as there is no Index entry for colonisation?

Response:
VICC advises that as IHPA Coding Rule Q3173 Carrier of drug resistant microorganisms is retired the information is no longer considered current and cannot be used to inform code assignment. VICC agrees with the enquirer that IHPA Coding Rule Q3173 Carrier of drug resistant microorganisms did not specifically adddress the colonisation component of the question.

VICC sought clinical advice which confirmed carrier and colonisation of an organism to be synonymous. VICC therefore advises where colonisation of an organism is documented and meets ACS 0002 Additional diagnoses, a code from category Z22 Carrier of infectious disease should be assigned, following Index entry Carrier (suspected) of.


Query Title:
Diffuse large B-cell lymphoma of CNS not specified as primary

Query Text:
Coding Rule Q3356 CNS lymphoma states that for primary central nervous system diffuse large B-Cell lymphoma assign C72.9 Malignant neoplasm, central nervous system, unspecified.

What codes are assigned for a central nervous system diffuse large B-cell lymphoma which is not specified as primary?

Response:
VICC sought clinical advice which indicates that primary CNS lymphoma and CNS lymphoma are not necessarily the same condition; primary CNS lymphoma is a distinct disease entity that occurs only in the CNS (brain and spinal cord); CNS lymphoma usually implies primary CNS lymphoma, however it can also represent systemic disease that has spread to the CNS.

VICC notes IHPA Coding Rule Q3356 CNS Lymphoma and the Index have ‘primary’ as an essential modifier. Therefore for documentation of central nervous system diffuse large B-cell lymphoma not specified as primary, VICC advises to follow Index entry Lymphoma (malignant)/B-cell NEC/diffuse large (anaplastic) (centroblastic) (DLBCL) to assign C83.3 Diffuse large B-cell lymphoma and M9680/3 Lymphoma, large B-cell, diffuse NOS. 

VICC considers that it is appropriate to seek clinical clarification in the absence of the term 'primary'.


Query Text:
Principal diagnosis: Biliary colic
Operations/ Procedure: Laparoscopic cholecystectomy

1.Can VICC please provide advice on what is the correct code to assign when there is documentation of biliary colic?

When discussed with one of our surgeons, it appears that it is a term used to describe symptomatic cholelithiasis without cholecystitis and is not the same as choledocholithiasis.

The index leads us to code calculus of bile duct. (K80.5-)

-- Colic (recurrent)
--- Biliary
---- Other/unspecified 

Normally there is no evidence of a calculus in the bile duct. The histopathology would usually indicate presence of gallbladder calculi.

In such cases, is it appropriate to code calculus in bile duct and an additional code to identify the calculus in gall bladder, as there are no inclusion / exclusion notes present at either of these codes?

Search Details
-- Colic (recurrent)
--- Biliary
---- Other/unspecified

Response:
Clinical advice and research indicates biliary colic can be caused by a calculus blocking the cystic duct or the common bile duct and the term can be used interchangeably. However, ICD-10-AM classifies biliary colic without further specification to category K80.5 Calculus of bile duct without cholangitis or cholecystitis, following the Index entry Colic (recurrent)/biliary.
  
For documentation of biliary colic, VICC advises that if there is further specificity of the site of the calculus, for example in a radiology or histopathology report, which confirms there is no calculus in the bile duct and that calculi are in the gallbladder or cystic duct, assign a code for cholelithiasis by following Index entry Calculus, calculi, calculous (impacted) (recurrent)/gallbladder or Calculus, calculi, calculous (impacted) (recurrent)/cystic duct. This is in accordance with ACS 0010 Clinical documentation and general abstraction guidelines section titled Test results and medication charts/Findings that provide more specificity about a diagnosis.


Query Text:
At our hospital we have had several patients recently who have had a Fanelli stent inserted.

These patients had a laparoscopic cholecystectomy and were also noted to have choledocholithiasis. During the surgery an intraoperative cholangiogram was performed and then a guidewire was passed into the cystic duct, through to the common bile duct and then the duodenum. The stent was passed over the guidewire into the common bile duct and deployed. 

We note the following index entries:
Insertion
- stent
--biliary tract (open) NEC 90337-00 [958]
---with examination of common bile duct 30454-00 [963]
---endoscopic (with dilation) 30491-00 [958]
---percutaneous (with dilation) 30492-00 [958]

In our episodes the Fanelli stent was inserted during a laparoscopic procedure.

Can VICC please advise what code should be assigned for insertion of a Fanelli stent?

When a biliary stent is inserted during a laparoscopic cholecystectomy, is it correct to follow the index: Insertion/stent/biliary tract (open) NEC and assign 90337-00 [958] Other stenting of biliary tract?

Response:
VICC sought clinical advice which advised that insertion of a Fanelli stent during a laparoscopic cholecystectomy is considered to be an endoscopic insertion. It is noted in the query that the stent was inserted via the intraoperative cholangiogram which involves placing a catheter into the cystic duct, that is, an endoscopic insertion. 

Therefore, VICC advises to assign 30452-01 [958] Choledochoscopy with stenting following Index entry Insertion/stent/common bile duct (endoscopic) (with dilation) for documentation of insertion of Fanelli stent into the common bile duct during laparoscopic cholecystectomy.

For documentation of insertion of Fanelli stent into the biliary system but not specified as into the common bile duct, assign 30491-00 [958] Endoscopic stenting of other parts of biliary tract following Index entry Insertion/stent/biliary tract (open) NEC/endoscopic (with dilation).


Query Title:
Deep vein thrombosis (DVT) due to arm port

Query Text:
Could you please assist with what codes would be assigned for a patient that has an axillary DVT due to their arm port?
 
We note example 4 in ACS 1904 Procedural complications, but we have a definite link between the device and the DVT.

We also note the exclusion note on T82.82 for 'postprocedural DVT' which indicates that I80.- should be used. Would this be in addition to T82.82 or instead of T82.82? Or should we just assign T82.82 and ignore the exclusion note?

Response:
VICC notes that as per ACS 1904 Procedural complications DVT is an example of a medical condition that is commonly seen in the postoperative period, not solely related to the procedure performed, but related to the complex interaction between the disease process and the procedure (that is, the cause of the condition is multifactorial). Therefore, VICC advises that when DVT is documented as a postprocedural DVT and there is no causal link between the DVT and a vascular device then the Excludes note at T82.82 Embolism and thrombosis following insertion of cardiac and vascular prosthetic devices, implants and grafts should be followed to assign a code from category I80 Phlebitis and thrombophlebitis alone.

However, for the scenario cited, as there is a documented link between the DVT and the vascular device (‘due to’), VICC advises the correct code to assign is T82.82 Embolism and thrombosis following insertion of cardiac and vascular prosthetic devices, implants and grafts following Index entry Complication(s) (from) (of) /vascular/device, implant or graft/thrombosis. The Excludes note should not be followed in this scenario. 

VICC also advises that an additional code from category I80 Phlebitis and thrombophlebitis should not be assigned to identify the site of the DVT. This is in accordance with IHPA Coding Rule TN1504 Eleventh Edition ACS 1904 Procedural complications – additional code to add specificity which states ‘The instruction in the ACS regarding ‘an additional code from Chapters 1 to 19 may be assigned where it provides further specificity’, is intended to provide further specificity of the condition, not an anatomical site’. This is consistent with IHPA Coding Rule Q3610 Vena cava thrombus or pulmonary embolism due to central or peripheral vascular catheter.


Query Text:
In our jurisdiction, preoperative COVID-19 testing is being undertaken routinely for elective and emergency surgical patients (according to certain restriction zones, screening checklists and clinical scenarios – as per DHHS guidelines and mandates). Whilst this is often done in a pre-admission/ outpatient setting, it is also performed for inpatients. 

These patients are:
• Asymptomatic for COVID
• The reason for presentation is another condition (not related to COVID) 
• Are not high risk for COVID (i.e. do not have another clinical reason for testing, such as immunosuppression etc)
• Have not had exposure to COVID
• Test result is negative
• COVID is rarely documented in the notes, only in path as a result

Is it the intent of IHPA’s How to Classify COVID-19 advice to assign Z11.5 Special screening examination for other viral diseases and U06.0 Emergency use of U06.0 [COVID-19, ruled out] for every such episode in accordance with Table 1c Suspected COVID-19 as reason for presentation, ruled out cases – Mandated screening by authority Symptoms = No, Exposure = No? 

If so, the tables in the How to Classify COVID-19 document are misleading as they are labelled “Suspected COVID-19 as reason for presentation”, which is not the case. The reason for presentation is not related to COVID and the testing is routine. 

Also, as per our last point, if the testing and/or the result of the COVID-19 swab is not documented outside of the pathology results, are we not to assign any codes according to the How to Classify COVID-19 document? (as per the Admitted care FAQs – Part 1, Application of U06.0 Emergency use of U06.0 [COVID-19, ruled out] for admitted patients with a negative test result for SARS-CoV-2 (COVID-19) “ACS 0010……….Do not use test result values, descriptions, medication charts, symbols and abbreviations in isolation to inform code assignment”. This is reiterated in Admitted care FAQs – Part 2, Application of U06.0 Emergency use of U06.0 [COVID-19, ruled out]. Therefore, are we to query every episode to assign Z11.5 and U06.0 to ensure data consistency?

Admitted care FAQs – Part 2, Application of U06.0 Emergency use of U06.0 [COVID-19, ruled out] does not apply as this refers to scenarios where COVID-19 is a differential diagnosis or there is a decision to rule out for other reasons (we assume other clinical reasons as paragraph 2 goes on to additional codes for observation for suspected conditions or exposure to communicable diseases).


Search Details
IHPA How to Classify COVID-19
Admitted care FAQs Parts 1 and 2
DHHS - COVID-19 screening for elective and emergency surgery patients in Victorian hospitals v.2
DHHS - Preoperative COVID-19 testing of elective and emergency surgery patients in Victorian hospital FAQ v2
ACS 0010/0002

Response:
IHPA has advised that the IHPA website ‘How to classify COVID-19’ remains the primary source of information on how to classify COVID-19. Queries that are frequently asked or appear to be common to the majority of jurisdictions are progressed for publication.

For guidance on assignment of Z11.5 Special screening examination for other viral diseases refer to COVID-19 Frequently asked questions – admitted care part 1 FAQ titled Assignment of Z11.5 Special screening examination for other viral diseases to rule out COVID-19, which says that Z11.5 is not assigned when a decision is made to routinely test for COVID-19 during an admission. Therefore it is not the intent to assign Z11.5 Special screening examination for other viral diseases for episodes where routine testing for COVID-19 occurs.

For the scenarios cited, VICC advises to apply the advice in COVID-19 Frequently asked questions – admitted care part 1 FAQ titled Application of U06.0 Emergency use of U06.0 [COVID-19 ruled out] for admitted patients with a negative test result for SARS-CoV-2 (COVID-19).

As per COVID-19 Frequently asked questions – admitted care part 3 FAQ titled Clinical documentation to support assignment of U06.0 Emergency use of U06.0 [COVID 19, ruled out], U06.0 Emergency use of U06.0 [COVID 19, ruled out] can be assigned where clinical documentation indicates that testing for COVID-19 has occurred but the presence of COVID-19 has been ruled out by virtue of a negative test result for SARS-CoV-2. The specific terminology of ‘ruled out’ is not required in order to assign this code. 

ACS 0010 Clinical documentation and general abstraction guidelines section Guidelines for generating appropriate queries to clinicians provides guidance about when it is appropriate to query a clinician. VICC considers this guidance would apply equally to this scenario as any other.


Query Title:
Using test results to add specificity - post discharge

Query Text:
Our question is in regards to pathology results not available on discharge but available post discharge and if we can use these to add more specificity to the documented conditions. 

ACS 0010 states that “test results may be used by the clinical coder to provide greater specificity to an already documented condition/diagnosis”

1) For example: 

Patient admitted with gastroenteritis (also the Principal diagnosis on discharge summary) – no test results available on discharge; however on coding, results were available indicating campylobacter. 

In the example provided, are we allowed to code A04.5 Campylobacter enteritis, provided that gastroenteritis is an already documented condition and campylobacter adds more specificity to the diagnosis?

If so, could VICC please provide clarification on what is classed as adding specificity?

2) Sometimes the discharge summary would indicate “results pending” or sometimes they are not mentioned on the discharge summary at all. We would like some clarification on when we are allowed to use the test results to add specificity, if they are not mentioned in the progress notes & the discharge summary?

3) Can we generalise the answers provided, for other conditions such UTIs and swabs available post discharge?

Response:
VICC advises that the same process for using test results to add further specificity to already documented conditions available during an admitted episode applies to when the test result becomes available after discharge.

To add specificity is to provide more detail about an already documented condition. Therefore, provided the test is performed during the episode and is related to a documented condition which meets ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses, then it is appropriate to use the results to add specificity even if results are returned post discharge. This applies to any documented condition where test results can add specificity to a documented condition as per ACS 0010 Clinical documentation and general abstraction guidelines, example 10. 

In the example cited it is appropriate to assign A04.5 Campylobacter enteritis for a diagnosis of gastroenteritis provided there is no conflicting documentation in the body of the record as to the cause of the gastroenteritis. Note that Index entry Gastroenteritis has a ‘see also’ Enteritis, under which campylobacter is an essential modifier. 

In relation to a diagnosis with the results listed as ‘pending’, for example, a clinical diagnosis of UTI but urine test is listed as pending, if the test results show an organism is cultured, the code for the organism can be assigned in addition to the UTI code. However, if the only documentation in the episode was ‘cloudy urine’, then even if an organism was cultured, UTI could not be coded unless the diagnosis of UTI was clarified with the clinician.


Query Text:
We have observed documentation of primary biliary cholangitis used interchangeably with primary biliary cirrhosis (both abbreviated as PBC). Clinician queries indicate both names refer to the same condition.

What is the correct code to assign for primary biliary cholangitis?

Response:
Clinical advice sought by VICC confirmed that primary biliary cholangitis and primary biliary cirrhosis are the same condition and that there was an official change from cirrhosis to cholangitis (the new term) in 2015. Coders may see variability in application because the change in terminology has taken some time to filter through.

Notwithstanding the clinical advice, VICC advises that the correct code to assign for documentation of primary biliary cholangitis is K83.0 Cholangitis following Index entry Cholangitis (ascending) (primary) (recurrent) (sclerosing) (secondary) (stenosing) (suppurative) as cholangitis is the lead term.  

VICC notes Index entry Cirrhosis, cirrhotic/biliary (cholangiolitic) (cholangitic) (hypertrophic) (obstructive) (pericholangiolitic)/primary cannot be followed for primary biliary cholangitis because there is no documentation of cirrhosis. 

VICC acknowledges the condition will be classified to different codes depending on the documentation.

You may wish to make a public submission to IHPA to improve the ICD-10-AM classification for primary biliary cholangitis.


Query Title:
Excludes note at O36 Maternal care for other known or suspected fetal problems

Query Text:
Excludes notes at O36 says:

Excludes: labour and delivery complicated by fetal stress [distress] (O68.-)
 
Does this mean we cannot use O36.5 Maternal care for poor fetal growth and O68.0 Labour and delivery by fetal heart rate anomaly together.

My interpretation is if the fetal heart rate was ‘known’ prior to labour we cannot use the codes from Category O36. However, if the patient was admitted for a specific reason (IUGR) but during labour fetal distress is discovered (unrelated to the known IUGR) then both codes apply. 

In our scenario, the patient was admitted for IOL due to IUGR later in labour fetal distress with fetal decelerations.

Response:
VICC advises that the Excludes note at O36 Maternal care for other known or suspected fetal problems 'Excludes: labour and delivery complicated by fetal stress [distress] (O68.-)' does not preclude the assignment of a code from O68 Labour and delivery complicated by fetal stress [distress] when a patient is admitted for induction of labour due to intrauterine growth retardation (IUGR) and later in labour has fetal distress with fetal decelerations. The Excludes notes is warning the coder that labour and delivery complicated by fetal stress [distress] is coded elsewhere (O68.-).
 
Therefore in the scenario cited it is appropriate to assign both O36.5 Maternal care for poor fetal growth and O68.0 Labour and delivery complicated by fetal heart rate anomaly.


Query Title:
Skip lesions or metastases in Ewing's sarcoma

Query Text:
A patient diagnosed with Ewing's sarcoma for femur. Their disease is described on discharge summary as "Primary site - R) distal femur, bone and skip lesion R) proximal femur, small lesions L) proximal femur - Presumed pulmonary disease, multiple small lung nodules bilaterally." The skip lesion has been listed on the staging report as bone metastasis.

Reading about skip lesions I found this definition:

Skip metastases are foci of tumor cells within the same bone as the primary lesion but are separated from the primary focus by normal intervening marrow
https://pubs.rsna.org/doi/pdf/10.1148/rg.281075015 
see p 282

This type of documentation in discharge summary and staging report plus the definition of the skip lesion/metastasis would support the coding of the metastatic bone site. However due to the skip lesion being of the same bone site is it still alright to code this as a metastatic site?

Response:
VICC advises for the scenario cited as there is documentation on the staging report of bone metastases, it is correct to assign C79.5 Secondary malignant neoplasm of bone and bone marrow for documentation of the skip lesion as per ACS 0010 Clinical documentation and general abstraction guidelines, section titled Test Results and Medication Charts, subsection titled Findings that provide more specificity about a diagnosis.

However, clinical advice obtained by VICC indicates that skip lesions are not necessarily synonomous with metastases. Therefore in the absence of documentation to support metastases, clinical clarification would need to be sought.


Query Text:
A patient was admitted to our hospital with a full thickness perforated gastric ulcer due to excessive NSAID use. She was taken to theatre where a laparotomy and omental patch repair of the gastric antral ulcer was performed.

VICC query #3062 Repair of perforated ulcer, explains how to code a perforated duodenal ulcer.

Can the committee please advise how an omental patch repair of a gastric ulcer should be coded?

Search Details
VICC query #3062 Repair of perforated ulcer

Response:
As omental patch repair uses a piece of omentum to repair a stomach ulcer, for the scenario cited VICC advises to assign 90304-00 [887] Other repair of stomach following Index entry Repair/stomach NEC.


Query Text:
The ACHI code 96037-00 [1824] Other assessment, consultation or evaluation includes:
Assessment NOS
Consultation NOS
Evaluation NOS
Interview NOS

The ACHI code 96090-00 [1869] Other counselling or education includes:
Counselling NOS
Education NOS

For example: 

A urology nurse practitioner reviews the patient.
Sometimes, this nurse specialist could be working on behalf of an urologist and do the routine post procedural reviews. As most of these reviews are for day procedures, sometimes they have a documented care plan and sometimes they do not.

The other times they could be working as a specialist nurse referred for continence issues. These assessments usually result into documentation of a diagnosis with a proper care plan.

Could the VICC please clarify what would be the right code to assign in either of these scenarios?

Response:
VICC advises that as per ACS 0016 General procedure guidelines, many procedures may meet the definition of a clinical intervention but if they are routine in the treatment of the diagnosis being coded, it may not be necessary to code them.  

A review by a clinician is expected or inherent in the diagnostic or therapeutic treatment plan of a patient and is not coded. However, this does not prevent a hospital from assigning a code for internal reporting purposes, but transmission of the code to the VAED must be suppressed.


Query Title:
Admission for CADD loading for chemotherapy

Query Text:
VICC query 2571 Loading of drug delivery device advises that if the patient only has their CADD loaded (even if it starts infusing whilst the patient is still in hospital) only 96209-00 [1920] Loading of drug delivery device is assigned. If the patient has both their CADD loaded and a separate IV infusion of an anti-neoplastic agent, both 96209-00 [1920] Loading of drug delivery device and 96199-00 [1920].

This advice appears inconsistent with Coding Rule TN207 Insulin pumps which advises that where insulin is administered via an insulin pump as the principal treatment in same-day episodes of care, assign both: 
96200-06 [1920] Subcutaneous administration of pharmacological agent, insulin 
96209-06 [1920] Loading of drug delivery device, insulin.

The ‘code also’ note in the Tabular List for 96209 Loading of drug delivery device instructs to ‘code also when performed: administration of agent - see Alphabetic Index: Pharmacotherapy/by route.’ This note does not state that administration of agent must be via a separate infusion.

ACS 0044 Pharmacotherapy states to assign the ACHI code for pharmacotherapy when a patient receives pharmacotherapy for a neoplasm or neoplasm (treatment) related condition. Therefore, should 96199-00 Intravenous administration of pharmacological agent, antineoplastic agent be assigned when infusion of chemotherapy via a CADD starts during the episode?

Search Details
VICC query
Loading of Drug Delivery Device
Publication Date: December 2010 
Implementation Date: 1/07/2020 
ICD 10 AM Edition: Seventh edition 
Query Number: 2571
We would like clarification on what procedure codes are to be assigned when a patient is admitted for loading of a CADD with an anti-neoplastic agent as per the following advice from the Hospital Admission Policy Chemotherapy Fact Sheet 1.7.10: 
"...However, there is a 'code also' instruction against the load drug delivery device codes, which requires health services to code for the administration of a specific agent. The department anticipates that the majority of 9620900 admissions should also have 9619900 coded. As such, these episodes would be Automatically Admitted." 

Does this mean we can routinely assign 96209-00 [1920] and 96199-00 [1920] when a patient is admitted for loading of a CADD only? 
Response
VICC advises that if the patient only has their CADD loaded (even if it starts infusing whilst the patient is still in hospital) only 96209-00 [1920] Loading of drug delivery device is assigned. 

If the patient has both their CADD loaded and a separate IV infusion of an anti-neoplastic agent, both 96209-00 [1920] Loading of drug delivery device and 96199-00 [1920] Intravenous administration of pharmacological agent is assigned. 

Please note that 96209-00 [1920] Loading of drug delivery device is on the not automatically qualified for admission list of the Victorian Hospital Admission Policy effective 1 July 2010. [end of VICC query 2571]

Coding Rule
Ref No: TN207 | Published On: 15-Sep-2007 | Status: Updated | Updated On: 15-Jun-2019
Insulin pumps
Q:
What is the correct code to assign for insulin delivered via an insulin pump? 
A:
An insulin pump is not implanted in the body. It is a small, pager-sized device you wear or carry. It is made up of a pump reservoir (like a regular syringe) filled with insulin, one or more small batteries, and a simple programmable interface. It is connected to the body via a thin tube, called an infusion set, which delivers small, constant amounts of insulin via a subcutaneous cannula attached to a small needle. In most cases patients insert and change the cannula/needle themselves, every 2-3 days, at home. The insulin pump is programmed (by the user) to administer a basal rate of insulin continuously throughout the day and night, depending on individual needs. Patients activate the pump to deliver a bolus dose of insulin during meals. Patients may also administer a bolus dose in response to high blood glucose levels. Insulin pumps contain ultra short acting insulin only. Patients may be admitted to hospital for fitting/commencement of an insulin pump or conversion to a new pump. Administration of insulin via an insulin pump is not normally coded as per ACS 0042 Procedures normally not coded:
Drug treatment should not be coded except if:
• the substance is given as the principal treatment in same-day episodes of care 
• drug treatment is specifically addressed in a coding standard (see ACS 0044 Pharmacotherapy, ACS 1316 Cement spacer/beads and ACS 1615 Specific diseases and interventions related to the sick neonate) 
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 
96209-06 [1920] Loading of 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: 
96209-06 [1920] Loading of drug delivery device, insulin
This advice has a minor modification to correspond with an update in a subsequent edition of ICD-10-AM/ACHI/ACS. [end of Coding Rule TN207]

ACS 0044 Pharmacotherapy
ACHI CLASSIFICATION
When a patient receives pharmacotherapy for a neoplasm or neoplasm (treatment) related condition multiple times during an episode of care, and the same ACHI code applies, assign the ACHI code once only.

Tabular List
96209-00 Loading of drug delivery device, antineoplastic agent 
A drug delivery device is an (external) infusion pump that is attached to a vascular access device or venous, spinal or other catheter to infuse substances over long periods of time
Filling of infusion device or pump (external)
Includes: maintenance such as:
• connection
• disconnection
• flushing
• injection of isotope to test pump
Code also when performed:
• administration of agent - see Alphabetic Index: Pharmacotherapy/by route
Excludes: maintenance (alone) (13942-02 [1922])
96199-00 Intravenous administration of pharmacological agent, antineoplastic agent 
Administration of pharmacological agent via:
• infusion port
• Port-A-Cath
• reservoir (subcutaneous)
• vascular access device
• venous catheter
Code also when performed:
• insertion, removal or revision of vascular access device (see block [766])
• loading of drug delivery device (96209 [1920])
Excludes: surgical catheterisation with administration of pharmacological agent (see block [741]). [end of ACS 0044]

Response:
VICC advises a CADD commencing to infuse is not the same as a patieint receiving a dose of insulin or antineoplastic agent. VICC interprets the sentence in the IHPA Coding Rule TN207 'If the patient's pump is loaded with insulin but they do not receive a dose during the episode of care…' to mean a bolus dose as opposed to the pump starting to infuse whilst the patient is still admitted. Therefore VICC does not consider VICC #2571 Loading of drug delivery device to contradict IHPA Coding Rule TN207 Insulin pumps.

In order to apply the 'code also when performed note' at 96209-XX Loading of drug delivery device (agent) there needs to be evidence of administration of chemotherapy by other routes or an additonal dose of chemotherapy during the episode in addition to the loading of the CADD. Please note that CADD loading alone does not meet criteria for reporting to the VAED.


Query Title:
Two or more diagnoses equally meeting the definition of principal diagnosis

Query Text:
I have recently been informed by an auditor that in the absence of a discharge summary or letter we should be looking for the "last documented entry" by the treating clinician in the medical record to determine what the pdx should be. It will be the first mentioned condition in that entry. This information was backed up by a publication from a private auditing company. I couldn't find any references elsewhere. I find this difficult to understand. The last entry is often referring to the current status of the patient and not particularly at any conditions that have resolved. Does the committee agree with the auditor? This would be a change of practice for my coding team.

Response:
VICC advises that a publication from a private auditing company is not considered ratified coding advice and therefore cannot be applied. 

Clinical coders must code in accordance with Australian Coding Standards and ratified national and state coding advice; there is no ACS or ratified national or state advice that supports the statement that the ‘last documented entry’ by the treating clinician in the medical record is the principal diagnosis. There are instances where the last documented entry may describe a condition that was not present at admission and therefore cannot be the principal diagnosis.

Therefore, when determining principal diagnosis follow ACS 0001 Principal diagnosis and other relevant ratified coding advice. If the principal diagnosis is unable to be determined from the documentation available, clinical clarification should be sought.


Query Title:
Nephrostomy with insertion of ureteric stent

Query Text:
Recently we have a patient admitted who had a nephrostomy performed through which a ureteric stent was inserted.

The procedure was performed in the radiology department using a needle, guidewire and fluoroscopic guidance. The procedure is percutaneous in nature, however, there is no documentation of ‘percutaneous’.

We note the two index entries below, both of which contain ‘percutaneous’ as an essential modifier.

Nephrostomy (open) (with drainage) 36552-00 [1056]
-with
--endoscopic biopsy of kidney 36561-00 [1047]
--nephrolithotomy — see Nephrolithotomy
--pyelolithotomy — see Pyelolithotomy
-percutaneous (closed) 36624-01 [1042]
--insertion of ureteric stent 36604-00 [1042]
---with
----balloon dilation (kidney) (kidney and ureter) (ureter) 36607-00 [1042]
----removal of calculus (kidney) (kidney and ureter) (ureter) 36605-00 [1042]


Insertion
-stent
--ureter (closed) (endoscopic) (JJ stent) 36821-01 [1067]
---with percutaneous nephroscopy
----and incision of
-----renal calyx 36633-01 [1043]
-----renal pelvis 36633-00 [1043]
-----ureter 36633-02 [1043]
---via
----percutaneous nephrostomy tube
-----with
------balloon dilation 36607-00 [1042]
------removal of calculus 36605-00 [1042]
-----using interventional techniques 36604-00 [1042]

Current National Coding Advice pertaining to percutaneous procedures :
Ref No: Q3130, CT guided core biopsy of the lung, Published On: 15-Mar-2017 
Ref No: Q3451, ACHI code for percutaneous cholecystostomy, Published On: 16-Dec-2019 

Can the committee please advise what procedure code should be assigned for the situation outlined above?

Response:
VICC notes procedures performed in radiology departments are usually percutanous in nature. VICC considers, for the scenario cited, the documentation that the procedure was performed ‘using a needle, guidewire and fluoroscopic guidance’ are indicators that the procedure was percutaneous. Therefore, VICC advises the correct code to assign is 36604-00 [1042] Passage of ureteric stent via percutaneous nephrostomy tube using interventional techniques following Index entry Nephrostomy (open) (with drainage)/percutaneous (closed)/insertion of ureteric stent.  

VICC notes the decision to code as percutaneous or other approach will be dependent on documentation. If documentation is unclear clarification should be sought from the clincian. 

VICC advises if the approach cannot be determined as percutaneous, for nephrostomy with insertion of ureteric stent, assign 36821-01 [1067] Endoscopic insertion of ureteric stent following Index entry Insertion/stent/ureter (closed) (endoscopic) (JJ stent) and 36552-00 [1056] Nephrostomy following Index pathway Nephrostomy (open) (with drainage).


Query Title:
Coding of a device or implant that is compromised by a delirious patient

Query Text:
A patient was transferred to our hospital for ongoing care of delirium following surgery for a humeral fracture (ORIF).

During the admission the patient became increasingly agitated and confused and started picking at the humeral surgical site. This created an open wound resulting in a large amount of bleeding and exposure of the metalware. The orthopaedics registrar was called to review the patient and removed a loose, protruding screw. The patient was then transferred back to the original hospital under their orthopaedic unit for further care.

I have read NCA Ref No: TN1504 ACS 1904 Procedural complications – due to/related to prosthetic devices, implants or grafts – Example 4: Urethral trauma/injury sustained from displacement of an indwelling catheter, but am not sure if this advice is applicable in this scenario.

Can the committee please advise how to code scenarios when a device is compromised by a patient who is delirious or has a mental condition, and the resultant compromise meets the criteria for coding?

Can the committee please advise what diagnosis codes should be assigned to capture the loose, protruding screw in the above scenario?

Response:
In answer to the first question, VICC considers it is difficult to provide general advice as the coding would be dependent on the specific scenario and the nature of the compromise.

VICC notes IHPA Coding Rule TN1504 ACS 1904 Procedural complications – due to/related to prosthetic devices, implants or grafts has been superseded by IHPA Coding Rule Q3503 Eleventh Edition ACS 1904 Procedural complications – due to/related to prosthetic devices, implants or grafts effective 1 October 2020.

Unlike example 4 in IHPA Coding Rule Q3503, where there was no resulting problem with the catheter, in this scenario there is a complication with the screw which requires intervention. 

Therefore, VICC advises for the scenario cited the correct code to assign for the loose, protruding screw is T84.1 Mechanical complication of internal fixation device of bones of limb following Index entry Complication(s) (from) (of)/orthopaedic/device, implant or graft/mechanical NEC/internal fixation device (any bone, except limb)/limb bone.  

Provided the open wound meets ACS 0002 Additional diagnoses, a code from category S41 Open wound of shoulder and upper arm is also assigned with external cause code Y34 Unspecified event, undetermined intent following Index entry External Causes of Injury/Injury, injured (accidental(ly)) NEC/self-inflicted (unspecified whether accidental or intentional) because the open wound was due to trauma (patient interference with the wound) and was not a complication of the surgical wound.

VICC advises the delirium or mental health condition could be coded if it was documented as an underlying cause of an injury, as per ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.


Query Title:
Assignment of supplementary code for obesity from BMI

Query Text:
ACS 0010 Clinical documentation and general abstraction guidelines states ‘Do not use test result value, descriptions, medication charts, symbols and abbreviations in isolation to inform code assignment.’

ACE Q3482 ‘Supplementary U code for obesity’ advises that documented components of a malnutrition screening tool, including body mass index (BMI), are not considered diagnoses for classification tools.

BMI scores are inherently a test result. Can VICC please clarify if the ACE advice regarding the BMI pertains only to malnutrition screening tools, or other forms of documentation (e.g. EMR fields, anaesthetic record, progress notes)? Can a supplementary U code for obesity ever be assigned from a BMI score alone in the absence of documentation of the word ‘obesity’?

Response:
VICC advises that IHPA Coding Rule Q3482 Supplementary U code for obesity applies to malnutrition and other screening tools. VICC does not consider the Coding Rule advice applies to EMR fields, anaesthetic records or progress notes.

VICC advises a supplementary U code for obesity can be assigned from a BMI score, provided it is appropriately documented (e.g. not on screening forms or patient completed forms) and is in the BMI range for obesity (BMI ≥ 30.00 kg/m2).

Although BMI is not indexed under subterm Supplementary/codes for chronic conditions, as the chapter code for obesity can be assigned from documentation of BMI ≥ 30.00 kg/m2 as per the Index entry BMI (body mass index), VICC considers it appropriate to assign the supplementary chronic condition code U78.1 Obesity when the obesity does not meet criteria for coding.

VICC also notes that BMI≥ 30.00 kg/m2 is listed as an inclusion term under code U78.1 Obesity.


Query Title:
Spinal cord compression not due to a neoplasm

Query Text:
This patient was admitted to our hospital with C6/C7 spinal cord compression due to displacement of the intervertebral disc. Anterior cervical discectomy and fusion (ACDF) was performed and the operation report documents that the cord was well decompressed.

We have assigned M50.0 Cervical disc disorder with myelopathy, by following the Index:
Compression
- spinal (cord) 
--by displacement of intervertebral disc NEC 
---cervical M50.0

We note that code M50.0 Cervical disc disorder with myelopathy, does not reflect that the patient has ‘cord compression’.

In September 2020 IHPA published coding rule Q3489 Spinal cord compression secondary to a neoplasm. The coding rule advises:

'Where spinal cord compression is documented as due to a neoplasm, assign:
A code for the neoplasm from Chapter 2 Neoplasms (C00-D48) with appropriate morphology code
G99.2* Myelopathy in diseases classified elsewhere
G95.2 Cord compression, unspecified
Sequence codes in accordance with the guidelines in ACS 0001 Principal diagnosis and ACS 0002 Additional diagnoses.

Follow the ICD-10-AM Alphabetic Index:
Myelopathy
- in (due to)
- - neoplastic disease NEC (M8000/1) (see also Neoplasm) D48.9+ G99.2*  
Compression
- spinal (cord) G95.2'

In this advice two codes are assigned in order to classify the concept of cord compression due to another condition (in this case a neoplasm).

Can the committee please advise when coding cord compression due to non-neoplastic conditions and a myelopathy code is assigned, should G95.2 Cord compression, unspecified also be assigned to fully classify the clinical concept into code?

Can the committee advise how spinal cord compression due to displacement of the C6/C7 intervertebral disc should be coded?

See also: TN219 Spinal cord compression secondary to neoplasm, 15 Sep 2004 (RETIRED - 30 Jun 2019)

Response:
VICC advises that the assignment of G95.2 Cord compression, unspecified as an additional code will be dependent on the condition being coded and if the clinical concept of cord compression is dealt with in the Index entry. 

For documentation of spinal cord compression due to displacement of the C6/C7 intervertebral disc, the clinical concept of cord compression is captured through the Index entry Compression/spinal (cord)/by displacement of intervertebral disc NEC/cervical. Therefore, the only code assigned is M50.0 Cervical disc disorder with myelopathy.


Query Text:
A patient was admitted to our hospital with a left ear cholesteatoma recurrence and proceeded to have a revision left canal wall up mastoidectomy.

There is no ACHI index entry for revision of a canal wall up mastoidectomy but there is an index entry for revision of intact canal wall technique mastoidectomy. Following this index entry 41566-00 [327] Revision of intact canal wall technique mastoidectomy, is assigned.

NCA Q2932 Transmastoid repair of tegmen defect with ossicular chain reconstruction (OCR) states: 
A transmastoid repair of tegmen defect with ossicular chain reconstruction (OCR) is also described as a 'canal wall up mastoidectomy' meaning the external auditory canal is kept intact i.e. an intact canal wall technique is used.

Can the committee please advise whether the background information in Q2932 regarding canal wall up mastoidectomy, can be used when coding revision canal wall up mastoidectomy? i.e. canal wall up is synonymous with intact wall.

Can the committee please advise what code should be assigned for the documentation of revision canal wall up mastoidectomy?

Search Details
NCA Q2932 Transmastoid repair of tegmen defect with ossicular chain reconstruction (OCR)

Response:
VICC research supports IHPA’s research that ‘canal wall up’ is synonymous with the ‘intact canal wall’ technique as advised in IHPA Coding Rule Q2932 Transmastoid repair of tegmen defect with ossicular chain reconstruction (OCR). 

Therefore, for documentation of revision canal wall up mastoidectomy, VICC considers the appropriate ACHI code is 41566-00 [327] Revision of intact canal wall technique mastoidectomy following Index entry Mastoidectomy (cortical) (simple)/revision/intact canal wall technique (with myringoplasty).


Query Title:
Admission for insertion of port and chemotherapy multi day admissions

Query Text:
We often see patients admitted for a multi-day stay admission, with a port inserted first and then administration of chemotherapy for their malignant neoplasm. We are seeking advice regarding principal diagnosis selection for the following common scenarios:
Scenario 1 – Principal diagnosis on discharge summary is elective admission for port insertion with further documentation on discharge summary and progress notes for port insertion and chemotherapy for cancer.

Scenario 2 – no discharge summary available and therefore no principal diagnosis documented.  Progress notes documentation for insertion of port and then chemotherapy to start next day for cancer treatment.
We are finding that there are differing views on how these scenarios should be coded.  

For scenario 1, some state that ACS 0001 should be applied and that the admission for the port insertion is the reason for admission as documented on the discharge summary and therefore is the principal diagnosis. They then follow the Index pathway for Admission/insertion of device – see Fitting.  Fitting/vascular access device (infusion port) (Port-A-Cath) (reservoir) to assign Z45.2 Adjustment and management of vascular access device.  The Excludes note at Z45.2 that excludes that for pharmacotherapy for neoplasm (Z51.1) is not being followed because they say this only applies for same day (Z51.1) cases.

Others are disagreeing that the Excludes note at Z45.2 can be ignored as a convention and are then applying ACS 0044 Pharmacotherapy to assign the cancer as the Principal Diagnosis (following the logic in the Multi-day episodes of care for pharmacotherapy for neoplasm section and examples).
For Scenario 2 we are finding most coders would assign the cancer as the principal diagnosis as although the port insertion is documented first, the reason for admission is treatment of the cancer and the port is inserted first to enable the chemotherapy to be administered.

We have been unable to find current advice which clarifies the correct principal diagnosis selection in these scenarios.  We have also noted the advice given in VICC #3439 Principal diagnosis selection for insertion of a continuous glucose monitoring (CGM) device.  The response was “VICC advises that if the documented condition is unstable type 1 diabetes, it is correct to assign the unstable type 1 diabetes as the principal diagnosis for a same day admission for an insertion of a continuous glucose monitoring device. A code from the Z40 - Z54 range would only be assigned in the absence of a documented condition.”

Can the logic that a code from the Z40 - Z54 range would only be assigned in the absence of a documented condition be applied to other scenarios such as admission for port insertion and chemotherapy for malignant neoplasms? 

There is also a note at categories Z40 – Z54 which states: Categories Z40–Z54 are intended for use to indicate a reason for care. They may be used for patients who have already been treated for a disease or injury, but who are receiving follow-up or prophylactic care, convalescent care, or care to consolidate the treatment, to deal with residual states, to ensure that the condition has not recurred, or to prevent recurrence.

Can VICC please clarify the application of the Excludes note at Z45.2 and provide advice on the correct principal diagnosis selection in these scenarios?

Search details: 
ACS 0044 Pharmacotherapy
VICC Q3439 Principal diagnosis for a same day admission for an insertion of a continuous glucose monitoring device (CGM).  
VICC Q2127 Coding of cancer with insertion/removal infusaport – Retired 30/6/2010
VICC Q2147 Insertion and removal of infusaport  – Retired 30/6/2013
Coding Matters September 2008 Volume 15, Number 2 Retired 30/6/2019

Response:
In accordance with ACS 0044 Pharmacotherapy, Classification section Multi-day episodes of care for pharmacotherapy for neoplasm, VICC advises for the scenarios cited the principal diagnosis is the neoplasm. Z45.2 Adjustment and management of vascular access device is not assigned. 

Even though the Excludes note at Z45.2 excludes that for pharmacotherapy for neoplasm (Z51.1) may only apply for same day episodes, Z45.2 would still not be assigned because in the scenarios cited, the neoplasm was the condition chiefly responsible for occasioning the episode of care and is therefore the principal diagnosis. The insertion of the port is part of the management and treatment of the neoplasm. 

This is supported by the note at category Z40-Z54 which states ‘Categories Z40–Z54 are intended for use to indicate a reason for care. They may be used for patients who have already been treated for a disease or injury, but who are receiving follow-up or prophylactic care, convalescent care, or care to consolidate the treatment, to deal with residual states, to ensure that the condition has not recurred, or to prevent recurrence.’ 

Therefore, Z45.2 Adjustment and management of vascular access device would only be assigned as principal diagnosis if the episode of care was for insertion of the port alone without commencement of treatment for the neoplasm.


Query Text:
Can the Committee please advise on the correct coding of Pregnancy Unknown Location (PUL)?

Occasionally patients are admitted with rising BHCG and abdominal pain and sometimes other symptoms. Ultrasound results don’t always show where the location of pregnancy is. That is the ultrasound could show “no intra/extrauterine pregnancy, ovaries NAD and no adnexal mass”.

Management can vary. Sometimes patients are sent home to return the next day to monitor BHCG levels and sometimes methotrexate is given. Querying with the clinician is not an option as this is their final diagnosis.

Response:
VICC acknowledges the difficulty in coding pregnancy of unknown location (PUL) as there is no specific code to assign. Assign codes for the presenting symptoms if PUL is the final diagnosis. 

VICC advises, if the classification criteria in ACS 1521 Conditions and injuries in pregnancy section titled Nonobstetric conditions complicating pregnancy have been met, assign a code from Chapter 15 Pregnancy, childbirth and the puerperium for a nonobstetric condition complicating pregnancy as per the Alphabetic Index, followed by an additional diagnosis code from another chapter to add specificity to the Chapter 15 code if appropriate.

For example, if the symptom is abdominal pain assign O99.8 Other specified diseases and conditions in pregnancy, childbirth and the puerperium following Index entry Pregnancy (single) (uterine)/complicated by/conditions in/R00-R99, followed by the appropriate code from category R10 Abdominal and pelvic pain. 

If the symptom is vaginal bleeding assign a code from category O46 Antepartum haemorrhage, not elsewhere classified following Index entry Pregnancy (single) (uterine)/complicated by/conditions in/N00-N99/N93.0-N93.9. An additional code code N93.9 Abnormal uterine and vaginal bleeding, unspecified is not required as it does not add specificity. 

If the classification criteria in ACS 1521 Conditions and injuries in pregnancy section titled Nonobstetric conditions complicating pregnancy have not been met, assign appropriate codes for the symptoms followed by Z35.8 Supervision of other high-risk pregnancies, following Index entry Pregnancy (single) (uterine)/supervision (for) (high-risk conditions and problems affecting management of pregnancy)/specified problem NEC.

If you consider these are frequently occurring scenarios you may wish to make a public submission to IHPA to improve the classification for pregnancy of unknown location.


Query Title:
Diabetes Mellitus with ARF due to colchicine (or other drug)

Query Text:
Can you assign E1x.29 for DM with ARF due to colchicine? There is no direct index pathway. ARF due to drugs - N14.1, Y54.8, Y92.23
N17-N19 excludes N14
Coding Rules June 2014 with update July 1 2017 "Contrast induced acute kidney failure (injury)" is specific to contrast only.

Response:
VICC advises that E1-.29 [type of] diabetes mellitus with other specified kidney complication is assigned for diabetes mellitus with acute renal failure because the Alphabetic Index contains the entry Diabetes, diabetic (controlled) (mellitus) (without complication)/with/failure/kidney/acute E1-.29. This is in accordance with ACS 0401 Diabetes mellitus and intermediate hyperglycaemia, Rule 3.

For documentation of ARF due to adverse effect of colchicine or other drug (drug-induced acute kidney failure), the correct code is N17.9 Acute kidney failure, unspecified following the Alphabetic Index entry Failure, failed/kidney/acute. 

VICC notes the Excludes note at N17-N19 Excludes drug- and heavy-metal-induced tubulo-interstitial and tubular conditions (N14.-), however codes in category N14 can only be reached through the lead term Nephropathy in the Alphabetic Index, which is not documented in this scenario. 

VICC also notes the advice in IHPA Coding Rule Q2768 Contrast induced acute kidney failure (injury) which states ‘However, assignment of N17.9 is incorrect if the Excludes note (which is consistent with ICD-10) at N17–N19 Kidney failure is followed:
“Excludes: drug- and heavy-metal-induced tubulo-interstitial and tubular conditions (N14.-)”

Analysis of code assignment in the data suggests it would be a major change in coding practice to assign N14.1 Nephropathy induced by other drugs, medicaments and biological substances rather than N17.9 Acute kidney failure, unspecified for contrast induced acute kidney failure (injury), therefore clinical coders should continue to assign N17.9 until further notice.’

VICC, therefore, advises the correct codes and sequencing for ARF due to colchicine are:
N17.9 Acute kidney failure, unspecified
Y54.8 Agents affecting uric acid metabolism
Y92.2- Health service area
E1-.29 [type of] diabetes mellitus with other specified kidney complication

Please also refer to VICC query #3802 Drug induced acute kidney impairment (AKI).

You may wish to submit a public submission to IHPA to improve the classification of drug-induced acute renal failure.


