# VICC queries

Query Title:
Interpretation of Vic 0002 Additional diagnoses

Query Text:
1. Vic 0002 specifies the requirement of a documented 'treatment plan' in order to meet certain criteria for assignment of an additional diagnoses code.
Could you please provide a definition with examples of what is considered to be acceptable documentation of a 'treatment plan'?

For example:
a. Nurse (Progress Notes): K 3.1 Slow K given. Medical Officer (Med Chart): Slow K ordered
b. Medical Officer (Progress notes): SPO2 88% Acute Respiratory Failure. Nurse (Progress Notes): O2 88% - oxygen commenced
c. Medical Officer (Progress notes): crackles SOB - physio. Physiotherapist (progress notes): crackles due to atelectasis
d. Surgeon (Operation report): adhesions divided
e. Medical Officer (Progress Notes): CCF. Plan Frusemide

2. Vic 0002 Point 1 states 'The short-term administration of treatment is not considered significant'.
a. Could you please provide a definition and further examples to better understand what is considered as 'short-term administration' - does this include factors such as duration or number of doses?
B. Could you please clarify how this impacts code assignment for more substantial clinical concepts than the examples used (i.e. pressure areas, iron deficiency, hypokalaemia vs 'headache', 'nappy rash')?

3. Vic 0002 Point 3 discusses increased clinical care and/or monitoring in the context of both 'management of the [specific] patient' and roneuti care for 'the condition'.
a. Could you please clarify how to determine what is routine care when applying this advice to;
i. Chronic conditions/diseases that require continued high level care on admission consuming hospital resources  (what is routine for that condition and what is routine for that patient e.g. MS, dementia, paraplegia, Parkinson's, cerebral palsy and requiring assisted ADLs, hoist transfers, reorientation, close supervision etc. )
ii. Patients transferred for ongoing management of conditions/diseases 
E.g. Patient admitted at hospital A for treatment of sepsis. Developed arrhythmia and was transferred to hospital B. Hospital B reason for admission was arrhythmia but treatment for sepsis was continued as planned at hospital A (not newly diagnosed and no change to treatment plan but continued active treatment).

Response:
1. A treatment plan is a plan of care that can appear in many parts of the medical record but would typically appear in the admission notes, the progress notes or on a care path. Treatment plans should be documented by a treating clinician including a diagnosis with a clear link to the planned treatment, or investigation.

All of the examples provided in the query are treatment plans/plans of care.

2. The term ‘short term’ has been removed from Vic 0002 Additional diagnoses to reduce confusion  related to this term. Please refer to the updated October release of the Victorian Additions to the Australian Coding Standards. 

3. Routine care is the care that is expected to be provided to the patient in the normal course of their surgical management or their recovery from a medical condition. It may include interventions or management that is provided to some but not all patients with that particular diagnosis or undergoing a specific intervention. Documentation of an intervention does not automatically justify the assignment of a diagnosis code, for example, replacement of an IV catheter that has fallen out does not justify the assignment of a code for complication of catheter.

With respect to chronic conditions, if the patient also had a chronic condition they may consume more resources than another patient having the same surgical procedure, or they may not. It should not be assumed that the patient would require increased clinical care because they have a chronic condition. In cases where there is no documented evidence of increased clinical care for a chronic condition apply ACS 0003 Supplementary codes for chronic conditions.  

Patients transferred for ongoing management of an acute condition/disease such as sepsis would generally have a treatment plan/plan of care documented on admission. If continued active treatment was provided and documented according to this treatment plan then the condition meets Vic 0002 Additional diagnoses 1a and a code would be assigned. 

Please see Feature Article: Application of Vic 0002 Additional diagnoses for further information and examples.


Query Text:
Could you please advise on the correct diabetes code for diabetes with osteoarthritis?

Clinical advice received has identified that osteoarthritis is a form of arthropathy therefore is it appropriate to use the look up term under Diabetes/with/arthropathy to assign E1x.61 Diabetes mellitus with specified musculoskeletal and connective tissue complication?

Response:
Arthropathy is a collective term for any disease of the joint, whereas osteoarthritis is a specific type of joint disease. 

Following the same logic as ACCD Coding Rules Query Q2871 Diabetes with gouty arthropathy, ICD-10-AM does not classify diabetes with osteoarthritis. Therefore it is not appropriate to use the lookup term under Diabetes/with/arthropathy to assign E1-.61 Diabetes mellitus with specified diabetic musculoskeletal and connective tissue complication when diabetes with osteoarthritis is documented. 

Each condition is coded individually if it meets criteria for coding.


Query Title:
Principal diagnosis in  same day endoscopy episode

Query Text:
With the new day case coding standards, we would like clarification of the status of the 'operative diagnosis'. The old standard has been retired as it was superseded by ACS 0046 which now no longer exists.

Our question - is an operative diagnosis considered a Principal diagnosis or a Finding?

The symptom is PR bleeding but the operative diagnosis states 'polyp' (which was snared).
If the operative diagnosis = a 'clearly documented' principal diagnosis and therefore ACS 0051 does not apply we would code the polyp as the PD.
OR
If the operative diagnosis is considered a "finding" and therefore ACS 0051 does apply  then PR bleeding would be PD with the polyp as additional diagnosis.

Response:
VICC advises that irrespective of the terms used in a form template, a causal link needs to be documented between the symptom and one of the findings.  If no causal link is documented, follow the guidelines in ACS 0051 Same-day endoscopy – diagnostic and code the indication/symptom as the principal diagnosis.


Query Title:
Definition of Clinician - ACS 0002 Vic additions

Query Text:
Would you please clarify ACS 0002 Vic additions as we are trying to follow these but are confused.
We are not sure what is meant by 'clinical' a 'treating clinician' in the following:
Point 1 'commencement, alteration or adjustment of therapeutic 
treatment' is significant when:
a) Treatment plan is commenced...following clinical consultation
b) Treatment plan is altered...following clinical consultation

Point 3 'increased clinical care and/or monitoring is more than routine...This would occur when:
c) The intention to provide increased monitoring is documented by a treating clinician.'

Point 1 - Does 'clinical' mean doctor? In the ACS introduon 'how to use this document' pg xv it says 'clinician refers to the treating medical officer but may refer to other clinicians such as midwives, nurses and allied health professionals. In order to assign a code associated with a particular clinician's documentation, the documented information must be appropriate to the clinician's discipline.' We have discussed documentation by a wound nurse or dietician and felt these could also mean 'clinical' because they ve expertise in the areas they are documenting.

Point 3 - The document uses "treating clinician" and we take this to potentially mean the actual clinician who treated the patient or wrote the notes. This would logistically be very difficult to send queries only to the treating clinician.

Although appreciating the intent of the Vic additions in mimimizing the coding of insignificant conditions, we are concerned at the potential loss of data if the Vic additions do, in fact, mean "doctor" and "treating doctor".

We appreciate your advice.

Response:
Vic 0002 Additional diagnoses uses the same definition of the term ‘clinician’ as the “How to use this document” section of the Introduction to the Australian Coding Standards, as follows:
The term ‘clinician’ is used throughout the document and refers to the treating medical officer but may refer to other clinicians such as midwives, nurses and allied health professionals.  In order to assign a code associated with a particular clinician’s documentation, the documented information must be appropriate to the clinician’s discipline.

A treating clinician refers to a health professional who has been involved in the management/treatment/planning for that patient. VICC considers the treating clinician to be the most appropriate health professional to give clinical advice in the first instance. However, when this is not possible it is appropriate to seek clinical advice from another clinician in accordance with the information in the introduction to the Australian Coding Standards ‘documented information must be appropriate to the clinicians discipline.’

Clinical consultation is an interaction between the clinician and the patient, or between multiple clinicians, or involves the clinician reviewing the patient’s results and determining a course of action, that results in documentation in the clinical record. This documentation is evidence of clinical consultation. The documentation may take the form of medication or test orders, additions to progress notes, and/or a plan of treatment/care/management elsewhere in the clinical record.

Please see Feature Article: Application of Vic 0002 Additional diagnoses for further information and examples.


Query Title:
Vic additions to the Australian Coding Standards

Query Text:
We seek clarification on:
· Whether the VICC additions to the ACS are applicable to Victorian private hospitals, as we note that the creation of the document was due to ‘DRG optimisation under AR-DRG V8.0;  We feel that this is not relevant, nor transferrable to our sites currently operating under a variety of DRG versions back to v4.2.
· Section 3b, which states ‘The intention to provide increased monitoring of a condition is documented by a treating clinician in the progress notes’.  In the private sector, it is necessary that clinical coders abstract information from sources other than the progress notes to assign a code or prompt a query, as per the guidelines in the ACS.  This is often due to the deficiencies in documentation in the private sector that prevent coders from abstracting information based on limited, but relevant information to the patient’s care.  Our question is what VICC advises if there is documentation of increasing monitoring of a condition(s) outside progress notes e.g. op and anaesthetic charts especially.

Response:
1. Victorian additions to the ACS supplement the advice in the ACS and apply to all Victorian coded data submitted to the VAED. This includes data submitted by private hospitals.

Although DRG optimisation under AR-DRG V8.0 expedited the introduction of Vic 0002 Additional diagnoses in Victoria ahead of national discussions, this was not the reason for its creation. The reasons for the creation of Vic 0002 Additional diagnoses are detailed in the Vic Additions to the Australian Coding Standards (ACS) document and are reproduced below.

Vic 0002 Additional diagnoses has been created in response to:
- An increase in coding queries to the Victorian ICD Coding Committee (VICC) regarding whether a condition meets criteria for coding
- The increased government focus on using coded data to monitor quality and safety outcomes for patients
- Recognition that clinical coders need clarity in interpreting ACS 0002
- Recognition that clinical coders need direction as to what constitutes significance for the purposes of the national morbidity data collection.

2. Vic 0002 Additional diagnoses has been amended to remove the words ‘in the progress notes’ from part 3b. As per the ACCD introduction 'analysis of the entire clinical record is performed before code assignment', a coder must use all available documentation to assist with code assignment. Vic 0002 Additional diagnoses does not change the requirement to use the entire medical record, just as ACS 0002 Additional diagnoses does not.


Query Text:
Please refer to attached operation report.

Based on this operation report and the guidelines in VIC Additions to ACS 0002 Additional diagnoses, is it appropriate to be querying the surgeon to determine the cause of the bleeding?

Also, how do you determine if the diathermy done to control the liver bleeding is routine or above routine care without querying the cause of the bleeding? And is it appropriate to query if the diathermy is routine or above routine care?

And so therefore, how do you establish if this liver bleed is significant or not without querying it? And how do you establish if the bleed was as a result of an accidental intraoperative injury if you can not query? Many accidental intraoperative injuries will not be coded if this is the case as many are never documented as such.

Response:
The operation report provided for this scenario states ‘Adhesions peeled off liver, mild bleed on liver surface controlled with diathermy’.  It would not be appropriate to write a documentation query to ask if this was an accidental intraoperative injury as the bleeding is already documented as due to the procedure of peeling off the adhesions.  By following the Index entry Bleeding/intraoperative NEC, T81.0 Haemorrhage and haematoma complicating a procedure, not elsewhere classified would be assigned if it meets Vic 0002 Additional diagnoses. 

As per Vic 0002 Additional diagnoses, documentation of an intervention does not automatically justify the assignment of a complication code, for example, when the intervention is routine care. However, VICC advises as there is clear documentation of an intervention being performed for the intraoperative bleeding, a documentation query may be sent to determine whether care or management is significantly beyond routine care as per ACS 1904 Procedural complications/Care beyond routine intraoperative/postoperative care.


Query Text:
Our hospital has a Nutrition and Dietician Assessment  form which has a front page with free style text box where a nutritional diagnosis is documented and tick boxes on the reverse side.

We sometimes have documentation of 'imbalance of protein energy' written on this form.

Following the index look up
Imbalance,
-Protein-energy (see also Malnutrition) E46
E46 can correctly be assigned.

On the reverse side of this form there is a section with  tick boxes (see examples of form attached) for:
'Well-nourished', 'mild to moderate malnutrition', 'severely malnourished' and 'at risk of malnutrition'

Could VICC  advise whether we can follow the index entry under Imbalance, protein-energy to assign E46 in the following cases (see examples provided) -
1. Protein energy imbalance documented on front of form AND 'well-nourished' ticked by dietician on back of form
2. Protein energy imbalance documented on front of form AND 'at risk of malnutrition' ticked by dietician on back of form

Response:
VICC advises that as per ACS 0002 Additional Diagnoses, conditions documented during a clinical assessment – such as on a Nutrition and Dietitian Assessment – should only be coded when they meet the rest of the criteria in ACS 0002 Additional Diagnoses or where the condition changes the standard treatment for a particular procedure/condition. 

Provided there is documentation for protein energy imbalance or malnutrition which meets ACS 0002 Additional diagnoses, E46 Malnutrition can be assigned.

From the information in the examples provided as there is no evidence of clinical significance a code cannot be assigned.


Query Title:
Victorian Additions to the Australian Coding Standards in the context of national coding advice

Query Text:
In the recently published Vic 0002 Additional diagnoses standard it is noted that for classification purposes a condition must be significant in order for a code to be assigned. Dot point 1 states the following:

1. Commencement, alteration or adjustment of therapeutic treatment is significant when one of the following occurs:
a) The treatment plan is commenced for a newly diagnosed condition following clinical consultation and documentation.
b) The treatment plan for a pre-existing condition is altered following clinical consultation and documentation.
c) A second health professional is engaged in determining the clinical care resulting in a documented change of treatment plan/management for the patient

The final paragraph of this standard states the following:
A symptom or condition that does not meet any of the requirements for significance outlined in this standard should not be the subject of a documentation query.

Bearing this in mind I would like to know how to deal with the following statement from the progress notes of a record: 'for commencement of K+ supplement'.

Clearly there is a treatment plan, however there is no condition documented for which the K supplement is to be commenced.

Can I generate a clinician query to ascertain why the potassium supplement was commenced?

The final line of the Vic 0002 standard appears to preclude the writing of such a query. However this identical scenario also appears in the ACCD's Tenth Edition education program in relation to the Standards for Ethical Conduct in Clinical Coding.

The example is:
Progress notes state: for commencement of K+ supplement
Ethical query: 
Please clarify the reason for potassium supplement:
- Hypokalaemia
- Prophylactic (to prevent hypokalaemia)
- Other (please provide clinical details)
- Unable to determine

My understanding has always been that national advice overrides the advice that is given at a state level.

Bearing this in mind, how can a query be disallowed according to a state ruling whilst the identical query is considered to be ethical from a national perspective?

Response:
Victorian additions to the Australian Coding Standards (ACS) supplement (not override) the advice in the ACS.

The sentence relating to documentation queries in Vic 0002 Additional diagnoses has been amended by adding the word ‘documented’ and is reproduced below:
A documented symptom or condition that does not meet any of the requirements for significance outlined in this standard should not be the subject of a documentation query. 

The Feature Article: Application of Vic 0002 Additional diagnoses goes on to clarify that ‘The clinician should not be queried to obtain documentation that the type of care delivered is significant when there is no basis in the record to support clinical significance’.

In the example cited a treatment plan for the commencement of a potassium supplement has been documented in the progress notes without a documented symptom or condition as the reason for its commencement. An ethical documentation query can therefore be generated to ascertain why the potassium supplement was commenced. 

Please see Feature Article: Application of Vic 0002 Additional diagnoses for further information and examples


Query Title:
Same day endoscopy - multiple endoscopies

Query Text:
Could you please confirm the expected application of ACS 0051 Same-day endoscopy - diagnostic and ACS 0052 Same-day endoscopy - surveillance in instances where a patient may have two scopes in the one episode where one scope meets the definition under ACS 0051 Same-day endoscopy - diagnostic and the other meets the criteria in ACS 0052 Same-day endoscopy - surveillance.

For example - Patient admitted for a gastroscopy and colonoscopy. Gastroscopy report indicated Abdominal Pain as the reason for the scope, colonoscopy reports indicates personal history of polyps as indication.

In the absence of a principal diagnosis documented or discharge summary provided how do we determine the principal diagnosis. Can both of these standards be applied in the same episode of care for each individual scope?

Response:
VICC advises when a patient has two scopes meeting the criteria of both same day endoscopy standards to apply ACCD Coding Rule TN1248 Tenth Edition FAQs Part 2: Same-day endoscopy which states ‘There is no hierarchy for assignment of the principal diagnosis…Follow the guidelines in ACS 0051 Same-day endoscopy – diagnostic and ACS 0052 Same-day endoscopy – surveillance where there are both diagnostic and surveillance endoscopies in the one episode. Then, apply the general principles in ACS 0001 Principal diagnosis to determine the principal diagnosis.  This has always been the case in these scenarios and has not changed with Tenth Edition’.

Note: This advice has been retired due to the retirement of TN1248 Tenth Edition FAQs Part 2


Query Text:
There is some confusion about the pathways when coding influenza, particularly influenza A. Our pathology reports simply state influenza A with no further clarification. Some of us are using J10.1 Influenza with other respiratory manifestations, other influenza virus identified, others are using J09 Influenza due to identified zoonotic or pandemic influenza virus. The two previous instructions have been retired and the ACS 1012 Influenza due to identified influenza virus doesn't seem to clarify it.

Response:
VICC advises as per ACS 1012 Influenza due to identified influenza virus, J09 Influenza due to identified zoonotic or pandemic influenza virus is only assigned for specific zoonotic or pandemic influenza strains.  At present, A/H5N1 [avian influenza] is the only type of influenza virus that is classified to J09.  

All other identified influenza virus strains (including where pathology states influenza A without further specification) should be assigned J10.- Influenza due to other identified influenza virus assigned.


Query Text:
The ACHI Index does not appear to provide a pathway leading directly to a code to classify the procedure of nerve root sleeve injection (NRSI).

Index pathways which have been considered are:

1.		 Administration/nerve/for/pain management-see Administration/specified site/nerve/by site

or

2.		 Administration/specified site/epidural/injection NEC

If the second option is the correct Index pathway, and both local anaesthetic and steroid are administered during the NRSI, should two codes be assigned?
18216-27 [32] Epidural injection of local anaesthetic following pathway Administration/specified site/epidural/injection NEC/local anaesthetic 
90028-00 [32] Epidural injection of steroid following pathway Administration/specified site/epidural/injection NEC/steroid 

Or one code?
90018-00 [32] Epidural injection of other or combined therapeutic substance following pathway Administration/specified site/epidural/injection NEC/combined substances 

Please advise the correct ACHI Index pathway to follow and code to assign to classify the procedure of nerve root sleeve injection?

Response:
For documentation of nerve root sleeve injection, VICC advises to assign a code from block [63] Administration of anaesthetic agent around other peripheral nerve following the pathway Administration/specified site/nerve and then by specific site. 

This is supported by the inclusion of nerve root in the Includes note at block [63] Administration of anaesthetic agent around other peripheral nerve;
Includes: administration around spinal nerve:
•	Branch
•	Plexus
•	Root.


Query Text:
The ACHI Index does not appear to provide a pathway leading directly to a procedure code to classify the insertion of a Bravo Capsule.

Internet research indicates that a Bravo Capsule is a device used for the measurement of gastroesophageal pH levels and transmits data to a recorder.

Possible Index pathway which may be appropriate is:
Monitoring/pH for assessment of gastro-oesophageal reflux (24 hours).
11810-00 [1859] Measurement of gastro-oesophageal reflux involving 24 hour pH monitoring

However, the specific terms in this pathway are not generally documented.

Please advise the correct ACHI Index pathway to follow, and code to assign to classify documentation of the insertion of a Bravo Capsule.

Response:
VICC agrees with the enquirer to assign 11810-00 [1859] Measurement of gastro-oesophageal reflux involving 24 hour pH monitoring when there is documentation that the procedure is being performed for gastro-oesophageal reflux as this is an essential modifier in the Index. 

As the capsule is usually placed via a gastroscopy, VICC advises to also assign a code for the gastroscopy when this is documented in the episode.


Query Text:
Patient admitted for radiofrequency of spinal nerves, not specified as the medial branch nerve or superior cluneal nerve or documented as a 'branch' of the spinal nerve.

For example, operation performed is documented as 'RF 4 levels lumbar spine bilateral'.

Index pathways which have been considered to classify the procedure of radiofrequency of spinal nerves are:

Radiofrequency - see also Destruction
Destruction/nerve - see also Neurotomy

Which Index pathway is then appropriate to follow?

Neurotomy/spinal/percutaneous 39115-00 [71] Percutaneous neurotomy of primary posterior rami of spinal nerve
Or
Neurotomy/spinal/percutaneous/branch, by/radiofrequency 39323-00 [72] Other percutaneous neurotomy by radiofrequency

Please advise the correct ACHI Index pathway to follow and code to assign to classify radiofrequency of spinal nerves, not specified as the medial branch nerve or superior cluneal nerve or documented as a 'branch' of the spinal nerve.

Search details:
ACCD Q2901 Radiofrequency pain management procedures (December 2014)

Response:
VICC advises to apply the same logic as in Coding Rule Q2901 Radiofrequency pain management procedures to classify radiofrequency of spinal nerves, including those not specified as the medial branch nerve or superior cluneal nerve or documented as a 'branch' of the spinal nerve. 

Assign  39323-00 [72] Other percutaneous neurotomy by radiofrequency following the pathway Radiofrequency-see also Destruction/nerve-see also Neurotomy/spinal/percutaneous/branch, by/radiofrequency.


Query Text:
To classify a gastric AVM, retired VICC query #2212 Bleeding gastric arterio-venous malformation advised to assign Q27.9 Congenital malformation of peripheral vascular system, unspecified following Index pathways:

Malformation (congenital) - see also Anomaly
Anomaly/artery (peripheral)

Is the advice in retired VICC query #2212 still applicable?
If no, please advise the correct Index pathway to follow and code to assign for gastric AVM.


Search Details
VICC query #2212 Bleeding gastric arterio-venous malformation (Retired 30/06/2010)

Response:
VICC advises that this query was awaiting a response to a query sent to ACCD regarding renal arteriovenous malformation, for which the ACCD advice was to code congenital AVM of the kidney to Q27.3 Peripheral arteriovenous malformation by following the ICD-10-AM Alphabetic Index:
Malformation (congenital) — see also Anomaly
- arteriovenous, aneurysmatic (congenital) Q27.3

Further to the ACCD advice, VICC noted that ”congenital, acquired or unknown origin of an AVM should be assigned Q27.3 Peripheral arteriovenous malformation as ‘congenital’ is a non-essential modifier in the Index entry mentioned above”. (See VICC query #3226 Renal arteriovenous malformation (AVM)).

Therefore, for gastric arteriovenous malformation, VICC advises to assign Q27.3 Peripheral arteriovenous malformation by following the ICD-10-AM Alphabetic Index:
Malformation (congenital) — see also Anomaly
- arteriovenous, aneurysmatic (congenital) Q27.3

The advice in retired VICC query #2212 Bleeding gastric arterio-venous malformation is superseded by the ACCD advice on the coding of arteriovenous malformation and will remain retired.


Query Title:
Rotablator of coronary artery with angiogram/angioplasty

Query Text:
Retired VICC #2552 Coronary angioplasty with rotablator and stent insertion advised to classify rotablator of coronary artery to PTCRA (Percutaneous Transluminal Coronary Rotational Atherectomy).

The ACHI Index has since been revised however 'rotablator' remains a non essential modifier. The suggested code in VICC #2552 requires lead term 'Atherectomy' or 'PTCRA' in the Index.

For documentation of angiogram/angioplasty with rotablator of coronary artery, without documentation of atherectomy or PTCRA, please advise the correct Index pathway to follow and code to assign.

Response:
VICC research indicates that rotablator by definition is a rotational atherectomy system.  Therefore VICC advises to look up the lead term Atherectomy to follow the Index entry Atherectomy/coronary artery/percutaneous transluminal rotational.


Query Text:
Macrosomia documented as the indication for obstetric care or intervention.

The ICD-10-AM Index does not appear to provide a pathway leading directly to a diagnosis code to classify the condition macrosomia.

Internet research indicates that macrosomia is used to describe a newborn that is large for gestational age.

Possible Index pathways which may be appropriate for this diagnosis:
Large-for-dates/affecting/management of pregnancy
Large-for-dates/affecting/labour or delivery

Please advise the correct Index pathway to follow and code to assign for macrosomia.

Response:
VICC research indicates that fetal macrosomia is defined as a fetus which is significantly larger than average for its gestational age. As ‘macro’ means ‘large’ VICC advises to follow the lead term Large/fetus – see Oversize fetus.  

You may wish to send ACCD a public submission to have macrosomia added to the Index as a lead term.


Query Text:
The ICD-10-AM Index does not appear to provide a pathway leading directly to a code to classify the diagnosis of Failed Neck Surgery Syndrome (FNSS).

We note that ICD-10-AM, Tenth Edition contains a code for failed back surgery syndrome and that retired advice, ACCD query Failed back syndrome (retired 30th June 2017) states that Failed back syndrome is a synonym for post laminectomy syndrome and therefore the correct code to assign is M96.1.  We often get documentation of FNSS (Failed Neck Surgery Syndrome), our research indicates that FNSS and FBSS are both terms used to describe pain that starts or persists after back or neck procedures.

Can we apply the same reasoning as the retired ACCD Failed Back Syndrome query and code FNSS to M96.1 Postlaminectomy syndrome, not elsewhere classified ?

If M96.1 is not appropriate for FNSS please advise the correct code to assign.


Search Details:
ACCD Failed back syndrome September 2016 (retired 30th June 2017)

Response:
VICC advises that the term neck is synonymous with cervical spine. Therefore it is correct to assign M96.1 Postlaminectomy syndrome, not elsewhere classified following the Index entry Failed/back syndrome.


Query Text:
Patient admitted for hip arthroscopy with debridement of labral tear.

VICC #2882 Femoro-acetabular impingement (FAI) indicates a labral tear of the hip is a tear of articular cartilage.

VICC #2882 Femoro-acetabular impingement (FAI) also indicates that the information provided in VICC #2391 Femoro-acetabular impingement is still current. VICC #2391 Femoro-acetabular impingement advises to follow Index pathway Debridement/joint/specific joint NEC 90574-01 [1561] Excision of joint, not elsewhere classified to classify debridement of a labral tear.

1.		 If a labral tear is classified as articular cartilage, is it more appropriate to follow Index pathway: Debridement/cartilage/with/any other orthopedic procedure - omit code?

2.		 If the Index pathway suggested in Question 1 is thought appropriate, is the 'omit code' convention applied and only a code for the hip arthroscopy would be assigned? Or hip arthroscopy is not considered to be 'any other orthopaedic procedure'?

There is not a subterm for 'as operative approach - omit code' after lead term 'Arthroscopy', unlike lead terms 'Arthrotomy' or 'Laparotomy' to exclude assigning a code for the hip arthroscopy if it can be determined that the arthroscopy is the approach only.

Please advise the correct ACHI Index pathway/s to follow and code/s to assign to classify the procedure of hip arthroscopy with labral debridement.

Please also consider/advise correct code assignment if other procedures (such as ostectomy or synovectomy) are performed in addition to the labral debridement during the hip arthroscopy.


Search Details
ACHI Index/Introduction/Conventions used in the Alphabetic Index of interventions/Cross references/Instructional references/Omit code
VICC #2882 Femoro-acetabular impingement (FAI) (2013-14 March Database)
VICC #2391 Femoro-acetabular impingement (FAI) (2007-08 June Database) - Retired
VICC #2559 Exploratory laparotomy in trauma episodes (2010-11 December database) - Retired

Response:
VICC advises that when hip arthroscopy with labral debridement is documented to assign 90574-01 [1561] Excision procedures on joint and other musculoskeletal sites following Index entry Debridement/joint/specific joint NEC or Debridement/cartilage/ joint NEC. As per ACS 0023 Laparoscopic/arthroscopic/endoscopic surgery also assign a code for the arthroscopy.


Query Text:
What is the most appropriate code to assign for a diagnosis of sputum retention? Assuming the conditions meeting the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnosis.

Response:
VICC advises that when sputum retention meets criteria for coding in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses, assign R09.89 Other specified symptoms and signs involving the respiratory system following the Index entry Symptoms specified/involving/respiratory system NEC.


Query Text:
ACS 1808 Incontinence states "Incontinence is clinically significant when the incontinence: is not clinically considered to be physiologically normal, is not clinically considered to be developmentally normal, or is persistent in a patient with significant disability or mental retardation. Urinary and faecal incontinence codes R32, R15 should be assigned only when the incontinence is persistent prior to admission, is present at discharge or persists for at least seven days." 
 
Victorians for many years now have adhered to this standard and have only assigned these codes when the above criteria has been met plus have required increased care.  The increased care means that incontinence pads have been changed, bed linen changed, the patient has been cleaned from urine and faeces etc.  At times multiple staff have been asked to assist in moving the patient to clean them up.  We acknowledge that ACS 0002 Additional diagnoses reporting referred to in other standards does not list ACS 1808 Incontinence so incontinence must still meet ACS 0002 Additional diagnoses.

Coders would not assign the incontinence code for the occasional incontinence episode where a pad has been changed.  This, according to ACS 1808 Incontinence is not clinically significant.

With the implementation of the Victorian additions to ACS 0002 Additional diagnoses, Point 3 states "Assignment of a code for the condition would not be justified when the condition receives routine care examples of routine care include but are not limited to: changing pads in a patient with known urinary incontinence."  Therefore, from July 2017, Victorian coders will no longer be assigning incontinence codes based on criteria in ACS 1808 Incontinence and ACS 0002 Additional diagnoses.

ACS 0604 Stroke, part 2 Severity also talks about “conditions listed here would be coded routinely during the abstraction process.  However, note that for a stroke case, dysphagia, urinary and faecal incontinence, should only be coded when certain criteria are met”.  When you refer to the table in that standard it states that both urinary and faecal incontinence “should be assigned only when the incontinence is present at discharge or persists for at least 7 days.”
 
So we can see that ACS 1808 Incontinence and ACS 0604 Stroke talk about when incontinence is clinically significant and should be coded when it meets the criteria plus is shown to be managed during the episode (ACS 0002 Additional diagnoses).  Can the Committee please specify what more does a coder need to see before assigning incontinence codes?  When does VICC deem incontinence clinically significant?

Can the Committee please provide an example of when the urinary/faecal incontinence meets the criteria in ACS 1808 Incontinence and ACS 0002 Additional diagnoses?

Response:
VICC considers the changing of pads and bed linen for urinary and faecal incontinence to be routine care. Incontinence may be considered significant when there is documentation of a plan of care, review and management by an incontinence nurse or urologist, urodynamic testing, investigation into the cause of incontinence, or diagnostic or interventional procedures. 

VICC acknowledges that the implementation of Vic 0002 Additional diagnoses will decrease the rate of incontinence being reported across Victoria.


Query Title:
VICC query #2752 Coding from nursing documentation

Query Text:
VICC Query #2752 Coding from Nursing Documentation was retired on 30 June 2017.

The query referred to documentation in the Introduction of ACS 'The term 'clinician' is used throughout the document and refers to the treating medical officer but may refer to other clinicians such as midwives, nurses and allied health professionals'.

The query response stated 'VICC considers that if a clinician has documented a condition, coders should trust that the clinician has documented appropriately to his or her discipline'.

Previously this query has been applied to code the principal diagnosis from nursing documentation for same day admissions when the documentation is appropriate to the nurse's discipline.

As VICC Query #2752 Coding from nursing documentation is now retired, please provide instruction for when there is a documented principal diagnosis by the nurse for same day admissions, i.e. anaemia.

Do we continue to follow advice and 'trust that the clinician has documented appropriately to his or her discipline'? Or does this documentation now require clarification with a medical officer?

Response:
VICC advises that the advice in VICC query #2752 Coding from nursing documentation advice is still accurate. Therefore, if a clinician has documented a condition, coders should trust that the clinician has documented appropriately to his or her discipline.


Query Text:
What is the correct code to assign for infection of skin flap? ACCD Coding Rules Q2811 states complication of skin flap should be coded to T86.88 Failure and rejection of other transplanted organ and tissue,  but this may need to be reviewed as there have been many new codes introduced. 

Which path should be followed in the Index? 

Complication/organ or tissue transplant, which leads to code T86.89 Other complications of transplanted organs and tissues, not elsewhere classified
Or 
Complication/graft/skin (flap)/infection/inflammation, which leads to code T85.78 Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts?

Response:
The codes for postprocedural complications have been extensively revised with the introduction of Tenth Edition. As such many existing queries that pertained to postprocedural complications, including ACCD Q2811, have been retired. 

VICC advises that for an infected surgically created skin flap the correct pathway to follow is Complication(s)/skin graft (flap) NEC/infection or inflammation to assign T85.78  Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts.


Query Title:
Coding and reporting of noninvasive ventilation hours for patient's own CPAP machine in ICU

Query Text:
1. Patient's own CPAP machine used while admitted in ICU and documented on ICU flow chart. 

Do these NIV hours need to be reported to VAED? We are unable to find instructions for this scenario. The only instruction from VAED (Coding and VAED reporting of ventilatory support July 2017) is 'The counting and duration of NIV in ICU is independent of the counting hours of NIV for coding'  but to report all CPAP/BIPAP hrs delivered in ICU.

Therefore, is it right to assume we report all CPAP/BIPAP hours regardless of whether it is the hospital's or patient's own machine used? Also, is it necessary for there to be clear documentation stating that medical/nursing staff are assisting patient with their CPAP machine?

2. Coding of CPAP in ICU. When patients own machine is used.

Is it correct to assume that when a patient is receiving CPAP in ICU via their own machine and CPAP hours are recorded by medical/nursing staff on the ICU flow chart, that all CPAP hrs received in ICU can be counted in order to assign the most appropriate CPAP procedure code. OR should medical/nursing staff  document that the patient required additional, beyond routine assistance with the use of their own CPAP machine before a code can be assigned?

Response:
Ventilation hours in ICU reflect the complexity of the patient. ACS 1006 Ventilatory support, classification point 1e states:
"Do not code ventilation when the patient brings their own ventilatory support devices (eg CPAP mahine) into hospital and the patient operates the device".

In the absence of documentation that the patient is operating their own CPAP machine themselves whilst in ICU:
- the hours of NIV can be coded in accordance with ACS 1006 Ventilatory support
- the hours of NIV in ICU should be reported to the VAED in accordance with the VAED Manual Reporting Guide.


Query Text:
Notwithstanding the fact that ACS 1436 Admission for trial of void has been deleted for Tenth Edition, is the advice in the retired VICC query #2714 ACS 1436 Trial of void still current?

#2714 ACS 1436 Trial of void Publication Date: 2011-12 June Database ICD 10 AM Edition: Seventh edition Retired Date: 30/6/2017.

Response:
VICC confirms that the advice in VICC query #2714 ACS 1436 Trial of Void is still current and is reproduced below:

As 'non-operative' is an essential modifier in the ACHI Index, VICC confirms that in the absence of documentation of 'non-operative' it is correct to assign the default code 36800-03 [1090] Endoscopic removal of indwelling urinary catheter following Index entry:

Removal
-catheter
--bladder (endoscopic) (indwelling) 36800-03 [1090]


Query Title:
Excision of muscle, bone or cartilage involved with lesion of skin

Query Text:
In ACHI there is a code 31340-00 [1566] Excision of muscle, bone or cartilage involved with lesion of skin.

Frequently we encounter situations where patients have a skin lesion excised and the clinician does not document that muscle, bone or cartilage was excised. However when the histology is reviewed the microscopic description will include one of these tissue types. E.g. 'sections show sun damaged skin including subcutis and skeletal muscle'.

In scenarios where the operation report does not state that muscle (or bone or cartilage) was excised yet the histology reveals that one of these tissues was obviously excised, can the code 31340-00 [1566] Excision of muscle, bone or cartilage involved with lesion of skin be assigned?

Or must the operation report specifically state that muscle (or bone or cartilage) was excised?


Search Details
Index
Excision
-muscle
--for lesion of skin 31340-00 [1566]

Tabular
31340-00 Excision of muscle, bone or cartilage involved with lesion of skin
Code first: excision of lesion of skin (31205, 31230, 31235 [1620])

Response:
In order to assign 31340-00 [1566] Excision of muscle, bone or cartilage involved with lesion of skin, a coder must follow one of the following Index entries:
Chondrectomy/for lesion of skin
Excision/bone/for/lesion of skin
Excision/cartilage/for lesion of skin
Excision/muscle/for lesion of skin
Myectomy/for lesion of skin

Therefore VICC advises that unless the operation report contains documentation or evidence supporting one of the above Index entries, or there is clinical documentation to support this, 31340-00 [1566] cannot be assigned.  This is regardless of the presence of muscle, bone or cartilage being identified in the specimen.


Query Title:
VICC Query #2692 Preparatory care for subsequent treatment retired

Query Text:
VICC Query #2692 Preparatory care for subsequent treatment was retired on 30 June 2017.

The query advised that Z51.4 Preparatory care for subsequent treatment, not elsewhere classified is assigned as principal diagnosis when the only documentation you have is preparatory care and there is no further documentation of the condition.

The query referred to scenarios that had documentation of work-up and a condition requiring treatment, and advised that the principal diagnosis for these scenarios would be the documented condition requiring treatment.

The query response stated Z51.4 Preparatory care for subsequent treatment, not elsewhere classified would only be assigned as an additional diagnosis when there is documentation of planning, work-up or similar.

As VICC Query 2692 Preparatory Care for Subsequent Treatment is now retired, please provide instruction for:

1. When there is no documentation of a condition and the only documentation we have is preparatory care, do we assign Z51.4 Preparatory care for subsequent treatment, not elsewhere classified as the principal diagnosis?

2. When there is documentation of both a condition requiring treatment and preparatory care, do we assign the documented condition requiring treatment as the principal diagnosis and Z51.4 Preparatory care for subsequent treatment, not elsewhere classified as an additional diagnosis?

3. Can Z51.4 Preparatory care for subsequent treatment, not elsewhere classified be assigned when there is documentation of planning, work-up or similar?

Response:
VICC considers that the advice in VICC query #2692 Preparatory care for subsequent treatment is still current.

Therefore it would be appropriate in scenario 1 to assign Z51.4 Preparatory care as principal diagnosis as there is no documentation of a condition requiring treatment.  

In scenario 2, VICC advises it is correct to assign the condition requiring treatment as the principal diagnosis, with Z51.4 Preparatory Care as an additional diagnosis only if it meets the criteria in ACS  0002 Additional diagnoses.

For question 3 VICC advises the terms ‘work up’ or ‘planning’ are synonymous with ‘preparatory care’.

Please also refer to ACCD Coding Rules Q2620 Principal diagnosis for insertion of fiducial markers and Q2687 Principal diagnosis for prophylactic PEG insertion prior to oropharyngeal radiation therapy.


Query Text:
1. Please advise the correct code assignment for a diagnosis of parainfluenza.

Our clinical advice explains that Parainfluenza is a viral disease in its own right, and could be described as an 'influenza-like disease'. Further, our respiratory PCR report displays parainfluenza as a distinct disease, similar to influenza or RSV.

The coding pathway for influenza-like disease leads to J10.1 Influenza with other respiratory manifestations, other influenza virus identified.

The coding pathway for other specified virus leads to B34.8 Other viral infections of unspecified site.

2. In light of this, please confirm the correct code/s to assign for a diagnosis of parainfluenza with acute bronchiolitis.

Our current practice is to assign J21.8 Acute bronchiolitis due to other specified organisms with an additional code of B97.8 Other viral agents as the cause of diseases classified to other chapters.

Response:
VICC research suggests that parainfluenza is a group of four viruses, each one having its own symptoms and illnesses.  Therefore for scenario 1, the correct diagnosis code for documentation of parainfluenza is B34.8 Other viral infections of unspecified site, following  Index entry Virus/specified.

In regards to scenario 2, VICC agrees with the enquirer to assign J21.8 Acute bronchiolitis due to other specified organisms with an additional code of B97.8 Other viral agents as the cause of diseases classified to other chapters for documentation of parainfluenza with acute bronchiolitis.

The enquirer may wish to send a public submission to ACCD to ask for an Index look up for parainfluenza.


Query Text:
Patient had bilateral below knee amputations many years ago and has had no problem until this admission when admitted with a new onset of cellulitis of amputation stump.  There is no documentation of "secondary to" or "due to" linking it to a post-procedural complication. I am unsure of the principal diagnosis.  

Codes I have considered are:

T87.4 Infection of amputation stump.  
Index lookup = infection, amputation stump (surgical). 
Is it correct to use this code if not documented as being a post procedural complication?
or
L03.13 Cellulitis of leg with additional code Z89.7 Acquired absence of both lower limbs.

Response:
VICC advises that in the absence of documentation which infers a causal link between the cellulitis and the procedure as per ACS 1904 Procedural complications, cellulitis of an amputation stump should not be coded as a complication. Therefore assign L03.13 Cellulitis of leg and Z89.7 Acquired absence of both lower limbs to identify the involvement of the amputation stump.


Query Text:
Research undertaken indicates that the terminology of 'Acute respiratory distress syndrome' is synonymously used with 'Adult respiratory distress syndrome'.

As there is no Index classification for acute respiratory distress syndrome, could VICC please advise if it is correct to assign J80 Adult respiratory distress syndrome when we have documentation of "Acute respiratory distress syndrome"?

Response:
VICC research indicates that adult respiratory distress syndrome and acute respiratory distress syndrome are synonymous terms.  As there is no Index classification for acute respiratory distress syndrome, VICC advises it is correct to assign J80 Adult respiratory distress syndrome when there is documentation of acute respiratory distress syndrome. Please note this query is not applicable to neonates.


Query Text:
ACS 0936 Cardiac pacemakers and implanted defibrillators outline various complications of the pacemaker or defibrillator system and their relevant codes. We often have documentation of 'high lead impedance' as either the reason for admission (PDx) or listed as a complication following insertion of a pacemaker/defibrillator and furthermore requiring revision of the affected lead.

Could VICC please advise the correct code assignment for high lead impedance?

Response:
VICC research indicates that lead impedence is the measurement of the sum of all resistance to the flow of current.  Therefore the amount of impedance impacts the current delivered by the lead.  If impedance increases, the current decreases, if impedance decreases, the current increases.  A wire fracture may cause the impedance value to rise because the fracture causes increased resistance to the current, and may prevent successful pacing or defibrillation, however impedence can also be influenced by the development of fibrotic tissue around leads that have been in place for some time.

Therefore, VICC advises that where high lead impedence is documented without documentation of a complication of the lead, to assign Z45.0 Adjustment and management of cardiac device as either the principal diagnosis or additional diagnosis as appropriate.


Query Text:
At our hospital we frequently encounter the term immunosuppressed.

An example of this was a woman who was admitted for a LLETZ. She had a history of a renal transplant and was on tacrolimus (an immunosuppressant) to prevent rejection. Notes from the attending doctor ordered that given her immunosuppression she be given metronidazole (oral) for 10 days.

There is no Index entry for immunosuppressed, but we note the following Index entries:

Immunocompromised status (acquired) (drug related) NEC D89.8 Other specified disorders involving the immune mechanism, not elsewhere classified
and
Immunodeficiency/drug related (acquired) D89.9 Disorder involving the immune mechanism, unspecified

Can the committee please advise how 'immunosuppressed' should be coded?

Response:
VICC sought clinical advice which stated that when there is documentation of a patient being ‘immunosuppressed’ it usually means by medical intervention rather than by disease, and that both (intervention and/or disease) result in immunocompromise. 

Therefore, VICC considers that ‘immunosuppression’ is synonymous with ‘immunocompromised status’ and that it is appropriate to assign D89.8 Other specified disorders involving the immune mechanism, not elsewhere classified, when one of these terms is documented, and it meets ACS 0002 Additional diagnoses.


Query Text:
Please advise the correct code for debridement of anal fissure / fistula.

Is it correct to follow the Index pathway below to assign destruction of other lesion or tissue of anus?

Destruction (ablation) (cauterisation) (coagulation) (cryotherapy) (diathermy) (HIFUS) (irreversible electroporation) (laser) (microwave) (radiofrequency) (thermotherapy)
-lesion (tissue) (tumour) - see also Destruction/by siteanus (open)

90315-01 [933] Excision of other lesion or tissue of anus

Anorectal myectomy
Destruction of lesion or tissue of anus
Excision of anal:
- fissure
- fistula NOS

Excludes: excision of anal fistula involving sphincter mechanism (32159-00, 32159-02, 32162-00, 32162-02 [937])

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

Debridement of an anal fistula/fissure is performed in conjunction with interventions at the same site (eg fistulotomy, lateral internal sphincterotomy, insertion of seton). Therefore, an ACHI code is not assigned for the debridement component, as per the guidelines in ACS 0016 General procedure guidelines which states:

Do not code procedures which are individual components of another procedure. These components would usually be considered a routine or inherent part of the more significant procedure being performed.

Note:  ACCD advised VICC that this query would not be published in CLIP.  Therefore VICC has published the query in accordance with the Committee's business rule to publish queries referred to ACCD that ACCD does not publish.


Query Text:
Can the VICC please advise the correct procedure code for removal of indwelling urinary catheter (IDC) for trial of void (TOV) admissions where there is no documentation of it being performed endoscopically?

Scenario one:
Admission for TOV post urethroplasty. 
IDC removed and patient had successful TOV

Scenario two:
Admission for TOV post hysterectomy.
IDC removed and patient had successful TOV

Index entry
Removal
-catheter
--bladder (endoscopic) (indwelling) 36800-03 [1090]
---with replacement 36800-01 [1090]
---nonoperative (nonendoscopic) NEC 92119-00 [1902]

36800-03 [1090] Endoscopic removal of indwelling urinary catheter
Excludes: that with replacement (36800-01 [1090])

92119-00 [1902] Removal of other urinary drainage device
Removal of indwelling urinary catheter
Excludes: endoscopic:
-removal of indwelling urinary catheter (36800-03 [1090])
-removal of ureteral catheter (92118-00 [1902])
-replacement of indwelling urinary catheter (36800-01 [1090])

36800-03 [1090] is on the Automatically Admitted Procedure List (AAPL) whereas 92119-00 [1902] is on the Not Automatically Qualified for Admission List (NAQAL).

We note that VICC Query # 2714 has been retired. Should coders continue to follow the logic in this query i.e. in the absence of documentation of 'non-operative', assign the default code?

Response:
VICC advises that the term 'endoscopic' is a nonessential modifier in the Index look up for 'Removal of indwelling catheter, bladder'.  Therefore the correct code to assign for both scenarios is 36800-03 [1090] Endoscopic removal of indwelling urinary catheter.

The advice provided in VICC #2714 is still correct. VICC advises to apply the default code unless there is documentation of 'non operative’ removal of catheter.


Query Title:
Postpartum conditions and nonobstetric conditions

Query Text:
Could you please advise on the correct way to code an episode in which a patient presents with a condition unrelated to pregnancy/puerperium and also has a condition that is a puerperal complication?  For example a patient presents 10 days post-delivery with viral gastroenteritis and is admitted for IV fluids.  During this episode she is commenced on antibiotics for a mild Caesarean wound infection.

In an antepartum or delivery episode of care, once one condition complicates pregnancy, all conditions are assigned appropriate obstetric chapter codes, as per ACS 1521 Conditions and injuries in pregnancy.  It would appear wrong to code the gastroenteritis as a postpartum complication, however ACS 1548 Puerperal/Postpartum Condition or Complication does not address what to do for scenarios such as this.

Should the codes be:
Pdx:       A08.4     Viral intestinal infection, unspecified
Adx:       O86.0    Infection of obstetric surgical wound
              Z39.0-   Postpartum care

Or           
Pdx:       O98.5    Other viral diseases in pregnancy, childbirth and the puerperium
Adx        A08.4     Viral intestinal infection, unspecified
             O86.0    Infection of obstetric surgical wound
             Z39.0-    Postpartum care

In the reverse, if the Pdx was the Caesarean wound infection and the patient was also treated for viral gastroenteritis, should the codes be:
Pdx:       O86.0    Infection of obstetric surgical wound
Adx:       Z39.0-    Postpartum care
              A08.4     Viral intestinal infection, unspecified

Thanks for your assistance.

Response:
VICC advises for the first postpartum scenario provided that the correct codes to assign are:

A08.4    Viral intestinal infection, unspecified
O86.0    Infection of obstetric surgical wound
Z39.0-   Postpartum care

VICC advises for the second scenario, if the principal diagnosis was the Caesarean wound infection and the patient was also treated for viral gastroenteritis which is a nonobstetric condition that is not documented as a postpartum complication, the correct codes to assign are:

O86.0    Infection of obstetric surgical wound
Z39.0-    Postpartum care
A08.4     Viral intestinal infection, unspecified

Following ACS 1548 Nonobstetric conditions in the puerperal period, dot points 3, 4 and Figure 1 - For all other admissions in the puerperal period (ie not in the delivery episode) assign a puerperal/postpartum code only for the condition with documentation indicating that the nonobstetric condition is a puerperal/postpartum complication.

Z39.0- is assigned as an additional diagnosis in both scenarios as the patient was readmitted within the puerperium period since delivering the baby/placenta and the mother has a puerperal/postpartum condition or complication.

Please also refer to VICC query #3344 Conditions/complications in the puerperal/postpartum period.


Query Text:
Pneumonia in patient from nursing home, documented as "facility acquired" pneumonia. Should Y95 nosocomial condition be documented for conditions acquired in nursing homes or hostels? ACCD Coding Rule July 2017 states Y95 is used to identify 'hospital or healthcare acquired' condition.

Response:
ACCD Coding Rule Q3132 Y95 Nosocomial condition July 2017 states that this code should be assigned for conditions that are acquired in hospitals or healthcare facilities. These include day procedure centres, health centres, hospices and outpatient clinics. ICD-10-AM classifies nursing homes and hostels as residential institutions. As such VICC advises that Y95 nosocomial condition should not be assigned for conditions documented as being acquired in nursing homes or hostels.


Query Title:
ACS 1521 Conditions and injuries in pregnancy - Fetal evaluation

Query Text:
ACS 1521 Conditions and injuries in pregnancy 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

1. Could you please confirm if an abdominal ultrasound in early pregnancy (to assess pregnancy location (ie. Intrauterine, tubal etc)) would be considered fetal evaluation?
2. If a patient were supervised / evaluated by a Gynaecologist, would this be a factor in meeting the criteria as complicating pregnancy?  For example, we have a patient admitted in early pregnancy for emergency appendectomy, the gynaecologist evaluated patient prior to surgery to assess fetal viability and attended the surgical procedure, as the patient was pregnant.

Response:
VICC advises that an abdominal ultrasound to assess pregnancy location would be considered to be fetal evaluation.
 
As a gynaecologist specialises in the female reproductive system, dealing with a wide range of issues including obstetrics, pregnancy and childbirth, VICC considers that supervision by a gynaecologist would meet the criteria in ACS 1521 Conditions and injuries in pregnancy under section Nonobstetric conditions complicating pregnancy.


Query Title:
Same day endoscopy for screening without further documentation of what is being screened

Query Text:
When a patient is admitted for a gastroscopy and/or colonoscopy with an indication of 'screening', when no further information is available what code would be assigned as Principal Diagnosis in the absence of being able to get a response from the treating clinician?

Z13.83 Special screening examination for digestive tract disorder
OR
Z13.9  Special screening examination, unspecified
OR
Other code

Response:
VICC advises that in the absence of documentation which specifies the condition that is being screened, the correct code to assign for the above scenario is Z13.9 Special screening examination, unspecified.

Note: This query was orignally published in March 2018 and retired 30 June 2020. The query has been reinstated as VICC considers the advice is still current for Eleventh Edition ICD-10-AM.


Query Title:
Documented BMI to enable code assignment of E11.72

Query Text:
If assigning a code for overweight or obesity from documentation of a BMI score, and the patient has Type II Diabetes, is it appropriate then to look up Diabetes /with / overweight or obesity? (even though the documentation present is a BMI score)?

Response:
VICC advises that as per ACCD TN1248 Subject: Tenth Edition FAQs Part 1: Obesity and BMI published 15 September 2017 for implementation 1 October 2017 it is appropriate to assign a code for Obesity based on a BMI score alone. 

Therefore use this logic to follow the pathway for diabetes/with/overweight or obesity to assign the correct code.


Query Text:
Could you please assist with the coding of this both diagnosis and procedure?  The patient presented via ED with a fracture/dislocation of humeral head.  The fracture and dislocation were reduced as GAMP in theatre.  The patient was returned to theatre in the same episode due to shoulder instability for 'remplissage of subscapularis into reverse Hill-Sachs lesion' (see operation report provided).

1. For the Hill-Sachs lesion should we be coding something in addition to the fracture/dislocation?  Is so what would this be?

2. For the procedure performed, the term 'remplissage' means 'to fill'. How do we code this? In the absence of indexing regarding this, we have assigned the following codes:
48930-00 [1404] Stabilisation of shoulder and
48212-00 [1417] Bone graft to humerus (not sure if anchors are internal fixation or not).

Response:
VICC research indicates that Hill-Sachs lesion is the same as Hill-Sachs fracture of posterolateral head of the humerus. It has been reported to be present in 40% to 90% anterior shoulder instability that is subluxation or dislocation.  Therefore, in the case cited only codes for fracture/dislocation of head of humerus should be assigned.

As both ‘remplissage' procedure and bone graft are documented VICC agrees with the enquirer to assign 48930-00 [1404] Stabilisation of shoulder and 48212-00 [1417] Bone graft to humerus. VICC does  not consider anchors to be internal fixation devices but to be a component of the stabilisation procedure.


Query Title:
ACS 1548 vs VICC query #2985 Delivered at Home, Placenta Delivered in Birthing Suite

Query Text:
Can you please advise the correct coding for an unplanned baby born at home and the placenta delivered in the hospital? (The placenta was not manually removed).

VICC Query #2985 BBA with delivery of placenta in birthing suite advises the following:
“Therefore where a patient has delivered a baby prior to the admitted episode of care but the placenta is expelled during the admitted episode of care, assign: 
- the appropriate code from O80 – O84 Delivery (also see Coding Rule Manual removal of placenta in a single vaginal delivery, published June 2014) 
- the appropriate code from Z37.- Outcome of delivery 
- Z39.03 Postpartum care after unplanned, out of hospital delivery to indicate that stage two has occurred prior to admission (this is an exception to the guidelines in ACS 1548 Postpartum condition or complication).”

However, ACS 1548 (July 2017), states “Z39.0- is never assigned in a delivery episode of care”. 

When I coded this episode following VICC Query #2985, I received a PICQ error F for the Z39.0 – code and a W1 error for the omission of the 9046700 [1336] – Spontaneous vertex delivery.

What is the recommended way for coding this scenario with the appropriate procedure code, while still capturing the baby’s birth at home and the placenta delivery in the hospital?

Response:
VICC advises that Coding Rule Q2900 Baby born prior to admission with placenta delivered in hospital was retired on 30 June 2017 with the revision of ACS 1548 Puerperal/postpartum condition or complication for Tenth Edition.

VICC query #2985 BBA with delivery of placenta in birthing suite is therefore also superseded by the revision of ACS 1548 for Tenth Edition, and should no longer be applied.  

As per Tenth Edition Obstetrics ACS education (slides 13 to 19), where a baby is delivered outside hospital, and placenta is spontaneously delivered in hospital, no ACHI code is assigned for the delivery.  Therefore the codes assigned would be:

O80 Single spontaneous delivery
Z37.0 Single live birth

A PICQ warning will be received for these episodes to ensure review of coding where an ACHI code for spontaneous vaginal delivery within the hospital should have been assigned.


Query Title:
Use of the words 'associated with' in ACS 1904 Procedural complications

Query Text:
Could you please clarify why the term 'associated with' does not infer a causal relationship with procedural complications?

Eg: Haematuria associated with cystoscopy 3/7 days ago, bladder washout performed.

Response:
VICC agrees that as per ACS 1904 Procedural complications, the ACCD does not consider 'associated with' to be a term which infers a causal relationship.

The Australian Coding Standards are created by the ACCD, and therefore VICC is unable to comment on the reasons behind this decision.

You may wish to make a public submission to the ACCD regarding this aspect of ACS 1904 Procedural complications.[end of original response].

Note: As of 1 July 2019 IHPA is responsible for ICD-10-AM/ACHI/ACS development.


Query Text:
In the ACCD Tenth edition education package the example on the Obstetric slide #22, could you please confirm if we should also assign O66.5 Failed application of vacuum extractor and forcepts, unspecified as it was not assigned in the example. The example was for failed forceps delivery.

Response:
VICC has reproduced below the slide referred to in your query:

Vaginal delivery of healthy (single) infant following failed forceps. Assign codes: 
O83 Other assisted single delivery
Z37.0 Single live birth
90468-05 [1337]

VICC advises that O66.5 Failed application of vacuum extractor and forceps, unspecified should be assigned in this example as per ACS 1500 Diagnosis sequencing in delivery episodes of care which states to assign codes for other conditions/complications (pregnancy, childbirth, puerperal or non obstetric) that meet the criteria for an additional diagnosis in ACS 0002 Additional diagnoses.


Query Text:
If adhesions are documented in the peritoneum of a female patient without the word "pelvis" documented, can we use our clinical knowledge of the information provided to assign N73.6? Or without the wording of "pelvis" do we default to the code K66.0 - peritoneal adhesions, even though the female pelvis is an exclusion?

Response:
VICC research indicates that the peritoneum is the membrane that lines the walls of the abdominal and pelvic cavities and viscera, therefore there is abdominal and pelvic peritoneum.

A female patient should not be assumed to have pelvic peritoneal adhesions without documentation of ‘pelvis’ or of a site that specifically leads to the female pelvic code in the Index, e.g. uterus. 

The Index at Adhesions/peritoneal, peritoneum (male) provides a default to K66.0 Peritoneal adhesions. The term ‘female pelvic’ is an essential modifier at the Index at Adhesions/peritoneal, peritoneum/female pelvic, indicating that ‘pelvic’ must be documented before this entry can be followed.


Query Text:
Could you provide clarification on the term "persistent" as referred to in ACS 1808 Incontinence?

For example, is documentation of longstanding or ongoing incontinence considered persistent even if they have some instances where they are continent during the admission?

Response:
VICC research indicates that ‘persistent’ does not mean continuous.  A patient can have persistent incontinence even when they have some instances of continence throughout an episode of care. 

Therefore, if the criteria in ACS 1808 Incontinence is met (persistent prior to admission, is present at discharge or persists for at least seven days), and if the incontinence meets ACS 0002 Additional diagnoses and Vic 0002 Additional diagnoses, a code for incontinence should be assigned.

The terminology of ‘longstanding’ or ‘ongoing’ would indicate persistent incontinence.


Query Title:
Oversewing of Patent Foramen Ovale (PFO)

Query Text:
Patient admitted for oversewing of Patent Foramen Ovale (PFO).

The ACHI Index does not appear to provide a pathway leading directly to a code to classify the procedure of oversewing of PFO.

Our interpretation of research is PFO is a type of atrial septal defect.

ICD-10-AM appears to classify PFO as an ASD.

Q21.1 Atrial septal defect
Excludes: primum atrial septal defect (Q21.21)
Q21.10 Atrial septal defect, unspecified
Q21.11 Patent or persistent foramen ovale
Nonclosure of foramen ovale
Q21.12 Sinus venosus defect
Q21.13 Ostium secundum defect
Type II atrial septal defect
Q21.14 Coronary sinus septal defect
Atrial septal defect located in coronary sinus
Q21.15 Lutembacher's syndrome
Q21.19 Other specified atrial septal defect
Cor triloculare biventriculare
Single common atrium

Possible Index pathways that have been considered to classify the procedure of oversewing of PFO are:

Closure / atrial / septal defect (open) (with patch graft) 38742-02 [617]
Or
Procedure / atrium, heart (intrathoracic) NEC 96221-01 [606]

1. Please advise if Patent Foramen Ovale (PFO) is an atrial septal defect?
2. Please advise the correct ACHI Index pathway to follow and code to assign to classify the procedure of oversewing of PFO.

Response:
VICC research indicates that the enquirer correctly interprets a patent foramen ovale (PFO) to be a type of atrial septal defect (ASD).  It also indicates that PFOs can be closed by a number of methods, including oversewing.  

Therefore VICC advises when oversewing of PFO is documented to follow the lead term Closure and the Index pathway Closure/atrial/septal defect (open)(with patch graft) to assign 38742-02 [617] Closure of atrial septal defect.


Query Text:
Patient admitted for a 35 mm taylor band annuloplasty of the mitral valve. Our interpretation of research is annuloplasty with band is a similar concept to annuloplasty with ring. The ACHI Index does not appear to provide a pathway leading directly to a code to classify the procedure of annnuloplasty with band.

Index pathway considered to classify the procedure of band annuloplasty of mitral valve:

Annuloplasty / mitral valve / with insertion of ring (Cosgrove-Edwards) 38477-00 [627]
Or
Annuloplasty / mitral valve 38475-00 [627]

Please advise if annuloplasty with insertion of band is a similar concept to annuloplasty with insertion of ring, and can annuloplasty with insertion of band be coded to annuloplasty with insertion of ring?  If not please advise what code to assign to capture the component of annuloplasty band insertion.

Response:
After research, VICC agrees with the enquirer that annuloplasty with insertion of the band is a similar concept to annuloplasty with insertion of ring.  A ring is a complete circle where a band has an opening.  Both are inserted in the same way to support the valve annulus.
  
Therefore VICC advises that when annuloplasty of the mitral valve with insertion of band is documented to follow the Index pathway Annuloplasty/mitral valve/with insertion of ring to assign 38477-00  Mitral valve annuloplasty with ring insertion.

Please note that this advice would apply to annuloplasty with insertion of band at all valve sites.


Query Title:
Bilateral femoral hernia - one side incarcerated

Query Text:
In coding an episode where a patient has bilateral femoral hernias and one side is noted to be incarcerated - should we code this as:
K41.3 Unilateral/unspecified femoral hernia with obstruction without gangrene
K41.9 Unilateral/unspecified femoral hernia without obstruction without gangrene
OR
K41.0 Bilateral femoral hernia, with obstruction, without gangrene.

Additionally with the laparoscopic repair of this should we use the bilateral procedure code (which is the same for an incarcerated hernia if unilateral too):
30615-00 Repair of incarcerated, obstructed or strangulated hernia
30390-00 Laparoscopy
OR
30615-00 Repair of incarcerated, obstructed or strangulated hernia
30390-00 Laparoscopy
30609-00 Laparoscopic repair of femoral hernia, unilateral.

Response:
Where bilateral femoral hernia – one side incarcerated is documented, follow the Index entry Hernia/femoral/bilateral/with obstruction to assign K41.0  Bilateral femoral hernia, with obstruction, without gangrene.  This code indicates that the hernia is bilateral, and that obstruction is present.

For the repair, VICC advises to assign the following codes:
30609-00 [991] Laparoscopic repair of femoral hernia, unilateral following Index entry Repair/hernia/femoral/unilateral/via laparoscopy
30615-00 [997] Repair of incarcerated, obstructed or strangulated hernia following Index entry Repair/hernia/femoral/unilateral/via laparoscopy/incarcerated
30390-00 [984] Laparoscopy in accordance with ACS 0023 Laparoscopic/arthroscopic/endoscopic surgery as 30615-00 [997] does not encompass the laparoscopic component.


Query Title:
Coding of anaesthesia not documented on an anaesthetic form

Query Text:
As VICC queries 2728, 2634 & 2649 have all been retired as of 30 June 2017 can we please have some guidance on the below circumstances for coding anaesthesia:

1. If a patient is given a nerve block documented only on the Operation Record (i.e. not on anaesthetic form) at the beginning of the procedure, are we able to code the block as anaesthesia as it is implied by being listed before the procedures performed that it is being performed for anaesthesia?

2. At the beginning of coronary angiogram reports we routinely see Midazolam listed under the heading of 'medication'.  Can we code this to IV sedation as this is administered prior to commencement of the procedure and therefore implied for anaesthesia?

3. When procedures are performed on the ward and only documented in the progress notes, such as bone marrow biopsy and lumbar punctures, if a drug typically used for anaesthesia is listed before the procedure is performed can a code for anaesthesia be assigned?

Response:
VICC advises that for the three scenarios cited, documentation of a block or drug only cannot be assumed to be for anaesthesia.  Please note the essential modifier ‘For/operative anaesthesia’ under the lead term Block in the Index. When the block or drug is associated with a procedure, look for terms such as ‘under’ or ‘with’ as evidence that it has been given for anaesthesia. 

VICC considers that if a block is documented on the anaesthetic form, it can be assumed it has been given for anaesthesia and a code can be assigned.

See also Coding Rule Q3223 TAP block performed at the end of surgical procedure published 15 March 2008.


Query Text:
What code(s) should you assign to classify venous eczema with ulcer?


Search Details
I83.2 Varicose veins of lower extremities with both ulcer and inflammation, appears to adequately classify both clinical concepts of venous eczema and ulcer. However following pathway:
-Eczema (acute) (chronic) (erythematous) (fissum) (rubrum) (squamous) Venous assigns I831 Varicose veins of lower extremities with inflammation.

At lead term Eczema if you follow see also Dermatitis, a sub-entry for varicose with ulcer assigns I83.2, but not a sub-entry for venous with ulcer.

In the absence of a sub-entry for 'with ulcer' at Eczema >Venous or an entry for Venous>with ulcer at Dermatitis do you have to assign both I83.1 and I83.0? Or can you interpret the instructional note at I83.2 that states 'any condition in I83.9 with both ulcer and inflammation' to confirm that you can assign I83.2 for venous eczema (inflammation) with ulcer (ulcer). Please also clarify the convention for these notes within I83.

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

Note the following with regard to category I83 Varicose veins of lower extremities:
- Four character codes are listed to classify lower limb varicose veins: with ulcer, with inflammation, with both ulcer and inflammation, and unspecified
- ‘With inflammation’ refers to inflammatory skin conditions such as eczema and dermatitis
- The terms eczema and dermatitis are synonymous in ICD-10-AM, this means that ‘venous’ eczema is synonymous with ‘varicose’ dermatitis
- ACCD acknowledges inconsistencies with the indexing of codes from category I83. 

Assign I83.2 Varicose veins of lower extremities with both ulcer and inflammation for venous eczema with ulcer, by following the Alphabetic Index:

Eczema (acute) (chronic) (erythematous) (fissum) (rubrum) (squamous) (see also Dermatitis)

Dermatitis
- varicose
- - with ulcer I83.2

Amendments will be considered for a future edition.

Note: this query will not be published in Coding Rules [end of ACCD response].


Query Text:
Can the VICC please explain why exercise 6.8 in the Tenth Edition Education Coding Exercise Workbook was not coded to J45.9 asthma and Z33 pregnant state incidental?

Scenario:
Final impression: Exacerbation of asthma.
Issues: Fetal movements - On 10 June, the patient reported that she had not felt fetal movements since waking that morning. She was reviewed by the midwife on duty, who reported FH 155bpm on Doppler.

The reason given in the answer is that 'as the patient was seen by the midwife and the fetal heart rate was monitored (Doppler), the case meets the criteria for Nonobstetric conditions complicating pregnancy in ACS 1521 Conditions and injuries in pregnancy.' However this only appears to meet one dot point in ACS 1521 ie fetal evaluation and/or monitoring was performed. Being 'seen by' a midwife is not one of the criteria and differs from being 'supervised/evaluated' by a midwife.

The point of the changes to the classification instructions was to enable antenatal admissions to be grouped to a more appropriate DRG but this is forcing them into an antenatal DRG.

Response:
In the ACCD response to exercise 6.8 in the Tenth Edition Education Coding Exercise Workbook, the ACCD states that ‘As the patient was seen by the midwife and the fetal heart rate was monitored (Doppler), the case meets the criteria for Nonobstetric conditions complicating pregnancy in ACS 1521 Conditions and injuries in pregnancy’.  VICC therefore considers that being ‘seen by’ a midwife is a synonymous term for being ‘supervised by’ or ‘evaluated by’ by a midwife, and that two of the criteria were met.


Query Title:
Negative pressure acute pulmonary oedema

Query Text:
Can the VICC please advise the correct code for negative pressure acute pulmonary oedema (APO)?

Internet searches indicate that it is a form of non-cardiac pulmonary oedema that results from the generation of high negative intrathoracic pressure needed to overcome upper airway obstruction.

Acute Pulmonary Oedema says that when 'acute pulmonary oedema' is documented without further qualification about the underlying cause, assign code I50.1 Left ventricular failure.

Is 'negative pressure' considered to be an underlying cau and therefore is assigned J81 following Index
Oedema
-lung (acute) J81

Response:
VICC research agrees with the enquirer that negative pressure (acute) pulmonary oedema (NPPE) is a form of non-cardiogenic pulmonary oedema resulting from high intrathoracic negative pressure generated by forced inspiration against an obstructed airway.

Follow the Index entry Oedema/lung to assign J81 Pulmonary oedema when negative pressure (acute) pulmonary oedema is documented as the underlying cause of the pulmonary oedema has been further specified.


Query Text:
As per the Conventions used in the Index, 'see' and 'see also' cross references provide the user with possible modifiers for a term or its synonyms.  Point 2. 'see also' directs the user to another index pathway where there are options that may provide more specificity.

Is the note in the ACHI Interventions Index under Stabilisation, joint to 'see also' arthrodesis correct?

The site specific codes for stabilisation and arthrodesis are different eg elbow
49103-00 Stabilisation of elbow
49106-00 Arthrodesis of elbow

As are the default codes
50106-00 Joint stabilisation, not elsewhere classified
Includes: ligament repair

50109-00 Arthrodesis of joint, not elsewhere classified

So the Index appears to be leading to a different procedure rather than a synonymous procedure or a procedure with more specificity.

Stabilisation
- joint (see also Arthrodesis) 50106-00 [1571]
- - with repair of ligament NEC 50106-00 [1571]
- - ankle 49709-00 [1542]
- - elbow (ligamentous) 49103-00 [1418]
- - radio-ulnar, distal 46345-00 [1469]
- - shoulder 48930-00 [1404]
- - - arthroscopic 48957-00 [1404]
- - specified site NEC 50106-00 [1571]
- - temporomandibular 45875-00 [1371]
- - wrist (for ligamentous disruption) 49227-00 [1468]

Arthrodesis (with fixation device) NEC 50109-00 [1571]
- adjacent joint
- - with en bloc resection of lesion (tumour) of long bone of limb
- - - lower 50218-02 [1570]
- - - upper 50218-00 [1570]
- ankle 49712-00 [1543]
- - subtalar (Grice procedure) 50118-00 [1543]
- carpometacarpal 46303-00 [1460]
- elbow 49106-00 [1418]
- foot 50109-00 [1571]
- - metatarsophalangeal, 1st 49845-00 [1543]
- - triple 49815-00 [1543]
- hand
- - carpometacarpal 46303-00 [1460]
- - intercarpal (with bone graft) 49203-00 [1460]
- - interphalangeal 46300-00 [1460]
- - metacarpophalangeal 46300-01 [1460]
- hip 49306-00 [1491]
- intercarpal (limited) 49203-00 [1460]
- interphalangeal
- - foot 90559-00 [1543]
- - hand 46300-00 [1460]
- knee 49509-01 [1512]
- - with
- - - removal of prosthesis 49512-00 [1512]
- - - resection of distal femur and proximal tibia 50411-00 [1515]
- - - - with rotationplasty 50414-00 [1515]
- - revision 49545-00 [1524]
- metacarpophalangeal 46300-01 [1460]
- metatarsophalangeal, 1st 49845-00 [1543]
- radiocarpal (with bone graft) 49200-00 [1468]
- radio-ulnar, distal
- - with reconstruction 46345-00 [1469]
- sacro-iliac 49300-00 [1491]
- shoulder 48939-00 [1403]
- - with removal of prosthesis 48942-00 [1403]
- specified joint NEC 50109-00 [1571]
- subtalar 50118-00 [1543]
- temporomandibular 45877-00 [1371]
- toe 90559-00 [1543]
- - claw toe 49851-01 [1548]
- - hammer toe 49851-00 [1548]
- - metatarsophalangeal, 1st 49845-00 [1543]
- wrist 49200-00 [1468]
- - carpometacarpal 46303-00 [1460]
- - radio-ulnar, distal
- - - with reconstruction 46345-00 [1469]

Should stabilisation of proximal interphalangeal joint be coded to stabilisation, specified site NEC 50106-00 [1571] or arthrodesis, interphalangeal, hand 46300-00 [1460]?

 46300-00 Arthrodesis of interphalangeal joint of hand

Response:
Both the ‘see also’ and ‘NEC’ Conventions in the Alphabetic Index of Interventions are relevant in assigning the appropriate code for stabilisation of proximal interphalangeal joint:

" ‘See also’ directs the user to another index pathway where there are options that may provide more specificity."

"NEC is used for two purposes which can only be determined by referring to the Tabular List of Interventions:

1. With ill-defined terms as a warning that specified forms of the procedure are classified differently.  The codes given for such terms should be used only if more precise information is not available.

2. Terms for which a more specific category is not provided in the Tabular List, and no amount of additional information will alter the selection of the code."

Therefore to assign a procedure code for stabilisation of proximal interphalangeal joint, the following Index pathways are considered:

Stabilisation/joint/specified site NEC 50106-00 [1571] Joint stabilisation, not elsewhere classified.

Stabilisation/joint – see also Arthrodesis.  Arthrodesis/interphalangeal/foot 90559-00 [1543] Arthrodesis of toe or hand 46300-00 [1460] Arthrodesis of interphalangeal joint of hand.

As more precise information about which joint is being stabilised is available, follow the second Index pathway and assign 90559-00 [1543] Arthrodesis of toe or 46300-00 [1460] Arthrodesis of interphalangeal joint of hand as appropriate.


Query Text:
Anaesthetist noted on admission 'difficult airway' and extra resources were used during the anaesthetic.  It was coded as T88.42 Difficult intubation (in the tabular list this code includes difficult airway).

As this was a known condition on admission, the condition onset flag of P was assigned.

PICQ Indicator number 105020 has reported this as a fatal error indicating it has to be a condition onset flag of C.

Could you please clarify what condition onset flag should be used?

Response:
When the presence of a difficult airway is known at the time of admission, anaesthetists may alter their approach to ensure that the actual procedure of intubation is not difficult.  If no difficulty eventuates, no code will be assigned.

However, if a difficulty does eventuate and meets the criteria in ACS 1924 Difficult intubation then it is correct to assign the T88.42 code, prefixed with C.

There are rare circumstances where T88.42 would be the principal diagnosis and therefore prefixed with a P (please see VICC #3233 Admission for airway monitoring following difficult intubation).


Query Text:
VICC Query #2763 Excision biopsy of nodule in axilla was retired on 30 June 2017.

The query referred to when there is documentation of 'lump', 'lesion' or other non-specific diagnoses could the histopathology be used to determine the code for the procedure.

The query response stated 'Where the operation report only contain nonspecific 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'.

As VICC #2763 is retired can we still apply the above logic when determining the procedure code for non-specific diagnoses?

Response:
VICC considers that it is still appropriate to apply the logic in retired query #2763 Excision biopsy of nodule in axilla to determine the procedure code for non-specific diagnoses.  This advice is reproduced below:

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.

The Tenth Edition code for removal of lesion from superficial peripheral nerve is 39324-02 [80] Removal of lesion from superficial peripheral nerve.


Query Text:
Patients who are admitted to our hospital for a bone marrow transplant (matched unrelated donor) often receive a Thymoglobulin infusion as part of their conditioning regimen.

Thymoglobulin (anti-thymocyte globulin) is an anti-human thymocyte immunoglobulin preparation made of purified polyclonal antibodies derived from rabbits.

Could the committee please advise how a Thymoglobulin infusion should be coded?

Is Thymoglobulin considered to be a blood product, and therefore coded to 13706-05 [1983] Administration of gamma globulin?

Or should it be coded to 96199-00 [1920] Intravenous administration of pharmacological agent, antineoplastic agent?

Response:
VICC advises that as Thymoglobulin is a blood product, it is appropriate to assign 13706-05 [1983] Administration of gamma globulin for the administration of Thymoglobulin.


Query Title:
Stenosis of peripheral artery with previous stent/graft

Query Text:
Patient admitted for angioplasty of superficial femoral artery (SFA) due to in-stent stenosis or stenosis of peripheral bypass graft.

According to ACS 0941 Arterial Disease stenosis should be coded to atherosclerosis unless documented as due to another cause.

ACS 1904 Procedural complications states that complications related to prosthetic devices, implants or grafts (eg mechanical complications, haematoma, pain, stenosis following insertion of prosthetic devices) should be classified to T82-T85 for complications of prosthetic devices, implants and grafts, except where directed by an Includes note or the Alphabetic Index.

Can the VICC please advise the correct codes for in-stent stenosis following previous peripheral vascular stent, and for stenosis of previous peripheral bypass graft?

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

Restenosis of previous angioplasty, arterial bypass and stent sites may occur as a result of recurrent atherosclerosis or tissue growth, in response to the vascular injury caused by the initial treatment (Fogoros 2017).

ACS 0941 Arterial disease/9. Stenosis states:
Stenosis is a quantitative anatomical term and often refers to atherosclerosis.
…stenosis of other arteries that is not documented as due to another cause is to be assigned the appropriate atherosclerosis code

Therefore, where documentation specifies that restenosis of a peripheral bypass graft/in-stent stenosis is due to recurrent atherosclerosis or the cause is unspecified, assign a code from category I70.2 Atherosclerosis of arteries of extremities.

Also assign Z95.8 Presence of other cardiac and vascular implants and grafts to indicate the stent status.

Where documentation specifies that restenosis of a peripheral bypass graft/in-stent stenosis is caused by a complication of the initial treatment, assign T82.84 Stenosis following insertion of cardiac and vascular prosthetic device, implants and grafts. Follow the Alphabetic Index:
Stenosis
- due to presence of device, implant or graft NEC
- - arterial graft NEC T82.84

Amendments may be considered for a future edition.

This query will be published as part of Q3361 Restenosis of previous vascular bypass, graft or stent.
[end of ACCD response]

Note:  ACCD advised VICC that this query would not be published.  Therefore VICC has published the query in accordance with the Committee's business rule to publish queries referred to ACCD that ACCD does not publish.


Query Text:
Can you please advise of the correct to code for neonatal viral sepsis?

Sepsis, Newborn NEC codes to P36.9.  However, the code description is 'Bacterial sepsis of newborn, unspecified'.

This does not seem the correct code when it is confirmed as 'Viral' Sepsis.

Do we follow the Index of: Sepsis (see also Infection).  Infection, newborn, specified type NEC P39.8, and add Virus, as cause of disease classified elsewhere (or specified if viral known) B97.8.

Response:
VICC advises that for documentation of neonatal viral sepsis, follow the Index pathway Sepsis - see also Infection/newborn/specified type NEC to assign P39.8 Other specified infections specific to the perinatal period.  

If the type of virus is not specified, follow the Index pathway Virus NEC/as cause of disease classified elsewhere to also assign B97.8 Other viral agents as the cause of diseases classified to other chapters as an additional code.


Query Text:
1) Could the committee please advise the correct procedure code to be assigned for an axillo-popliteal bypass using synthetic graft? There is currently no index entry for axillo-popliteal at bypass, arterial

2) Could the committee please advise of the correct procedure code to be assigned when the initial axillo-popliteal bypass is extended from SFA to AK popliteal?

Response:
VICC notes that there is no specific Index entry for axillo-popliteal at bypass, arterial.

Therefore for each question, VICC suggests the following:  

1. To assign a procedure code for an axillo-popliteal bypass using synthetic graft follow the Index pathway Bypass/arterial/with/synthetic material to assign 32763-01 [712] Other arterial bypass using synthetic material.  

2. To assign a procedure code for extension of the initial axillo-popliteal bypass from superficial femoral artery to above knee popliteal using a synthetic graft, follow the Index pathway Bypass/arterial/with/synthetic material/femoro-popliteal/above knee anastomosis to assign 32751-00 [712] Femoro-popliteal bypass using synthetic material, above knee anastomosis.


Query Text:
A patient was admitted to our facility with haematemesis. A gastroscopy was performed which showed a Dieulafoy's ulcer in the fundus of the stomach. The ulcer was treated with clipping and bipolar bicap electrocautery. We have also seen electrocautery via gastroscopy used to treat bleeding from lesions other than ulcers.

Block 1007 Panendoscopy with destruction contains codes for panendoscopy with various treatment modalities but not electrocautery.

Can the committee please advise how to code a gastroscopy with electrocautery?

Response:
VICC research indicates that electrocautery is a process in which a current is generated to produce heat.  This heat can then be used to achieve haemostasis or varying degrees of tissue destruction.  

Where gastroscopy with electrocautery is used to control bleeding from a gastrointestinal ulcer, as in the first scenario provided, use the Index pathway Control/haemorrhage/gastrointestinal/from peptic ulcer/via endoscopy to assign 90296-00 [887] Endoscopic control of peptic ulcer or bleeding.

Where gastroscopy with electrocautery is used to control bleeding from lesions other than ulcers, follow the Index entry Cauterisation - see also Destruction; Destruction/lesion and the appropriate site. 

If the site is not indexed at Destruction, follow the Index entry Panendoscopy/with/diathermy to assign 30478-01 [1007] Panendoscopy to duodenum with diathermy as VICC considers diathermy to fit the definition of electrocautery.


Query Text:
At our hospital we have recently had two patients who were diagnosed with a chyle leak. Both patients had been treated earlier in the admission for an oral malignancy. This involved resection of the tumour, radical neck dissection and tracheostomy. One of the patients was returned to theatre for repair of the chyle duct by lateral suture and local muscle flap repair.

Our research indicates that chyle is a fluid consisting of a mixture of lymphatic fluid and chylomicrons that has a milky appearance.Chyle leak formation is an uncommon but serious sequela of head and neck surgery when the thoracic duct is inadvertently injured, particularly with the resection of malignancy low in the neck. The thoracic duct is the primary structure that returns lymph and chyle from the entire left and right lower half of the body. Chyle extravasation can result in delayed wound healing, dehydration, malnutrition, electrolyte disturbances, and immunosuppression. International Journal of Otolaryngology, Volume 2017 (2017), Article ID 8362874

There is no Index entry for chyle leak.
We do however note the following code: I97.83 Postprocedural lymphocele, lymphoedema and chylothorax.

Can the committee please advise how to code:
1. An accidental laceration/injury to the thoracic duct during a procedure?
2. A chyle leak that results from a procedure?

Response:
VICC advises that the documentation provided in this query meets the criteria for assigning a procedural complication code. 

Therefore in scenario 1 it is correct to assign I97.39  Accidental puncture and laceration of circulatory system organ or structure during a procedure, not elsewhere classified following the pathway Complication/accidental puncture or laceration during procedure NEC/circulatory system or structure NEC. 

For scenario 2 it is correct to assign I97.89  Other intraoperative and postprocedural disorders of circulatory system, not elsewhere classified following pathway Complication/circulatory/intraoperative or postprocedural/specified NEC.


Query Text:
Could you please provide advice on the ACHI code to assign for release of haematometra via hysteroscopy.

There does not appear to be an appropriate code selection under Release or any other synonymous terms to allow consistent code assignment.

Response:
VICC research indicates that the process of introducing the hysteroscope to the uterus also releases haematometra (retained blood/clots in the uterus).  For documentation of release of haematometra via hysteroscopy, follow the Index term Hysteroscopy to assign 35630-00 [1259] Diagnostic hysteroscopy.


Query Title:
Barrett's oesophagus follow-up and ACS 0052 Same-day endoscopy - surveillance

Query Text:
Can the committee please provide guidance as to the following scenario:
When a patient with a history of Barrett's oesophagus is admitted for follow-up of Barrett's (post PPI treatment of GORD) and there is no Barrett's oesophagus seen on gastroscopy should we be coding the PDx as K22.7 Barrett's oesophagus or Z09. Follow-up examination after treatment for conditions other than malignant neoplasms?

There are different views amongst coders regarding Barrett's oesophagus- some view it as a chronic incurable condition in which case K22.7 should always be assigned as the PDx when it is not found on follow-up endoscopy and others view it as a condition that can be treated and therefore a Z09 code would be assigned.

ACS 0052 Same-day endoscopy - surveillance has coding examples 8 and 12 for  Barrett's oesophagus which are adding to the different views amongst coders. 

Are these scenarios for patients that only have current Barrett's oesophagus?

Indications:          
Follow-up of Barrett's oesophagus

Medicines:          
Midazolam (Hypnovel) 5 mg IV, Fentanyl (Sublimaze)   75 micrograms IV

Procedure:		 
After obtaining informed consent, the Endoscope was introduced through the mouth, and advanced to the second part of duodenum. The upper GI endoscopy was accomplished without difficulty.The patient tolerated the procedure well.

Findings:             
The Z-line was irregular and was found 35 cm from the incisors. The entire examined stomach was normal. There were a few cystic fundic glandular polyps.The examined duodenum was normal.

Complications:      
No immediate complications.

Impression/Preliminary Dx:
No Barrett's oesophagus seen. Z line was irregular but it didn't extend more than 1 cm proximal to the GOJ.

Recommendation:            
Continue current GORD management with PPI and H2 blockers. Can have a repeat gastroscopy in five years.

Response:
VICC research indicates that Barrett’s oesophagus is a chronic incurable condition that can be managed by treating the symptoms of gastro-oesophageal reflux disease.  

As there is documentation of follow-up of Barrett’s oesophagus, VICC advises to follow ACS 0052  Same-day endoscopy – surveillance which instructs to assign the pre-existing condition under surveillance (including chronic incurable conditions) as principal diagnosis.  Therefore in the scenario cited K22.7 Barrett’s oesophagus should be assigned as principal diagnosis.


Query Title:
Conditions/complications in the puerperal/postpartum period

Query Text:
Can you please clarify how lower limb numbness (or any other non-obstetric condition) in the postpartum period (but not the delivery episode) should be coded?

Patient presents 3 days post NVD with numbness in lower limb, suspected DVT and symptomatic anaemia.

Patient was admitted to our obstetric hospital, to the obstetric ward for review.  Anaesthetist examined the patient on two separate occasions, as the patient had had an epidural during the prior delivery admission.

The only documentation within the record is that the patient is 3 days postpartum, with no reference of these conditions 'complicating' the puerperal/postpartum as per ACS 1548 Puerperal/postpartum condition or complication (dot point 3).

ACS 1548 flow chart and example 11 indicate that as the condition was not specified as a puerperal complication, we are unable to assign puerperal/postpartum code/s. (O9*.- and Z39.0-)

However, as we are an obstetric hospital ACS 1521 Conditions and injuries in pregnancy makes it very clear that non-obstetric conditions complicating 'pregnancy', and meeting 2 or more of the criteria (e.g. admitted to Obstetric unit and supervised by Obstetrician/midwife) assign a code from Chapter 15 (O9*.-) and an additional diagnosis code from another chapter to add specificity to Chapter 15 code.

The confusion is around that we are an obstetric hospital, and majority of our patients meet the 'complicating pregnancy' criteria for antenatal and delivery episodes.  However, postpartum/puerperal ACS 1548 does not 
seem to follow the same criteria.  The fact that the patient is readmitted back to the obstetric facility, should this have some impact when determining puerperal complications?

Response:
As is noted in the query, ACS 1521 Conditions and injuries in pregnancy and ACS 1548 Puerperal/postpartum condition or complication use different criteria to determine whether a condition is assigned a code from Chapter 15 Pregnancy, childbirth and the puerperium or another chapter of ICD-10-AM as directed by the Alphabetic Index.

While admission to an obstetric unit is relevant in ACS 1521 Conditions and injuries in pregnancy, it is not included in ACS 1548 Puerperal/postpartum condition or complication.

Follow the instructions in the relevant ACS depending on whether the condition has occurred in pregnancy or in the postpartum period.

You may wish to send a public submission to the ACCD suggesting improvements to ACS 1548 Puerperal/postpartum condition or complication.


Query Text:
VICC query # 2659 Bursectomy with repair of rotator cuff has been retired.

The response stated that when bursectomy is documented in conjunction with a repair of the rotator cuff/shoulder reconstruction, it is not necessary to include a separate code for the removal of the bursa.

In the absence of an update to the classification can we still follow this advice?

Response:
In the absence of an update to the classification VICC considers that the advice in #2659 Bursectomy with repair of rotator cuff is still current and is reproduced below:
 
Clinical information obtained by the Coding Committee regarding rotator cuff repair indicates that bursectomy is an operative approach performed during reconstruction of the shoulder, in order to expose the cuff margins, and is considered to be a routine part of the procedure. 

Therefore, when bursectomy is documented in conjunction with a repair of the rotator cuff/shoulder reconstruction, it is not necessary to include a separate code for the removal of the bursa. This information was verified by the NCCH.
 
The NCCH will consider the addition of bursectomy to the includes list in code 48960-00 [1405] 'Arthroscopic reconstruction of shoulder' and any other relevant codes for a future edition of ICD-10-AM.

You may wish to submit a public submission to ACCD to have bursectomy added to the includes list in code 48960-00 [1405] Arthroscopic reconstruction of shoulder.


Query Title:
Meniscectomy with total knee replacement

Query Text:
Should meniscectomy be coded in addition to a total knee replacement? 

We have one surgeon only who documents this but not on all his cases. There is no 'excludes' note on the meniscectomy in relation a TKR and no 'includes' note on the TKR to indicate a menisectomy is inherent in that code so we have been coding both codes - 49518-00 & 49503-00

Response:
VICC research indicates that in a total knee replacement along with the distal femur and proximal tibia, the entire articular cartilage of the knee joint is removed.  This includes the meniscus, and therefore meniscectomy is an integral part of a total knee replacement.  

VICC advises to assign 49518-00 [1518] Total arthroplasty of knee, unilateral when total knee replacement of one knee is documented.  An additional code for the meniscectomy is not required.  This is in accordance with ACS 0016 General procedure guidelines: Procedure components.


Query Title:
Retained foreign body in subcutaneous tissue

Query Text:
Recently a patient was admitted to our hospital with a retained foreign body (glass) in their forearm.

Two months prior the patient suffered an open wound to their forearm from a glass coffee table. The patient then fell onto the glass which fragmented into the wound.

In this admission the patient was taken to theatre where the surgeon has noted:
Original scar excised, 5x3cm glass in subcutaneous plane extracted, washout, closed with 4.0 monocryl/4.0 nylon.

A diagnosis code exists for retained foreign body in soft tissue, M79.53 Residual foreign body in soft tissue, forearm.  However we cannot find a similar code for retained foreign body in skin/subcutaneous tissue.

Can the committee please advise what diagnosis code should be assigned for a retained foreign body in subcutaneous tissue?

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

There is no code in ICD-10-AM for retained foreign body in skin and subcutaneous tissue. Therefore, assign a code from category M79.5 Residual foreign body in soft tissue as a best fit.

Amendments will be considered for a future edition.

Note: This response will not be published in Coding Rules. [end of ACCD response]


Query Text:
A patient was admitted to our facility with an acute type A aortic dissection and was taken to theatre for an ascending aorta hemiarch replacement with aortic valve resuspension.

In this type of procedure the aortic valve is neither repaired nor replaced.

Our research indicates that with a valve resuspension procedure the normal valves are not removed when replacing diseased sections of the aorta.  Instead, surgeons save the valve by detaching them from the area of the aorta being replaced.

Following this the graft replacing the removed section of aorta is sewn to the heart, with the aortic valve suspended within the graft. Finally, the graft is connected to the rest of the patient's aorta. At the end of the procedure, the patient's aortic valve has been preserved, despite the replacement of the aorta that feeds into it.

We note the following codes in block [688] Replacement of aortic arch and ascending thoracic aorta:

38559-01 Replacement of aortic arch and ascending thoracic aorta
38562-02 Replacement of aortic arch and ascending thoracic aorta with aortic valve repair
38562-03 Replacement of aortic arch and ascending thoracic aorta with aortic valve replacement
38565-02 Replacement of aortic arch and ascending thoracic aorta with aortic valve repair and implantation of coronary arteries
38565-03 Replacement of aortic arch and ascending thoracic aorta with aortic valve replacement and implantation of coronary arteries

Codes exist for aortic arch and ascending aorta replacement with aortic valve repair and replacement, but there is no code for aortic valve resuspension.

Can the committee please advise how to code ascending aorta hemiarch replacement with aortic valve resuspension?

Response:
VICC research confirms with the enquirer that the valve is preserved and reattached.

VICC advises to follow the Index pathway Replacement/aorta, aortic/arch/with ascending thoracic aorta replacement – see block [688].  As the valve has not been repaired or replaced and there is no documentation of implantation of coronary arteries VICC considers it appropriate to assign 38559-01 [688] Replacement of aortic arch and ascending thoracic aorta for the example cited.


Query Title:
Fetal decelerations without documentation of fetal distress

Query Text:
What is the correct code to assign for fetal decelarations (meeting ACS 0002 for eample, indication for instrumental or surgical intervention) during labour/delivery but without documentation of fetal distress?

We note that VICC query #3164 Labour and delivery complicated by fetal stress indicates that O68.0 Labour and delivery complicated by fetal heart rate anomaly is the most appropriate code for decelerations. We note that advice from ACS 1546 Fetal heart rate decelerations has now been incorporated into the Alphabetic Index.  Deceleration(s)/fetal heart rate/with fetal distress - see also Distress/fetal/affecting labour and delivery O68.0 Distress/fetal/complicating labour and delivery O68.-. However without documentation of fetal distress we cannot get to code O68.0.

We note the following pathway which may be appropriate to follow for documentation of fetal decelerations.
Abnormal/fetus, fetal/heart rate - see Distress/fetal/affecting/labour and delivery O68.-.

If this pathway is appropriate would the correct 5th digit to select be '0' labour and delivery complicated by fetal heart rate anomaly or '8' labour and delivery complicated by other evidence of fetal stress?  That is, should fetal decelerations (without documentation of fetal distress) be classified as a specific heart rate anomaly or electrographic evidence of fetal distress?

Response:
VICC advises that when fetal decelerations are documented, the correct Index entry to follow is Decelerations/fetal heart rate.  Please note however that there are essential modifiers 'with fetal distress' and 'requiring instrumentation or surgical intervention in labour and delivery' under this Index entry.

Therefore without documentation of one of these essential modifiers, a code cannot be assigned for fetal decelerations.

As decelerations is a specific Index term, VICC does not consider it to be appropriate to classify fetal decelerations as either a specific heart rate anomaly or electrographic evidence of fetal distress for the purposes of assigning a code.

However, in your example, where fetal decelerations are the indication for instrumental or surgical intervention, follow the Index entry Decelerations/fetal heart rate/requiring instrumental or surgical intervention in labour and delivery to assign O68.0 Labour and delivery complicated by fetal heart rate anomaly.


Query Text:
Could VICC please advise if IV saline administration is required to be coded and if so, what is the correct procedure code to use?

Research suggests that saline is part sodium chloride, which is an electrolyte and therefore could this be coded as an electrolyte as per ACS 1615 Specific diseases and interventions related to the sick neonate? The correct code would therefore be 96199-08 [1920] IV administration of pharmacological agent, electrolyte.

We note that IV saline is not listed in the substances in ACS 1615 Specific diseases and interventions related to the sick neonate under parenteral fluid therapy (there is TPN, electrolytes and dextrose) so we are wondering if it is not included here does saline come under ACS 0042 Procedures not normally coded?

Response:
VICC research indicates that IV saline is an isotonic solution primarily given for volume maintenance in patients who cannot take fluids orally and have developed or are in danger of developing dehydration.

If documentation clearly indicates that IV saline is being given for treatment of a specific electrolyte disorder, it would be appropriate to assign a code for the electrolyte component in accordance with ACS 1615 Specific diseases and interventions related to the sick neonate under the heading Parenteral fluid therapy.


Query Title:
Mental health coding & ACS 0002 Additional diagnoses

Query Text:
In mental health a number of Z codes are used to identify issues that have occurred in the past/present that have had an effect on the person's mental health, eg. death of family member, homelessness, legal issues such as a pending court case, unemployment, financial issues, removal from home as a child, problems with partner, etc.  ACS 0002 Additional diagnoses now directs us to only code those conditions that are significant.  I am unsure what impact this will have on mental health coding as the use of these Z codes does not really fit into the adjustment of therapeutic treatment, diagnostic procedure or increased clinical care or monitoring.  If we are directed not to code this sort of information, in my opinion we will lose a lot of valuable information for mental health. I await your advice.

Response:
VICC advises that the Australian Coding Standards apply to all admitted episodes, regardless of care type.  Therefore ACS 0002 Additional diagnoses must be followed in mental health admitted episodes in order to determine significance before a code can be assigned.

If mental health clinicians request that Z codes are assigned, but documentation does not support their assignment, you may assign codes at a local level but flag them so that they are not transmitted to the VAED.  

You may also wish to liaise with mental health clinicians regarding the level of documentation required for the assignment of these Z codes according to ACS 0002 Additional diagnoses.


Query Title:
Repair of semicircular canal dehiscence (SCD) via middle cranial fossa craniotomy

Query Text:
We want to know what to code for both the diagnosis and repair for semicircular canal dehiscence (SCD), via craniotomy. The semicircular canals are a component of the bony labyrinth of the inner ear. Patients are admitted to our facility for this type of repair as it involves both ENT and neurosurgeons.

SCD causes vestibular and auditory symptoms and is a result of dehiscence of the bone overlying the superior semicircular canal of the inner ear. The cause of the dehiscence can be due to erosion of the bone, trauma, infection or a neoplasm.

Definitive therapy involves resurfacing of the dehiscent bone.  Surgical approaches include either a middle fossa craniotomy or a trans-mastoid approach.

The middle fossa craniotomy approach involves entering through the side of the skull above the ear and an incision is then made in the dura of the brain. The region of the superior semicircular canal is located with identification of the arcuate eminence. A dehiscence of the superior semicircular canal can be covered/plugged/repaired with bone wax, bone cement, or fascia, or the canal can be ablated with wax or bone cement. The trans-mastoid approach is made behind the ear, through the mastoid to expose the superior canal and plug it. The actual SCD defect is never visualized directly and new holes are made in the canal to plug it.

We have considered the following codes:

Diagnoses codes for SCD where no other cause is described:

M95.2 Other acquired deformity of head (skull/bone), following the lead term Deformity/head (Deformity/ear codes are congenital)
Or
H83.8 Other specified diseases of inner ear, following the lead term Disease/ear/inner/specified.

For the repair
90117-00 [332] Other repair of inner ear following the pathway: Repair/ear/inner/labyrinth NEC.

However, this code alone does not recognise the procedural complexity differences between trans-mastoid and craniotomy approaches.  There is also no craniotomy default code that can be added unless a dural repair has been performed (which is inherent in the procedure as the dura is opened). Craniotomy as an operative approach is not usually coded. Other potential codes come from following the pathway Cranioplasty - with bone graft etc. 40600-xx [23].

Response:
For documentation of semicircular canal dehiscence (SCD), VICC advises to follow the Index pathway Disease/ear/inner/specified to assign H83.8 Other specified diseases of inner ear, in accordance with the Conventions in the Tabular List of Diseases which provide advice when the terminology used by a clinican cannot be found in ICD-10-AM.

For documentation of repair of semicircular canal dehiscence via middle cranial fossa craniotomy, VICC advises to following the Index pathway Repair/ear/inner/labyrinth NEC to assign 90117-00 [332] Other repair of inner ear. 

As per the ACHI Index there is no code assigned for craniotomy as it is the operative approach for surgery.

You may wish to submit a public submission to ACCD suggesting revision of the Index to include ‘via craniotomy approach’ or ‘code also craniotomy’.


Query Text:
VICC #2785 Principal diagnosis selection for same-day TOE admissions was retired on the 30/06/2017 (Seventh Edition).

Could VICC please review this query and advise if the information is still applicable/current?

Response:
VICC considers that the advice in VICC #2785 Principal Diagnosis selection for same-day TOE admissions is still correct and is reproduced below:

"Query: 
We would like to seek advice as to what is the appropriate principal diagnosis in same-day transoesophageal echocardiogram (TOE) admissions, where the indication for the TOE is either ?Cardiac Source of Embolism or Stroke/Infarct and there is no final diagnosis. 

1. Indication: Stroke 

Should the stroke be the principal diagnosis or should it be Z03.5 Observation for other suspected cardiovascular diseases? 

2. Indication: ?Cardiac Source of Embolism 

Should the Embolism be the principal diagnosis or should it be Z03.5 Observation for other suspected cardiovascular diseases? 

Search Details: 
VICC #1899 - TOE for investigation of recent CVA

Response:
VICC advises that the correct principal diagnosis for the scenarios noted in the query is the documented condition that occasioned the episode of care, that is, the stroke in scenario one and the embolism in scenario two. This is in accordance with the advice in query #1899 TOE for investigation of recent CVA which VICC considers to still be correct. 

As per ACS 0001 Principal diagnosis under heading 'Codes from the Z03.0–Z03.9 series, medical observation and evaluation for suspected diseases and conditions' codes from category Z03 are assigned as principal diagnoses for admissions to evaluate the patient's condition, therefore Z03.5 Observation for other suspected cardiovascular diseases is not considered an appropriate principal diagnosis in these cases, which are to investigate the underlying cause."


Query Title:
Stiff total knee replacement (TKR) and stiffness post TKR

Query Text:
We have a number of patients readmitted post Total Knee Replacement (TKR) with knee/TKR stiffness for manipulation.

We have had previous clinical/coding advice that a stiff TKR may be multifactorial (ie due to the actual prosthesis, due to the procedure in general, unknown reasons, patient not compliant with exercises etc) and therefore have been advised that we should be querying for the reason of stiffness before assigning a complication code.

With the updates to ACS 1904 Procedural complications with ICD-10-AM-Tenth Edition we would like to take this opportunity to confirm the correct code/codes to assign for documentation of stiff TKR and stiffness post TKR.

ACS 1904 Procedural complications overview criteria, points 2 and 3, instruct the coding of a procedural complication when:
'Certain conditions where the relationship is inherent in the diagnosis (e.g. infection or bleeding of a surgical wound, stoma or anastomosis, wound dehiscence, transfusion related acute lung injury)  Conditions classified to T82-T85 for complications related to prosthetic devices, implants or grafts (e.g. mechanical complications, haematoma, pain, stenosis following insertion of prosthetic devices) (see Example 3) For a medical condition occurring during or following insertion of prosthetic devices but not classified to T82-T85, see Intraoperative/postoperative medical conditions below.'

1. Can VICC confirm whether either of these points can be applied to documentation of:
a) stiff TKR
b) stiffness post TKR
in order to assign a code for a procedural complication?

2. And if so, can you please confirm if the correct code assignment for scenarios a) and b) above is T84.89 Other specified complications following insertion of internal orthopaedic prosthetic devices, implants and grafts following index pathway Complication/orthopaedic/device, implant or graft/joint NEC?

Search Details
ACS 1904 Procedural complications

Response:
VICC confirms that ACS 1904 Procedural complications Overview section, dot points 2 and 3 apply to documentation of stiff TKR and stiffness post TKR because there is an inferred relationship between the stiffness and the prosthetic device.  

In these cases, follow the Index pathway Complication/orthopaedic/device,implant or graft/joint NEC to assign T84.89 Other specified complications following insertion of internal orthopaedic prosthetic devices, implants and grafts and Index pathway Stiffness, joint/knee to assign M25.66 Stiffness of joint, not elsewhere classified, lower leg to add specificity.


Query Text:
VICC query #3211 Follow up scopes advises 'when there is no available histology in the current admission, assign a code based on the clinical documentation.  Coders cannot assume histology from a previous admission is the only histology for that patient…'.
The advice is to use the information documented in the current admission.

1.  Does this advice relate only to 'follow up scopes'?

It is becoming increasingly confusing as to when coders are permitted to use information outside of the current admission.  Would you please comment on the following:

Pg xiii of the Australian Coding Standards states 'it is assumed that coding decisions are not made solely based on information provided on the clinical record front sheet and/or the discharge summary (or copy of same) but that analysis of the entire clinical record is performed before code assignment'.

VICC query #3227 Definition of 'entire clinical record' -  'VICC interprets 'entire clinical record' to mean the clinical information available to a coder, in order to classify the principal diagnosis, additional diagnoses and procedures for each episode of care…'. The last paragraph goes onto say 'Coders must ensure that decisions for assignment of codes appropriate to an episode of care are made in accordance with the clinical information related to that episode of care, however that is presented'.

The clinical information available to a coder would, in the past, have included reference to correspondence, previous histology etc. providing, of course, that these related to the current admission and weren't dated after the admission.

Would the committee please provide clear advice on when and under what circumstances coders can refer to information outside of the current admission in order to code to provide specificity?

We are concerned about inconsistency and inaccuracy of data from admission to admission and are also quite unsure when and if we, as coders, are able to use our 'coders' creed'.

Search Details
ACS pg viii
VICC 3211 Follow up scopes
VICC 3227 Definition of 'entire clinical record'

Response:
VICC confirms that the advice in VICC #3211 Follow up scopes only applies to follow up scopes.  Therefore, do not apply this advice outside follow-up endoscopy episodes.

The entire medical record should be used when necessary in order to to add further specificity to a diagnosis that is documented in the current admission.  It should not be used in order to select a diagnosis in the first instance - this decision should be informed by the documentation in the admission being coded.


Query Text:
Can the VICC please confirm whether it is ethical to seek clarification from the clinician as to whether adhesions were divided in the following scenario?

No mention of division of adhesions in operation report title.

Operation findings include adhesions from prior open cholecystectomy.

No indication of division of adhesions in operation notes but MBS code for division of adhesions documented by surgeon on operation report.

Response:
As you have indicated in your query, a code for division of adhesions cannot be assigned from the existing documentation in the record, as MBS codes are not to be used to assign procedure codes.  However, you are not precluded from using the information represented in an MBS code to generate a query to a clinician for further clarification regarding whether an additional procedure has occurred.


Query Text:
A patient presented to our hospital with # distal tibia following fall from ladder. It's noted the patient also had significant metaphyseal bone loss at the time of injury.
Procedure performed:
Left 43 Distal Tibia ORIF Tibia and
5cm metaphyseal defect filled lightly with Palacos R+G cement- Masqulet 
technique (stage 1 of Masquelet procedure)

It's planned for the patient to undergo stage 2 of the Masquelet procedure in 8 weeks.

There is no pathway for Administration - Filling Material (filing of defect) - Bone

Can VICC please advise how to code Stage 1 Masquelet Procedure.

Below is a copy of the operation report.

Operation Title
Left 43 Distal Tibia ORIF Tibia

Diagnosis
Open # Left 43 Distal Tibia

Operation details
Pre-operative consultation.
2 weeks post debridement and Ex-fix Grade 3 Open distal tibia fracture. Significant metaphyseal bone loss at time of injury
Informed Consent.Time Out. IV Abx. Prewash. Sterile Prep & Drape.
Anterolateral skin incision
SPN protected
Fibula exposed and cleared of soft tissues
Anatomical reduction of fibula and fixation with 6 hole 3.5mm LCP plate
Anterolateral approach to distal tibia
Anterior compertment tendons retracted medially
Tillaux and anterior fragments mobilised and cleared of sft tissues
Arthrotomy in sagittal plane fracture to visualise joint surface
Small comminuted fragments of carilage excised from between fracture line
Provisional reduction of articular block with k wires
Rigid fixation with 2 x IF screws AP and 1 x IF screw from anterolateral
Articualr reduction and fixation excellent
Synthese VA Anterolateral distal tibia plate fixed to tibia distally and proximally
Alignment in AP and lateral planes good

5cm metaphyseal defect filled lightly with Palacos R+G cement- Masqulet technique
Washout. Closure in layers. Dressings. Backslab

Plan for second stage grafting of defect in 8 weeks

Response:
VICC research indicates that the Masquelet procedure is a two stage technique.  In the first stage there is debridement and filling of bone loss with an acrylic cement spacer.  In the second stage there is bone reconstruction by replacing the spacer with a cancellous bone graft.

In the scenario cited, the cement spacer was placed in conjunction with open reduction and internal fixation of the tibia.  ACS 1316 Cement spacer/beads states 'if a cement spacer is part of another procedure…it is not necessary to code the insertion or removal of the cement spacer'. As such VICC advises that a procedure code for the placement of the spacer should not be assigned.


Query Title:
Acute kidney failure in a renal transplant patient

Query Text:
In Ninth Edition an amendment was made to the classification regarding kidney transplant failure/kidney transplant status including Revision of ACS 1438 Chronic kidney disease to include the published classification advice regarding kidney transplant failure/kidney transplant status and addition of index entries to support code assignment.

Can VICC please provide guidance on how to code acute kidney failure in the following scenarios?

a) The patient was admitted with a fractured NOF, the patient's past history includes a renal transplant in 2010. During the admission the patient develops AKI (without documentation of kidney transplant failure)
b) The patient was admitted with a fractured NOF, the patient's past history includes a renal transplant in 2010. During the admission the patient develops AKI, documentation by nephrologist states the kidney transplant is not failing.

Do we follow the index entry below and assign T86.1 Kidney transplant failure and rejection?

Failure, failed/kidney/following/kidney transplant/acute T86.1

Or, in regards to the word following, do we apply ACS 1904 Procedural complications and only assign T86.1 Kidney transplant failure and rejection when documentation specifies a causal relationship? Therefore, should N17.9 Acute kidney failure, unspecified be coded?

Would Z94.0 Kidney transplant status also be appropriate to assign?

Search Details
ACCD References to changes for Ninth Edition 2015
Alphabetic Index
ACS 1904 Procedural complications
ACS 1438 Chronic kidney disease

Response:
Kidney failure, kidney transplant status and kidney transplant failure are three separate diagnoses.  Kidney failure can occur in a person with kidney transplant status without it necessarily being a complication of the kidney transplant or due to kidney transplant failure.  There may be other causes of the kidney failure, such as dehydration.

In both the scenarios cited, follow the Index entry Failure/kidney/acute to assign N17.9 Acute kidney failure, unspecified.  

The Index entry Failure/kidney/following/kidney transplant/acute would be followed to assign T86.1 Kidney transplant failure and rejection only if there was a causal relationship documented between the kidney failure and the kidney transplant as per ACS 1438 Chronic kidney disease, under the section Kidney transplant failure.

Z94.0 Kidney transplant status may also be assigned if it meets the criteria in ACS 0002 Additional diagnoses.


Query Text:
Can the committee please advise of the procedure code for a colonoscopy performed with dye spray?

Response:
VICC research indicates that colonoscopy performed with dye spray is also known as chromoscopy or chromoendoscopy.

Chromoendoscopy is a diagnostic method in which a chemical substance is sprayed onto the mucosal surface of the gastrointestinal tract to highlight specific areas or distinguish among different types of epithelia.

For documentation of colonoscopy with dye spray, VICC advises to follow the Index entry Chromoendoscopy, by colonoscopy to assign 32090-02 [905] Fibreoptic colonoscopy to caecum with administration of tattooing agent.


Query Text:
Principal diagnosis on the discharge summary is Mirror Syndrome. Patient is 23.2 weeks gestation and also presented with hypertension in pregnancy, gestational proteinuria and  fetal hydrops.

How should the Mirror Syndrome be coded?

Response:
VICC advises to follow the advice in ACS 0005 Syndromes to classify Mirror Syndrome and assign codes for the documented manifestations.

Principal diagnosis selection will be dependent on the documentation and should be guided by ACS 0005 Syndromes, with the most severe condition assigned as principal diagnosis if there is no one diagnosis receiving treatment.

You may wish to make a public submission to ACCD for a specific code for Mirror Syndrome.


Query Text:
Procedure name in the operation report is Right leg superficial venous arterialisation from distal SFA using GSV.

Procedure Note:

On table US to mark the medial marginal vein of foot
Exposure of LSV from thigh to below knee
Exposure of SFA, Sartorius taken medially
Heparin
End to side anastomosis using 5.0 prolene
Medial marginal vein exposed to ankle
Le Maitre valvulotome passed, good pulse to mid calf but nil in foot
Pulse only recovered by dividing the fascia over the LSV in the calf to ankle
Retrograde passage of dilators 2mm, 2.5mm and 3mm into foot to break valves
Ontable DSA, poor flows
Further passage of Mills valvulotome up and dilators down into dorsal arch and other vessels
DSA satisfactory flow

We have not seen the word arterialisation used in the past and queried the vascular team about the procedure.  The response is:
For patients with non-reconstructible lower extremity arterial disease, venous arterialisation provides for reverse flow to capillary beds.  The distal SFA is anastomsed to great Saphenous vein, then the vein is "turned into" an "artery" with extensive work endovascularly with breaking the vein valves.  The consultant surgeon considers this procedure a Major Bypass.

Searches include:
ACCD and VICC - nothing found
Internet - research papers only

Current coding:
34509-00 [765 ] Arteriovenous anastomosis of lower limb (clinical confirmation that this was part of the procedure)
Consideration was given to coding the bypass and valvulotomy, however suitable codes could not be found.

Should we be coding other components of this procedure and if so, can the committee provide appropriate codes?

Search details:
Bypass - is it arterial or venous?
Valvulotomy - only indexed for heart valves

Response:
As you have confirmed with your clinician that the procedure was an arterial bypass, it is correct to look up the lead term Bypass.

In the absence of documentation of femoral bypass to a specified vessel, follow the Index entry Bypass/arterial/with vein to assign 32763-00 [711] Other arterial bypass using vein.  As per ACS 0016 General procedure guidelines, do not assign codes for procedure components.


Query Text:
Could the committee please advise the correct code for 'refeeding syndrome'?  

Patient with malnutrition and early refeeding syndrome.  Seen by dietitian several times during admission for management of both malnutrition and refeeding syndrome.  There is no documentation of any specific electrolyte imbalances, only the term 'refeeding syndrome'.

E87.8 Other disorders of electrolyes and fluid balance, not elsewhere classified is the code suggested by  www.icd10data.com/ICD10CM/Codes/E00-E89/E70-E88/E87-/E87.8.

Response:
VICC research indicates that refeeding syndrome can occur when prolonged starvation is followed by recommencement of nutrition as a result of metabolic and hormonal changes which may lead to electrolyte and fluid disturbances.  Refeeding syndrome can have a number of manifestations across a range of body systems and is potentially fatal if not identified early and treated.

VICC advises that as there is no code for refeeding syndrome to code out any documented manifestations according to the advice in ACS 0005 Syndromes.  However, if the only documentation is 'refeeding syndrome' please seek further clarification from the clinician to determine whether there were any manifestations. 

In the scenario cited it is not appropriate to assign E87.8 Other disorders of electrolyte and fluid balance, not elsewhere classified for documentation of refeeding syndrome as there is no documentation of an electrolyte imbalance.


Query Text:
The advice in VICC #3254 Coding of intravitreal triamcinolone acetonide injection (IVTA) with cataract extraction is that intravitreal triamcinolone acetonide injection (IVTA) is not a routine part of cataract extraction and should, therefore, be coded.  This codes to injection into posterior chamber of the eye.

Our ophthalmology registrar has advised that intracameral and subconjunctival injections are now fairly routine in cataract surgery. Intracameral injections involve delivery of a drug into the anterior chamber of the eye.  AB's are administered for the prevention of infection of the eye that can occur after cataract surgery.

Intracameral injection codes to  42740-02 [185] Administration of therapeutic agent into anterior chamber.  This changes DRG in cataract cases. We had discussion in a recent VAED audit as to whether or not this should have been coded.

Are intracameral and subconjunctival injections considered to be routine drug therapy and, therefore, not coded as per ACS 0042 Procedures normally not coded or are they to be coded?

Response:
Clinical advice provided to VICC supports the clinical advice that you have received regarding the routine nature of intracameral and subconjunctival injection of antibiotics in cataract surgery.  

Therefore in accordance with ACS 0042 Procedures normally not coded point 8 Drug treatment/pharmacotherapy/prescription of drugs a code for administration of antibiotics is not assigned.

The advice in VICC #3254 Coding of intravitreal triamcinolone acetonide injection (IVTA) with cataract extraction is still correct as the IVTA is not considered to be a procedural component of cataract treatment as it is performed for a different condition.


Query Text:
Can VICC please advise of the correct procedure code to use when coding a replacement of a PEG (percutaneous endoscopic gastrostomy) tube?

The replacement of the tube is done in hospital for the first replacement only, all other replacements after this are done in the community.  The replacement takes less than ten minutes and does not require an anaesthetic.   The replacement is not done endoscopically; it is a replacement of the tube only.  It is not invasive or traumatic for the patient.

There are two index entries in contention:

Replacement/tube/gastrostomy, percutaneous endoscopic (PEG) 30482-00 [870] Repeat insertion of percutaneous endoscopic gastrostomy (PEG) tube

Or

Replacement/tube/intestine/small 92079-00 [1986] Replacement of tube or enterostomy device of small intestine

Please note - the first code can also be found under Insertion/PEG/repeat insertion.

As the replacement is not being performed endoscopically we are reluctant to use the first code (30482-00) as 'percutaneous endoscopic' is an essential modifier. However, we are also concerned this is what the code is designed for and the index entry is referring to the name of the tube being replaced rather than how it is being replaced.   Our clinicians have said that if 30482-00 is not used for replacement of PEG tube, it would be very rarely used as replacement is not often done endoscopically.

It is also an issue because 30482-00 is on the 2017 Automatically Admitted Procedure List and 92079-00 is not.

Response:
VICC advises that for documentation of replacement of PEG tube, follow the Index entry Replacement/tube/gastrostomy, percutaneous endoscopic to assign 30482-00 [870] Repeat insertion of percutaneous endoscopic gastrostomy (PEG) tube.

VICC notes that the essential modifier ‘percutaneous endoscopic’ in the Index entry Replacement/tube refers to the type of tube rather than the approach of the procedure.

VICC acknowledges the non-invasive nature of the procedure in relation to the code assigned.


Query Title:
Diagnosis for same-day insertion of Reveal Loop Monitor

Query Text:
What should the principal diagnosis be for a patient who is admitted for insertion of a Reveal Loop Monitor?
Should it be the symptom/condition that is under investigation?
Should it be a Z code to indicate the admission was for the insertion of a device?

Example:
Patient with multiple strokes and recurrent dizziness. A Reveal device was implanted to look for underlying atrial fibrillation.

In line with VICC #2785 Principal diagnosis selection for for same-day TOE admissions (retired) it would appear that we should be coding the stroke and dizziness as principal diagnosis.  However, unlike a TOE we do not get a result for the episode.  The device recording is followed up about a month later as an outpatient and the outcome is not known at the time of coding.  The episode is not treating a condition it is to insert a device to be used for diagnostic purposes.

Could you please provide advice on this to assist with consistency of coding in this area? Thank you for your assistance.

Search details:
VICC #2785 Principal diagnosis selection for same-day TOE admissions (retired)
VICC #3035 Removal of cardiac event monitor
I cannot find advice specific to the loop monitor.

Response:
VICC agrees that the reveal loop monitor is inserted for diagnostic purposes, rather than for treatment purposes, however VICC does not consider it appropriate to assign a code from the Z40-Z54 range of codes in cases where a device is being inserted to aid in diagnosis.  

This is in accordance with the note at the beginning of the Z40-Z54 range of codes 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.'

In the example cited, VICC suggests to assign the principal diagnosis in accordance with documentation of the reason for the procedure and ACS 0001 Principal diagnosis. In your example, stroke and dizziness would be assigned with sequencing according to ACS 0001 Principal diagnosis.


Query Text:
Could you please advise on how to code 'paraneoplastic syndrome' (PNS)?  

The example we had most recently was documented several ways including 'paraneoplastic cerebellar syndrome', 'paraneoplastic encephalitis' and 'paraneoplastic syndrome ataxia'.  There are two codes in ICD-10-AM that appear to reflect this being G13.0 Paraneoplastic neuromyopathy and neuropathy and G13.1 Other systemic atrophy primarily affecting central nervous system in neoplastic disease. However, I don't have the words (such as neuropathy or encephalopathy) required to reach these codes through the index.

From internet searches it is apparent that there are many forms of PNS.  However there do not appear to be the codes and index entries in the classification to support capturing this condition.

In this instance the symptoms that the patient had were dysarthria, dysphagia, ataxia and possible encephalitis with cerebellar signs.  Final diagnosis was 'high grade serous pelvic carcinoma with paraneoplastic cerebellar syndrome'.  Note 'pelvic because mass involves uterus, ovaries and peritoneum unable to determine primary site'.

Response:
There is no one code for paraneoplastic syndrome although, as you have stated, there is a code for paraneoplastic neuromyopathy and neuropathy that require the documentation of these terms.  

In the scenario cited, the documented manifestations were dysarthria, dysphagia, ataxia and possible encephalitis with cerebellar signs.   Therefore, VICC advises to follow ACS 0005 Syndromes and assign a code for each of the manifestations.

You may wish to make a public submission to ACCD for a  code for paraneoplastic syndrome not otherwise specified.


Query Title:
Infective exacerbation bronchiectasis and COPD

Query Text:
A recent discussion at our in-house coding meeting raised the scenario of infective exacerbation of bronchiectasis in a patient who also has COPD. 

Can an infective exacerbation of bronchiectasis (a chronic lung disease by definition) indicate the application of an additional code for infective exacerbation of COPD?

The index doesn't lead to an automatic link between the two and there are no include/exclude notes. Our respiratory physician has clarified in the past that these are two separate diseases but in many cases, the doctors continue to use these terms interchangeably.

Response:
VICC agrees with the clinical advice that bronchiectasis and COPD are two separate diseases.  A code can be assigned for each condition depending on the documentation in the medical record.  

In the scenario cited, J47 Bronchiectasis is assigned.  A code for an infective organism is also assigned if known.  

An additional diagnosis code of J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection would only be assigned if the infective exacerbation of COPD meets the criteria in ACS 0002 Additional diagnoses.  If it does not meet criteria for coding, the supplementary code for chronic conditions U83.2 Chronic obstructive pulmonary disease are assigned instead.


Query Text:
VICC query #2735 Intraoral osseointegrated implants was retired 30 June 2017.

Can the committee please review this retired query and advise if the advice is still applicable?

Search details: 
ACCD Q3133: Osseointegration of limb implants on amputees, 15 September 2017.

Response:
VICC considers that the advice in VICC #2735 Intraoral osseointegrated implants is still current and is reproduced below.

‘Query: We have patients at our hospital who present for intraoral osseointegrated implants into their maxilla and/or mandible. This is a one or two stage procedure which involves the implantation of artificial tooth roots, used to support dentures or artificial tooth crowns. The patients at our facility have invariably had teeth removed as part of their treatment for an oral or maxillofacial cancer. They are now having the implants inserted to replace their teeth for functional and/or aesthetic reasons. This is often performed several years after the teeth were originally extracted. 

We referred to ACS 1204 Plastic Surgery in order to assign a diagnosis code for these cases. It states 'when the reason for cosmetic or reconstructive plastic surgery (eg micromastia, redundant facial tissue, bat ears, revision of scar, skull deformity, etc) is documented, code this condition, current disease or injury as the principal diagnosis'. 

Example 3 in this standard provides guidance on how to code a repair of skull deformity following removal of a malignant neoplasm. However in the case of intraoral implants it is not a jaw deformity that is being corrected. The purpose of the procedure is to replace missing teeth that have been extracted. Accordingly we consider the most appropriate diagnosis code/s in this instance are: 

K08.1 Loss of teeth due to accident, extraction or local periodontal disease 
Z85.8 Personal history of malignant neoplasms of other organs and systems (where appropriate) 

Following ACS 1912 Sequelae of Injuries, Poisoning, Toxic Effects and Other External Causes and ACS 1904 Procedural Complications, we do not believe that the condition can be coded as a sequelae. The condition (i.e. absence of teeth) is not a result of injury, poisoning or toxic effects nor is it the result of a previously occurring procedural complication. The absence of teeth is actually the desired outcome of the extraction or surgical procedure. 

Search Details: 
Index look-up 
Absence/tooth, teeth (congenital)/acquired  K08.1 Loss of teeth due to accident, extraction or local periodontal disease 

ACS 0809 Intraoral Osseointegrated Implants 
ACS 1204 Plastic Surgery 
ACS 1904 Procedural Complications 
ACS 1912 Sequelae of Injuries, Poisoning, Toxic Effects and Other External Causes

Response: 

VICC agrees with the logic applied and code selection of K08.1 Loss of teeth due to accident, extraction or local periodontal disease for the scenario cited. 

Z85.8 Personal history of malignant neoplasms of other organs and systems is added if it meets ACS 2112 Personal history.’


Query Text:
Can VICC please advise the correct ACHI code for Saline suppression test?

Patient is admitted as a same day admission and is continuously monitored over 5 hours for the saline suppression test. The patient is given a salt solution through an IV, after which the levels of aldosterone and renin in the blood are measured.

There is no specific index entry listed in the ACHI for saline suppression test.

Response:
As the patient is a planned sameday admission to receive an intravenous intervention as part of a saline suppression test, VICC advises to assign 96199-19 [1920] Intravenous administration of pharmacological agent, other and unspecified pharmacological agent for the administration of IV saline.  

The code can be assigned in accordance with ACS 0042 Procedures normally not coded as the procedure is the principal reason for admission in a same-day episode of care.  

VICC also advises to assign 13839-00 [1858] Collection of blood for diagnostic purposes because the administration of saline and collection of blood together represent the procedure of the saline suppression test.


Query Text:
An ICU patient is initially given 0.5 hours of BiPAP.  After two hours break from NIV, more BiPAP is given continuously for 24 hours.  Finally, two hours later, an additional 0.5 hours of BiPAP is given before patient is completely weaned of ventilatory support. 
  
1) Are the initial and final 0.5 hours added to the total NIV hours for coding (total = 25hrs) or they are not added because they are both less than 1 hour (total = 24hrs) (rounded down in both cases if required)?
 
2) Is the answer the same for VAED reporting – the initial and final 0.5 hours are added to the total NIV hours (total = 25hrs) or they are not added because they are both less than 1 hour (total = 24hrs) (rounded up in both cases if required)? 
  
(Noted also that “two hours” without NIV discounts the ≤ 1 hour rule) 
  
We would also like clarification for coding a total of 24.5 hours of NIV rounded down to 24 hours.  Is the code assigned: 
  
1) 92209-00 [570] Management of noninvasive ventilatory support, <= 24 hours? Or 
2) 92209-01 [570] Management of noninvasive ventilatory support, > 24 and < 96 hours?

Response:
As per ACS 1006 Ventilatory Support, classification point b, subsequent periods of the same type of ventilation when used for treatment should be added together.  

In the scenario cited, the patient had 0.5 hours of NIV, then another 24 hours of NIV, and later another 0.5 hours of NIV.  This adds to 25 hours.

Therefore, the total NIV hours for coding is 25 hours, and 92209-01 [570] Management of noninvasive support >24 and <96 hours would be assigned.

The hours of NIV reported to the VAED would be 25 hours.

To answer your final question, the procedure code to assign for 24.5 hours of NIV rounded down to 24 hours would be 92209-00 [570] Management of noninvasive ventilatory support, <= 24 hours.


Query Text:
Patient with a long term IDC was admitted for trial of void. During the day the patient had a vasovagal episode and was admitted overnight. The following morning the patient was well but did not pass trial of void so IDC was reinserted. 

Our coders are divided about what to assign as the principal diagnosis - Z46.6 Fitting and adjustment of urinary device or R33 Retention of urine?

Response:
VICC advises that in the scenario cited, the correct principal diagnosis is Z46.6 Fitting and adjustment of urinary device by following the Index entry Admission (for)/trial of void as the patient was admitted for trial of void.


Query Text:
Can the committee please advise if the advice in VICC #2481 Fine needle aspiration (FNA) of lymph node (retired 30/06/2015) is still valid?

Search Details:
VICC #2481 Fine needle aspration (FNA) of lymph node (retired)

Response:
VICC considers that in the absence of an Index entry, the advice in VICC #2481 Fine needle aspiration (FNA) of lymph node is still current and is reproduced below.

'Query: How do you code FNA of lymph node? Is it coded as biopsy because aspiration is the method used to obtain the specimen, for example 30075-00 [805] Biopsy of lymph node? 

There is an entry for Aspiration, biopsy - see Biopsy, but I don't have documentation of biopsy.

Response: VICC research indicates that fine needle aspiration (FNA) is a type of biopsy (diagnostic procedure) where a sample of tissue or fluid is removed with a needle. Therefore by default, FNA would be coded as a biopsy by following index entry Aspiration, biopsy - see biopsy by site.'


Query Text:
This query refers to Example 2 of Conventions used in the Tabular list of diseases/Multiple condition coding, where it states:

In classifying a condition with an underlying cause, if the Alphabetic Index (see Example 2) or Excludes note (see Example 18) 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.

Example 2: 
Diagnosis: Leg ulcer due to venous insufficiency 
Index:      Ulcer 
                    - lower limb …L97.9 
                    - - venous 
                    - - - due to venous insufficiency I87.2 
Assign:      L97.9 Ulcer of lower limb, unspecified 
                 I87.2 Venous insufficiency (chronic) (peripheral) 

The Index entry provided in the example is causing confusion. The example refers to a leg ulcer due to venous insufficiency, not a venous leg ulcer. 

Therefore, to assign both L97.9 and I87.2 should you follow the Index pathway provided in the example?

Ulcer, ulcerated, ulcerating, ulceration, ulcerative
- Lower limb (atrophic) (chronic) (neurogenic) (perforating) (pyogenic) (trophic) (tropical)
- - Venous
- - - Due to venous insufficiency I87.2 Venous insufficiency 

Or both index entries below?

Ulcer, ulcerated, ulcerating, ulceration, ulcerative
- Lower limb (atrophic) (chronic) (neurogenic) (perforating) (pyogenic) (trophic) (tropical) L97.9 Ulcer of lower limb, unspecified

AND

Insufficiency, insufficient
- Venous (chronic) (peripheral) I87.2 Venous insufficiency

Search Details:

If it were a venous leg ulcer due to venous insufficiency I would assume only I87.2 would be assigned as per ACCD advice titled Use of subterms in (due to) in ICD-10-AM Alphabetic index which states 'where the ICD-10-AM Alphabetic Index has linked two conditions using the subterms in (due to), this index entry should be followed except where a specific cause for the condition has been otherwise indicated in the clinical record.'

However, because the example assigns both L97.9 and I87.2 it has led me to think the example should use the two pathways to assign the codes. Can you please clarify?

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

The Conventions used in the Tabular list of diseases/Multiple condition coding Example 2 demonstrates that in ICD-10-AM two parts of a clinical concept may be classified using the same lead term.

The index entries for ulcer (any type or site) due to venous insufficiency are derived from ICD-10 and are applicable to single condition/mortality coding, where they identify the underlying cause of the ulcer alone. Note that ‘ulcer due to venous insufficiency’ is classified to I87.2 Venous insufficiency (chronic)(peripheral), regardless of whether or not the ulcer is qualified by the term ‘venous’:

Ulcer, ulcerated, ulcerating, ulceration, ulcerative
- due to
- - venous insufficiency I87.2

Therefore, the two codes cited are correct to fully describe the clinical concept (ie leg ulcer due to venous insufficiency).

Amendments have been made for Eleventh Edition.

Note: ACCD advised VICC that this query would not be published in CLIP.  Therefore VICC has published the query in accordance with the Committee's business rule to publish queries referred to ACCD that ACCD does not publish.


Query Text:
Can the committee please provide guidance on whether we are able to code division of adhesions for the documentation of adhesions taken down? 

Currently there is no index entry for the term taken down in ACHI.

Our example operation report states adhesions between transverse colon and descending colon taken down.

Are we able to use the code for division/freeing of adhesions in scenarios when taken down has been documented as per the above example?

We also often see documentation of release of adhesions.

We note that release of adhesions is indexed however we are limited by the classification sites available in the index. Is release synonymous with division? If so, are we able to use the index under division of adhesions if our site is not indexed under release of adhesions?

Response:
VICC research indicates that adhesiolysis is surgery that is performed to remove or divide adhesions or scar tissue in order to restore normal anatomy and function.  Therefore VICC considers that when in reference to adhesions, terms such as 'taken down', 'divided', 'released', ‘dissection/dissected’, ‘stripped down’, ‘separated’ or 'freed' are synonymous with adhesiolysis.

In the scenario cited, follow the Index entry Adhesiolysis - see also Division/adhesions: Division/adhesions/abdominal to assign 30378-00 [986] Division of abdominal adhesions.

You may wish to make a public submission to ACCD for improvements to the Index.


Query Title:
Trans-oesophageal echocardiogram (TOE) - selection of principal diagnosis

Query Text:
We have a number of TOE procedures performed at our health service and want to ensure that we are consistent with coding out these scenarios. Could you please assist us with the following questions:

1) Is a TOE a form of endoscopy, should we apply ACS 0051 Same-day Endoscopy - diagnostic and ACS 0052 Same-Day Endoscopy - Surveillance?

2) If a patient is admitted for investigation of cause of stroke through a TOE - do we code as principal diagnosis the stroke or should we use a surveillance code, or an observation code in the absence of a finding?

3) Patient is admitted for investigation of cause of stroke through a TOE and a coronary thrombosis is found, do we code the stroke or the thrombosis or both? Which should be principal diagnosis?

4) Patient with recent CABG and sternal wound infection is admitted for TOE to rule out endocarditis - no evidence of endocarditis found.  Should the principal diagnosis be Z13.6 Special screening examination for cardiovascular disorders or Z03.5 Observation for suspected cardiovascular diseases?

5) Patient admitted for investigation of shortness of breath - TOE finding is mild aortic stenosis. There is no causal link documented for the symptom and finding.  If considered an endoscopy should we follow ACS 0051 Same-day Endoscopy - diagnostic? If not an endoscopy what should we be coding out for this scenario?

We have reviewed the advice in VICC #2785 Principal diagnosis selection for same-day TOE admissions (retired 30 June 2017) and are not sure if this is still current.

Response:
VICC considers the advice in VICC #2785 Principal diagnosis selection for same-day TOE admissions (retired 30 June 2017) to still be correct.  

The principal diagnosis is the documented condition that occasioned the episode of care.  As per ACS 0012 Suspected conditions under heading 'Observation for suspected diseases and conditions', codes from category Z03 are assigned as principal diagnoses for admissions to evaluate the patient's condition.  Therefore an observation code is not considered an appropriate principal diagnosis in these cases, which are to investigate the underlying cause.

If there is a documented link between the condition being investigated and a finding on TOE, assign a code for the finding in accordance with ACS 0001 Principal diagnosis, Problems and underlying conditions section, point 1, Coding the underlying condition as principal diagnosis.  If there is no documented link, a code for the condition being investigated should be assigned as principal diagnosis.

In answer to your specific questions:

1. VICC does not consider a trans-oesophageal echocardiogram (TOE) to be a form of endoscopy.  Therefore, ACS 0051 Same-day endoscopy - diagnostic and ACS 0052 Same-day endoscopy - surveillance should not be applied when assigning codes for TOE.

2. In the scenario cited the principal diagnosis would be the stroke because it is the cause of the stroke that is being investigated.

3. In the scenario cited VICC advises to assign a code for stroke as principal diagnosis unless there is a documented link between the coronary thrombosis and the stroke.  

If there is a documented link between the coronary thrombosis and stroke, assign a code for the coronary thrombosis as principal diagnosis in accordance with ACS 0001 Principal diagnosis, Problems and underlying conditions section, point 1, Coding the underlying condition as principal diagnosis.  

If there is no documented link assign a code for stroke as principal diagnosis with coronary thrombosis as an additional diagnosis if it meets ACS 0002 Additional diagnoses.

4. In the scenario cited, the TOE (to rule out endocarditis) is being performed because the patient had a sternal wound infection. VICC considers that as no endocarditis was found, the principal diagnosis is the sternal wound infection.

5. In the scenario cited, VICC advises that as there is no causal link documented between the patient's shortness of breath and the TOE finding of mild aortic stenosis, the principal diagnosis is shortness of breath.  Clarification can be sought from the clinician to establish if there a causal link between the indication and finding.


Query Text:
We require clarification regarding the coding of symptoms/manifestation of allergic reactions as per advice ACS 2115 Admission for Allergen Challenge and ACCD Coding Rule Q2905 Coding of Allergic Reactions NOS and Anaphylactic Reactions.

ACS 2115 states that 'additional chapter codes can also be assigned where they are required to classify the clinical concept'. ACCD Coding Rule Q2905 however states that 'symptoms such as wheeze, urticaria and swelling should not be coded when a diagnosis of allergic reaction or anaphylaxis has been established unless the symptom is significant in its own right and treated independently of the of the allergic reaction (see also, Note at the beginning of Chapter 18 Symptoms, Signs and Abnormal Clinical Findings, not elsewhere classified)'.

Our interpretation of the advice is that an allergic reaction to food is coded to T78.1 Other adverse food reactions, not elsewhere classified with additional codes for the allergic manifestation only when they meet the critieria in the Note at the beginning of Chapter 18 and are treated independently of the allergic reaction.

It is also our understanding that in the setting of an allergic reaction to medication, the allergic manifestation would be coded instead of T88.7 Unspecified adverse effect of drug or medicament, following the Excludes note at this code.

Can you confirm whether the above interpretations are correct?

2. Our second question relates to allergic urticaria as an allergic reaction to food and the ACCD Coding Rule instruction not to code urticaria unless it meets the critieria in the Note at the beginning of Chapter 18 and is treated independently of the allergic reaction.

Considering that Urticaria is a condition classifiable to Chapter 12 Diseases of the Skin and Subcutaneous Tissue and is indexed with an essential modifier for 'allergic', we are unsure why it is subject to the criteria in Chapter 18 Symptoms, Signs and Abnormal Clinical and Laboratory Findings. Furthermore, subjection to this criteria would mean that in many cases specific information about the allergic reaction, such as allergic urticaria would not be captured and therefore the clinical 
concept not adequately classified.  

For the following options, can you please clarify which allergic manifestations (occurring as allergic reaction to food) should be subject to the instruction in ACCD Coding Rule Q2905?

A) conditions classifiable to Chapter 18
b) conditions classifiable to Chapters outside of Chapter 18 when they do not have an essential modifier for allergic
c)  conditions classifiable to Chapters outside of Chapter 18 when they have an essential modifier for allergic.

Response:
For patients admitted for an allergy challenge, VICC advises to follow the instructions in ACS 2115 Admission for allergen challenge and assign codes for any allergic manifestations arising from the challenge, along with additional chapter codes where required to classify the clinical concept.

For all other admissions for allergic reactions not otherwise specified outside of an allergen challenge, only assign additional diagnosis codes for documented symptoms/manifestations where they are significant in their own right and treated independently of the allergic reaction. The reference to Chapter 18 in the Coding Rule advice is illustrating that symptoms are only coded if they are significant and treated independently of the allergic reaction.  This is in accordance with ACCD Coding Rule Q2905 Coding of allergic reactions NOS and anaphylactic reactions.

In answer to your second question, the Coding Rule should only be applied where the principal diagnosis is allergic reaction not otherwise specified, or similar wording.  If the principal diagnosis is a specific allergic condition, such as allergic urticaria or allergic dermatitis, follow the exclusion note at T78.1 Other adverse food reactions, not elsewhere classified and assign the more specific code.


Query Text:
We are trying to find the best way to code for a positive BRCA for either a patient who has a past history of breast cancer or a patient who has a family history of breast cancer. 

We are using the prophylactic surgery code of Z40.00 Prophylactic surgery for risk-factors related to malignant neoplasms, Breast or Z40.01 Prophylactic surgery for risk-factors related to malignant neoplasms, Ovary for breast or ovary removal and adding Z80.3 Family history of malignant neoplasm of breast or Z85.3 Personal history of malignant neoplasm of breast /Z80.4 Family history of malignant neoplasm of genital organs or Z85.4 Personal history of malignant neoplasm of genital organs as personal/family history of cancer.

Is there any other code to capture the positive BRCA gene itself for more specificity?

Response:
There is no code to capture the presence of the positive BRCA gene. 

In the scenario of prophylactic surgery with personal history of breast cancer, VICC advises to follow example 2 of  ACS 2114 Prophylactic surgery:

EXAMPLE 2: 
Patient admitted for prophylactic laparoscopic bilateral salpingo-oophorectomy after being found to have the BRCA2 gene fault on predictive gene testing. Patient has a past history of breast carcinoma with left mastectomy 28 years ago. 
Codes: 
Z40.01 Prophylactic surgery for risk-factors related to malignant neoplasms, ovary 
Z85.3 Personal history of malignant neoplasm of breast 
35638-12 [1252] Laparoscopic salpingo-oophorectomy, bilateral 
(See also ACS 2112 Personal history.)

In the scenario of prophylactic surgery with family history of breast cancer, VICC advises to assign Z80.3 Family history of malignant neoplasm of breast as an additional diagnosis.


Query Text:
Our questions relate to questions number 1-9 that were recently published in the Vic 0002 Additional diagnoses education workshops - Questions and Answers, section Pressure Injury questions, particularly the answer reproduced below:

However if there is a documented pressure injury, interventions /documentation that would indicate clinical significance include:
- A documented plan of care to support the management of the pressure injury, e.g. a regime of regular dressings
- Referral to a wound specialist with a documented plan of care for the pressure injury
- Documentation of discussion with a second nurse regarding management of the pressure injury with a documented plan of care
- Application of vacuum dressing/ device, not previously required for the pressure injury, to replace a conventional dressing.

1. Does this section only apply to new pressure injuries?

2. For a pre-existing pressure injury/ulcer does the completion of a wound chart, by a general nurse, with a documented treatment plan meet point 3b of Vic 0002, increased clinical care and/or monitoring and therefore a preexisting ulcer can be coded when a treatment plan is documented on the wound chart? If so, which criterion does this satisfy in Vic 0002?

3. In a health service that has a wound specialist but may not always be on site or available, is a general nurse acting in that capacity (e.g. documenting a treatment plan for an ulcer) considered to be a second health professional?

4. When a treatment plan for an ulcer is documented and the plan is for change of dressings PRN, is this enough to code or do we need documentation of regular frequency, for example 2nd daily etc?

5. Can you please provide further examples of how a preexisting pressure injury/ulcer would meet Vic 0002?

Response:
In relation to each of your questions, VICC advises the following:

1. The pressure injury questions section of the Vic 0002 Additional diagnoses education workshops - Questions and Answers applies to all pressure injuries, whether new or pre-existing.

2. A wound chart may be routinely established for all potential wounds therefore clinical coders need to be confident that a treatment plan exists on the chart for the management of the pressure injury.  Documentation of a plan of care for the condition indicates significance where the plan meets one of the criteria in points 1 or 3 of Vic 0002 Additional diagnoses.

3. A general nurse can complete a wound care chart and write up a treatment plan.  A general nurse can be considered a second health professional provided that there is documentation of the interaction between the two health professionals.

4. Where a plan has been documented, there should be evidence that it has been carried out before a code for the condition can be assigned.

5.  VICC is not able to provide further examples of how a pre-existing pressure injury/ulcer would meet Vic 0002 Additional diagnoses. The clinical coder needs to make a decision based on the published advice and documentation available.


Query Title:
Plan of care and Vic 0002 Additional diagnoses

Query Text:
Our questions relate to questions number 7 and 29 that were recently published in the Vic 0002 Additional diagnoses education workshops - Questions and Answers, section Other Additional Diagnosis Questions and whether these apply when the original treating clinician (not a second health professional) makes the plan of care.

Question 7 reproduced below:
Patient documentation says 'no further care required' following assessment of a suspected condition. Does the condition meet Vic 0002 criteria for coding?
Answer: Yes, the suspected condition can be coded as the patient has been assessed and a documented plan exists for the management of the patient's suspected condition.
NB. The suspected condition must also meet the criteria in ACS 0012 Suspected condition.

1. Can you please explain which criterion in Vic 0002 is satisfied in order that the suspected condition can be coded in Question 7?  Our interpretation of Vic 0002 is that unless a second health professional is involved and makes this assessment for 'no further care required' or unless any other criteria under Vic 0002 are met, (for example, a diagnostic procedure was performed) that a code for a suspected condition would not be assigned.

Question 29 reproduced below:
If a doctor documents 'continue current treatment', can the condition be coded?
Answer: This depends on the circumstance of the doctor's review, for example, if this was of a condition documented during a clinical assessment (as per Assessments section of ACS 0002), then the condition would not be coded.
But if the doctor reviews a patient's condition and documents 'continue current treatment', a treatment plan has been documented. Therefore the condition can be coded.

2. Can you please explain which criterion in Vic 0002 is satisfied in order that the condition can be coded in Question 29?  Our interpretation of Vic 0002 is that unless a second health professional is involved and makes this assessment plan for 'continue current treatment' or unless any other criteria under Vic 0002 are met, (for example, a diagnostic procedure was performed) that a code for the condition assessed would not be assigned.

Response:
In response to your questions, VICC advises the following:

1. In the scenario cited, assessment of a suspected condition with documentation of 'no further care required' meets the first criteria in Vic 0002, Documentation of a plan of care for the condition.  For further clarification refer to point 1a, 'the treatment plan is commenced for a newly diagnosed condition following clinical consultation and documentation'.  In this scenario the specific condition has been assessed and the treatment plan is for no further care.  Note that the suspected condition must also meet the criteria in ACS 0012 Suspected conditions.

2. In the scenario cited, documentation of 'continue current treatment' meets the first criteria in Vic 0002, Documentation of a plan of care for the condition. For further clarification refer to point 1.


Query Text:
We are wondering if there is another way we should be coding unconscious collapse or should we still be following VICC Query #1933 Unconscious collapse (retired 2010) which states to code both and sequence based on documentation.

The other option is to follow collapse as the lead term and code this first and then unconsciousness as an additional diagnosis to further specify as there is no Index entry at collapse that covers the unconscious component.   VICC Query #1933 also states 'the Committee discussed the concept of collapse with and without loss of consciousness, with the overriding opinion being that it is possible to collapse without losing consciousness'.

Can the Committee please specify what the correct way to code this condition is to ensure consistency not only in our coding team but across the state?  There are DRG impacts depending on which code is sequenced first.

Response:
The advice in #1933 Unconscious collapse is no longer current and therefore cannot be followed.

Unconscious collapse is a condition where collapse has been further described as involving loss of consciousness.

VICC agrees that when unconscious collapse is documented, to first follow the lead term Collapse and assign R55 Syncope and collapse.  Then follow the lead term Unconscious(ness) to assign R40.2 Coma, unspecified as an additional diagnosis.


Query Text:
The opening statement of ACS 0012 Suspected conditions mentions 'terms that indicate uncertainty about the final diagnosis (such as probable, suspected, possible, likely, query, ?) or other similar qualifying expressions'. There is no mention of differential diagnoses.

Can the VICC please advise what should be coded when there is documentation of both a suspected condition and a differential diagnosis?

We are unsure of how to apply ACS 0012 to the following case:
Diagnosis on Discharge Summary: Fever/ nausea/ high stomal output
- Probable gastroenteritis. Differential Dx exacerbation of usual high stoma output

In this case should we code the symptoms or the gastroenteritis?

The dot point under example 2 in ACS 0012 states: 'if more than one suspected condition is documented as the differential diagnosis:
assign code(s) for the documented symptom(s)
OR
if there are no symptom(s) documented, assign codes for all suspected conditions.'

If no symptoms are documented why not follow the advice on observation for suspected diseases and conditions (Z03.0 - Z03.9) in the same standard and assign Z codes? 

We note the Errata 3 change to ACS 0012 and the instruction that if there are no symptoms documented to code all suspected conditions.  We are wondering why the advice on observation for suspected diseases and conditions (Z03.0 - Z03.9) that is in the same standard is not followed and Z codes assigned instead?

Response:
VICC considers that the term differential is an example of a qualifying expression that indicates uncertainty about a final diagnosis, and therefore diagnoses on the discharge summary that have been documented as differential should be classified in the same way as suspected conditions. 

In the scenario cited, VICC advises to assign a code for each of the documented symptoms of fever, nausea, and high stomal output in accordance with the amended (Errata 3) ACS 0012 Suspected conditions where it states 'if more than one suspected condition is documented as the differential diagnosis, assign code(s) for the documented symptoms'.

In the rare circumstance where there is more than one suspected condition but no symptoms documented, follow the amended (Errata 3) ACS 0012 Suspected conditions where it states 'if there are no symptoms documented, assign a code for all suspected conditions'.

ACS 0012 Suspected conditions - Observation for suspected diseases and conditions (Z03.0-Z03.9) applies to situations where no supporting evidence for the suspected condition is found and no treatment is currently required.


Query Text:
As there is no Index entry for neurogenic claudication can VICC please advise the correct code for neurogenic claudication secondary to central lumbar canal stenosis? We have queried several cases with a Neurosurgeon who has clarified that this term can be further described as nerve root compression.

If unable to obtain clarification from the clinician and if VICC cannot provide a default code, is it correct to code this to G95.8 Other specified diseases of spinal cord following Index entry:

Disease, diseased
- spinal (cord) G95.9
-- congenital Q06.9
-- specified NEC G95.8.

Response:
For documentation of neurogenic claudication secondary to central lumbar canal stenosis where the clinician has clarified that the neurogenic claudication is nerve root compression, VICC considers it appropriate to follow Index entry Compression/nerve/root or plexus/with spinal (vertebra) stenosis or Stenosis/spinal/with nerve root compression to assign M48.06 Spinal stenosis, lumbar region and G55.3 Nerve root and plexus compressions in other dorsopathies. 
 
As the term neurogenic means giving rise to or arising from the nervous system, in the absence of clinical clarification VICC considers the appropriate Index entry to follow for documentation of neurogenic claudication is Disease/nervous system to assign G98 Other disorders of nervous system, not elsewhere classified.

You may wish to send a public submission to ACCD for improvements to the Index.


Query Title:
ACS 1521 Conditions and injuries in pregnancy - non obstetric conditions in pregnancy

Query Text:
ACS 1521 Conditions and injuries in pregnancy - non obstetric conditions complicating pregnancy states that:
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). 

If a condition is documented as 'not complicating the pregnancy' is it correct to not code this as an obstetric complication even if it meets the criteria above?

For example principal diagnosis on Discharge Summary: Low back pain not complicating pregnancy. During the admission fetal monitoring was performed and the patient was evaluated by an obstetrician but the conclusion was that the low back pain was not related to the pregnancy and not complicating the pregnancy. Should this be coded to M54.5 Low back pain and no codes from Chapter 15 assigned?

Is it considered ethical to query with the clinician whether a condition is 'not complicating the pregnancy' and therefore the coder doesn't have to follow the dot points above?

Response:
The dot point criteria in ACS 1521 Conditions and injuries in pregnancy - Nonobstetric conditions complicating pregnancy are to be used in the absence of specific documentation.  If a condition is documented as 'not complicating the pregnancy' it should not be coded as an obstetric complication. 

In the scenario provided, the principal diagnosis was low back pain not complicating the pregnancy.  The diagnosis has been specifically documented as not complicating the pregnancy, therefore M54.5 Low back pain should be assigned rather than codes from Chapter 15 .  This is regardless of fetal monitoring and evaluation by an obstetrician.

In regard to the last question about whether it is considered ethical to query with the clinician whether a condition is 'not complicating the pregnancy',  unlike some other standards, ACS 1521 does not specifically instruct  the coder to seek clarification from the clinician is as it is clear about what to do in the absence of specific documentation of 'not complicating pregnancy'.  Therefore VICC does not consider it necessary to query whether a condition is 'not complicating pregnancy' with the clinician.


Query Title:
Percutaneous transluminal angioplasty (PTA) of multiple peripheral vessels

Query Text:
ACCD Coding Rule Q3134 PTA (Percutaneous Transluminal Angioplasty) of multiple peripheral vessels advises coders to assign multiple ACHI codes when interventions such as angioplasties are performed on multiple peripheral vessels as the procedures are performed on different lesions although the query does not explain what the different lesions are.  

The answer refers to ACCD Coding Rule Q2882 Thrombectomy and embolectomy of multiple arteries which advises coders to assign multiple ACHI codes when the procedures are performed on different lesions. This advice quotes the second dot point of Point 2 Multiple procedures in ACS 0020 Bilateral/multiple procedures as stating embolisation of left and right uterine arteries applies to treating the same condition/lesion which is uterine fibroid. However ACS 0020 Point 2 does not mention that the condition/lesion is a uterine fibroid.

When angioplasties are performed on multiple peripheral vessels to treat the same condition (eg atherosclerosis) is it correct to follow ACS 0020 Multiple Procedures, Point 2 and only assign one ACHI code? Note: insertion of multiple vascular stents is given as an example under this dot point.

Response:
VICC considers that atherosclerosis can be comprised of a number of lesions in different vessels.  Although atherosclerosis is one condition, when it is found in multiple locations/vessels each instance is a separate lesion.  When angioplasties are performed on multiple vessels they are being performed on different lesions.  

Therefore, follow the advice in Coding Rule Q3134 PTA (percutaneous transluminal angioplasty) of multiple peripheral vessels and ACS 0020 Bilateral/multiple procedures, Point 3 to assign multiple ACHI codes for angioplasties performed on multiple peripheral vessels.  The number of codes assigned will depend on the number of peripheral vessels that have been treated. 

Point 2 of ACS 0020 applies when multiple stents are treating the same lesion/condition.


Query Title:
INR monitoring in ACS 0303 Abnormal coagulation profile due to anticoagulants

Query Text:
ACS 0303 Abnormal coagulation profile due to anticoagulants strictly advises that there must be INR monitoring to assign Z92.1 Personal history of long term (current) use of anticoagulants, however this instruction is subsequently followed by two very clear examples of when to code Z92.1, and these don't mention INR monitoring at all (copied below). 

The Tenth Edition FAQ Coding Rule TN1248 also advises INR monitoring is required.

EXAMPLE 1:
Patient on long term anticoagulants, admitted one day prior to TURP for heparinisation.
Code: Z92.1 Personal history of long term (current) use of anticoagulants (as an additional code)

EXAMPLE 2:
Patient on long term warfarin had an unwitnessed fall. Patient was admitted for management of his traumatic subarachnoid haemorrhage. Warfarin was withheld during the admission to prevent exacerbation of the subarachnoid haemorrhage.
Codes: Z92.1 Personal history of long term (current) use of anticoagulants (as an additional code)
In this example, D68.3 Haemorrhagic disorder due to circulating anticoagulants is not assigned as the documentation does not state that the subarachnoid haemorrhage was the result of the anticoagulation use.

Are the examples in ACS 0303 incorrect, or can Z92.1 be coded without an INR in specific scenarios where an anticoagulant is changed, or changes the patient's length of stay.

Is the ACCD able to provide clarifying advice?

Response:
VICC acknowledges that the examples do not include the terminology of requiring monitoring, however theTenth Edition FAQ Coding Rule TN1248 (published 15 September 2017) clarified that documentation of INR monitoring was required in order to assign Z92.1 Personal history of long term (current) use of anticoagulants. The Coding Rule is specific to Z92.1 Personal history of long term (current) use of anticoagulants and R79.83 Abnormal coagulation profile. 

Therefore regardless of whether an anticoagulant is changed, or changes the patient's length of stay, there must be documentation in the clinical notes that the INR is being monitored in order to assign Z92.1 Personal history of long term (current) use of anticoagulants.

ACS 0303 Abnormal coagulation profile due to anticoagulants is being reviewed for Eleventh Edition, and therefore VICC considers it unlikely that the ACCD would provide any further advice at this stage.  Additionally VICC notes that there is another query already with ACCD on this topic.

Please also refer to Coding Rule Q3367 Anticoagulants not requiring INR level monitoring, published on 15 December 2018 which provides the following advice:

Q: Do the guidelines in ACS 0303 Abnormal coagulation profile due to anticoagulants apply to Novel/Non-vitamin K Oral Anticoagulants (NOAC) (ie anticoagulants that do not require INR level monitoring)?   

A: The guidelines in ACS 0303 Abnormal coagulation profile due to anticoagulants apply to abnormal INR (ie abnormal coagulation profile) due to anticoagulant use; therefore, if INR monitoring is not required, ACS 0303 does not apply to the episode of care.

Note also that antiplatelets are not anticoagulants, and INR monitoring is not required when these agents are administered.

ACS 0303 states:

Patients taking oral anticoagulants may require bridging anticoagulant therapy prior to a planned procedure. This involves replacing their usual oral anticoagulant (eg warfarin) with a short action agent such as Clexane or heparin until the patient can resume their usual anticoagulant therapy. The intention of bridging therapy is to minimise the risk of developing a thromboembolic event after a procedure. 

CLASSIFICATION

If patients on long term anticoagulants require anticoagulant level monitoring during an episode of care and the INR level is within the target therapeutic range (ie no supratherapeutic or subtherapeutic INR is documented), assign Z92.1 Personal history of long term (current) use of anticoagulants as an additional diagnosis

ACS 0303 has been amended for Eleventh Edition. In the interim, apply the following guidelines to clarify the assignment of Z92.1:

Assign Z92.1 Personal history of long term (current) use of anticoagulants as an additional diagnosis if a patient is on long term anticoagulants and:

	bridging anticoagulant therapy is administered prior to or following a planned procedure, or 

	anticoagulant therapy is withheld because the patient has a medical condition that contraindicates the continued use of anticoagulants, or 

	anticoagulant level monitoring is undertaken during an episode of care and the INR level is within the target therapeutic range (ie no supratherapeutic or subtherapeutic INR is documented).


Query Title:
Born before arrival with spontaneous delivery of placenta in labour ward

Query Text:
Patient delivered baby at home (unplanned) and was admitted to hospital, where placenta was delivered spontaneously.

Are the following codes correct:

O80 Single spontaneous delivery
Z37.0 Single Livebirth
Z39.03  Postpartum care after unplanned out of hospital delivery

Do we also need to assign 90467-00 [1336] Spontaneous vertex delivery to capture delivery of placenta?

Response:
As the placenta was delivered after admission to hospital, the episode is considered a delivery episode.  In accordance with ACS 1548 Puerperal/postpartum condition or complication Z39.0- is never assigned in a delivery episode of care.  Therefore the correct codes to assign for the scenario cited are: 

O80 Single spontaneous delivery 
Z37.0 Single live birth 

As per Tenth Edition Obstetrics ACS education (slides 13 to 19), where a baby is delivered outside hospital, and placenta is spontaneously delivered in hospital, no ACHI code is assigned for the delivery. 

A PICQ warning will be received for these episodes to ensure review of coding where an ACHI code for spontaneous vaginal delivery within the hospital should have been assigned.


Query Title:
Abnormal INR secondary to antibiotics with warfarin use

Query Text:
High INR is clearly documented as being secondary to antibiotics. Warfarin is adjusted accordingly during patient's admission. I have also discussed this with the clinician to support this documentation. 

When I code R79.83 Abnormal coagulation profile as an adverse effect of antibiotics and Z92.1 Personal history of long term (current) use of anticoagulants, I have an error appear on the Codefinder referring to ACS0303 - do not assign Z92.1 and R79.83 in the same episode. 

There is an excludes note in the tabular under R79.83. There is no causal relationship evident between the increased INR and the warfarin usage and I feel that both these codes are relevant to this episode of care.

Response:
As advised in ACS 0303 Abnormal coagulation profile due to anticoagulants and the excludes notes in the Tabular, the codes R79.83 Abnormal coagulation profile and Z92.1 Personal history of long term (current) use of anticoagulants are mutually exclusive and cannot be assigned together.

In the scenario cited, as the INR value is documented as high the correct code to assign is R79.83 Abnormal coagulation profile.  As there is a documented relationship between the high INR and antibiotic use, assign Y40.9 Systemic antibiotic, unspecified causing adverse effects in therapeutic use as the external cause code.

Also assign Y44.2 Anticoagulants in accordance with the use additional code note at R79.83 Abnormal coagulation profile and the second dot point in the classification section of ACS 0303 Abnormal coagulantion profile due to anticoagulants.


Query Title:
Neonatal sepsis / risk of sepsis / suspected sepsis

Query Text:
We are unsure of which coding standard/s to apply in the following instance and would appreciate your advice please:

Premature newborn babe in birth episode.  Admitted to Special Care Nursery (not NICU but is higher intensity than ward care) for septic workup due to mother's premature rupture of membranes.  An attempt was made to insert IV cannula into baby for antibiotics, however, this was unsuccessful and AB's were not given.  Documentation states babe was jittery at time of attempted cannulation.  Babe's inflammatory markers remained stable.

Discharge summary principal diagnosis is 'presumed sepsis'.

Should this be coded as:

- P36.9 bacterial sepsis of newborn (ACS 0012 suspected conditions)?
- Z03.71 observation of newborn for suspected infectious condition (ACS 1617)?

Does admission to an area of higher acuity influence the decision as to what to code?

Do IV AB's always have to be given before P36.9 neonatal sepsis can be coded?

We have considered VICC 3117 Presumed sepsis (with documented symptoms) in neonates. But are still unsure as IV AB's were administered in both of the examples in this query.

Response:
As per VICC query #3117 Presumed sepsis (with documented symptoms) in neonates, there has to be treatment of a neonatal condition or symptom in conjunction with documentation of presumed sepsis in order for P36.9 Neonatal sepsis to be assigned. 

In the case cited a plan of care was made for the documented diagnosis of presumed sepsis, even though it was not able to be completed, and there was a documented symptom (jittery).   Therefore it is appropriate to code sepsis in accordance with ACS 0012 Suspected conditions and VICC query #3117 Presumed sepsis (with documented symptoms) in neonates.  

Neither ACS 1611 Observation and evaluation of newborn and infants for suspected condition not found nor 1617 Neonatal sepsis/risk of sepsis apply to the scenario cited therefore Z03.7- Observation and evaluation of newborn for suspected condition not found is not assigned.  

Admission to an area of higher acuity can influence the decision on whether there is a condition that can be coded, but not which condition.  A condition may meet Vic 0002 Additional diagnoses when documentation states the condition requires admission to higher acuity area of the hospital.[end of original response].

Following publication of ACCD Coding Rules on 15 December 2018, the VICC response is superseded by the following advice titled Neonatal sepsis/risk of sepsis:

Q: What code is assigned for suspected neonatal sepsis?

A: ACS 0012 Suspected conditions provides the following guidelines in regard to suspected diseases and conditions in neonates:

Z03.7- Observation and evaluation of newborn for suspected condition not found is assigned following the criteria in ACS 1611 Observation and evaluation of newborn and infants for suspected condition not found and ACS 1617 Neonatal sepsis/risk of sepsis.

ACCD acknowledges that the Note at category Z03.7 Observation and evaluation of newborn for suspected condition not found and the risk of sepsis classification instructions within ACS 1617 Neonatal sepsis/risk of sepsis are ambiguous, as neonates with risk of/suspected sepsis may be symptomatic and have other conditions. However, coders should apply the guidelines in ACS 1617 regardless of whether the neonate has signs or symptoms, or coexisting conditions documented.

Therefore:

• when there is documentation of “suspected neonatal sepsis” but there is conflicting, unclear or no supporting documentation in the body of the clinical record, seek clinician clarification prior to code assignment

• where a diagnosis of ‘neonatal sepsis’ is confirmed, assign a code for sepsis, as per the guidelines ACS 1617 Neonatal sepsis/risk of sepsis

• 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.

Amendments may be considered for a future edition.

VICC notes that this will be a change of practice for Victorian coders.


Query Title:
Quadriplegia - documentation to meet Vic 0002 Additional diagnoses

Query Text:
Would you please consider the following documentation and advise if it is sufficient to meet criteria for Vic 0002 Additional diagnoses to assign a code for quadriplegia?  We are unsure how strictly we must interpret the example given in the Vic 0002 workshops regarding links necessary between the use of hoist (or other specialised equipment) and quadriplegia.

Example:
Quadriplegic patient admitted for an unrelated condition.  Nursing care plan documents patient is quadriplegic and wheelchair bound.  Nursing progress notes refer to patient being unable to pull himself up as he 'doesn't have a bed stick'.  Nurse tried to get bed stick but ward one did not fit onto the bed.  Referrals were made to physiotherapy and occupational therapist to provide appropriate bed stick as patient had risk of pressure injury and required assistance with movement.

There is no documentation that strictly meets the example in the Vic 0002 workshop i.e. it does not say 'quadriplegia - needs bed stick to pull self up in bed'.

In the absence of any other documentation that would indicate an alternative reason the patient could not move enough to pull himself up in bed, can coders use coders creed and assign a code for quadriplegia (based on documentation cited above) without having to first clarify with the clinician?

Response:
In the scenario cited, even if there was documentation making the link between quadriplegia and the need for a bed stick, as per Vic 0002 Additional diagnoses a bed stick is not significant special equipment.

Therefore based on that documentation alone, assign U80.5 Tetraplegia, paraplegia, diplegia, monoplegia and hemiplegia, due to any cause.


Query Title:
Removal of intermaxillary fixation screws

Query Text:
Can the committee please advise what diagnosis and procedure codes should be assigned when a patient presents for the removal of intermaxillary fixation screws under local anaesthetic? The screws had previously been inserted to treat a mandibular fracture.

Response:
VICC research indicates that intermaxillary fixation screws are self-drilling or self-tapping screws inserted from the outside of the maxilla and mandible through the gum above the teeth into the bone.  They are used to anchor wires or bands which in turn reduce the fracture.  VICC considers that intermaxillary fixation screws are external fixators that are applied to bone.  

For the scenario described, assign:

Z47.8 Other specified orthopaedic follow-up care by following the Index entry Removal/device/fixation/external

47948-00 [1554] Removal of external fixation device by following the Index entry Removal/fixation device/external.

This is supported by the advice in ACCD Q3166 Removal of external fixation involving removal of pins and/or wires.


Query Text:
Could you please clarify the correct diagnosis and morphology codes to use to classify a mucosal Schwann cell hamartoma of the appendix.

Response:
VICC research indicates that a hamartoma is a benign (noncancerous) tumour-like growth consisting of a disorganised mixture of cells and tissues normally found in the area of the body where the growth occurs.

VICC advises that for documentation of schwann cell hamartoma of appendix, follow the Index entry Hamartoma, hamartoblastoma and assign Q85.9 Phakomatosis, unspecified.

See also Coding Rule Q3119 Angiomyomatous hamartoma of the lymph node published 15 September 2017.


Query Text:
We have a Type 1 diabetic patient with documented diabetic ketosis with no acidosis. We note the patient has starvation ketosis documented elsewhere in the record.  The patient has many other complications of their type 1 diabetes. Can you please indicate how we should code this?

At present we are going via the Index coding to diabetes/with/ketoacidosis E10.11 T1DM w ketoacidosis wo coma but it doesn't seem to capture the condition accurately.

Response:
VICC advises that as the diagnosis is documented as diabetic ketosis, VICC considers the correct Index entry to follow is Ketosis/diabetic – see Diabetes/with/ketoacidosis to assign E10.11 Type 1 diabetes mellitus with ketoacidosis, without coma.  Although there is no documentation of ketoacidosis the classification directs the coder to the code.

As per VICC #3026 Starvation ketosis, the term 'starvation' refers to the type of ketosis rather than a clinical diagnosis of starvation, therefore VICC does not support the assignment of a code for starvation.   Please note that in VICC #3026 Starvation ketosis there is no documentation of diabetic ketosis.


Query Text:
My question is about the site code for embryonal sarcoma of liver. The index leads to C22.9 malignant neoplasm of liver unspecified. However in the tabular list there is a code C22.4 other sarcomas of liver. I could not find a pathway for embryonal sarcoma of liver that would lead to C22.4. I understand that we are not meant to tabular browse but I did wonder if we should be using C22.4 rather than C22.9? Is there a pathway that I have missed?

Response:
VICC advises that while C22.4 Other sarcomas of liver seems to be an appropriate code for embryonal sarcoma of liver, the code can only be reached through the Index entry Tumour/mesodermal, mixed/liver. Therefore for documentation of embryonal sarcoma of liver, follow the Index entry Neoplasm/liver to assign C22.9 Malignant neoplasm of liver, unspecified.

You may wish to send a public submission to the ACCD for improvements to the Index.


Query Title:
Different description of same morphology code when behaviour changes

Query Text:
This patient was diagnosed with clear cell meningioma with germline SMARCE1 mutation. The morphology code is  M9538/1 clear cell meningioma uncertain whether benign or malignant. A PET scan showed 'Bilateral seventh cranial nerve activity is greater than would be expected and most likely represents metastatic disease.' The clinician confirmed that whilst there were no metastases that the tumour was malignant. 

My problem is that the description for this patient's tumour does not include malignancy (3) for clear cell meningioma. If I use the morphology code the descriptor is changed to papillary:

M9538/0 Clear cell meningioma, benign
M9538/1 Clear cell meningioma, uncertain whether benign or malignant
M9538/2 Papillary meningioma, in situ
M9538/3 Papillary meningioma

Is it correct to change a morphology code when the behaviour is stated as malignant but the morphology description of the same code is different?

Response:
In accordance with Appendix A of the Tabular list, 'In the nomenclature listed here, the morphology codes include the behaviour code appropriate to the histological type of neoplasm; it is appropratiate to assign a different behaviour code if supported by documentation in the clinical record'.  

It is correct to change the behaviour code when the behaviour is stated as malignant, even if the morphology description of the same code is different. 

Therefore in the example cited, malignant clear cell meningioma is assigned a morphology code of M9538/3 Papillary meningioma with a disease code of C70.9 Malignant neoplasm of meninges, unspecified.


Query Title:
Procedure code assignment for amniotic membrane graft to cornea

Query Text:
What would be the most appropriate procedure code for an amniotic membrane graft to the cornea? Currently we are assigning 90066-00 [174] - Other repair of cornea. Although the index directs us to go to "keratoplasty" when searching for "graft" and then "cornea", the closest subterm under "keratoplasty" is "using conjunctival tissue" which leads you to block [174] Other repair procedures on cornea.

Response:
VICC advises that for documentation of amniotic membrane graft to the cornea, follow the Index entry Graft/cornea - see keratoplasty, Keratoplasty to assign 90064-00 [173] Other keratoplasty.


Query Title:
Pharmacist documentation of nicotine dependence

Query Text:
We would like to clarify the status of Pharmacist in view of the statement below, as implemented on 1 November 2017.

VICC Query #3262 Definition of a clinician (Published 2017-2018 October database)
'A treating clinician refers to a health professional who has been involved in the management/treatment/planning for that patient. VICC considers the treating clinician to be the most appropriate health professional to give clinical advice in the first instance.'

Pharmacists have an increasing role in our hospital as members of clinical teams and especially on special projects. There is an intention to question every patient re tobacco use and to encourage smoking cessation.  It has fallen to the pharmacist to collect information on the Inpatient Management of Nicotine Dependence & Withdrawal Clinical Pathway.  This will involve completion of the Fagerstrom Test for Nicotine Dependence.  The pharmacist will also advise the patient re strategies and medication available to assist with withdrawal.  The medical officer will prescribe medications based on the pharmacist's recommendations for that patient.

Question:  When the pharmacist is designated to make the assessment, is a pharmacists signed statement that the patient is tobacco dependent sufficient to assign F17.2 Tobacco dependence syndrome?

Response:
VICC confirms that a pharmacist is a health professional like any other involved in the management/treatment/planning for a patient.  Therefore where a pharmacist makes the assessment of tobacco or nicotine dependence and has documented dependence, F17.2 Tobacco dependence syndrome can be assigned.  

Please note that as per ACCD Coding Rule Q3204, a score on the Fagerstrom Test for Nicotine Dependence cannot be used to assign F17.2 Tobacco dependence syndrome.


Query Title:
Atrial fibrillation meeting ACS 0002 Additional diagnoses when anticoagulants are altered/ceased

Query Text:
Can you please advise what directive we should be following in regards to elective warfarin/anticoagulation cessation in patients with AF?  The December 2017 ACCD code it! Newsletter advice that adjustment (including cessation) of warfarin prescribed for AF means both AF and long term use of anticoagulants meet ACS 0002 (and Vic 0002), or the Vic 0002 Additional diagnoses education workshop FAQs - Other additional diagnoses questions, Question 1 response that overrides this - that coders should not consider Warfarin as treatment for AF (as per previous Coding Rules and practice) and that the CR advice only applies to assignment of Z92.1 Personal history of long term (current) use of anticoagulants.

In the Vic 0002 Additional diagnoses education workshop FAQs - Other additional diagnoses questions, Questions 1 and 2, the reason for not coding AF is quoted as not meeting criteria as per ACCD Coding Rules Q2897ACS 0002 Additional diagnoses and alteration to treatment and Q3017 ACS 0002 Additional diagnoses and alteration to treatment - Part 2.  Is this due to the line in Q3017 that reads 'however, the advice is specific to anticoagulants and should not be applied to other conditions or scenarios.' i.e. that the cited coding rules apply only to the application of the code Z92.1 Long term use of anticoagulants, and not for the condition of AF?

This is also how coders at our facility understood the coding rules when published.  However, the advice at the HIMAA/NCCH Conference that was published in the ACCD code it! Newsletter, December 2017 (also noted as supporting the Vic FAQ reply), seems to supersede these rules. The Newsletter question, Adjustment of warfarin in a patient with AF, why do we code the AF? Response did appear to be a reversal of the previous coding rules, however, it was clear that AF could be coded in circumstances where: '..a patient is on a specified medication as a result of having a clinical condition, and that specified medication has been altered during an episode of care, the clinical condition should be coded'.

Therefore, coding rules Q2897 and Q3017 should not be used to support the FAQ as they are no longer current even though not retired.

The Vic FAQ Other additional diagnoses questions, Question 2, then goes on to say ,'As there is specific ACCD advice about the adjustment and management of warfarin, coders are instructed to follow the ACCD advice. This is consistent with the Vic 0002 education slides.'

This directly contradicts the preceding content, causing confusion.

Response:
The ACCD code it! Newsletter, December 2017 HIMAA NCCH Conference Question 5 response is silent regarding the specific question about medication that has been stopped and recommenced for surgery.

VICC considers that where warfarin prescribed for AF has been ceased in order for a patient to have surgery, the cessation is routine and therefore VICC does not consider it to be adjustment or management of medication to treat AF.  Therefore, in accordance with Vic 0002 Additional diagnoses a code for AF should not be assigned where warfarin has been ceased for surgery.

Where warfarin has been adjusted or managed for AF (rather than ceased), coders are instructed to follow the specific ACCD newsletter advice regarding the adjustment and management of warfarin.


Query Title:
Adding specific injury codes to accidental laceration/perforation during surgery codes

Query Text:
Should an unintentional perforation of the mesentery occurring during a surgical procedure only have code K91.68 Accidental puncture and laceration of peritoneum during a procedure assigned, or should code S36.82 Injury of mesentery be added to provide further specificity of the site?

Response:
VICC advises that for unintentional perforation of the mesentery occurring during a surgical procedure and meeting ACS 0002 Additional diagnoses, only K91.68 Accidental puncture and laceration of peritoneum during a procedure is assigned, along with appropriate external cause codes. An additional code for injury of mesentery is not assigned.

As per the ACE Coding Rule TN1504 Eleventh Edition ACS 1904 Procedural complications – additional code to add specificity "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", and "the purpose of S codes in Chapter 19 Injury, poisoning and certain other consequences of external causes is to classify injuries due to trauma (ie an injury not related to an intervention)".


Query Text:
Could you please clarify if stones spilling from the gallbladder during cholecystectomy requiring irrigation and suction meets the criteria under ACS 0002 and ACS 1904 or would need to be clarified through a query as to whether this constituted management that was significantly beyond routine care?

Previous advice from NCCH (Volume 15 number 2, September 2008) has been retired but example 17 in ACS 1904 indicates this would be coded as an intraoperative complication.

Response:
VICC notes that not all stone spills will require a code to be assigned.  As per the clinical advice in Coding Matters Vol 15 No 2 TN203 Stones spilling from the gallbladder during cholecystectomy, some spillage may occur as part of a cholecystectomy.  Therefore there must be a documented link between the spillage and the irrigation and suction before a code can be assigned.

In the scenario cited, because there is documentation that the stone spill required irrigation and suction VICC considers that the spill meets the criteria under ACS 0002 Additional diagnoses and can be coded.  

Codes are assigned in accordance with example 17 of ACS 1904 Procedural complications:
K91.89 Other intraoperative and postprocedural disorders of digestive system, not elsewhere classified
Y83.6 Removal of other organ
Y92.24 Place of occurrence, health service area, this facility.


Query Title:
Diathermy and Surgicel as treatment for iatrogenic injury during a procedure

Query Text:
Is the use of diathermy and/or Surgicel to treat an iatrogenic liver laceration considered to be significant enough to code K91.65 Accidental puncture and laceration of liver during a procedure or does there need to be further documentation that the diathermy/Surgicel was significantly beyond routine management for the surgery?

Response:
In the scenario cited, the diathermy and Surgicel was for the treatment of an iatrogenic liver laceration which is not a routine part of surgery, therefore VICC considers that this meets ACS 0002 Additional diagnoses.  As the laceration has been documented as iatrogenic, VICC considers it to be an unintended injury which is classified as a procedural complication as per the Figure 1 Flowchart in ACS 1904 Procedural complications.

Assign the following codes:

K91.65 Accidental puncture and laceration of liver during a procedure by following the Index entry Complication/accidental puncture or laceration during procedure/digestive system organ or structure/liver
Y60.0 Unintentional cut, puncture, perforation or haemorrhage during surgical operation by following the Index entry Unintentional event/cut, cutting, haemorrhage, perforation or puncture/surgical operation
Y92.24 Place of occurrence, health service area, this facility.


Query Title:
Open reduction and internal fixation of shaft of tibia

Query Text:
There seems to be inconsistency relating to how prepositional terms are indexed and therefore applied in ACHI.

Conventions used in the Alphabetic Index of Interventions states:

PREPOSITIONAL TERMS. Wherever a preposition from the list below immediately follows a lead term or subterm, they always take precedence over symbols, numbers and the alphabetic sequence of subterms:
as
by
for
with
without

EXAMPLE 3:
Flap (repair)
- gingival (≤ 8 teeth) 97232-00 [456]
- - for crown lengthening 97238-00 [456]
- - with alveolar osseous procedure (≤ 8 teeth) 97233-00 [456]
- - - > 8 teeth 97233-01 [456]
- - > 8 teeth 97232-01 [456]

EXAMPLE 4:
Formation
- fistula
- - arteriovenous
- - - with
- - - - graft, vein 34512-00 [765]*
- - - - prosthesis (Gore-tex) 34512-01 [765]
- - - limb (extremity)
- - - - lower 34509-00 [765]**
- - - - upper 34509-01 [765]

In the above example, ‘formation of an arteriovenous fistula of the lower limb with graft’ would be assigned code 34512-00 [765]* rather than code 34509-00 [765]** because entries under ‘with’ take precedence over the alphabetic subterm of ‘limb’.

When multiple prepositional references are present, they are listed in alphabetic sequence.

Using this logic there has been discussion in our department in regards to the coding of e.g. ORIF of shaft of tibia? 

On review of the index at the lead term, see below: 

Reduction 
- fracture 
- - tibia, tibial

‘Open’ is at the same indent level as ‘with’ therefore as per the convention rule regarding prepositional terms, should 47566-00 [1509] Closed reduction of fracture of shaft of tibia with internal fixation be assigned for all episodes where there is internal fixation of a fractured tibia? 

If the above code is assigned it does not capture that this was an open reduction. Is this the intent of the index? We note that this indexing format has occurred at a number of site entries under the lead term ‘Reduction’ fracture, e.g. radius, skull, toe, ulna etc. There seems to be inconsistency as to the way ‘with’ is used as a prepositional term and will potentially lead to different code assignment.

Could the committee please clarify this rule in this instance?

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

The Conventions used in the Alphabetic Index of Interventions state:

Wherever a preposition from the list below immediately follows a lead term or subterm, they always take precedence over symbols, numbers and the alphabetic sequence of subterms:
• as
• by
• for
• with
• without

ACHI classifies reduction of fractured tibial shaft as either ‘closed’ or ‘open’:

[1509] Closed reduction of fracture of shaft of tibia or fibula
[1510] Open reduction of fracture of shaft of tibia or fibula

The indexing for reduction of fractured tibial shaft defaults to the classification for ‘closed’ reduction (block [1509]), rather than listing both of the terms ‘closed’ and ‘open’ as essential modifiers. Hence, where fracture reduction is not specified as ‘closed’ or ‘open’, a code for closed reduction is assigned:

Reduction
- fracture (bone) (with cast) (with splint)
- - tibia, tibial
- - - shaft (closed) 47564-00 [1509]
- - - - with internal fixation (cross) (intramedullary) 47566-00 [1509]
- - - - intra-articular 47567-00 [1509]
- - - - - with internal fixation (cross) (intramedullary) 47566-02 [1509]
- - - - open 47570-00 [1510]
- - - - - with internal fixation (cross) (intramedullary) 47566-01 [1510]
- - - - - intra-articular 47573-00 [1510]
- - - - - - with internal fixation (cross) (intramedullary) 47566-03 [1510]

ACCD acknowledges that the above (and similar) indexing at Reduction/fracture is misleading if the conventions regarding prepositional terms are strictly applied in isolation. Assign codes from block [1510] Open reduction of fracture of shaft of tibia or fibula for ‘open’ reduction with internal fixation (ORIF) of tibial shaft fracture. 

Note: ACCD advised VICC that this query would not be published in CLIP. Therefore VICC has published the query in accordance with the Committee’s business rule to publish queries referred to ACCD that ACCD does not publish.


Query Title:
Ragged membranes with a complete placenta

Query Text:
Should ragged membranes be coded as an abnormal placenta? 

VICC query #3247 states 'VICC considers that from a classification perspective the membranes are part of the placenta'.  This VICC query was in relation to retained membranes but a question has been raised re coding ragged membranes as an abnormal placenta. 

Our consensus is that is the ragged membranes is a result of the delivery not of any placental abnormality. The documentation in the case in question stated 'placenta complete, ragged membranes'.

Response:
VICC agrees that while membranes are considered to be part of the placenta, ragged membranes are not a placental abnormality.  In the scenario cited, as the documentation states ‘placenta complete, ragged membranes’, VICC advises that there is no requirement to assign a code for ragged membranes.


Query Text:
Patient with glaucoma had  trabeculectomy and iridectomy performed in a previous admission.  Re-admitted with trabeculectomy bleb leak which was repaired with glue.

Procedure details are:
'Leak point identified with 2% Fluorescein, then dried. 3mm punch of clear drape taken. Histocryl glue to patch and placed on leaking point'.

We have considered the following codes but would appreciate your advice as to the correct one for this procedure:

a. 42857-00 [163] resuture of operative wound following previous intraocular procedure.
- lookup:  repair, eyeball, for postoperative wound dehiscence,
'Wound dehiscence' is not documented though.

b. 90060-00 [163] other repair of eyeball
- lookup: repair, eyeball, NEC

c. 42749-00[191] revision of scleral fistulisation procedure
- lookup:  trabeculectomy, revision

d. 90089-00 [256] other procedures on conjunctiva
- lookup:  repair, conjunctiva
This option considered as google search for bleb repair suggests blebs are formed in conjunctiva.

We favour option c due to the inclusion notes under this code i.e. 'revision of filtering bleb' and Block [191] describes procedures for glaucoma, which this patient has.  However, documentation does not mention the word 'revision'.  It only mentions application of glue (for repair of the leak).

Response:
VICC research indicates that trabeculectomy blebs are formed in the subconjunctival space, leading to an elevation of the conjunctiva.  A trabeculectomy bleb leak may occur when the conjunctival tissue is very thin or where a small hole has developed.

For documentation of repair of trabeculectomy bleb leak, follow the Index entry Repair/conjunctiva to assign 90089-00 [256] Other procedures on conjunctiva.  Index entry Revision/filtering bleb is only followed when there is specific documentation of a revision procedure.


Query Title:
Long term/nursing home type inpatients and non-acute care

Query Text:
85yr old patient admitted with short unresponsive episodes associated with Lewy Body Dementia. Plan of care/treatment was documented to monitor and treat these episodes when occur. On day 3 patients home situation was reviewed and due to carer stress/patient safety it was recommended and agreed that the patient requires permanent placement in a nursing home. 

Patient remained in for a further 20 days and was then transferred to a nursing home.

As we are a small rural hospital we are faced with the above scenario often. My question is if a patient is admitted with an acute condition that is treated and their admission is then prolonged to await nursing home placement after assessment do we assign as an additional code Z75.41 Unavailability and inaccessibility of residential aged care service, Z75.11 Person awaiting admission to residential aged care service or neither as ACS 2105 and ACS 2117 imply these codes are to be used as Principal Diagnosis when patient admitted without the need for acute care.

As per ACS 2105 in Eighth Edition we would assign the code Z75.11 as an additional diagnosis code to represent this scenario but now find the advice in the current standards confusing.

Response:
VICC agrees that in the scenario cited it is appropriate to assign Z75.11 Person awaiting admission to residential aged care service as an additional diagnosis.  This is because the patient was admitted for an acute condition, and therefore ACS 0001 Principal diagnosis is applied.  ACS 2105 Long term/nursing home level inpatients and ACS 2117 Non-acute care provide guidance about principal diagnosis selection when the patient is admitted for non-acute care.


Query Title:
Erosion/grade changes of all joints to be in line with ACS 1343 Erosion of knee

Query Text:
We often see grade or erosion changes written on operation reports for shoulders.  ACS 1343 Erosion of knee permits coding specificity for knee joints only.

Can VICC advise if the grade or erosion changes can be used to greater specify osteoarthritis of joints other than knees?

Response:
ACS 1343 Erosion of knee is specific to the knee and should not be generalised to other joints.  

VICC research indicates that there is no standardised grading for shoulder erosion.  Therefore VICC suggests to seek clinical clarification whether the erosion is of bone or cartilage.  Where it is not possible to seek clinical advice, follow the Index entry Disease/joint to assign M25.91 Unspecified joint disorder, shoulder region.


Query Text:
I am seeking advice on how to code a change of battery for a deep brain stimulator.  The operation report states that the previous scar tissue was excised.  Battery identified and capsule opened.  Old battery removed and new one placed.  The rep checked the function of the battery to make sure it was working appropriately.  Wound irrigated.  Deep dermis was closed. Skin closed.

Search details: ACCD Q3227 - Repositioning neurostimulator wires/battery but no query regarding change of battery.

Response:
VICC considers that changing a neurostimulator battery is replacement of the neurostimulator generator.

Follow the Alphabetic Index entry Replacement/neurostimulator – see Insertion/neurostimulator and Removal/neurostimulator.
Insertion/neurostimulator (epidural) (intracranial) (peripheral) (sacral) 39134-01 [1604] Insertion of subcutaneously implanted neurostimulator. 
Removal/neurostimulator (epidural) (intracranial) (peripheral) (sacral) 39135-00 [1604] Removal of subcutaneously implanted neurostimulator.


Query Text:
What are the correct procedure codes for the removal and or resection of adhesions from the abdominal wall and/or pelvis? There is no index pathway or links to the words 'division' or 'adhesiolysis'.  Is removal or resection of adhesions synonymous with division?

Search details: ACS 0047 Adhesions

Response:
In accordance with the response in VICC Query #3387 Take down of adhesions, VICC considers removal or resection of adhesions to be synonymous with adhesiolysis.  

The response to VICC Query #3387 Take down of adhesions is reproduced below.

'VICC research indicates that adhesiolysis is surgery that is performed to remove or divide adhesions or scar tissue in order to restore normal anatomy and function.  Therefore VICC considers that when in reference to adhesions, terms such as 'taken down', 'divided', 'released', ‘dissection/dissected’, ‘stripped down’, ‘separated’ or 'freed' are synonymous with adhesiolysis.

In the scenario cited, follow the Index entry Adhesiolysis - see also Division/adhesions: Division/adhesions/abdominal to assign 30378-00 [986] Division of abdominal adhesions.

You may wish to make a public submission to ACCD for improvements to the Index.'


Query Text:
VICC #2534 Stroke with hemiplegia which resolves prior to admission was retired on the 30/06/2017 (Seventh Edition.).

Could VICC please review this query and advise if the information is still applicable/current?

Search details:
VICC 2534 Stroke with hemiplegia which resolves prior to admission
ACCD - ACS 0002 Additional diagnoses and specialty standards

Response:
In accordance with ACCD Coding Rule Q2684 Stroke with hemiplegia, if hemiplegia has resolved prior to admission it does not meet the criteria for code assignment as per ACS 0002 Additional diagnoses.


Query Title:
Assignment of procedure code 50620-00 [1393] Other revision of spinal procedure

Query Text:
We are seeking clarification on when it is appropriate to assign 50620-00 [1393] Other revision of spinal procedure, in regards to the application of the ACHI Index Convention 'NEC'.

The convention states:
'NEC is used for two purposes which can only be determined by referring to the Tabular List of Interventions:
1. With ill-defined terms as a warning that specified forms of the procedure are classified differently. The codes given for such terms should be used only if more precise information is not available.
2. Terms for which a more specific category is not provided in the Tabular List, and no amount of additional information will alter the selection of the code.'

In regards to assigning 50620-00 [1393] Other revision of spinal procedure does the NEC convention statement 'The codes given for such terms should be used only if more precise information is not available' mean that:

50620-00 [1393] Other revision of spinal procedure can only be assigned when more precise information is not available regarding the revision procedure. Therefore if there is documented procedures classifiable via the index, codes for the specified procedures should be assigned and not the 'revision spinal procedure NEC' code. For example a patient has revision of spinal canal decompression one level assign 90024-00 [48] Decompression of lumbar spinal canal 1 level and 50620-00 [1393] Other revision of spinal procedure should not be assigned.

However when there are procedures performed that cannot be reached via the index, then is it appropriate to follow the index Revision/spinal procedure NEC and assign the 'revision spinal procedure NEC' code?

OR

Assign 50620-00 [1393] Other revision of spinal procedure not elsewhere classified code when the revision procedure cannot be classified to another revision procedure code ie the following codes in block [1393]:
50616-00 Revision of spinal procedure with adjustment of spinal fixation
50616-01 Revision of spinal procedure with removal of spinal fixation
50616-02 Revision of spinal procedure with bone graft
For example, for documentation of revision of spinal fusion, code 50620-00 [1393] would be assigned. We note the includes note at 50620-00 [1393] Includes: fusion.

Following index pathway Revision/spinal procedure NEC….
We note the advice in ACCD Coding Rule Q2995 Revision of prosthetic device. Whilst this is specific to revision of prosthetic devices it instructs coders to follow the index entry when 'revision' is documented and goes on to say:

'However, the following general principles should be followed:
Clinical coders must be guided by the documentation in the clinical record and operation report. Where 'revision' of a prosthetic device is documented, follow Alphabetic Index terms (lead or subterms) specifying 'revision' and assign appropriate codes.'

We think that the logic in the above advice, whilst applying to revision of prosthetic device, could apply here and it would make sense to assign a code to reflect a revision where it is performed, even if it is an NEC code.

Therefore in the following scenarios could you please advise the correct revision procedure codes to be assigned? Please refer to additional documentation submitted.

Scenario 1
Patient admitted for revision L3/L4 decompression of lumbar canal stenosis.
Details of operation performed: L3/L4 laminectomy, R L3/4 hemi-facetectomy, rhizolysis L4 root, right L3/4 microdiscectomy

What codes should we assign for the revision decompression?

A) 50620-00 [1393] Other revision of spinal procedure following index pathway Revision/spinal procedure NEC
Or
b) 90024-00 [48] Decompression of lumbar spinal canal 1 level following index pathway ecompression/spinal/canal/lumbar/1 level
Or
c) Both 50620-00 [1393] Other revision of spinal procedure and 90024-00 [48] Decompression of lumbar spinal canal 1 level

We note for this scenario provided we would also assign additional procedure codes for the rhizolysis and microdiscectomy.

Scenario 2

Patient admitted for revision laminotomy/rhizolysis and removal of fibrin glue.
What procedure codes should we assign for this scenario?

Response:
VICC notes that there are many procedures that may be peformed as a revision or a reoperation procedure.  Unless there is a specific Index entry or specific coding advice, this aspect of the procedure may not be reflected in the code that is assigned.

VICC advises to follow the Index to assign codes for the specific procedures that have been documented.  If there are revision procedures performed on the vertebral column that cannot be reached via the Index, then it is appropriate to follow the Index entry Revision/spinal procedure NEC and assign 50620-00 [1393] Other revision of spinal procedure.

In Scenario 1 there is documentation of revision L3/L4 decompression of lumbar canal stenosis, further specified as laminectomy, hemifacetectomy, rhizolysis and microdiscectomy. 

Follow the Index entry Decompression/spinal/canal/lumbar/1 level to assign 90024-00 [48] Decompression of lumbar spinal canal, 1 level.  Also assign 40330-00 [49] Decompression of spinal nerve roots for rhizolysis.  The discectomy is included in 90024-00 [48] Decompression of lumbar spinal canal, 1 level.

In Scenario 2, the procedures performed were revision laminotomy/rhizolysis and removal of fibrin glue.

Follow the Index entry Rhizolysis/spinal and assign 40330-00 [49] Decompression of spinal nerve roots.  To assign a code for the removal of fibrin glue, follow the Index entry Removal/foreign body/spinal canal and assign 90011-01[59] Other procedures on spinal canal or spinal cord structures.


Query Text:
Seeking your interpretation of the following statement within ACS 1907 Multiple injuries.

'Sequencing of multiple injuries: In the case of multiple specified injuries, select as the principal diagnosis the condition which presents the most serious threat to life. If the most serious condition is not identified in the record, then clarification with the clinician should be sought.'

Many episodes contain multiple injuries/trauma, and the clinician does not state the most serious condition/threat to life in the episode notes. Many of these cases are in a SSU (short stay unit) for various abrasions, minor open wounds, fractures and contusions.

It's often difficult for the coder to ask which abrasion or contusion on the body had the most serious threat to life; similarly its difficult to ask whether the abrasion of the leg or the rib fractures was the most serious threat to life.

This doesn't seems like a documentation issue, as clinicians would seldom consider that a superficial injury of the knee is a threat to life over the one contusion the hand for example.

1. Does this rule pertain to all cases of multiple injuries regardless of injury type?
2. If the clinician lists an injury as the principal diagnosis on the discharge summary or final impression, without specification of a serious threat to life, can this be coded as the principal diagnosis?
3. In cases where there is no clear principal diagnosis or discharge summary, is it appropriate to send a query to the clinician asking for clarification of the principal diagnosis, without having to ask if there was a threat to life?

Response:
VICC agrees that many episodes contain multiple injuries/trauma without clear statement of which is the most serious condition or threat to life.  In these situations, VICC advises to seek further clarification from the clinician or apply ACS 0001 Principal diagnosis and assign a code for the first mentioned injury.

In response to your specific questions, the quoted statement from ACS 1907 Multiple injuries does pertain to all cases of multiple injuries regardless of injury type.  If the clinician lists an injury as the principal diagnosis on the discharge summary or final impression, without specification of a serious threat to life, it can be coded as the principal diagnosis.  In cases where there is no clear principal diagnosis or discharge summary, it is appropriate to send a query to the clinician asking for clarification of the principal diagnosis, without having to ask if there was a threat to life.

You may wish to send a public submission to the ACCD asking for further direction on the most appropriate sequencing of multiple injuries when there is no clear threat to life.


Query Text:
We have two examples of discharge summaries (attached) with the following diagnoses:
Left femoral wound infected seroma (surgical wound)
Infected right groin haematoma (surgical wound)

Both admissions were treated for an infection and a haematoma, but coders are confused on which condition to assigned first as we have varying opinions.

The infection as it is mentioned first
T81.4 Wound infection following a procedure, not elsewhere classified
T81.0 Haemorrhage and haematoma complicating a procedure, not elsewhere classified
or
The haematoma/seroma as the infective is considered a descriptor.
T81.0 Haemorrhage and haematoma complicating a procedure, not elsewhere classified
T81.4 Wound infection following a procedure, not elsewhere classified

Codes assigned above just to demonstrate the concepts and are not indicative of the summary and procedures supplied.

Response:
VICC considers that in the scenarios cited, as the documentation is infected haematoma/seroma, and both have been treated, the haematoma/seroma has been further specified as being infected. 

Therefore the correct lead terms to follow are Haematoma or Seroma - see Haematoma to assign T81.0 Haemorrhage and haematoma complicating a procedure, not elsewhere classified as the principal diagnosis, followed by T81.4 Wound infection following a procedure, not elsewhere classified to describe the infection of the haemtoma/seroma.


Query Text:
Can you please advise whether the term 'borderline diabetes' is synonymous with 'prediabetes' and therefore assign a code from E09.- Intermediate hyperglycaemia.

Search Details: ACS 0401 Diabetes Mellitus and Intermediate Hyperglycaemia

Response:
VICC obtained clinical advice which indicates that borderline diabetes is not an official term and should not be used to mean prediabetes.  Additionally there is no Index entry for borderline diabetes.  

Therefore VICC advises to seek clinical clarification in cases where borderline diabetes is documented as to whether the condition is impaired glucose tolerance or prediabetes, as these terms are indexed.


Query Title:
Cancer confirmed on pathology report without documentation on endoscopy report

Query Text:
Patient presented for same day Endobronchial ultrasound bronchoscopy (EBUS).

Indication on EBUS: for Mediastinal & hilar lymphadenopathy.

Body of the EBUS report: station 7 examined and sampled with 3 passes. 
Sample sent for cytopathology.

Cytopathology results:
Transbronchial needle aspiration (TBNA) subcarina: Carcinoma, immunochemistry consistent with poorly differentiated squamous cell carcinoma
Bronchial washings: carcinoma

There is no documentation on the EBUS report of a diagnosis or linking the indication to the finding.

We have different opinions within our coding team regarding the principal diagnosis for this episode and which ACS should be applied.

Some coders believe ACS 0051 Same-day endoscopy - diagnostic should be applied given the episode is for a same day bronchoscopy, while other coders believe ACS 0010 General abstraction guidelines should be applied.

Can VICC please:
1) Confirm the principal diagnosis for this episode
2) Clarify the ACS applied AND why
3) Confirm the procedure code based on sampling being documented on EBUS and cytopathology analysed (TBNA).

Response:
VICC advises that ACS 0051 Same-day endoscopy - diagnostic applies to the scenario cited because the episode is for a same day diagnostic endoscopy and there is no documented principal diagnosis.

In the absence of a documented causal link between the indication/symptom and the findings, as per point 1.2 of ACS 0051, assign a code for the indication/symptom as the principal diagnosis and assign codes for all findings as additional diagnoses. 

In the scenario cited, the principal diagnosis is R59.1 Generalised enlarged lymph nodes following Index entry Lymphadenopathy (generalised).  The carcinoma is coded as an additional diagnosis.

Based on the documentation provided, VICC advises the following intervention codes:
41898-05 [543] Bronchoscopy
30688-00 [1949] Endoscopic ultrasound (EBUS).

41898-04 [544] Endoscopic [needle] biopsy of bronchus can be assigned if the procedure has been documented on the EBUS report; it cannot be assigned from documentation of bronchial washings on the cytology report alone.

Whilst VICC considers that Transbronchial Needle Aspiration (TBNA) is a biopsy as per VICC #3385 Fine needle aspiration (FNA) of lymph node, further specification of the site is needed before a code can be assigned.  In the body of the EBUS report provided, the documentation 'sampling of station 7' does not describe a site.

Note: This query was originally published in December 2018 and was retired 30June 2020. The query has been reinstated as VICC considers the advice is still current for Eleventh Edition ICD-10-AM.


Query Text:
Scenario one:

Operation report - Bladder adherent to peritoneum. Careful division of adhesions.

Do the Index entries for Adhesions/Adhesive, bladder and gallbladder refer to adhesions within the bladder/gallbladder or when the bladder/gallbladder is adherent to other organs/tissue? There is no Index entry for Adhesions/bladder/internal (as there is for uterus), however perivesical adhesions (ie situated or occurring around the bladder) are Indexed to N32.8 Other specified disorders of bladder.

Should we assign codes for adhesions, bladder N32.8 AND adhesions, peritoneum/peritoneal K66.0?

Adhesions, adhesive (postinfective) K66.0
- bladder (sphincter) N32.8
- gallbladder K82.8
- peritoneum, peritoneal (male) K66.0
- perivesical N32.8
- uterus, uterine (periuterine) (to abdominal wall) (see also Adhesions/peritoneum/female pelvic) N73.6
- - internal N85.6

Can VICC also please clarify the intention of ACHI codes for division of adhesions?

In the scenario above, in addition to coding Division/adhesions/peritoneum, should we follow Index entry Division/adhesions/bladder even though the code description is 'division of intraluminal bladder adhesions' and there is no mention of entry into the bladder on the Operation Report and 'intraluminal' is a non-essential modifier in the Index?

Division (freeing)
- adhesions
- - bladder (intraluminal) (neck) 37008-06 [1095]
- - - endoscopic (transurethral) 36812-02 [1095]
- - peritoneum (open) 30378-00 [986]
- - - via laparoscopy 30393-00 [986]

37008-06 Division of intraluminal bladder adhesions
Excludes: transurethral division of intralumial adhesions (36812-02 [1095])

30378-00 Division of abdominal adhesions
Includes: insertion of long intestinal tube

Scenario two:

Division of inflammatory adhesions between appendix and bowel and appendix and abdominal wall.

Should we assign codes for adhesions, appendix K38.8 AND adhesions, bowel and abdominal wall K66.0?

Response:
VICC considers that the Index entries for Adhesions/Adhesive, bladder and gallbladder refer to adhesions within the bladder/gallbladder.  

In scenario one, as the operation report states bladder adherent to peritoneum, the correct code to assign is K66.0 Peritoneal adhesions because there is no documentation of adhesions within the bladder.  In regard to the ACHI code, the correct code to assign is 30378-00 [986] Division of abdominal adhesions.  

VICC does not consider that 37008-06 [1095] Division of intraluminal bladder adhesions should be assigned in addition.  In answer to the question regarding the term 'intraluminal' being in the code title, because intraluminal is a non-essential modifier in the Index, it does not matter if the term is in the code description.

In scenario two, as the adhesions are between bowel loops and the abdominal wall, K66.0 Peritoneal adhesions is the only code assigned.


Query Title:
Qualifying comments on histopathology reports

Query Text:
Histopathology reports often contain phrases indicating a degree of uncertainty about the diagnosis such as:
- the features are suggestive of
- consistent with
- most in keeping with
- indicative of
- raise the possibility of
- are compatible with
- are probably those of.

Studies have shown marked variability between individuals in the probability they associate with these terms. How should the condition be coded when such terminology is used? 

Does the following part of ACS 0012 Suspected Conditions apply? 
'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.'

Can struma ovarii be coded in the following scenario?

Diagnosis on Request for Elective Admission (REA) form: Bilateral ovarian cysts
Principal diagnosis on Discharge Summary: Large right ovarian mass
Operative diagnosis on Operation Report: 9cm right ovarian cyst
Diagnosis on histopathology Report: Features suggestive of struma ovarii. 
Supplementary report to follow. Supplementary report: There is positive TTF-1 staining confirming thyroid tissue. Additional sections processed and examined show more benign thyroid tissue. The features are consistent with struma ovarii.

Would the answer be the same if any of the other qualifying terms mentioned above were used?

Response:
VICC advises that in the case cited the principal diagnosis is documented as ovarian mass, and ACS 0010 General abstraction guidelines Test results - Findings that provide more specificity about a diagnosis can be applied.  

Therefore VICC considers it correct to code struma ovarii as the principal diagnosis for the case cited provided there is no further diagnosis in the body of the record. 

If the terminology in the histopathology report indicates uncertainty about the final diagnosis VICC considers that ACS 0012 Suspected conditions can be applied to the qualifying terms in the histology report. The qualifying terms noted in ACS 0012 Suspected conditions are not exhaustive.

Note: This query was originally published in December 2018 and was retired 30 June 2020. The query has been reinstated as VICC considers the advice is still current for Eleventh Edition ICD-10-AM.


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

Query Text:
Can VICC please provide guidance on what code should be assigned as the principal diagnosis for a same day admission for an insertion of a continuous glucose monitoring device (CGM) for unstable T1DM?

Response:
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.  In this circumstance VICC considers Z45.89 Adjustment and management of other implanted devices as the appropriate code to assign.


Query Text:
Operation Report for tonsillectomy with adenoidectomy lists findings of 'Grade 3 tonsils' and 'large adenoids'.

Is it permissible to code hypertrophy of tonsils/adenoids when documented as 'Grade' or large as neither of these has an index option?

At a recent audit, the auditor stated that hypertrophy of tonsils could not be assigned, as there is no index look up. However, research clearly indicates that Grade 3 tonsils = hypertrophy.

We found it astounding that coders in this instance could not use the coder's creed to assign hypertrophy of tonsils/adenoids.

Response:
VICC advises that because the Lead term 'Large' does not have subterms for tonsils or adenoids, hypertrophy of tonsils and adenoids cannot be assigned based on documentation of large.  Similarly hypertrophy of tonsils cannot be assigned based on grade.  

As per the Conventions used in the Tabular list of Diseases, in the absence of a subterm under the main term, search the Index for Disease, diseased adenoids (and tonsils).

Therefore in the case cited, if the reason for the tonsillectomy with adenoidectomy is documented as 'Grade 3 tonsils and large adenoids' VICC advises to assign J35.9 Chronic disease of tonsils and adenoids, unspecified.  

In regard to the Clinical Coders’ Creed, the Conventions are one of the fundamental components and whilst research can be undertaken, Conventions must still be applied.  Clinical knowledge gained from research can be used to inform the development of a documentation query to the clinician.

This response is superseded by Coding Rule Q3426 Large or grade 3 tonsils published on 20 March 2020.


Query Text:
Cool caps are occasionally used during a patient's chemotherapy treatment.  What is the most suitable treatment code for the use of scalp hypothermia by cooling the scalp with cooling caps (cold caps) during chemotherapy for the prevention of hair loss?

Response:
As scalp cooling is a preventative measure rather than therapeutic treatment, VICC does not consider scalp cooling to meet the criteria for code assignment in accordance with ACS 0016 General procedure guidelines.  

Therefore VICC advises that no code should be assigned for application of scalp cooling cap for the prevention of hair loss.


Query Title:
Removal of Tenckhoff catheter - ACCD coding exercise workbook 2017

Query Text:
My query relates to question number 4.11 in the 'Coding Exercise Workbook 2017' under education in ACCD website.

Why isn't the principal procedure the removal of the Tenckhoff catheter?

My reasons for thinking that the principal procedure should be the removal of the Tenckhoff catheter are as follows:
- The principal diagnosis was acute peritonitis attributing Tenckhoff as the source the infection
- Removal of Tenckhoff is not listed under procedures normally not coded
- Removal of Tenckhoff is not like other routine procedure. It needs a mini laparotomy and suturing usually under GA.

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

The focus of Exercise 4.11 in the ICD-10-AM/ACHI/ACS Tenth Edition 2017 Coding Exercise Workbook was the ICD-10-AM (end of chapter) procedural complication codes (eg T85.71 Infection and inflammatory reaction due to peritoneal dialysis catheter), which were introduced for Tenth Edition.

Assign 13110-00 [1062] Removal of indwelling peritoneal catheter for peritoneal dialysis for removal of Tenckhoff catheter. Follow the ACHI Alphabetic Index:

Removal
- catheter
- - peritoneal
- - - for long term renal dialysis (indwelling) (Tenckhoff) 13110-00 [1062]

Amendments will be made to the workbook, which is located on the Education page of the ACCD website https://www.accd.net.au/Education.aspx.

Note: ACCD advised VICC that this query would not be published in CLIP. Therefore VICC has published the query in accordance with the Committee’s business rule to publish queries referred to ACCD that ACCD does not publish.


Query Text:
Is the advice in the retired VICC query #2627 Replacement of polyethylene liner of a total knee replacement still current? 

#2627 Replacement of polyethylene liner of a total knee replacement
Publication Date: 2010-11 June Database
ICD 10 AM Edition: Seventh edition 
Retired Date: 30/6/2017

Query: Please provide advice on how to code replacement of the polyethylene liner component of a total knee replacement. 
The procedure was performed during an arthrotomy and joint lavage for an infected total knee replacement. Documentation is as follows: 
The polyethylene insert was removed without difficulty and the back of the knee was debrided and thoroughly irrigated before reinserting a new polyethylene insert. 
I elected to use code 49527-00 [1524] Revision of total knee replacement. 
Is this code correct, or is there another code which better reflects the minor nature of the procedure, which was performed almost incidentally to the joint debridement. 

Search Details: 
Revision 
- joint replacement (prosthesis) 
--knee, total (with removal of prosthesis) 49527-00 [1524]

Response: As the polyethylene liner is a component of the prosthesis, VICC considers the replacement of the polyethylene liner is a revision of the arthroplasty. Therefore the appropriate code to assign for the procedure is 49527-00 [1524] Revision of total arthroplasty of knee by following index entry: 
Revision (partial) (total) 
-joint replacement (prosthesis) 
--knee, total (with removal of prosthesis) 49527-00 [1524]

Response:
VICC considers that the advice in VICC query #2627 Replacement of polyethylene liner of a total knee replacement still current and is reproduced below:

Query:
Please provide advice on how to code replacement of the polyethylene liner component of a total knee replacement. 
The procedure was performed during an arthrotomy and joint lavage for an infected total knee replacement. Documentation is as follows: 
The polyethylene insert was removed without difficulty and the back of the knee was debrided and thoroughly irrigated before reinserting a new polyethylene insert. 
I elected to use code 49527-00 [1524] Revision of total knee replacement. 
Is this code correct, or is there another code which better reflects the minor nature of the procedure, which was performed almost incidentally to the joint debridement. 

Search Details: 
Revision 
- joint replacement (prosthesis) 
--knee, total (with removal of prosthesis) 49527-00 [1524]

Response:
As the polyethylene liner is a component of the prosthesis, VICC considers the replacement of the polyethylene liner is a revision of the arthroplasty. Therefore the appropriate code to assign for the procedure is 49527-00 [1524] Revision of total arthroplasty of knee by following index entry: 
Revision (partial) (total) 
-joint replacement (prosthesis) 
--knee, total (with removal of prosthesis) 49527-00 [1524]


Query Text:
1)  Could you please advise the correct codes for a patient who develops hypotension during general anaesthesia which is treated intraoperatively and is documented as hypotension due to anaesthesia. 

Should the correct codes be:
T88.59 Complications of anaesthesia, not elsewhere classified and I95.9 Hypotension, unspecified
OR
T88.59 Complications of anaesthesia, not elsewhere classified and I95.2 Hypotension due to drugs
OR 
I95.2 Hypotension due to drugs?

2)  Could you please advise the external cause codes for hypotension due to general anaesthesia.  Do we follow ACS 1904 Postprocedural Complications or ACS 1902 Adverse Effects?

Should the correct codes be? 
Y65.8 (other specified unintentional events during surgical and medical care)
OR
Y48.2 (other and unspecified general anaesthetic causing adverse effects in therapeutic use)

3)  Could you please advise the correct codes including external cause code for documentation of hypotension due to general anaesthetic drugs.

Response:
For documentation of hypotension due to anaesthesia but not due to a specific anaesthetic drug/s, VICC advises the following codes: 
T88.59 Complications of anaesthesia, not elsewhere classified following the Index entry Complication/anaesthesia, anaesthetic
I95.9 Hypotension, unspecified following the Index entry Hypotension 
Y84.8 Other medical procedures as the cause of abnormal reaction, or of later complication, without mention of unintentional events at the time of the procedure following the Index entry External causes of injury/complication/procedures other than surgical operation/specified 
Y92.24 Place of occurrence, health service area, this facility.

Where hypotension is documented as being due to a specific anaesthetic drug/s, the correct code to assign is I95.2 Hypotension due to drugs following the Index entry Hypotension/drug-induced.  In accordance with ACS 1902 Adverse effects, the correct external cause code to assign is a code from the range Y48 Anaesthetics and therapeutic gases causing adverse effects in therapeutic use.


Query Text:
Conventions used in the Tabular List of Diseases Multiple Condition Coding states 'In Australia, multiple condition coding (meaning that multiple conditions may be assigned in an episode of care) is used to provide the necessary specificity to fully describe the episode of care. This does not mean multiple codes are assigned to describe a single condition (unless otherwise instructed). 

It is unnecessary for conditions to be explicit in a code title or Inclusion term to be correctly classified. Do not assign an additional code to further classify a condition unless directed by an Instructional note in the Tabular List or an Australian Coding Standard.

If, by following the Alphabetic Index, a residual code is assigned (ie other or unspecified), do not assign an additional code to further classify the condition unless directed by an Instructional note in the Tabular List or an Australian Coding Standard.'

There is an instructional note at codes B95-B97 Bacterial, viral and other infections agents which states that 'a code from these categories must be assigned if it provides more specificity about the infectious agent. Do not assign a code from these categories if the same agent has been identified in the infection code (eg streptococcal sepsis in A40.-)'.

In the case of viral upper respiratory tract infection (URTI), does this mean that B97.8 Other viral diseases as the cause of diseases classified to other chapters should be assigned to provide more specificity about the infectious agent as per the note at B95-97?

Or, because the clinical concept 'viral' is accounted for in the Index entry, does this mean that only J06.9 Acute upper respiratory infection, unspecified should be assigned although this is a residual code and there is an instructional note to assign a B95-97 code? 

Infection
-respiratory (tract) NEC J98.8
--upper (acute) NEC J06.9
---chronic J39.8
---multiple sites NEC J06.8
---streptococcal J06.9
---viral NEC J06.9

J06.9 Acute upper respiratory infection, unspecified  
Upper respiratory:
 disease, acute
 infection NOS

In the case of viral pharyngitis, the concept 'viral' is accounted for in the Index, but there is a use additional code from B95-97 instruction in the Tabular List which appears to be instructing to add a B code. This seems inconsistent with viral URTI. 

Pharyngitis (acute) (catarrhal) (gangrenous) (infective) (subacute) (suppurative) (ulcerative) J02.9
-viral NEC J02.8

J02.8 Acute pharyngitis due to other specified organisms  
Use additional code (B95-B97) to identify infectious agent.
Excludes pharyngitis (due to):
 enteroviral vesicular (B08.5)
 herpesviral [herpes simplex] (B00.2)
 infectious mononucleosis (B27.-)
 influenza virus:
 identified (J09, J10.1)
 not identified (J11.1)

Response:
VICC advises that for documentation of viral URTI, the only code assigned is J06.9 Acute upper respiratory infection following Index entry Infection/respiratory/upper/viral NEC.  This is because the Index entry pathway contains all the terms in the clinical statement and in accordance with the Conventions there is no instructional note to assign another code.

VICC agrees that viral pharyngitis is classified differently. Follow the Index entry Pharyngitis/viral to assign J02.8 Acute pharyngitis due to other specified organisms.  As the Tabular list has an instructional note, follow it and use an additional code from B95-B97 to identify the infectious agent.


Query Title:
TAP block performed at the end of the surgical procedure

Query Text:
VICC query #3326 (March 2018) Coding of anaesthesia not documented on an anaesthetic form, example 1, states that a nerve block documented only on the Operation Record (ie not on anaesthetic form) cannot be assumed to be for anaesthesia unless evidenced by terms such as 'under' or 'with'. 

This appears to confict with Coding Rule Q3223 (March 2018) TAP block performed at the end of surgical procedure, which states that for TAP blocks initiated in theatre at the end of the surgical procedure, default to coding anaesthesia, although it seems incongruous to default to anaesthesia at the end of a procedure.

Please advise the correct coding of TAP block that is performed at the end of the surgical procedure.

Response:
VICC advises to follow the ACCD Coding Rule Q3233 TAP block performed at the end of the surgical procedure, and where it is not possible to obtain clarification from the clinician whether this is for operative anaesthesia or post-operative analgesia, default to coding anaesthesia.

For other types of blocks or drugs not documented on an anaesthetic form, follow the advice in VICC query #3326 Coding of anaesthesia not documented on an anaesthetic form.


Query Title:
Staging laparotomy for gynaecological malignancy without lymph node sampling

Query Text:
Scenario: Staging laparotomy - total abdominal hysterectomy/bilateral salpingo-oophorectomy/omentectomy for ovarian malignancy.

In this case the operation and histopathology reports state that there was no lymph node sampling. 

Can the VICC please advise the correct codes to assign in this scenario?

Should we assign total abdominal hysterectomy with removal of adnexa 35653-01 [1268] and Staging laparotomy 35726-01 [985] (which includes excision of omentum)?

But 35726-01 excludes staging laparotomy for gynaecological malignancy 35723 [810].

35726-01 Staging laparotomy
Biopsy, excision or sampling of:
 lymph node
 omentum
 peritoneal tissue
Tissue sampling to establish spread of malignant disease
Code also when performed:
 hysterectomy (35653, 35667-00 [1268], 35667-01 [1269])
Excludes:staging laparotomy for:
 gynaecological malignancy (35723 [810])

However, the 35723 codes in block [810] are all lymph node sampling for gynaecological malignancy and my example has no lymph node sampling. 

Should the Excludes note at 35726-01 [985] read 'staging laparotomy for gynaecological malignancy WITH lymph node sampling'?

If I assign a 35723 code, I have also lost the detail of the omentectomy.

Omentectomy (open) 96189-00 [989]
-with debulking of lesion (tumour)
--intra-abdominal 30392-00 [989]
--pelvic cavity, female 35720-00 [1299]
-in staging laparotomy 35726-01 [985]

Response:
In the case cited, there is documentation that lymph node sampling did not occur. Therefore VICC advises to assign the default code 35726-01 [985] Staging laparotomy.  

Whilst the default code looks to be incorrect as the patient has a documented gynaecological malignancy, the Excludes note cannot be followed because it is not possible to select an appropriate code from [810] Excision procedures on lymph nodes for gynaecological malignancy.  

Also assign 35653-04 [1268] Total abdominal hysterectomy with removal of adnexa, following Index entry Hysterectomy/abdominal/with salpingo-oophorectomy

VICC is aware that the issue will be addressed in ICD-10-AM/ACHI/ACS Eleventh Edition.


Query Text:
Documentation states: 'G2P1 13 week pregnant lady presented with 3/7 of lower abdominal pain. Given Tazocin IV because Gentamicin is category D in pregnancy. Unable to give contrast for MRI due to pregnancy.'

ACS 1521 Conditions and injuries in pregnancy states that 'nonobstetric conditions are classified as complicating pregnancy when the condition meets the criteria in ACS 0001 Principal diagnosis, ACS 0002 Additional diagnoses or ACS 1500 Diagnosis sequencing in delivery episodes of care in an antepartum or delivery episode of care, and documentation specifies that the condition is complicating the pregnancy'.

Is this sufficient documentation that the conditions were complicating pregnancy?

Which of the following codes should be assigned in this example?

1) R10.3 Pain localised to other parts of lower abdomen
2) R10.3 Pain localised to other parts of lower abdomen and Z33 Pregnant state incidental 
3) R10.3 Pain localised to other parts of lower abdomen and Z34.8 Supervision of other normal pregnancy.

Response:
In the scenario cited, although certain treatments/investigations were precluded by the pregnancy, the documentation does not specify that the lower abdominal pain is complicating the pregnancy, or that the lower abdominal pain meets the criteria for a pregnancy complication that are listed in ACS 1521 Conditions and injuries in pregnancy. 

Therefore VICC advises to assign R10.3 Pain localised to other parts of lower abdomen and Z33 Pregnant state, incidental in accordance with ACS 1521 Conditions and injuries in pregnancy, Nonobstetric conditions not complicating pregnancy.

It is not appropriate to assign Z34 Supervision of normal pregnancy as an additional diagnosis in this scenario as there is no documentation of nonobstetric injury/poisoning meeting the criteria for a pregnancy complication.


Query Title:
Conditions indexed with subterm 'in pregnancy'

Query Text:
In the Tenth Edition Alphabetic Index the term 'complicating pregnancy' has been replaced by 'in pregnancy', particularly for conditions not exclusive to the pregnancy state ie non-obstetric conditions (ACCD, 2017 Tenth Edition Education Program, Obstetrics, ICD-10-AM Tabular List Changes,) eg alcohol addiction, anaemia, hypertension, urinary tract infection and vomiting.

Addiction (see also Dependence) - code to F10-F19 with fourth character .2 
-alcohol, alcoholic (ethyl) (methyl) (wood) F10.2
--in pregnancy, childbirth or puerperium NEC O99.3

Anaemia
-in pregnancy, childbirth or puerperium O99.00
--childbirth or puerperium O99.03
---with mention of pre-existing anaemia O99.04
--pregnancy O99.01
---with mention of pre-existing anaemia O99.02
--puerperal, postpartum NEC O99.03
---with mention of pre-existing anaemia O99.04

Hypertension
-in pregnancy, childbirth or puerperium NEC O16

Infection
-urinary (tract) NEC N39.0
--in pregnancy O23.4
--puerperal, postpartum O86.2

Vomiting (see also Hyperemesis) R11
-in pregnancy (excessive) NEC O21.9
--after 20 completed weeks gestation O21.2
--before 20 completed weeks gestation O21.0

Coding Rule Q2993 (Dec 15) Use of subterms in (due to) in ICD-10-AM Alphabetic Index states that the indexing of a condition with subterm 'in' implies a cause and effect relationship between the two conditions. Where the ICD-10-AM Alphabetic Index has linked two conditions using the subterms in (due to), this index entry should be followed except where a specific cause for the condition has been otherwise indicated in the clinical record.

Q2993 also states that 'classification of diabetes mellitus is governed by specific guidelines in ACS 0401'. ACS 1521 contains specific criteria that need to be met before assigning obstetric codes but ACS 1521 was altered after this Coding Rule was published so we are not sure if this Coding Rule advice applies to nonobstetric conditions.

In ACS 1521 Conditions and injuries in pregnancy / Nonobstetric conditions not complicating pregnancy (incidental pregnant state) example 8 a pregnant patient admitted with iron deficiency anaemia for an iron infusion has been coded to D50.9 iron deficiency anaemia unspecified and Z33 incidental pregnant state rather than O99.00 anaemia, in pregnancy, childbirth and the puerperium, presumably because the criteria are not met.

Anaemia
-in pregnancy, childbirth or puerperium O99.00
--affecting fetus or newborn P00.8
--childbirth or puerperium O99.03
---with mention of pre-existing anaemia O99.04
--pregnancy O99.01
---with mention of pre-existing anaemia O99.02
--puerperal, postpartum NEC O99.03
---with mention of pre-existing anaemia O99.04
-iron deficiency D50.9
--secondary to blood loss (chronic) D50.0
--specified type NEC D50.8

Can the VICC please clarify, where there is no specific cause documented, do conditions need to meet the criteria in ACS 1521 non obstetric conditions complicating pregnancy in order to follow the 'in pregnancy' Index pathway?

We also note Coding Rule Q3258 (March 18) Ligament pain in pregnancy states to code ligament pain in pregnancy to O34.8 Maternal care for other abnormalities of pelvic organs but in the example provided this does not appear to meet the criteria in ACS 1521 for a non-obstetric condition complicating pregnancy. We note that the Index pathway cited is 'Pregnancy/complicated by' rather than 'in' pregnancy. Is the O code assigned because the condition is 'common in pregnancy' or 'exclusive to pregnancy' (as per Tenth Edition education). Does this mean that ligament pain in pregnancy should always be coded to O34.8?

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

Coding Rule 'Use of the subterms in (due to) in ICD-10-AM Alphabetic Index' provides general advice regarding these subterms. Coding Rule 'Ligament pain in pregnancy' advises clinical coders to assign O34.8 Maternal care for other abnormalities of pelvic organs in the absence of explicit index terms.

These coding rules do not circumvent the classification process as summarised in the Guidance in the use of ICD-10-AM. That is, when classifying a condition in (due to) pregnancy:
• refer to the ICD-10-AM Alphabetic Index (eg Pregnancy/complicated by or condition/in pregnancy or condition/in pregnancy, childbirth or puerperium)
• refer to the ICD-10-AM Tabular List
• refer to the ACS (ie general standards eg ACS 0001, ACS 0002, and specialty standards eg in Chapter 15 Pregnancy, childbirth and the puerperium)

Note also the following:
• ICD-10-AM Alphabetic Index Introduction states:
The index…is intended to include most of the diagnostic terms currently in use. Nevertheless, reference should always be made back to the Tabular List and its notes, as well as to the guidelines provided in the Australian Coding Standards, to ensure that the code given by the index fits with the information provided by a particular episode of care.

• ACS 0001 Principal diagnosis states:

For general guidelines regarding assignment of additional diagnoses in delivery episodes of care, see ACS 1500 Diagnosis sequencing in delivery episodes of care.

See also ACS 1521 Conditions and injuries in pregnancy and ACS 1548 Puerperal/postpartum condition or complication.

• ACS 0002 Additional diagnoses states:

For general guidelines regarding assignment of additional diagnoses in delivery episodes of care, see ACS 1500 Diagnosis sequencing in delivery episodes of care.

See also ACS 1521 Conditions and injuries in pregnancy and ACS 1548 Puerperal/postpartum condition or complication.

• ACS 1521 Conditions and injuries in pregnancy states:

Chapter 15 Pregnancy, childbirth and the puerperium lists codes for conditions that:
• exclusively or predominantly occur only in a pregnant patient (ie obstetric conditions/complications).
Assign codes for these conditions/complications that meet the criteria for assignment as per ACS 0001 Principal diagnosis, ACS 0002 Additional diagnoses and ACS 1500 Diagnosis sequencing in obstetric episodes of care.
…

Nonobstetric conditions are classified as complicating pregnancy when the condition meets the criteria in ACS 0001 Principal diagnosis, ACS 0002 Additional diagnoses or ACS 1500 Diagnosis sequencing in obstetric episodes of care in an antepartum or delivery episode of care, and documentation specifies that the condition is complicating the pregnancy.

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/gynaecologist (or other medical clinician responsible for obstetric care), 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).

Therefore, assign codes for nonobstetric conditions indexed as ‘in pregnancy’ that meet the criteria in ACS 1521 Conditions and injuries in pregnancy.

Note: This response will not be published
[end of ACCD response]

In summary, VICC advises that a nonobstetric condition (that is, a condition that could occur in any patient) must be documented as complicating pregnancy, or must meet two or more of the criteria in ACS 1521 Conditions and injuries in pregnancy/nonobstetric condition complicating pregnancy in order to follow the ‘in pregnancy’ essential modifier in the Alphabetic Index. 

Note:  ACCD advised VICC that this query would not be published.  Therefore VICC has published the query in accordance with the Committee's business rule to publish queries referred to ACCD that ACCD does not publish.


Query Text:
In coding a CT colonoscopy should we apply the rules in ACS 0051 and ACS 0052 as this is a 'virtual colonoscopy' or should we code it and the findings as we would any radiology?  Where a patient is admitted overnight or longer should we be coding the intervention? We would not normally code a CT and the same day patients do not meet the 'Criteria for Reporting'.

Response:
VICC advises that ACS 0051 Same-day endoscopy - diagnostic and ACS 0052 Same-day endoscopy - surveillance do not apply to CT colonoscopy as it is an imaging procedure rather than an endoscopy procedure.  

In accordance with ACS 0042 Procedures normally not coded, intervention codes for imaging procedures are not generally assigned. Therefore if the patient is admitted overnight or longer the CT would not be coded.  If cerebral anaesthesia was required for the intervention assign 56549-01 [1962] Computerised tomography of colon.
 
Diagnosis codes should be assigned in accordance with ACS 0001 Principal diagnosis and ACS 0002 Additional diagnoses and any applicable specialty standards.


Query Text:
The AIRVO 2 system features a humidifier with integrated flow source that comfortably delivers high flows of air/oxygen mixtures to spontaneously breathing patients, through the unique Optiflow nasal interface.

ACS 1006 states: 
Noninvasive ventilation refers to all modalities that assist ventilation without the use of an ETT or tracheostomy. For the purpose of this standard, noninvasive devices may include: face mask, mouthpiece, nasal mask, nasal pillows, nasal prongs, nasal tubes, nasal high flow cannula (high flow therapy) and nasopharyngeal tubes, however clinical coders should ensure that NIV is being provided via the device, and not assign a code for NIV based on the device alone.

Can VICC please confirm whether documentation of AIRVO that is delivered via nasal prongs can be coded in the same way as High Flow therapy?

Response:
VICC research indicates that AIRVO is a trade name for a system that can be used to deliver high flows of humidified air/oxygen mixtures.  As per Coding Rule Q2953 High flow therapy, high flow therapy is more than simple oxygen enrichment or humidification as it involves the administration of ventilatory support. 

VICC does not consider that documentation of a trade name such as ‘AIRVO’ alone is sufficient. Clinical documentation must be clear that high flow therapy is being provided via nasal cannula/prongs before a code can be assigned for non-invasive ventilation.


Query Text:
PICO dressing: PICO Single Use Negative Pressure Wound Therapy system is indicated for patients who would benefit from a suction device (Negative Pressure Wound Therapy) as it may promote wound healing via removal of low to moderate levels of exudate and infectious materials.

VAC dressing: Negative-pressure wound therapy (NPWT) is a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds and enhance healing of second- and third-degree burns.

Can VICC please confirm whether a PICO dressing can be coded in the same as a VAC dressing 90686-00? 

Or, are they considered a dressing only and not coded as per ACS 0042 - Procedures not normally coded?

Response:
PICO is a canister-free, single use negative pressure wound therapy system consisting of a single-use sterile pump and two multi-layered adhesive dressings.  VICC considers that PICO can be coded the same way as a VAC dressing.

VICC advises to follow the advice in Coding Rule Q2977 Vacuum assisted wound closure (VAC) dressings and assign 90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue or 90686-00 [1627] Nonexcisional debridement of burn when PICO dressing is documented.


Query Text:
The index for ORIF of tibial fracture requires an essential modifier of 'medial' or 'lateral' in order to assign a code, however, the codes are exactly the same. The code title also includes both terms 'Open reduction of fracture of medial or lateral tibial plateau with internal fixation'. Is this intentional not to have a default code in the index for ORIF of tibial fracture? 

Reduction
-fracture
--tibial
---upper end (head) (proximal) - see Reduction/fracture/tibia, tibial/plateau

Reduction
-fracture
--tibial
---tibial/plateau
----medial
-----open 
------with internal fixation 47549-01 [1508]

Reduction
-fracture
--tibial
---tibial/plateau
----lateral
-----open 
------with internal fixation 47549-01 [1508]

Response:
VICC referred your query to the ACCD, who provided the following response:

The Conventions used in the Alphabetic Index of Interventions state:

Wherever a preposition from the list below immediately follows a lead term or subterm, they always take precedence over symbols, numbers and the alphabetic sequence of subterms:
• as
• by
• for
• with
• without

ACHI classifies reduction of fractured tibial plateau or shaft as either ‘closed’ or ‘open’:

[1507] Closed reduction of fracture of tibial plateau
[1508] Open reduction of fracture of tibial plateau
[1509] Closed reduction of fracture of shaft of tibia or fibula
[1510] Open reduction of fracture of shaft of tibia or fibula

The indexing for reduction of fractured tibia, by site defaults to the classification for ‘closed’ reduction, rather than listing both of the terms ‘closed’ and ‘open’ as essential modifiers. Hence, the ACHI Alphabetic Index below at Reduction/fracture is misleading if the conventions regarding prepositional terms are strictly applied in isolation.

Reduction
- fracture (bone) (with cast) (with splint)
- - tibia, tibial
- - - plateau
- - - - lateral (closed) 47546-00 [1507]
- - - - - with internal fixation 47546-01 [1507]
- - - - - and medial plateau 47555-00 [1507]
- - - - - - with internal fixation 47555-01 [1507]
- - - - - open 47549-00 [1508]
- - - - - - with internal fixation 47549-01 [1508]
- - - - - - and medial plateau 47558-00 [1508]
- - - - - - - with internal fixation 47558-01 [1508]
- - - - medial (closed) 47546-00 [1507]
- - - - - with internal fixation 47546-01 [1507]
- - - - - and lateral plateau 47555-00 [1507]
- - - - - - with internal fixation 47555-01 [1507]
- - - - - open 47549-00 [1508]
- - - - - - with internal fixation 47549-01 [1508]
- - - - - - and lateral plateau 47558-00 [1508]
- - - - - - - with internal fixation 47558-01 [1508]
- - - shaft (closed) 47564-00 [1509]
- - - - with internal fixation (cross) (intramedullary) 47566-00 [1509]
- - - - intra-articular 47567-00 [1509]
- - - - - with internal fixation (cross) (intramedullary) 47566-02 [1509]
- - - - open 47570-00 [1510]
- - - - - with internal fixation (cross) (intramedullary) 47566-01 [1510]
- - - - - intra-articular 47573-00 [1510]
- - - - - - with internal fixation (cross) (intramedullary) 47566-03 [1510]

Clinical coders should be guided by the following:

ACHI Tabular List
Guidance in the use of ACHI
6. Refer to the Tabular List to verify the suitability of the code selected.

ACHI Alphabetic Index
Introduction:
Both the ACHI Alphabetic Index and Tabular List are meant to be used together. It is not recommended that the Alphabetic Index or Tabular List be used in isolation of each other.

Assign codes from block:
• [1508] Open reduction of fracture of tibial plateau for ‘open’ reduction with internal fixation (ORIF) of tibial plateau fracture
• [1510] Open reduction of fracture of shaft of tibia or fibula for ‘open’ reduction with internal fixation (ORIF) of tibial shaft fracture

Note also that the ACHI Alphabetic Index does not list a default code for reduction of fracture of tibia NOS (ie unspecified site). Clinical coders should be guided by documentation in the health care record (eg Xray report) or seek clinical advice to identify the specific site of the tibia requiring reduction.

Note: This response will not be published.
Amendments may be considered for a future edition.

[end of ACCD response]

In addition to the advice provided by the ACCD, VICC advises to assign a code for open reduction of shaft of tibia as a last resort when a coder has exhausted all means of confirming the specific site of tibial fracture.

Note: ACCD advised VICC that this query would not be published. Therefore VICC has published the query in accordance with the committee’s business rule to publish queries referred to ACCD that ACCD does not publish.


Query Text:
Can VICC please confirm the correct codes and sequencing for the principal diagnosis 'Alcohol withdrawal seizure' in the following scenarios?

Tabular description at F10.-:
.3 Withdrawal state:

A group of symptoms of variable clustering and severity occurring on absolute or relative withdrawal of a psychoactive substance after persistent use of that substance. 
The onset and course of the withdrawal state are time-limited and are related to the type of psychoactive substance and dose being used immediately before cessation or reduction of use. 
The withdrawal state may be complicated by convulsions.  

Scenario 1:  The patient presents following a seizure and after study this was found to be due to alcohol withdrawal. 

Option a:
F10.3 Mental and behavioural disorders due to use of alcohol, withdrawal state

Option b:
R56.8 Other and unspecified convulsions
F10.3 Mental and behavioural disorders due to use of alcohol, withdrawal state

Scenario 2: The patient presents with known alcoholic withdrawal seizures for treatment. 

Option a:
F10.3 Mental and behavioural disorders due to use of alcohol, withdrawal state

Option b:
R56.8 Other and unspecified convulsions
F10.3 Mental and behavioural disorders due to use of alcohol, withdrawal state

Response:
Without the benefit of the full episode notes, VICC interprets scenario one as the patient presenting with a problem, and during the episode the underlying condition is identified, in this case alcohol withdrawal.  VICC therefore advises to assign F10.3 Mental and behavioural disorders due to use of alcohol, withdrawal state as per ACS 0001 Principal diagnosis, Coding the underlying condition as the principal diagnosis.  There may be circumstances where documentation indicates that the seizures meet ACS 0002 Additional diagnoses  as important problems in their own right , in which case it would be appropriate to assign additional code R56.8  Other and unspecified convulsions in accordance with dot point f in the Note at the beginning of Chapter 18 Signs and symptoms.

In Scenario 2 it is unclear from your query whether the admission is for treatment of the seizures or alcohol withdrawal or both.  VICC interprets scenario 2 as meaning patient was admitted for treatment of seizures only, therefore assign seizures as principal diagnosis.  As there is a clearly documented relationship to alcohol withdrawal, assign alcohol withdrawal (F10.3) as additional diagnosis in accordance with ACS 0503 Drug, alcohol and tobacco use disorders.


Query Text:
The codes for J36 Peritonsillar abscess and J03.- Acute Tonsillitis exclude each other.  

Can VICC please confirm whether this is intentional?
 
Which code should assigned if the clinician documents both in the episode and they meet criteria for coding? 

J36 Peritonsillar abscess
Excludes	
retropharyngeal abscess (J39.0)
tonsillitis:
 acute (J03.-)
 chronic (J35.0)
 NOS (J03.9)

J03 Acute tonsillitis
Excludes	
peritonsillar abscess (J36)
sore throat:
 acute (J02.-)
 NOS (J02.9)
 streptococcal (J02.0)

Response:
The enquirer clarified that quinsy and tonsilitis were documented as two distinct diagnoses in this patient.  Therefore where both conditions are documented and meet criteria for coding, VICC advises to apply ACS 0001 Principal diagnosis, seeking clarification from the clinician if possible.


Query Text:
A bed alarm was used during a patient’s admission due to a high falls risk as the patient was not following instructions due to their dementia. 

When determining whether the dementia meets ACS 0002 and Vic 0002 we have considered Vic 0002 Additional diagnoses education workshop questions and answers: Clinician queries question 9, other additional diagnoses questions question 33 and the pressure injury questions answer.

Can you please clarify is a bed alarm used due to dementia considered a significant use of specialised equipment and therefore dementia can be coded or is it considered routine care/management of a dementia patient?

Response:
VICC notes that bed alarms are used to reduce risk of falls in patients and does not consider them to be specialised equipment.  

In the scenario cited, even if there was documentation making the link between dementia and the need for a bed alarm, as per Vic 0002 Additional diagnoses a bed alarm is not significant special equipment.

Therefore based on that documentation alone, assign U79.1 Dementia (including in Alzheimer's disease).


Query Text:
Patient admitted for an oesophagogastrostomy. The ACHI Index does not appear to provide a pathway leading directly to a code to classify the oesophagogastrostomy procedure. Clinician advice was sought and the clinician responded the alternative terminology/which ACHI procedure code best reflects the oesophagogastrostomy was oesophagostomy and gastrostomy. 

Can you please advise the correct procedure code assignment for oesophagogastrostomy?

Response:
VICC referred this query to ACCD, and received the following response:

Oesophagogastrostomy is the surgical formation of an artificial communication between the oesophagus and the stomach (Merriam-Webster, 2019).

It is acknowledged that there currently is no ACHI Alphabetic Index entry for oesophagogastrostomy.

As a best fit assign 30375-31 [881] gastro-gastrostomy.

This response will not be published.

Amendments may be considered for a future edition.

References:
https://www.merriam-webster.com/medical/esophagogastrostomy
[end of ACCD response]

Note: ACCD advised VICC that this query would not be published. Therefore VICC has published the query in accordance with the committee’s business rule to publish queries referred to ACCD that ACCD does not publish.


Query Text:
VICC query #2530 & ACCD query Q2952 High Stoma Output which advises to code high stoma output to K91.4 Colostomy and Enterostomy have both been retired. 

K91.4 no longer exists in Tenth Edition. K91.49 Malfunction of stoma of the digestive system (which includes high output ileostomy in the tabular) is the new code in tenth edition. 

1. Can the advice in retired VICC 2530 & ACCD 2952 queries still be used to code high stoma output to K41.49 Malfunction of stoma?
 
2. Can you please advise on the correct index classification for high stoma output?

Response:
VICC considers that high output stoma is a functional complication of the stoma. For documentation of high stoma output, follow the lead term Complication/enterostomy (stoma) to assign K91.49 Malfunction of stoma of the digestive system, not elsewhere classified.

You may wish to submit a public submission to have an Index entry created for high output stoma, as it is listed as an inclusion term at K91.49.


Query Title:
Coding of same day diagnostic angiograms

Query Text:
Could the committee please advise on principal diagnosis selection for same day coronary angiogram cases when a patient is investigated for a symptom, and there is a finding of coronary artery disease, with no intervention.

For example, a patient is admitted as a day case for a coronary angiogram for investigation of chest pain. The finding on the angiogram cath lab report was mild coronary artery disease (CAD) for medical management only. Should the principal diagnosis be the chest pain (symptom) or the CAD (finding) eg:
1) R07.4 Chest pain, unspecified with I25.11 Atherosclerotic heart disease, of native coronary artery as an additional code, or
2) I25.11 Atherosclerotic heart disease, of native coronary artery alone

ACS 0001 Principal diagnosis states that codes for symptoms, signs and ill-defined conditions are not to be used as principal diagnosis when a related definitive diagnosis has been established. 

In the absence of a discharge summary, and the only documentation is of symptoms and findings on a diagnostic report, are we able to make the link that the chest pain is due to the CAD, ie that the CAD is a related definitive diagnosis?

There is a query that answers our question, however it is retired. The query is Same day coronary angiograms principal diagnosis selection (VICC Query #2192) published 2005-06 Second Quarter. 

Can the principles from the above retired query still be applied?

Response:
In the scenario cited there is no discharge summary and no documented link between the symptom of chest pain and the finding of coronary artery disease.  VICC therefore advises that in the scenario cited, assign R07.4 Chest pain as the principal diagnosis, with I25.11 Atherosclerotic heart disease, of native coronary artery as an additional diagnosis if it meets ACS 0002 Additional diagnoses.


Query Text:
Clinicians will often describe a condition called 'clot retention', or 'urinary clot retention', or 'urinary retention with clots'. In most cases, this occurs in the post operative period. 

There's currently no sequencing guidelines or index for 'clot retention'. 

Could VICC please confirm the most appropriate code assignment and sequencing for documentation of:

a) Clot retention due to the procedure (meeting ACS 1904 Procedural complications)

b) Clot retention (no further specificity).

Response:
VICC research indicates that clot retention may occur when there has been bleeding in the urinary tract which may lead to urinary retention.  Although this often occurs in the post-operative period, procedural complication codes can only be assigned if the criteria in ACS 1904 Procedural complications are met.  VICC advises that ACS 1904 Procedural complications states that if the documentation is not clear, clarification should be sought from the clinician.

When the clot retention is documented as due to the procedure assign N99.89 Other intraoperative and postprocedural disorder of genitourinary system following the Index pathway Complication/postprocedural/urinary/specified.

When there is no documentation that the clot retention is specified as being due to the procedure follow the appropriate lead term for the documented site of the clots. For example, for documentation that the clot is located in the bladder, assign N32.8 Other specified disorders of bladder following Index entry Clot/bladder and for documentation that the clot is located in the urethra assign N36.8 Other specified disorders of urethra following Index entry Disease/urethra/specified NEC . If there is no documentation of the site of the clot, assign N39.88 Other specified disorders of urinary system by following the lead term Disease/urinary (tract)/specified NEC.

In both cases, R33 Retention of urine can only be assigned as an additional code if urinary retention has been specifically documented.

See also ACCD Coding Rule Q3276 Clot retention secondary to transurethral resection of the prostate (TURP).


Query Text:
Some health professionals are reportedly reluctant to use the term 'obesity' as they feel the term is potentially offensive or stigmatising to overweight adults and children. The dictionary defines the word 'bariatric' to mean 'of or relating to the treatment of obesity'.

We often find that patients who are admitted to our health service for procedures for obesity do not have the term 'obesity' documented. Instead the term 'bariatric' is used. For example 'Patient admitted for preparatory care for bariatric surgery'.

Therefore can the term 'bariatric' be seen as synonymous to the term 'obesity'?

Response:
VICC does not consider that the term bariatric can be used to classify obesity, despite it being commonly documented. The term bariatric relates to the branch of medicine that deals with the study and treatment of obesity, therefore a diagnosis of obesity should not be assumed for documentation of bariatric.


Query Text:
Can you please clarify if the previous advice regarding coding of general anaesthesia versus sedation is still correct? The advice we refer to is VICC query #2492 ACS 0031 Anaesthesia 2009 -2010 December Database retired 30/06/2015.

We would like to clarify does there need to be documentation of the use of an artificial airway such as endotracheal tube, laryngeal mask or Guedel (oropharyngeal) airway to support the assignment of a general anaesthetic (GA) code when only GA is documented by the clinician?

An example of this would be if the anaesthetist has ticked ‘GA’ as the type of anaesthesia on the anaesthetic form, however has not documented the airway. Is there a requirement to prove the use of an artificial airway before assigning the GA code?

Another example is if the clinician has written 'General Anaesthesia for angiogram' on the operation notes but there is no anaesthetic chart available. In this case would it be appropriate to assign a General Anaesthetic code?

Response:
VICC considers that the advice in ACS 0031 Anaesthesia regarding the use of an artificial airway applies when the distinction between sedation and general anaesthesia is unclear from the clinical documentation.  When documentation of general anaesthesia is clear, whether in writing or by the use of a tick box, there is no requirement for this documentation to be supported by evidence of the use of an artificial airway.  

In answer to the examples, when an anaesthetist has ticked GA as the type of anaesthesia on the anaesthetic form, but has not documented the airway, there is no requirement to prove the use of an artificial airway before assigning the GA code.  When the clinician has written 'General anaesthesia for angiogram' on the operation report but there is no anaesthetic chart available, it is appropriate to assign a general anaesthetic code.


Query Text:
Could the committee please specify what the correct procedure code is for a gastroscopy with clipping of a bleeding erosion at the gastro-oesophageal junction(i.e. gastritis)?

We have considered pathways:
Gastroscopy/with/diathermy
Destruction/Lesion/Oesophagus
Control/Haemorrhage/Gastrointestinal/for peptic ulcer 

We have attached an operation report for your perusal. 

Search Details:
VICC Query #3339 Gastroscopy with electrocautery
NCCC Endoscopic clipping of a bleeding duodenal arteriovenous malformation? (NCCC)15 Dec 2012
We note our scenario is slightly different to both of these.

Response:
VICC advises that when there is documentation of gastroscopy with clipping of a bleeding erosion at the gastro-oesophageal junction, follow the advice in ACCD Coding Rule Q3338 Endoscopic clipping of bleeding upper gastrointestinal lesions published in the December 2018 Coding Rules to assign 90296-00 [887] Endoscopic control of peptic ulcer or bleeding.


Query Text:
VICC query #2688 coding of cancer post surgery was retired on 30/06/2017.

Could VICC please review this query and advise if the information is still current?

Response:
VICC advises that the information in query #2688 Coding of cancer post surgery is not current. This query resolved confusion between a previous VICC query #2205 Coding of carcinoma post resection and the application of ACS 1204 Plastic surgery at that time.

For coding of cancer post surgery, VICC advises to follow the appropriate standards, that is, ACS 0002 Additional diagnoses, ACS 0236 Neoplasms and ACS 1204 Plastic surgery.


Query Text:
VICC #2455 Asthma exacerbated by upper respiratory tract infection (URTI) was retired on 30/06/2015.

Could VICC please review this query and advice if the information is still current?

Response:
VICC advises that for documentation of asthma exacerbated by upper respiratory tract infection (URTI), assign J45.9 Asthma, unspecified and J06.9 Acute upper respiratory infection as an additional code as the URTI is the underlying cause of the problem being treated. This is in accordance with ACS 0001 Principal diagnosis and ACS 0002 Additional diagnoses/Problems and underlying conditions.


Query Title:
Intramuscular haematoma secondary to self-injected steroids and hormones

Query Text:
Patient presented with right rectus femoris intramuscular haematoma secondary to self-injected steroids and growth hormones. 

Documentation indicates patient was injecting these steroids and hormones regularly prior to going to the gym. There is no evidence that these drugs were injected for therapeutic use or self-harm. 

1. What are the correct diagnosis codes to assign for this scenario?

Search Details
NCCH Ischaemic Fingers – Volume 16 Number 1, June 2009 - still current in ACCD Coding Rules

Response:
If documentation indicates that the haematoma is due to the drugs (steroids and growth hormones), VICC advises to assign:
T38.8 Other and unspecified hormones and their synthetic substitutes
M79.85 Other specified soft tissue disorders, pelvic region and thigh
Y14 Poisoning by and exposure to other and unspecified drugs, medicaments and biological substances, undetermined intent
Y92.9 Unspecified place of occurrence.
U73.8 Other specified activity

In the absence of documentation that indicates the cause of haematoma is the drug, VICC advises to assign:
S70.1 Contusion of thigh
W46 Contact with hypodermic needle
Y92.9 Unspecified place of occurrence.
U73.8 Other specified activity


Query Text:
We are starting to see new abbreviations for heart failure patients, specifically HFpEF (Heart failure with preserved Ejection Fraction). There is also HFrEF, which is 'Heart Failure with reduced Ejection Fraction'.

When we have these abbreviations recorded in lieu of CCF or LVF how should we be coding them? 

I have discussed this with our cardiologists and they said that this is the way that they are now classifying heart failure.

Response:
VICC advises that as the ICD-10-AM/ACHI/ACS classification does not contain subterms for HFpEF or HFrEF under Index entry Failure/heart, in the absence of documentation of CCF or LVF, assign I50.9 Heart failure, unspecified.  

VICC acknowledges that the ICD-10-AM/ACHI/ACS classification is not in keeping with the changing clinical classification of heart failure.

Note: This query has been superseded by IHPA Coding Rule Q3624 Characteristics of left ventricular failure, published March 2021, for implementation 1 April 2021.


Query Text:
On occasion, we have cases where a post-surgical patient (most often a hip or knee replacement) develops a blister at the surgical site. 

In these cases the exact cause of the blister is often unclear (e.g. if due to friction or dressing) and further information is unable to be obtained.

Could the committee please provide advice on code assignment when ‘post-surgical blister’ is documented without further specification?

Response:
VICC research indicates that a wound blister from surgery is an abnormal swelling in the skin caused by various kinds of trauma associated with the surgery. These blisters may be a result of skin irritation caused by prolonged skin exposure to surgical tape or bandages, the removal of surgical tape or bandages, or from direct trauma associated with the surgery, such as the cutting of tissue.

VICC advises that when ‘post-surgical blister’ is documented without further specification and the post surgical blister meets ACS 0002 Additional diagnoses assign the following codes:
A code for Blister/by site
X58 Exposure to other specified factors
Y92.2- Place of occurrence, health service area
U73.9 Unspecified activity

Please also refer to ACCD Coding Rules Q3284 Fracture blisters, published September 2018.


Query Text:
We have identified a significant escalation in clinician queries generated post the initial coding in regard to respiratory failure in patients, using decreased oxygen saturation alone as a reference point for generating a query.

By definition respiratory failure is: A syndrome in which the respiratory system fails in one or both of its gas exchange functions: oxygenation and carbon dioxide elimination. 

Hypoxic respiratory failure (type 1) is characterised by an arterial oxygen tension (Pa O2) lower than 60 mm Hg with a normal or low arterial carbon dioxide tension (Pa CO2).

Hypercapnic respiratory failure (type II) is characterized by a PaCO2 higher than 50 mm Hg. Hypoxemia is common in patients with hypercapnic respiratory failure who are breathing room air. (Medscape, 2015)

It is not possible to accurately determine the partial pressures of oxygen and carbon dioxide without arterial blood gas analysis. This is why arterial blood gas analysis is considered the ‘gold standard’ (American College of Physicians 2013) for diagnosis.

The inference that arterial blood gas analysis is the gold standard measure also arises from the standard use of partial pressure measures from arterial blood gas analysis for most, if not all, clinical studies examining the various forms of respiratory failure and their treatment options. Generally, oxygen saturation measures alone do not satisfy the diagnostic nor outcomes measurement sensitivity and specificity requirements of clinical studies.

We have sought current clinical advice on respiratory failure and we believe that in order for respiratory failure to be coded, blood gases are essential in diagnosis and that decreased oxygen saturations alone are not sufficient to generate a query.

We believe that in all cases where respiratory failure is queried a blood gas measurement should be obtained to substantiate the PaO2 and Pa CO2 in each patient, to ensure that an accurate diagnosis can be made. 

1) Should respiratory failure be queried based on oxygen saturation readings alone?

2) Can VICC please provide some direction in relation to the querying of respiratory failure?

References:
Kaynar, A, 2018, ‘Respiratory Failure’, Medscape, 25 July 2015, viewed 16 August 2018, https://emedicine.medscape.com/article/167981-overview.

Pinson,R, 2013, ‘Revisiting Respiratory Failure’, October 2013, viewed 15 August 2018, https://acphospitalist.org/archives/2013/10/coding.htm.

Response:
VICC notes your research that arterial blood gas (ABG) on room air is the “gold standard” for the diagnosis of respiratory failure, however the saturation measured by pulse oximetry may be used as a practical surrogate for monitoring of oxygenation in some patients. The use of pulse oximetry rather than ABG does not preclude the coder from generating a clinician query.
 
However, a query should not be generated on the basis of vital sign readings, such as oxygen saturations on an observation chart, or ABGs on a pathology report alone.
 
Where oxygen saturation readings or ABGs are documented within the body of a record, and there is evidence that they represent a condition that meets the criteria in ACS 0002 Additional diagnoses, VICC considers it can be appropriate to generate a clinician query to clarify the diagnosis.  
 
Following ethical query guidelines, an example of a query would be:
 
Oxygen saturations on 23/2 were (xx %) as per (where documented) and high flow oxygen therapy via nasal prongs (HFNP) was commenced in response to this. Why was this patient commenced on HFNP?


Query Text:
When coding a high anterior resection it is common that a section of the colon is removed also, this can be part or all of the sigmoid colon and may extend into the left colon. 

Does the code 32024-00 High anterior resection of rectum include a colectomy or do we need to capture this separately with a more specific code to indicate the extent of colon removed?

In discussing this with our Director of Surgery he indicated that they will only document 'anterior resection' but may then remove part of the colon and consider this inherent.

Thank you for your assistance.

Search Details
http://sussexsurgical.co.uk/information.php?t=High-Anterior-Resection&s=Colorectal-Surgery&id=119

Response:
VICC notes that the lead term Resection requires documentation of the essential modifier ‘rectum’ in order to assign 32024-00 [935] High anterior resection of rectum.

VICC research supports the clinical advice that the colectomy of varying amounts is inherent in 32024-00 [935] High anterior resection of rectum, therefore an additional code for colectomy is not required for documentation of high anterior resection of rectum.


Query Text:
Q1. Can you please clarify what is the correct code to assign when there is documentation of pyeloscopy however there is no documentation of retrograde? We note previous advice in VICC query #2794 Flexible pyeloscopy 2012-2013 June Database however this was retired on the 30/06/2017.

Q2. We also often see documentation of ureteroscopy (URS) with fragmentation of renal calculus however often don’t see retrograde or RGP documented. We note ACCD Q3185 Ureteric stone with fragmentation by laser in the kidney however in most cases we find that the documentation is that the calculus was in the kidney, not the ureter.

Can you please clarify the correct code to assign for documentation of ureteroscopy (URS) with fragmentation of renal calculus without mention of ‘retrograde’?

Search Details
VICC Q2794 Flexible pyeloscopy 2012-2013 June Database retired 30/06/2017.
ACCD Q3185 Ureteric stone with fragmentation by laser in the kidney published 15/12/17

Response:
As per #2794 Flexible pyeloscopy the Index entry for Pyeloscopy requires an essential modifier for antegrade or retrograde and there is no default code. 

Unless there is documentation that the pyeloscopy is performed percutaneously, assign 36652-00 [1040] Retrograde pyeloscopy following the Index entry Pyeloscopy/retrograde (endoscopic). 

For documentation of ureteroscopy or URS with fragmentation of renal calculus, VICC advises to follow the Index entry Fragmentation/calculus/kidney/via retrograde pyeloscopy to assign 36656-02 [1041] Endoscopic fragmentation of calculcus of kidney.  This code includes ureteroscopy.


Query Text:
Can you please clarify the correct code assignment for patients with multiple heart valve disorders? 

We note the index pathways leads to assigning a code from I08 Multiple valve diseases when specified as rheumatic or of unspecified origin.  Some of our coders feel that assigning a code from I08 Multiple valve diseases only does not capture the full details of the patient’s condition, however the excludes notes seem to imply that only when the valve disorders are of a specified origin can we assign a code I34 – I38. 

We also note ACS 0015 Combination Codes states “Assign only the combination code when that code fully identifies the diagnostic conditions involved and when the Index so directs. Multiple codes should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis.” 

Therefore we would like some clarification as to whether we can assign codes from I08 and I34 – I38.

For example, can you please clarify the correct codes to assign in the following multiple heart valve disorder scenarios?

1. Patient admitted with aortic stenosis. The doctor has also documented a history of mitral valve regurgitation. No cause of either aortic stenosis or mitral valve regurgitation is specified.

2. Patient admitted with aortic stenosis due to previous endocarditis. They also have a documented comorbidity of mitral valve insufficiency, no cause specified.

3. Patient admitted with both mitral and aortic valve insufficiency specified to be due to calcium deposits.

Response:
VICC referred this query to IHPA who provided the following response in Coding Rule titled Multiple heart valve diseases published 20 March 2020:

Follow the classification convention for the prepositional term ‘with’ in the ICD-10-AM
Alphabetic Index, which is based on ICD-10. Before assigning a code, users of ICD-10-AM must also apply the Instructional notes in the ICD-10-AM Tabular List and the Australian Coding Standards (ACS) (eg ACS 0001 Principal diagnosis and ACS 0002 Additional diagnoses).

The Instructional notes at category I08 Multiple valve diseases states:

Includes: whether specified as rheumatic or of unspecified origin
Excludes: …
multiple valve diseases of specified origin other than rheumatic heart
diseases (use appropriate codes in I34–I38, Q22–Q23 and Q24.87)

For cited scenario 1
Assign I08.0 Disorders of both mitral and aortic valves.
Follow the ICD-10-AM Alphabetic Index:
Stenosis (cicatricial)
- aortic (valve) I35.0
Follow the Excludes note at category I35 Nonrheumatic aortic valve disorders:
Excludes: unspecified cause but with mention of diseases of mitral valve (I08.0)

For cited scenario 2
Assign I35.0 Aortic (valve) stenosis.
Follow the ICD-10-AM Alphabetic Index:
Stenosis (cicatricial)
- aortic (valve) I35.0

The Excludes note at category I35 does not apply to scenario 2 because the aortic stenosis is documented as due to a specified cause (ie endocarditis). A code for mitral valve regurgitation is not assigned because it does not meet the criteria in ACS 0002 Additional diagnoses.

Scenario 3
Patient admitted for treatment of mitral and aortic valve insufficiency due to calcium deposits.
Assign I34.0 Mitral (valve) insufficiency and I35.1 Aortic (valve) insufficiency.

Follow the ICD-10-AM Alphabetic Index:
Insufficiency, insufficient
- mitral
- - with
- - - aortic valve disease (unspecified origin) I08.0

The mitral and aortic valve insufficiencies are due to a specified origin (ie calcium deposits). Therefore, follow the Excludes note at category I08 and assign appropriate codes from the range I34–I38 (specifically I34.0 and I35.1). [end of IHPA response]

Further to the IHPA response, VICC notes that when a code from range I08 Multiple valve disorders is not assigned, each valve disorder must meet ACS 0002 Additional diagnoses.

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:
What code(s) should be assigned for documentation of double diabetes? Research indicates that double diabetes occurs when a patient with Type 1 Diabetes develops features of insulin resistance. 

Given the code E10.72 doesn't exist, and coding diabetic complications with both E10.- and E11.- codes would produce multiple PICQ errors, how do we best capture this condition?

Response:
VICC advises to only assign appropriate code/s from E10 Type 1 diabetes mellitus where double diabetes is describing Type 1 diabetes with features of insulin resistance.  

Diabetes with insulin resistance can only be classified to categories E11, E13 and E14, which are excluded with E10 Type 1 diabetes mellitus, therefore it is not possible to capture features of insulin resistance in a Type 1 diabetic.


Query Text:
Could VICC please advise the correct diagnosis code to assign for breast asymmetry not further specified?

Possible Index pathway which has been considered is:
Asymmetry – see also Distortion
Distortion/organ/or site not listed – see Anomaly/by site
Anomaly, anomalous/breast Q83.9

Response:
For documentation of breast asymmetry, without any further information regarding the cause, VICC advises to assign Q83.9 Congenital malformation of breast, unspecified by following the Index entry Asymmetry - see also Distortion, Distortion/organ/or site not listed - see Anomaly/by site, Anomaly/breast.

If there is further information available regarding the cause of the breast asymmetry, such as previous surgery on the breast, follow the advice in ACS 1204 Plastic surgery and Coding Rule TN210 Dog ears of breast to assign Z42.1 Follow-up care involving plastic surgery of breast.


Query Title:
Gastrointestinal endoscopy with application of clip

Query Text:
The ACHI Index does not appear to provide a pathway leading directly to a procedure code to classify a clip applied during gastrointestinal endoscopy for bleeding not related to a peptic ulcer/AVM or achieving haemostasis. 
  
For example: 
- Endoscopic clipping of bleeding angiodysplasia of stomach. 
- Endoscopic clipping of bleeding gastric polyp. 
- Endoscopic clipping of bleeding vascular areas in oesophagus. 
  
Please advise the correct ACHI Index pathway to follow and code to assign to classify a clip applied during gastrointestinal endoscopy for bleeding not related to a peptic ulcer/AVM or achieving haemostasis. 

Query Search: 
  
ACCD Q2789 Endoscopic clipping of a bleeding duodenal arteriovenous malformation (December 2012) 
VICC #2913 Insertion of haemostatic clip/endoclip during endoscopy (2013-14 June Database).

Response:
When there is documentation of gastroscopy with clipping for bleeding, follow the advice in ACCD Coding Rule Q3338 Endoscopic clipping of bleeding upper gastrointestinal lesions published in Coding Rules December 2018 to assign 90296-00 [887] Endoscopic control of peptic ulcer or bleeding.


Query Text:
Could VICC please advise the correct diagnosis code to assign for post haemorrhoidectomy/polypectomy bleed not further specified?

Scenario 1
Discharge summary states ‘bleeding post haemorrhoidectomy’. Progress notes indicate patient admitted Day 6 post haemorrhoidectomy with PR bleeding. There is no further documentation regarding the site or cause of the bleed.

Scenario 2
Patient readmitted post a colonoscopy. Discharge summary states ‘post polypectomy bleed’. Nursing documentation states ‘PR bleed after colonoscopy today with removal of polyps’. There is no further documentation regarding the site or cause of the bleed. The colonoscopy report for the previous admission includes findings of diverticular disease and colonic and rectal polyps.

ACS 1904 Procedural complications overview point 2 states ‘Certain conditions where the relationship is inherent in the diagnosis (eg infection or bleeding of a surgical wound, stoma or anastomosis, wound dehiscence, transfusion related acute lung injury)’

Is the documentation of ‘post haemorrhoidectomy’ or ‘post polypectomy’ bleed enough to apply the above advice in ACS 1904 Procedural complications that the relationship is ‘inherent’ and therefore code as a procedural complication? Or as PR bleeding can occur from any site in the digestive tract do we need a direct link with the surgery or clear documentation that the bleeding is specifically from the haemorrhoidectomy/polypectomy site in order to assign a procedural complication code and therefore without this link K92.2 would be assigned?

Response:
VICC advises that where per rectal (PR) bleeding is described as ‘bleeding post haemorrhoidectomy’ or ‘post polypectomy bleed’, that the relationship between the bleed and the procedure cannot be assumed to be inherent in the diagnosis because there is no documentation that the site of the bleeding is the surgical wound.

As PR bleeding can occur from any site in the digestive tract, in order to assign a procedural complication code, documentation must be clear that the bleeding arose as a complication of the procedure, or is secondary to, or due to the procedure. This is in accordance with the first paragraph of ACS 1904 Procedural complications, and the second dot point. Without this documentation, the correct code to assign is K92.2 Gastrointestinal haemorrhage, unspecified.


Query Text:
We are seeing the word 'refractory' used more frequently in relation to epilepsy. It appears that this word is synonymous with intractable. 

If we have documentation of 'refractory', 'medication resistant' or 'poorly controlled' epilepsy for codes in G40 can we use the 5th character of '1' to indicate that the epilepsy is 'intractable'?

Response:
VICC research agrees that the terms refractory epilepsy and medication-resistant epilepsy are synonymous with intractable epilepsy. VICC advises that when these terms are documented, the 5th character of 1 'with intractable epilepsy' can be used for codes in G40 Epilepsy.

VICC does not consider that the term 'poorly controlled' is synonymous with intractable, as there may be multiple causes for poor control, such as non-compliance with medication. Therefore the 5th character of 1 'with intractable epilepsy' should not be assigned for documentation of poorly controlled epilepsy.


Query Text:
VICC query #3318 Use of the words 'associated with' in ACS 1904 Procedural complications notes that 'ACCD does not consider 'associated with' to be a term which infers a causal relationship thus cannot be coded'. 

Ventilator associated pneumonia (VAP) has the same terminology however there is an index entry for this and it automatically codes to a procedural complication.

As there is conflicting advice from VICC and ACCD, should the index pathway for VAP still be followed?

Response:
VICC advises that query #3318 is about documentation of conditions documented as associated with a procedure, and not about a specific clinical condition, as is the case with ventilator associated pneumonia (VAP).

VICC research indicates that VAP is the name of a nosocomial condition, and when so described indicates that the ventilator is the cause of the pneumonia.


Query Text:
A bifocal germinoma is a tumour that arises in the suprasellar and pineal regions of the brain at the same time. 

Would it be correct to code them as two separate primary lesions: suprasellar to C71.9 Malignant neoplasm of brain, unspecified and pineal gland to C75.3 Malignant neoplasm of pineal gland?

Response:
For documentation of bifocal germinoma arising in the suprasellar and pineal regions of the brain, VICC advises to assign C71.9 Malignant neoplasm of brain, unspecified and C75.3 Malignant neoplasm of pineal gland because there are two primary sites.


Query Title:
IV fluids given as part of protocol for venesection

Query Text:
As part of our hospital protocol, patients undergoing venesection are always given IV fluids (saline) for volume depletion.

As the patients are admitted specifically for IV fluids as well as venesection, please advise if it is correct to follow ACS 0042 Procedures normally not coded to assign 96199-19 for IV fluids (that is, procedures normally not coded are only assigned if they are the principal reason for admission in a same day episode).

Response:
For patients undergoing venesection, VICC considers the administration of IV fluids to be a routine or inherent part of the venesection. In accordance with ACS 0016 General procedure guidelines/Procedure components only the code for venesection would be assigned.


Query Text:
Research undertaken indicates that the terminology of 'Syrinx' is synonymously used with 'Syringomyelia and syringobulbia'. 

As there is no Index classification for Syrinx, could VICC please advise if it is correct to assign G95.0 Syringomyelia and syringobulbia when we have documentation of 'Syrinx'?

Response:
VICC research indicates that a syrinx is a fluid filled cyst. Syringomelia and synringobulbia is the development of a fluid filled cyst in the spinal cord and brain stem, respectively. Therefore for documentation of a syrinx in the spinal cord or brain stem, it is correct to assign G95.0 Syringomyelia and syringobulbia.


Query Text:
Research undertaken indicates that the terminology of 'epiretinal membrane' is synonymously used with ‘macular pucker’ and ‘macular degeneration’. 

As there is no Index classification for epiretinal membrane could VICC please advise if it is correct to assign H35.3 Degeneration of macula and posterior pole when we have documentation of 'Epiretinal membrane'?

Response:
VICC research could not confirm that the terms ‘macular pucker’ and ‘macular degeneration’ are synonymous with epiretinal membrane.

For documentation of macular pucker or macular degeneration, follow Index lead term Puckering, macula or Degeneration, macula to assign H35.3 Degeneration of macula and posterior pole. For documentation of epiretinal membrane, follow Index lead term Disease/retina/specified NEC to assign H35.8 Other specified retinal disorders.


Query Text:
VICC query #2655 Urethroplasty and buccal graft states ‘that whilst a buccal graft is not performed with every urethroplasty, it is still considered to be a component of the urethroplasty when it is performed. Therefore it is correct to follow ACS 0016 General procedure guidelines and only assign the 37342-00 [1121] Urethroplasty – Single stage procedure’ 

Given VICC query #2655 is now retired could VICC please confirm if this advice is still current?

Response:
VICC considers that the advice in query #2655 Urethroplasty and buccal graft is still current, and is reproduced below:

Query:
We have come across the procedure Urethroplasty and buccal graft performed for urethral stricture and are unsure how to code the buccal graft component as there is no appropriate code in the ACHI index. 

On review of other urethroplasty admissions in our organisation for urethral stricture, most do not mention the use of a buccal graft, so we are hesitant to say it is a procedural component and apply ACS 0016 General procedure guidelines as outlined in an old NCCH Query #906.

Further research conducted also supports that a buccal graft is not routine in nature and one of a number of options for a urethroplasty. The buccal graft is also harvested from the mouth via a separate incision.

Would we be correct to follow ACS 0016 General procedure guidelines and only assign the 37342-00 [1121] Urethroplasty – Single stage procedure OR would we need to translate the buccal graft? If so, what code should we use for the Buccal graft?

Answer:
VICC query #2655 Urethroplasty and buccal graft states that 'whilst a buccal graft is not performed with every urethroplasty, it is still considered to be a component of the urethroplasty when it is performed. Therefore it is correct to follow ACS 0016 General procedure guidelines and only assign the 37342-00 [1121] Urethroplasty – Single stage procedure’


Query Title:
ACS 0051 Same-day endoscopy - diagnostic

Query Text:
ACS 0051 Same-day endoscopy - diagnostic says 'This standard does not apply where principal/additional diagnoses are clearly documented.'

Our hospital has discharge summaries for same day endoscopy patients, on which a clear principal diagnosis is documented. Does VICC Query #3261 (which refers to 'operative diagnosis') still apply in this instance? If so, do VICC Queries override Australian Coding Standards?

Response:
VICC advice is intended to clarify understanding of Australian Coding Standards and ICD-10-AM/ACHI for Victorian coders, hence VICC query #3261 Principal diagnosis in same day endoscopy episode was published to clarify what to do where there is no clear principal diagnosis for a same day endoscopy.

In your hospital there is a discharge summary with a principal diagnosis, therefore ACS 0001 Principal diagnosis should be followed as ACS 0051 Same-day endoscopy – diagnostic does not apply.


Query Title:
Iron infusion in a patient with gestational diabetes mellitus

Query Text:
This 33yo woman was admitted as a day patient for an iron infusion.

The notes document that she has iron deficiency anaemia and also that she has gestational diabetes mellitus (GDM). In accordance with ACS 0401 Diabetes mellitus and intermediate hyperglycaemia a code for the GDM was assigned. The patient was not admitted to an obstetric unit and was not transferred to another facility for obstetric care. She was also not supervised by an obstetrician/midwife and fetal evaluation/monitoring was not performed.

Should ACS 1521 Conditions and injuries in pregnancy be applied in these type of admissions?

As a code from chapter 15 Pregnancy, childbirth and the puerperium has been assigned, do the other diagnosis codes for this episode also need to have a corresponding ‘O code’?

Can the committee please advise what codes should be assigned in this scenario?

Response:
Iron deficiency anaemia (IDA) is a condition that may occur in any patient therefore it is a nonobstetric condition. In this scenario, VICC considers that the criteria in ACS 1521 Conditions and injuries in pregnancy are not met for the IDA as it is not documented as complicating the pregnancy and does not meet two or more of the four dot points, therefore IDA is not classified to Chapter 15 Pregnancy, childbirth and the puerperium.

As per ACS 0401 Diabetes mellitus and intermediate hyperglycaemia, gestational diabetes mellitus (GDM) is assigned a code from Chapter 15 Pregnancy, childbirth and the puerperium. As it only occurs in pregnancy, GDM is an obstetric condition so the criteria in ACS 1521 do not apply.

Note also that ACS 1521 states:
"Once the decision has been made to classify one nonobstetric condition as complicating pregnancy, assign all other nonobstetric conditions in the episode of care as pregnancy complications".

In this scenario, there is only one nonobstetric condition, being the IDA. Therefore the disease codes for the scenario cited are:
D50.9 Iron deficiency anaemia, unspecified
O24.4- Diabetes mellitus arising during pregnancy


Query Text:
I have come across patients with back pain who are admitted for a caudal epidural steroid injection (CESI) as per the following example.

Chronic lower back pain - CESI
- Omnipaque to confirm placement on lateral XR.
- Negative aspiration
- 10ml: 2ml 1% llignocaine, 5.7mg Celestone, 7ml NaCl 0.9%

In trying to code this procedure I have considered the following index entries:

Administration, specified site, spinal, caudal, injection NEC, combined substances 90019-00 [34] Caudal injection of other or combined therapeutic substance(s)

Administration, specified site, epidural, injection NEC, combined substances 90018-00 [32] Epidural injection of other or combined therapeutic substance(s)

Can VICC please advise which procedure code(s) should be assigned for a CESI?

Response:
VICC research indicates that a caudal injection is an injection into the lowest portion of the epidural space, and is therefore a specific type of epidural injection. Caudal injection is one approach for the delivery of steroid into the epidural space whereby the sacral hiatus (a small bony opening just above the tailbone) is used to allow for needle placement into the very bottom of the epidural space.

Therefore, for documentation of caudal epidural steroid injection (CESI), VICC advises to assign 90028-02 [34] Caudal injection of steroid following the Index pathway Administration/specified site/spinal/caudal/injection NEC/steroid.


Query Title:
Anticoagulation - pre operative cessation

Query Text:
Tenth Edition FAQs Part 1: Abnormal coagulation profile due to anticoagulants (ACCD) directs that, in order for Z92.1 personal long term use of anticoagulants to be assigned, INR levels need to be monitored during an episode of care, with multiple values required to demonstrate a trend.

We are trying to apply this advice to the following case but are confused as to where this crosses over with ACS 0002 (alteration of medication) and ACS 0303 (Abnormal coagulation profile) and what advice to follow. We would appreciate your advice.

Pt admitted electively for TURP with 3 day LOS. On Rivaroxaban for AF and this was ceased prior to admission. Plan on admission was to continue current management. No INR readings were done during admission.

Medication chart from day of admission notes 'withhold Rivaroxaban until advised by urology'. Urology progress notes day following TURP 'Large TURP. Plan. TOV. Not to restart Rivaroxaban'.

Should Z92.1 History of long term use of anticoagulants be coded based on ACS 0002 'withholding of medication' and documented plans re: continuing to withhold?

Should Z92.1 not be coded based on no INR levels during admission i.e. withholding anticoagulation without monitoring is considered routine management?

Is our understanding correct re: unless more than one INR level is documented during an episode of care, Z92.1 History of long term use of anticagulants would not be coded?

Response:
VICC advises that ACS 0303 Abnormal coagulation profile has been amended for Eleventh Edition. ACCD Coding Rules Q3367 Anticoagulants not requiring INR level monitoring (December 2018, retired 30 June 2019) provided guidelines to clarify the assignment of Z92.1 Personal history of long term (current) use of anticoagulants when INR levels do not require monitoring for Tenth Edition.

Therefore, if there is no INR monitoring during the episode, Z92.1 can still be assigned when the patient requires bridging anticoagulant therapy or when the patient has a medical condition that contraindicates the continued use of anticoagulants.

In the scenario cited, there is no documentation of bridging therapy or a medical condition that contraindicates the continued use of anticoagulants, therefore Z92.1 cannot be assigned. By way of further clarification, whilst there was evidence of a plan of care for the management of anticoagulation therapy (ACS 0002 Additional diagnoses), the requirements of the specialty standard (ACS 0303 Abnormal anticoagulation profile due to anticoagulants) are not met.


Query Text:
We note that at D46.9 Myelodysplastic syndrome, unspecified there is a note, includes: anaemia.

Does this note mean that all types of anaemia are included in myelodysplastic syndrome? (e.g. aplastic anaemia, haemolytic anaemia, sickle-cell anaemia). 

Or is it only anaemia, unspecified that is included in the concept of myelodysplastic syndrome?

A patient presented to this facility for a platelet transfusion. The indication for the transfusion was aplastic anaemia/myelodysplastic syndrome.

Can the committee please advise what codes should be assigned in this scenario?

Response:
VICC obtained clinical advice confirming that anaemia is regarded as a symptom of myelodysplastic syndrome (MDS), and that specific types of anaemia (such as aplastic, haemolytic and sickle-cell anaemia) generally do not present together with MDS. Specifically, a patient would almost never have aplastic anaemia and MDS, however symptoms and results can be similar.

Therefore, where anaemia without further specification is documented with MDS, an additional code for anaemia is not assigned. If a specific type of anaemia, e.g. aplastic anaemia, is documented with MDS, seek clarification from the clinician if possible, as to whether this is two separate conditions. If clarification is not possible, assign a code for each condition because two conditions are documented, with sequencing as per ACS 0001 Principal diagnosis and ACS 0002 Additional diagnoses.


Query Text:
VICC query #2790 Faecal transplant is not retired. 

Is this advice still current given there is an actual code for faecal microbiota transplantation (FMT) 96223-00 [1895]?

92075-00 [1895] has an excludes note for intestinal instillation for FMT.

Response:
VICC advises that query #2790 Faecal transplant (Eighth Edition) whilst not retired on the VICC queries database, is not current because it was firstly superseded by ACCD Coding Rule Faecal microbiota transplantation (FMT) (March 2014) which was then superseded by updates to the classification for Ninth Edition.

VICC advises that as part of ongoing work to review the currency of queries in the Victorian ICD Coding Committee queries database, this query will be retired as soon as possible.

Coders are still encouraged to notify VICC via the online query form if a non-retired query requires retirement, or if a retired query is still current.


Query Title:
Use of MBS codes for further clarification of procedures

Query Text:
It is common to see MBS codes noted on an operation report and they can often indicate that a procedure has been performed. Without evidence within the operative notes, we are unable to assign a code to represent the procedure. 

Could VICC please confirm whether the information represented in an MBS code can be used to generate a query to a clinician for further clarification regarding whether an additional procedure has occurred or to add specificity to a documented procedure?

Response:
VICC agrees that MBS item numbers noted on an operation report can be an indicator that a particular procedure has been performed, however VICC also notes that MBS numbers and descriptions do not always correlate with ACHI and could represent a procedural component.

Because this is primarily a documentation issue, you are not precluded from using the information represented in an MBS code to generate a query to a clinician for further clarification regarding whether a procedure has been performed.

An example of a documentation query would be:
The operation report for laparoscopic appendicectomy contains the MBS item number for division of abdominal adhesions but there is no text describing the division of adhesions. As clinical coders are not permitted to use MBS item numbers to assign intervention codes, could you please clarify whether this patient’s adhesions were:
a)	 divided
b)	 not divided
c) other - please specify
d)	 unknown/unable to determine

Coders should note that, for this particular example, the site of the adhesions is indicated by use of a specific MBS item number, however there may be other examples when clarification of the correct diagnosis code may also need to be sought.


Query Title:
Obstructive hydrocephalus in neoplastic disease

Query Text:
Could VICC please advise on what codes can be assigned for documentation of obstructive hydrocephalus in (due to) neoplastic disease? 

Given that G94.1 does not specify the type of hydrocephalus, can we assign codes:

G91.1 Obstructive hydrocephalus AND

G94.1* Hydrocephalus in neoplastic disease 

with relevant neoplastic codes (C00–D48†)?

Response:
VICC advises that in accordance with ICD-10-AM/ACHI/ACS Eleventh Edition, General Arrangement of the Disease Index: 'the indexing of a condition with the subterm in (due to) in the ICD-10-AM Alphabetic Index implies a cause and effect relationship between two conditions', and 'where the ICD-10-AM Alphabetic Index links two conditions using the subterms in (due to), follow this index entry except where a specific cause for the condition is indicated in the clinical record'.

Therefore, for documentation of obstructive hydrocephalus in or due to neoplastic disease, follow the ICD-10-AM Alphabetic Index lead term Hydrocephalus(acquired) (external) (internal) (malignant) (recurrent)/in (due to)/neoplastic disease NEC to assign G94.1 Hydrocephalus in neoplastic disease. Also assign relevant code/s for the neoplasm. 

VICC considers that it is appropriate to also assign G91.1 Obstructive hydrocephalus because the clinical concept of ‘obstructive’ hydrocephalus has not been accounted for in the Index as per the Guidance in the Use of ICD-10-AM in the Tabular List. This does not contravene the Conventions Used in the Tabular List of Diseases, section titled Multiple Condition Coding.


Query Text:
Coder had submitted a documentation query asking if  the principal diagnosis was confusion or cerebral infarct, and the response was ‘acute disorientation, subsequent CT brain demonstrating arterial infarcts, cardioembolic in nature’. A second documentation query was submitted asking if ‘acute deterioration and confusion could be further specified as acute confusional state', to which the response was ‘acute confusional state’.

1. Can you please advise if the second documentation query form is a valid query?

2. Please advise if the diagnosis of confusion meets ACS 0002 Additional diagnoses.

3. If the second documentation query is valid and confusion meets ACS 0002 , please advise the correct code for confusion – Is it F05.9 Delirium, unspecified or R41.0 Disorientation, unspecified? 

The doctor has ticked ‘acute confusional state’ which codes to F05.9 Delirium (coding pathway ‘state – confusional – acute’). However, from both documentation queries, the confusion is clearly not considered delirium. Also from the first query the doctor has specified acute disorientation. Can you please advise?

Response:
In response to the questions in the query, VICC advises the following:

The second documentation query was about whether a documented diagnosis of acute disorientation was in fact acute confusional state. The correct code for acute confusional state is F05.9 Delirium, unspecified, following the ICD-10-AM Alphabetic Index lead term State/confusional/acute or subacute.

The format of the query was ethical in that it provided multiple choice answers, but the content of the query was not valid as the description used by the query writer (acute deterioration) did not match the clinical documentation of ‘acute disorientation’.

In addition, VICC considers that the documentation query should have only been submitted if the clarification allowed the coder to assign a code. On review of the documentation supplied, it appears that confusion did not meet ACS 0002 Additional diagnoses as the cause of confusion was identified as a stroke, and confusion was not treated as a condition in its own right.


Query Text:
We are a private organisation seeking national advice on the following issue:

There is an Excludes note on the code block K56 which states: Excludes: with Hernia (K40 - K46).

Can you please clarify that in cases where the hernia is not at the same site as the obstruction (eg obstruction due to sigmoid cancer), and is being treated separately, if this excludes note prevents the assignment of K56.6.

Please see attached operation report as an example.

Response:
VICC advises that according to the operation report provided with this query, documentation was clear that the underlying cause of the obstruction was the cancer in the sigmoid colon, meaning the obstruction was at a different site to the umbilical hernia. In this circumstance, for the hernia, assign K42.9 Umbilical hernia without obstruction or gangrene.  

Consequently, for this episode, the excludes note “with hernia (K40-K46)” at category K56 Paralytic ileus and intestinal obstruction without hernia does not prevent the assignment of K56.- for the obstruction, provided the obstruction meets ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.

VICC advice is intended to clarify understanding of Australian Coding Standards and ICD-10-AM/ACHI for Victorian coders, consequently national advice is only sought if it is brought to VICC’s attention that another state or jurisdiction has provided conflicting advice, or if VICC cannot answer the query.


Query Title:
Coding of clinical diagnosis from test reports

Query Text:
We are seeking clarification on using the indications for coding and querying from test reports such as a BMAT or Myelogram when no other information is available.

VICC #2582 Coding of clinical diagnosis from test results, now retired, previously allowed the coding of indications on test results when a diagnosis has been unable to be obtained from the clinician. 

VICC #3086 Principal diagnosis for bone marrow biopsy also seems to imply that the indication and histology conclusion on a BMAT report can be used to support coding.

We note ACCD TN1028 Coding from findings on medical imaging (radiology) reports states that where clinical advice is unavailable to clarify the significance of a test result or imaging finding and a documented condition, clinical coders should not use the test result to inform code assignment.

We also note that in the Clarification on the application of the Standards for ethical conduct in clinical coding – section Ethical use of the interdisciplinary engagement process for pathology/radiology test results it states that 'documentation issues may be clarified with the clinician'.

Therefore we would like to clarify can the indications of a pathology/radiology test report be used:

1. To generate a documentation query to the clinician to clarify the diagnosis?

2. To assign diagnosis code(s) when a diagnosis has been unable to be obtained from the clinician and the only clinical documentation is on the investigation report?

Response:
VICC advises that the indication/s on a pathology or radiology test report are clinical documentation of why the test was required. The indication/s can be used to assign a diagnosis when a condition/sign/symptom has not been otherwise documented or is unable to be obtained from the clinician. However, the indication may not represent the final diagnosis after study and a documentation query may be required for clarification.


Query Title:
Coding of angiograms with percutaneous heart valve replacement

Query Text:
Can you please clarify when a coronary angiogram code should be assigned when it is performed with a percutaneous heart valve replacement?

We note there that the codes for percutaneous heart valve replacements include cardiac catheterisation as per the includes notes. However we are unsure when we should be assigning a code for a coronary angiogram.

VICC query #3060 Cardiac angiography (December 2015) is a query seeking clarification about coding coronary angiography with stenting and angioplasty, referencing ACCD advice which states that 'When a coronary angiography is performed in addition to a catheter based cardiac intervention i.e. not for access alone, assign 38215-00 Coronary angiography. 

The code also when performed instruction for coronary angiography has been deleted from a number of percutaneous cardiac procedures to avoid confusion with catheter access for percutaneous procedures, which should not be assigned a separate code. If a diagnostic coronary angiography (classified to block [668]) is performed in conjunction with these procedures, then an additional code from block [668] is assigned and an instructional note is unnecessary'.

The ACCD coding rule Q2908 Catheter based cardiac intervention with angiogram published 15 Sept 2014 states that 'When a coronary angiography is performed as an additional procedure during a catheter based cardiac intervention, assign 38215-00 Coronary angiography'.

Some of our coders interpret this advice to mean that we can assign a code for coronary angiogram whenever it is performed with percutaneous heart valve replacement. Other coders argue that this is not the intent and that a code is only assigned when it’s clear that the angiogram is diagnostic. 

1. Can you please clarify, is it necessary that a coronary angiogram is for ‘diagnostic’ purposes before a code can be assigned when performed during the same operative episode as a percutaneous heart valve replacement?

2. And if so, can you please clarify how we can determine if the angiogram is diagnostic? For example, is commentary on the Operation Record about the patency of the coronary arteries sufficient evidence of diagnostic coronary angiography or is the term ‘diagnostic’ required?

Response:
VICC advises that although cardiac catheterisation is inherent in catheter based cardiac interventions (e.g. percutaneous heart valve replacement), coronary angiography is considered an additional procedure regardless of the reason it is being performed.

This is in accordance with ACCD Coding Rules Q2908 Catheter based cardiac intervention with angiogram published 15 Sept 2014, in particular the paragraph: "When a coronary angiography is performed as an additional procedure during a catheter based cardiac intervention, assign 38215-00 Coronary angiography".


Query Title:
Lower respiratory tract infection vs pneumonia

Query Text:
Principal Diagnosis on Discharge Summary 'LRTI'

Admission date: 16/1
Separation date: 22/1

Parainfluenza virus detected on NPA PCR 17/1.

Progress notes 18/1: 'Parainfluenza Type 3 – NPA.
Initially treated community acquired pneumonia with Benzylpenicllin / Doxycycline. Benzylpenicillin ceased 17/1- remains on Doxycycline'.

There is no documentation in the notes that community acquired pneumonia was ruled out, but the last entry in the progress notes on 22/1 states 'viral LRTI. Parainfluenza type 3'.

We note that J22 Unspecified acute lower respiratory infection is a NOS code, and NEC in the Index for some of the entries, so a more specific code should be assigned where possible. 

Can the VICC please clarify where LRTI is documented as Principal Diagnosis which is further specified as pneumonia in the notes, should this be coded as J22 Unspecified acute lower respiratory infection or pneumonia (as further specificity of the type of lower respiratory tract infection)?

Response:
VICC advises that for the scenario cited, lower respiratory tract infection (LRTI) should be coded as the principal diagnosis. This is because it is the documented principal diagnosis, and it is supported by the clinical documentation in the progress notes. Whilst there is documentation of initial treatment for community acquired pneumonia, VICC has not assumed that this is more specific documentation of 'LRTI', as the initial treatment may have been the same regardless of LRTI or pneumonia.

VICC advises that in circumstances where there is sufficient evidence that the documentation of LRTI versus pneumonia was ambiguous, conflicting or incomplete, it would be appropriate to generate a query to the clinician for the correct principal diagnosis.


Query Title:
Urinary retention due to caesarean section in the delivery episode

Query Text:
Can VICC please advise the correct Index pathway to follow for urinary retention due to caesarean section in the delivery episode?

Option 1: Index Complications, puerperal, postpartum – See Puerperal. Puerperal, complications, specified NEC 

Codes
O90.8 Other complications of the puerperium not elsewhere 
N99.89 other intraoperative and postprocedural disorders of the genitourinary system 
R33 urinary retention

Complication(s)
- puerperal, postpartum — see Puerperal 

Puerperal, puerperium
- complications O90.9
- - specified NEC O90.8

Option 2: Index Pregnancy, complicated by, conditions in N00-N99 O26.81 and also Pregnancy complicated by conditions in R00-R99 O99.8.

Codes
O26.81 Kidney disorders in pregnancy, childbirth and the puerperium
N99.89 Other intraoperative and postprocedural disorders of the genitourinary system 
O99.8 Other specified diseases and conditions in pregnancy, childbirth and the puerperium
R33 urinary retention

Pregnancy
-complicated by
- - conditions in 
Note: The following subterms (code ranges) refer to codes for nonobstetric conditions complicating pregnancy 
— see also ACS 1521 Conditions and injuries in pregnancy
- - - N00–N99 NEC O26.81
- - - R00–R99 O99.8

Response:
VICC advises that for urinary retention due to caesarean section in the delivery episode, assign codes as per option 1:
O90.8 Other complications of the puerperium, not elsewhere classified
N99.89 Other intraoperative and postprocedural disorder of the genitourinary system 
R33 Retention of urine
Y83.8 Other surgical procedures
Y92.24 Health service area, this facility

VICC considers that the correct Index lead term to follow is Puerperal, puerperium/complications/specified NEC, rather than Index lead term Pregnancy/complicated by/ because urinary retention occurred after delivery and was documented as a complication of the caesarean section. N99.89, R33 and external cause codes can be assigned to fully classify the clinical concept of urinary retention due to caesarean section.


Query Text:
Could you please clarify what is the correct code to assign when there is documentation of low iron?

Should the Index under Abnormal, blood level (of), iron be followed and code R79.0 Abnormal level of blood mineral assigned? Or can the Index under Deficiency, iron be followed to assign E61.1 Iron deficiency?

Response:
VICC acknowledges the difficulty in assigning a code for documentation of low iron, without further specification, as there are three different Index lead terms that could potentially be followed, each resulting in a different code:
Deficiency/iron (E61.1)
Disorder/metabolism/iron (E83.1)
Abnormal/blood level/iron (R79.0)

VICC advises to follow the principle of ACCD Coding Rules TN1035 Low magnesium (published 15 December 2015), which is that it is not appropriate to follow Index lead term Deficiency/iron if there is no documentation of iron deficiency, nor is it appropriate to assign R79.0 Abnormal level of blood mineral as R79.0 excludes both disorders of mineral metabolism (E83.-) and nutritional mineral deficiency (E58-E61).

Therefore, for documentation of low iron, VICC advises to firstly clarify the documentation of low iron with the clinician if possible, to obtain a more specific diagnostic term. If clarification is not possible, assign E83.1 Disorders of iron metabolism.


Query Title:
Newborn conditions and Vic 0002 Additional diagnoses

Query Text:
VICC Query #3145 ‘Newborn conditions and ACS 0002 Additional Diagnoses’ states that it is appropriate to assign a code for clicking hips in a newborn when the only management is the organisation of an outpatient ultrasound.

In view of the release of Vic 0002 Additional diagnoses could the Committee please advise if VICC #3145 is still applicable?

We also note that NCCC Q&A, Q2639 titled ACS 0002 Additional diagnoses and newborn conditions (2 of 2) published June 2011 which stated that a code should be assigned for a condition that is referred for an external opinion was retired as of June 2017.

Response:
VICC advises that query #3145 Newborn conditions and ACS 0002 Additional Diagnoses was a Ninth Edition query and is superseded by the addition of the Incidental findings and conditions section and updates to the Abnormalities noted on examination of the newborn section of ACS 0002 Additional diagnoses for Tenth Edition.

As per ACS 0002 Additional diagnoses, findings or conditions that are incidental to the episode of care and are only flagged for follow-up or referral post discharge do not qualify for code assignment (see example 6 of ACS 0002 Additional diagnoses Tenth Edition, now example 28 in ACS 0002 Additional diagnoses Eleventh Edition regarding talipes noted in newborn).

For separations up until 30 June 2019, if a condition does not meet ACS 0002 Additional diagnoses, then it cannot meet Vic 0002 Additional diagnoses. See Q26 in Other additional diagnoses questions section of the Vic 0002 Additional Diagnoses education workshops questions and answers document and the ACS 0002 Additional diagnoses and Vic 0002 Additional diagnoses and specialty ACS flowchart. Please note that for separations from 1 July 2019, Vic 0002 Additional diagnoses is no longer applicable.


Query Title:
ACS 1904 - terms that indicate a procedural complication

Query Text:
ACS 1904 Procedural Complications states that the terms 'secondary to' or 'due to' infer a causal relationship between a condition and a procedure in contrast to terms such as 'postop', 'following' or 'associated with'.

Can the VICC please clarify whether the term ‘complicated by’ also infers a causal relationship and how ACS 1904 should be applied in the following scenarios?

Scenario 1: Progress notes state 'femoral hernia repair complicated by ileus.'

Scenario 2: Progress notes state 'total hip replacement complicated by acute myocardial infarction on day 2 post op.'

Response:
VICC considers that the documentation of ‘complicated by’ in these scenarios is not clear as to whether the medical condition was a complication of the procedure (i.e. a direct causal relationship) or arose following the procedure.  

Acute myocardial infarction and ileus are examples of medical conditions listed in the Intraoperative/postoperative medical conditions section of ACS 1904 Procedural complications, and may have a multifactorial cause, therefore the causal relationship must be explicitly documented (see Examples 1, 2, 4 and 5).

Therefore, VICC advises to assign I21.9 Acute myocardial infarction, unspecified and K56.7 Ileus, unspecified for these scenarios. This does not preclude generation of a query to the clinician to clarify whether the medical condition was a complication due to or secondary to the procedure.


Query Title:
Hernia or bowel obstruction with adhesions due to previous surgery

Query Text:
Scenario one: Patient admitted for repair of incarcerated ventral hernia with adhesions due to previous surgery.

Scenario two: Patient admitted with adhesive small bowel obstruction. Adhesions documented as due to multiple previous intra-abdominal operations.

1. Is it appropriate to assign K91.89 Other intraoperative and postprocedural disorders of digestive system, not elsewhere classified to indicate that the adhesions were due to previous surgery?

2. If so, should K91.89 be sequenced as principal or an additional diagnosis as both the hernia and bowel obstruction codes include the concept of adhesions but the adhesions themselves did not occasion the episode of care?

We note K91.89 is sequenced as principal diagnosis in ACS 1904 Procedural complications example 1, however in this example the adhesional small bowel obstruction has been documented as secondary to the surgery whereas in our example only the adhesions have been documented as due to the surgery.

3. Would the advice be the same for other types of hernias regardless of whether they have the note 'Includes: that with adhesions'?

Response:
In answer to the first question, VICC advises that it is appropriate to assign K91.89 Other intraoperative and postprocedural disorders of digestive system, not elsewhere classified following Index entry Adhesions/postprocedural/peritoneal NEC when adhesions are documented as due to previous surgery.

In answer to the second question regarding sequencing for your scenarios; as the classification includes adhesions in the condition codes for ventral hernia with obstruction and adhesive bowel obstruction, VICC advises to assign K91.89 as principal diagnosis.

Therefore, for scenario 1, assign:
K91.89 Other intraoperative and postprocedural disorders of digestive system, not elsewhere classified
K43.6 Other and unspecified ventral hernia with obstruction, without gangrene
(+ appropriate external cause codes)

For scenario 2, assign:
K91.89 Other intraoperative and postprocedural disorders of digestive system, not elsewhere classified
K56.5 Intestinal adhesions [bands] with obstruction
(+ appropriate external cause codes)

In answer to the third question, if a patient were admitted for repair of another type of hernia with adhesions due to surgery, the principal diagnosis would depend on whether the hernia code includes adhesions. If the hernia code does not include adhesions, and the adhesions meet ACS 0002 Additional diagnoses and ACS 1904 Procedural complications, assign a code for the hernia as principal diagnosis, with K91.89 Other intraoperative and postprocedural disorders of digestive system, not elsewhere classified followed by a code for the adhesions as additional diagnoses.


Query Title:
Coding and VAED reporting of ventilatory support in contract care episodes

Query Text:
Patient had a surgical procedure in Hospital A and was transferred to Hospital B ICU for post-operative management. Patient was intubated for general anaesthesia and ventilatory support was provided during surgery as per normal. In Hospital B ICU the patient was extubated after 9 hours with no further ventilation support required; the patient was then transferred back to Hospital A. 

Could VICC please advise regarding the following coding questions: 

a) Should Hospital B code the MV (even though post-operative MV was well under 24 hours) as patient was admitted already intubated?

b) Should Hospital B omit coding as per post-surgical MV guidelines (as documentation clearly indicates patient intubated for general anaesthesia albeit in another facility/Hospital A)?

Could VICC please confirm/deny regarding the following VAED reporting assumptions: 

1) Hospital A – to report total hours in ICU and MV hours whilst in ICU

2) Hospital B – to report total hours in ICU and MV hours whilst in ICU

*Please note, I have attempted to source information surrounding these issues in the following publications:

Coding and VAED reporting of ventilatory support (VICC feature article)
Clarification of contracted procedures coding and flagging (VICC feature article 2007)
VAED manual 2018-2019
DHHS Policy and Funding Guidelines 2018

Response:
VICC advises that as per ACS 1006 Ventilatory support , Hospital B should assign 13882-00 [569] Management of continuous ventilatory support, ≤ 24 hours as the patient was admitted intubated and ventilated. Hospital A should not assign a code for mechanical ventilation as it did not continue after surgery for more than 24 hours (unless there is a contracted service arrangement, see last paragraph). As Hospital B did not perform surgery, the duration of CVS is calculated from time of admission to Hospital B.

In answer to the VAED reporting questions, if the patient went to ICU in Hospital A after surgery and prior to transfer to Hospital B, then Hospital A should report (but not code) the appropriate number of hours ventilated in ICU and the total hours in ICU. Hospital B should report (and code) the appropriate number of hours ventilated in ICU and the total hours in ICU.

If there is a contracted service arrangement between hospital A and B, refer to Duration of Mechanical Ventilation in ICU in Section 3 – Data definitions, VAED manual, which states: "A patient who receives MV in an ICU in Hospital B during a contracted service episode has the duration of that MV reported by Hospital B; Hospital A also reports the MV hours received in Hospital B in addition to any MV hours the patient received in an ICU at Hospital A".


Query Text:
Could VICC please advise the correct diagnosis code to assign for documentation of dentofacial deformity without further specification? We commonly see this diagnosis in the context of jaw surgeries such as Le Fort and BSSOs. There is no specific pathway for Deformity/dentofacial. Is it appropriate to code this as dentofacial anomaly?

Research indicates that dentofacial deformities are conditions where the upper or lower jaws are out of proportion with the rest of the face and head. 

Possible Index pathways which have been considered include:

Deformity/ jaw (acquired) (congenital) K07.9
Deformity/head (acquired) M95.2 – Note M95 excludes dentofacial anomalies. 
Anomaly/dentofacial K07.9

Search Details

https://www.nuh.com.sg/udc/patients-and-visitors/diseases-and-conditions/jaw/dentofacial-deformity.html
https://www.texaschildrens.org/health/dentofacial-deformity

Response:
VICC research indicates that the clinical terminology of ‘dentofacial deformity’ is an umbrella term referring to an imbalance of the position, size, shape, or orientation of the bones that comprise the upper and lower jaws, requiring corrective oral surgery.

If dentofacial deformity is the only clinical term documented, VICC advises that it is appropriate to follow Index lead term Anomaly/dentofacial to assign K07.9 Dentofacial anomaly, unspecified.

VICC is aware that a public submission (reference number P346) has been sent to ACCD requesting an appropriate index entry for the term ‘dentofacial deformity’.


Query Text:
Our service wishes to begin performing insertion of a ventricular cardiac support/assist device named Impella. The Impella device is a microaxial heart pump that acts as mechanical circulatory support in patients in hemodynamic compromise. It is most commonly used in high-risk patients in cardiogenic shock who may also have incurred an acute AMI or other cardiac insult, or for treatment of pulmonary oedema in patients on ECMO. It works by pulling blood from the left ventricle through the device and expelling it from the catheter into the ascending aorta.

Technically Impella operates as an LVAD (Left Ventricular Assist Device), but is a very different device and is peformed via a less invasive approach. It is inserted percutaneously, usually via the femoral artery, into the ascending aorta and across the valve into the left ventricle. The insertion is usually performed in a cardiac cath lab rather than an OR and cardiopulmonary bypass is not required. In the US these devices are sometimes referred to as pVADs (percutaneous). The risks associated with this percutaneous procedure are less than those seen with surgical VAD insertions. 

The patients that will be considered appropriate Impella insertion will be a combination of elective and emergency presentations. The anticipated LOS would be greater than 5 days and the patient would require admission to ICU whilst the device is in place. Patients may or may not also receive continuous mechanical ventilation and ECMO within the Impella insertion episode. PCI may also be performed.

It is anticipated that the use of this device in favour of more invasive support methods may become more commonplace in the future. To date, 17 of these devices have been inserted in Queensland and is the subject of an ACCD ACHI Public Submission (Ref. No. P391).

Based on this information and further clinical input, our suggested codes for Impella insertion are:

38615-00 [608] Insertion of Left Ventricular Assist Device (LVAD)
• Lead Term – Insertion, device, ventricular assist, left OR Insertion, ventricular assist device, left
• Impella insertion is a technically and financially vastly different procedure to current typical VAD insertion

38456-14 [615] Other intrathoracic procedures on ventricle of heart without cardiopulmonary bypass
• Lead Term – Procedure, ventricle, heart (intrathoracic) (without cardiopulmonary bypass), NEC
• Implies an open procedure (intrathoracic), though intrathoracic is a non-essential modifier
• There is a code at the atrial rubric, 96221-00 [606] Percutaneous intrathroacic procedures on atrium, NEC, but no similar closed/percutaneous option for the ventricle exists

38362-00 [682] Percutaneous insertion of intra-aortic balloon pump
• Lead Term – Insertion, pump, balloon, intra-aortic, percutaneous
• Not intra-aortic, not a balloon, does not reflect device inserted into ventricle

90225-01 [572] Extracorporeal membrane oxygenation (ECMO)
• Lead Term – No Lead Term but Impella considered another type of venoarterial circulation support (ECMO)

Search Details:

http://www.abiomed.com/impella/impella-25

https://en.wikipedia.org/wiki/Impella

https://www.accd.net.au/Clip/UserSubmissionDetails.aspx?refId=2818

https://www.cathlabdigest.com/article/Impella-50-Brief-Overview

http://www.scancrit.com/2013/07/15/ecmo-impella/

Response:
VICC agrees with your research that the Impella is a catheter-mounted microaxial rotary blood pump designed for rapid percutaneous insertion to allow for temporary LV support and that there are different types of Impella ventricular support devices used for different indications.

VICC advises if the insertion of an Impella ventricular support device is the only procedure performed then 38615-00 [608] Insertion of Left Ventricular Assist Device (LVAD) is the most appropriate code to assign, acknowledging that the code is intended for use for implantable devices (and reflected in the DRG weight).

However where the device is used temporarily in conjunction with another procedure during the same operative visit, such as during high-risk percutaneous coronary interventions (PCI), then it should be considered a procedural component and not coded.


Query Text:
Could you please clarify whether ‘purulent exudate’ or ‘purulent wound’ at a post-operative wound site with commencement of antibiotics is coded to T81.4 Wound infection following a procedure, not elsewhere classified without clinician documentation of ‘infection’?

ACS 1904 Procedural complications, Care beyond routine postoperative care, dot point 4 states that commencement of antibiotics e.g. for purulent (pussy) exudate or discharge can be assigned as a procedural complication. 

ACS 1904 Procedural complications, Procedural wound infection defines a wound infection in a surgical wound as one from which purulent material drains or is obtained. 

ACCD Ref No Q2804 Wound ooze (published December 2014 and retired June 2017) stated that post-operative wound ooze may refer to purulent (pussy) exudate – a yellow, grey or green odiferous discharge – and indicates infection.

Response:
VICC advises that documentation of ‘purulent exudate’ or ‘purulent wound’ at a post-operative wound site with commencement of antibiotics cannot be coded to T81.4 Wound infection following a procedure, not elsewhere classified unless wound infection, or one of the other Index lead terms for this code is specifically documented.

Dot point 4 of ACS 1904 Procedural complications/Care beyond routine postoperative care indicates that commencement of antibiotics for a condition is an example of care or management that is significantly beyond routine. VICC does not consider that this is a directive of how to code purulent exudate .

ACS 1904 Procedural complications/Postprocedural wound infection definition does state that a wound infection in a surgical wound is one from which purulent material drains or is obtained, however definitional information in an ACS cannot be used for classification purposes. This was stated in TN1248 Tenth Edition FAQs Part 1: Use of definitional information. Although these FAQs were retired by ACCD on 30 June 2019 (as they were Tenth Edition FAQs), VICC considers this general classification principle should be followed.


Query Text:
Can you please provide advice on the application of ACS 0010 Clinical documentation and general abstraction guidelines in the following example:

A patient presents with gallstones and has a laparoscopic cholecystectomy - histopathology confirms gallstones with chronic cholecystitis.

Can the code K80.10 Calculus of gallbladder with other cholecystitis be assigned, as the cholecystitis is providing further specificity to an already documented condition (gallstones)? We note that ACS 0010 for ICD-10-AM Eleventh Edition, dot point 3 of Example 10 states to assign K80.10 where documentation shows cholecystitis and ultrasound confirms the presence of gallstones.

Response:
VICC considers that it is appropriate to assign K80.10 Calculus of gallbladder with other cholecystitis, without mention of obstruction when gallstones are documented and there is a histological finding of chronic cholecystitis, as this is an example of where a pathological result is adding specificity to an already documented condition which meets the criteria for coding.

This is in accordance with Example 10 of ACS 0010 Clinical documentation and general abstraction guidelines which states to code K80.10 Calculus of gallbladder with other cholecystitis, without mention of obstruction where documentation shows cholecystitis and ultrasound confirms the presence of gallstones. This example is used to demonstrate that the ultrasound result has added specificity to an already documented condition that meets the criteria for a principal or an additional diagnosis.

VICC notes that the ACCD coding advice TN1028 Coding from findings on medical imaging (radiological) reports has been retired as of 30 June 2019.


Query Title:
Assignment of low birth weight and feeding problems in newborns

Query Text:
Could the committee please advise the correct codes to assign in the following scenario?

A premature infant (born at 27 weeks: birth weight 700g) was transferred from another hospital at 30 days of age for feeding establishment. The baby initially received feeding via a nasogastric tube and was eventually discharged home on full bottle feeds.

We would assign P07.22 Extreme immaturity, 24 or more completed weeks but less than 28 completed weeks in accordance with ACS 1605 and Coding Rule Q2957 Prematurity and documentation of gestational age (updated), however, we are unsure if we should assign a code for the low birth weight. Coding Rule Q2648 Low birth weight and prematurity states that a code for low birth weight should only be assigned in a subsequent episode of care it if meets ACS 0002 Additional diagnoses. There is no plan of care for LBW as such documented in the history, only a feeding plan for ‘feeds’ and ‘feeding establishment.’ 

We also would like advice as to whether P92.9 Feeding problem of newborn, unspecified is appropriate to assign as the baby was admitted to establish feeds with a feeding plan clearly documented, however no feeding problem as such was listed.

Response:
VICC advises that establishment of feeds and transition from nasogastric tube to oral feeding is routine in the care of premature infants. 

For Tenth Edition, this is supported by ACCD Coding Rules Q2648 Low birth weight and prematurity which states that “low birth weight is usually not significant in subsequent neonatal admissions and therefore should not be routinely assigned. A code for low birth weight should only be assigned in a subsequent episode of care if it meets ACS 0002 Additional diagnoses”. Therefore in order to code low birth weight in episodes subsequent to the birth episode, documentation would need to indicate that the low birth weight was significant in terms of requiring more than routine care. This may be evidenced by specific documentation of the low birth weight with an associated specific plan of care. VICC also notes that ACCD Coding Rules Q3336 Assignment of additional diagnosis codes for prematurity states to “assign a code from subcategories P07.2 Extreme immaturity or P07.3 Other preterm infants for: … episodes of care subsequent to the birth episode of care, when immaturity/prematurity meets the criteria in ACS 0002 Additional diagnoses”. Therefore, for your scenario, both prematurity and low birth weight would need to meet ACS 0002 Additional diagnoses.

For Eleventh Edition, VICC notes that Q2648 Low birth weight and prematurity has been retired as of 30 June 2019, however Q3336 Assignment of additional diagnosis codes for prematurity is still current, and that "Code also low birth weight (P07.0-, P07.1-), if known" has been added at P07.2- Extreme immaturity and P07.3- Other and unspecified preterm infants in the Tabular list. VICC advises that for episodes subsequent to the birth episode, where prematurity meets the criteria in ACS 0002 Additional diagnoses, that a code for low birth weight should also be assigned.

VICC also advises that it is only appropriate to assign P92.- Feeding problem of newborn if a feeding problem has been documented and meets the criteria in ACS 0002 Additional diagnoses.


Query Title:
Pyelonephritis with renal calculus and hydronephrosis with an infection

Query Text:
Could VICC please confirm the correct code/s to assign for Pyelonephritis with renal calculus and hydronephrosis with an infection?

ACCD advice TN200 Pyelonephritis with renal calculus and hydronephrosis retired 30th June 2017 suggested to code both N13.2 Hydronephrosis with renal and ureteral calculus obstruction and N13.6 Pyonephrosis when an infection is present. 

Please also refer to the excludes note at N13.0 – N13.5 ‘Excludes: with infection (N13.6)’ that has been on these codes since First Edition.

Search Details:
ACCD Coding Rule TN200 (Retired 30 June 2017)
VICC 2263
Tabular List

Response:
For documentation of pyelonephritis with renal calculus and hydronephrosis with infection, VICC advises to firstly follow the ICD-10-AM Alphabetic Index lead term Pyelonephritis/with calculus/with hydronephrosis. This leads to N13.2 Hydronephrosis with renal and ureteral calculus obstruction. Then follow the Excludes note ‘with infection’ to assign N13.6 Pyonephrosis. The same code (N13.6) is reached if Index lead terms of calculus or hydronephrosis are used.  

VICC notes that pyelonephritis is an inclusion term for codes in N10–N16 Renal tubulo-interstitial diseases and an additional code should not be assigned. Therefore N13.6 Pyonephrosis is the only code to assign.


Query Title:
Coding of acute appendicitis with serositis

Query Text:
Please advise on the correct diagnosis code assignment for the following scenario:

Patient admitted for an appendicectomy due to appendicitis. Histopathology states: Florid acute appendicitis and serositis.

Which of the following options is correct?

1. K35.8 Acute appendicitis, other and unspecified
2. K35.3 Acute appendicitis with localised peritonitis 
3. K35.8 Acute appendicitis, other and unspecified, and send a clinician query to confirm whether documentation of serositis indicates that patient has peritonitis.

Response:
VICC notes that serositis in the histopathology report may indicate that the surface (serosa) of the appendix was inflamed, rather than indicating a clinical diagnosis of peritonitis.

For the scenario cited, VICC advises to assign K35.8 Acute appendicitis, other and unspecified because the Index entries at Appendicitis do not contain ‘with serositis’. 

To assign a code for serositis, serositis would need to meet ACS 0002 Additional diagnoses and be documented as ‘multiple’ or ‘peritoneal’ serositis as these terms are essential modifiers at the lead term Serositis.

Appendicitis with serositis would need to be clarified with the clinician as to whether the serositis was localised or generalised peritonitis in order to assign K35.2 Acute appendicitis with generalised peritonitis or K35.3 Acute appendicitis with localised peritonitis.


Query Title:
Computer Navigated Total Knee Replacement

Query Text:
Could you please advise us on which code(s), if any, should be assigned for a computer navigated total knee replacement? 

Please find attached an example operation report, where a computer navigated total knee replacement has been performed.
“A computer navigated total knee replacement is a tool to guide the surgeon and improve the outcome of the surgery. It provides the surgeon with real time 3-D images of the mapped patient’s knee and the surgical instruments during surgery. The data for the images is provided by the infrared sensors fixed to the bones of the knee and the surgical instruments. Their position is tracked by an infrared camera placed above the surgical table connected to the computer. The computer generates real time images with help of the software it guides the surgeon to precisely resurface and cut the bones to the knee and fix the implant precisely and accurately.”

How can our organisation capture the difference between a regular total knee replacement?

Response:
VICC advises that as the computer is assisting to capture images during the procedure, a code should not be assigned. The ACHI Index entry Image assisted interventions instructs to code the specific procedure performed and block [1923 ] Technology-assisted interventions excludes computer assisted image guidance.

However, this does not prevent a hospital from assigning 96234-00 [1923] Technology-assisted intervention, not elsewhere classified for local use, but transmission of the code to the VAED must be suppressed.

This differs to robotic assisted interventions for which ACS 0053 Robotic-assisted intervention should be followed.


Query Title:
Diabetes with unspecified renal failure or unspecified renal impairment

Query Text:
Can you please advise us on how to code diabetes with unspecified renal failure or unspecified renal impairment when further information cannot be obtained from a clinician?

The following are two retired VICC queries: VICC query #2423 Diabetes with unspecified renal failure and unspecified kidney impairment’ and VICC query #2132 Renal failure NOS with diabetes. These queries state when unspecified kidney failure or unspecified kidney impairment is documented in a patient with diabetes, it is correct to default to 'chronic' for the kidney disease or kidney impairment.

Can this advice still be followed as there has been no further advice published? 

If we are able to assign a code for diabetes with chronic kidney disease for these scenarios, are we able to then assign a supplementary code for the CKD (If the renal impairment doesn’t meet additional diagnosis criteria)? ACS1438 Chronic Kidney Disease, states we can assign a stage based on eGFR from a pathology result. This would be following the same logic as ‘Obesity and BMI’ ACCD Tenth Edition FAQ Part 1 where BMI can be used to assign overweight or obesity.


Search Details
VICC 2423- Diabetes with unspecified renal failure and unspecified kidney impairment
VICC 2132- Renal failure NOS with diabetes

Response:
In answer to the first question, VICC advises that diabetes with unspecified kidney failure cannot be classified as diabetes with kidney complication because the Index lead term Diabetes/with/failure/kidney does not have a default code for when acute/chronic/end-stage kidney failure is not documented.

In answer to the second question, VICC considers that the advice in VICC queries #2423 and #2132 was based on old NCCH advice (Coding Matters Volume 13 no 2), prior to the revisions of ACS 0401 Diabetes mellitus and intermittent hyperglycaemia through Sixth and Seventh Editions. As these revisions did not result in any change to the indexing of diabetes with kidney failure, VICC advises to follow the Alphabetic Index.

In answer to the third question, VICC advises that as per ACS 1438 Chronic kidney disease, classification section, eGFR levels can only be used to assign the stage of CKD, provided that CKD is already documented, not to interpret that a patient has chronic kidney disease. Similarly, the supplementary code U87.1 Chronic kidney disease, stage 3 to 5 should only be assigned if CKD is documented, and eGFR or documentation indicate the stage is 3, 4 or 5.


Query Text:
A patient is admitted for a BKA due to critical limb ischaemia from PVD. After the surgery they have an extended LOS due to 'phantom pain' with a lot of day to day management by the Acute Pain Service. They note 'persisting phantom limb pain since operation'.
1) How do we code 'phantom limb pain' in the absence of 'syndrome' being documented?
2) If we do get correct documentation and can use G54.6 - do we code it as a procedural complication if linked to the surgery, or is this inherent in the code?

Response:
According to the Australian Pain Management Association, phantom limb pain is pain in the limb which is missing, and can occur with the elimination of other body parts such as a breast or tongue. Phantom limb pain begins soon after the amputation and can be continuous or intermittent. The pain is generally felt in the furthest part of the amputated limb (feet, hands) and is often described as:  stabbing, burning, squeezing or being crushed. It can vary in its intensity which may be slight to excruciating.
https://www.painmanagement.org.au/using-joomla/extensions/components/content-component/article-category-list/190-phantom-limb-pain.html

VICC acknowledges that the ICD-10-AM classification is not in keeping with the changing clinical classification of phantom limb pain, because the codes G54.6 Phantom limb syndrome with pain and G54.7 Phantom limb syndrome without pain can only be reached via the Index lead term Phantom limb syndrome, or Syndrome/phantom limb. Therefore VICC advises to seek clinical documentation of ‘syndrome’ in order to assign the appropriate code.

If the clinical documentation of phantom limb syndrome cannot be obtained, VICC advises to follow the Index lead term Pain to classify pain to the phantom site, along with an appropriate code for acquired absence of the amputated body part. For example, for documentation of phantom limb pain of foot after below knee amputation of leg, assign:

M79.67 Pain in limb, ankle and foot
Z89.5 Acquired absence of leg at or below knee

VICC does not consider that it is correct to code phantom limb pain as a postprocedural complication as it is a condition only associated with amputation.

You may wish to submit a public submission for the classification of phantom limb pain.

Note: This query is superseded by IHPA Coding Rule Q3566 Phantom limb pain published 21 September 2020 for implementation 1 October 2020.


Query Text:
Can the Committee please advise the correct procedure code to assign for excision of a cyst of the skin of the breast?

Response:
As your documentation is excision of a cyst of the skin of the breast, VICC advises to follow the ACHI Index pathway Excision/cyst/skin/benign or malignant - see Excision/lesion(s)/skin and subcutaneous tissue/specified site.

At Excision/lesion/skin and subcutaneous tissue/specified site NEC there is no essential modifier for breast, therefore assign the default code 31205-00 [1620] Excision of lesion of skin and subcutaneous tissue of other site.


Query Text:
This patient presented with one week of intermittent vertigo symptoms that occurred when moving her head or eyes. There was no nystagmus and CT brain was clear. She was diagnosed with vestibular neuritis.

There is no index entry for vestibular neuritis. However, there is an ICD-10-AM code for vestibular neuronitis: H81.2. 

Our research has shown that vestibular neuritis and vestibular neuronitis are the same condition.
https://www.eyeandear.org.au/icms_docs/289536_Vestibular_neuritis_and_labyrinthitis.pdf 

Can the committee please advise what code should be assigned for vestibular neuritis?

Response:
VICC agrees with your research that vestibular neuritis and vestibular neuronitis are different terms for the same condition. This is supported by the Royal Victorian Eye and Ear Hospital patient information page which states:
“Vestibular neuritis (or vestibular neuronitis) and labyrinthitis are disorders that result in inflammation of the inner ear and/or the nerve connecting the inner ear to the brain”. https://www.eyeandear.org.au/page/Patients/Patient_information/Balance_Disorders/What_are_some_types_of_balance_disorders/Vestibular_neuritis_and_labyrinthitis/ (accessed 21 May 2019)

Therefore, for documentation of either vestibular neuritis or vestibular neuronitis, VICC advises to assign H81.2 Vestibular neuronitis.


Query Text:
VICC query 2776 advised coders to assign R53 Malaise and fatigue for documentation of functional decline. As this advice is retired can I confirm that it can still be applied.

Response:
VICC advises that the advice in query #2776 Functional decline is still applicable and is reproduced below, with an amendment because Z74.1 Need for assistance with personal care is no longer an unacceptable principal diagnosis.

Question:
We have several GEM beds at our hospital. The doctors regularly use 'functional decline' as a principal diagnosis for many of these GEM admissions. Can you please advise me on which code/s to use for this diagnosis? 

Is it acceptable to use Z codes such as Z74.1 Need for assistance with personal care as a principal diagnosis?

Answer:
VICC considers the correct code to assign for documentation of functional decline is R53 Malaise and fatigue following Index lead term Decline (general) (see also Debility) R53.

VICC recommends querying with the clinician if there is an underlying cause for the functional decline if you are in a position to do so. VICC advises there is no restriction on assignment of Z74.1 Need for assistance with personal care as principal diagnosis if documentation supports the use of this code.


Query Text:
Can you please provide instruction on how to code insertion of TraceIT® ?
Our research and clinical advice obtained indicates that this is a hydrogel inserted into the prostatic fossa, often under ultrasound guidance, in preparation for radiotherapy and serves the purpose of both a fiducial marker and SpaceOar. 

Search Details
https://www.spaceoar.com/about-augmenix/traceit/
ACCD Coding Rule: Injection of SpaceOAR® (spacing organs at risk) via TRUS (June 2015), 
retired June 2017 -> ACHI Index 10th edition: Administration/specified site/ periprostatic tissue (SpaceOAR) (spacing organs at risk) 37218-01 [1160].

Response:
VICC agrees with your research that TraceIT® is is a type of injectable hydrogel. This is supported by the SpaceOAR website which states: “TraceIT hydrogel has unique properties and is unlike any other product. Consisting of iodinated polyethylene glycol hydrogel particles, TraceIT hydrogel is easily injectable through small needles and catheters. The iodine content results in CT, CBCT and mammography visibility without artifact, while the high water content makes the hydrogel MRI and ultrasound visible”.
https://www.spaceoar.com/about-augmenix/traceit/ (accessed 21 May 2019)

For administration of TraceIT® hydrogel into the prostatic fossa, follow the ACHI Index lead term Administration/specified site/periprostatic tissue to assign 37218-01 [1160] Administration of agent into prostate. If TraceIT® is administered to another site, follow the appropriate essential modifier for that site.


Query Title:
Diagnosis after discharge/patient request to have information changed

Query Text:
Patient has notified our hospital that after review at a Melbourne hospital, she was told she had not had Non-ST elevation myocardial infarction (NSTEMI) and wanted this deleted from her medical record here. Director of Medical Services and GP have discussed this with the cardiologist and are in agreeance with the patient. The discharge summary principal diagnosis originally read "80F with NSTEMI complicated by large GI bleed". 

It has now been amended to include "(Later reviewed by Dr. XXXXX at X hospital who feels not an infarct)" We have been asked to amend the coding accordingly but as per our coding standards we feel we should code by the condition (which was treated) suspected on transfer. Could you please clarify our position in this case?

Response:
VICC considers that the diagnosis clarification described in this query has resulted from a clinical review of the documentation at the transferring health service, therefore the diagnosis codes should reflect that clarification, that is, the NSTEMI code should not be assigned. 

This is similar to the processes undertaken during retrospective documentation audits that may require amendments to the codes assigned.


Query Title:
Left ventriculograms and aortograms with catheter based cardiac interventions

Query Text:
Can you please clarify should additional procedure codes be assigned when a left ventriculogram or an aortogram are performed with a catheter based cardiac intervention e.g. percutaneous heart valve replacement?

We note there are no includes or excludes notes at the procedure codes for percutaneous replacement, left ventriculogram or aortogram which would preclude us from assigning a procedure code. There are also no ‘code also’ notes to direct us to code these procedures in these cases.


Search Details
Catheter based intervention with angiogram (ACCD, Coding Rules, September 2014)

Response:
VICC advises that whilst the code for percutaneous heart valve replacement includes cardiac catheterisation when performed as the operative approach, additional codes for specific procedures performed in conjunction with cardiac catheterisation should be assigned.

This is in accordance with ACS 0933 Cardiac catheterisation and coronary angiography, classification section which states “assign additional codes if a ventriculogram, aortogram or coronary artery blood flow measurement (fractional flow reserve (FFR)) is performed in conjunction with cardiac catheterisation and/or coronary angiogram”.


Query Text:
I am seeking clarification on how to code admissions where both UTI and urosepsis are documented as in the scenarios below.

Scenario A - Urosepsis documented in every medical entry throughout notes – UTI is recorded as the principal diagnosis on the summary. Patient treated with IV antibiotics and discharged home on oral antibiotics.

Scenario B - Urosepsis documented once in progress notes, all other entries and principal diagnosis on summary state UTI. However, beneath the diagnosis of urosepsis there is a treatment plan which states to continue with IV antibiotics, monitor and for consultant review in pm.

The index entry for urosepsis is as follows:
Urosepsis — see Sepsis AND Infection, infected (opportunistic)/urinary (tract) NEC 

I note also the ACCD advice, Q3096 Urosepsis which states: 
The See reference in the above indexing:
• directs coders to two lead terms, as two codes are assigned to classify urosepsis
• is not a sequencing instruction.
Apply the guidelines in ACS 0001 Principal diagnosis and ACS 0002 Additional diagnoses to determine whether sepsis or urinary tract infection (UTI) is the principal diagnosis for each individual case, based on the clinical documentation.

1) In scenario A, should the index entry of urosepsis be followed to assign a code for both sepsis and UTI? – with UTI as the principal diagnosis as per the summary. 

2) In scenario B, the principal diagnosis is clearly UTI, but should sepsis be assigned as an additional diagnosis? - by following the index entry Urosepsis, as this condition meets ACS 0002 Additional diagnoses.

3) Can the committee please advise the correct sequencing of codes for scenarios A and B?

Response:
VICC considers that despite urosepsis requiring two codes for classification, when UTI is documented as the principal diagnosis, coders should clarify with the clinician whether sepsis (ie generalised sepsis) was present during the episode of care before assigning a code for sepsis, as the final diagnosis of UTI may indicate that sepsis was ruled out.


Query Text:
A patient was admitted to this hospital for a gastroscopy to investigate possible mast cell disorder. The conclusion of the scope was normal gastroscopy. Biopsies were taken and histology showed normal oesophageal and gastric mucosa.

We do not have documentation of systemic tissue, leukaemia, sarcoma or tumour which would permit us to following existing index entries related to mast cells. There is no index entry for mast cell disease unspecified. 

Our research indicates that mast cells are types of white blood cells. We note also the IHPA Coding Rule  Q3154 Mast cell activation syndrome.

Should mast cell disease be coded to D72.8 Other specified disorders of white blood cells? 
(Following the index: Disease, white, blood cells, specified NEC.)

Or should the advice in IHPA Coding Rule Q3154 be followed to assign D89.8 Other specified disorders involving the immune mechanism, not elsewhere classified? (Even though we do not have documentation of activation syndrome).

Response:
VICC notes for the scenario cited, the patient is having a gastroscopy for a possible condition. Therefore, the principal diagnosis selection is guided by ACS 0051 Same-day endoscopy – Diagnostic and ACS 0012 Suspected conditions. 

For the scenario cited, there is insufficient information provided whether ‘possible mast cell disorder’ is the final diagnosis (i.e. whether the normal histology ruled out the diagnosis or it remains a clinical diagnosis as per ACS 0010 Clinical documentation and abstraction guidelines), or whether the symptoms or a Z code should be assigned.

Regarding the appropriate code for mast cell disorder, VICC research indicates that mast cells are part of the immune system (see http://www.mastcellaware.com/mast-cells/about-mast-cells.html). If 'possible mast cell disorder' meets criteria for coding (e.g. after following the above ACS) and in the absence of a specific code or Index entries for mast cell disorder, in accordance with the Conventions Used in the Tabular List of Diseases section titled 'Other and unspecified' codes, VICC considers it is appropriate to follow Index entry Disease, diseased/immune to assign D89.9 Disorder involving the immune mechanism, unspecified.


Query Text:
We had a patient admitted to our hospital for a biopsy of a tongue swelling. The biopsy was performed under GA and histology showed no abnormality.

We are unsure how to code the patient’s presenting symptom of tongue swelling.

Following the lead term of swelling, there is no index entry for tongue; however, there is an index entry for head. As the tongue is located within the head, should we assign R22.0 Localised swelling, mass and lump, head?

Or should we follow the advice located in Conventions Used in the Tabular List of Diseases - Example 32 and follow the index: Disease, tongue, specified NEC and assign K14.8 Other diseases of tongue?

Response:
VICC advises that because there is no Index entry for tongue at the lead term of Swelling, to follow the Conventions Used in the Tabular List of Diseases, section titled 'Other and unspecified' codes, Example 44, and refer to the Alphabetic Index lead term Disease, diseased/tongue/specified NEC to assign K14.8 Other diseases of tongue.


Query Text:
This patient was admitted with a laceration to her left index finger (including the finger nail) that occurred when she accidentally turned on a blender.

The title of the operation report is ‘Debride & repair L) index finger’. The body of the operation report indicates that LA was given, and that excisional debridement of the wound edges was performed. It then documents that the nail plate was removed and that the nail bed was repaired. Jelonet/gauze/crepe dressing was then applied.

I have referred to ACCD Coding Rules Q2880 Debridement of skin with suturing, and VICC query #3073 Debridement and repair, and am uncertain whether this advice applies to this scenario. 

Is the nailbed repair a procedural component of the debridement?

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

Response:
VICC notes that ACCD Coding Rule Q2880 Debridement of skin (retired 30 June 2019) states 'it is not necessary to assign an additional code for suturing of a wound at the same site of the debridement. The suturing of the wound is a component of the procedure'.

For Tenth Edition (separations up until and including 30 June 2019), VICC considers that repair of a nail bed is not the same as suture of wound, and is therefore not necessarily a procedural component, therefore for the scenario cited, an additional code for repair of nail bed can be assigned.

For Eleventh Edition (separations from 1 July 2019), there is a new code for debridement 90665-01 [1628] Debridement of skin and subcutaneous tissue, not elsewhere classified. 

Note that in the Addition to Errata 1, the Excludes note for 'that: with repair (suture) of wound of skin and subcutaneous tissue [1635]' was deleted. Therefore, for the case cited, an additonal code for repair of nail bed can be assigned.


Query Text:
Can you please clarify whether documentation of ‘persistent’ is required to code a fistula that is clearly documented to be a complication of a procedure? 

We note that modifiers in the index pathways for post procedural fistula seem to be inconsistent depending on the lead term followed:

When following the lead term ‘Fistula’ it appears that ‘persistent’ is an essential modifier (EM):
Fistula/postprocedural, persistent NEC/…

When following lead term Complication, ‘persistent’ is a non-essential modifier (NEM):
Complication(s) (from) (of)/ postprocedural/ fistula (persistent) NEC T81.82/specified site — see Fistula/postprocedural, persistent/by site 

In the pathway for ‘Complication’, our understanding is that when the site of the fistula is specified, the cross reference to ‘see Fistula/postprocedural, persistent/by site’ must be followed as per coding convention ‘Cross References’, irrespective of whether ‘persistent’ is documented.

In Tenth Edition, many procedural complication codes are accessed via the lead term ‘Complication’. This in contrast to previous editions where procedural complication codes were typically accessed via the lead term indicating the condition and where ACS 1904 instructed the look up of the lead term for the conditions first. This directive in ACS 1904 Procedural complications was removed in Tenth Edition. 
1. Can you please advise the correct index pathway and codes for post procedural fistulas (meeting criteria in ACS 1904) of the following sites:
a) the chest
b) the abdominal wall
c) an unspecified site 

2. Can you please also include commentary about the requirement for documentation of ‘persistent’ for each of the above examples?

Response:
VICC advises that the steps to assign a code for fistula as a complication of a procedure are:

1. Look up lead term Fistula/postprocedural, persistent NEC T81.82. However, this Index entry does not allow assignment of a code due to the essential modifier 'persistent', which leads a coder to seek alternative lead terms.

2. Follow the Index lead term Complication(s)/postprocedural/fistula (persistent)/specified site - see Fistula/postprocedural, persistent/by site. This Index entry leads the coder back to Fistula/postprocedural, persistent. Follow the essential modifier for the site as applicable because the Index has directed this by use of a 'see' instruction.

Therefore, documentation of 'persistent' is not required to code a fistula that is documented to be a complication of a procedure.

By following the above:

For postprocedural fistula of chest, following the Index lead term Fistula/postprocedure, persistent, chest assign:
J95.89 Other intraoperative and postprocedural disorders of respiratory system, not elsewhere classified
J86.0 Pyothorax with fistula (assign as an additional code to specify the condition by following Index lead term Fistula/chest (wall) J86.0)

To code postprocedural fistula of the abdominal wall, assign:
T81.82 Persistent postprocedural fistula, not elsewhere classified

For Tenth Edition (separations up to and including 30 June 2019), add K63.2 Fistula of intestine by following Index lead term Fistula/abdomen (wall).

For Eleventh Edition (separations from 1 July 2019), as per ACE Coding Rule TN1504 Eleventh Edition ACS 1904 Procedural complications – additional code to add specificity, as the condition is already classified, an additional code for site is not assigned.

To code postprocedural fistula of an unspecified site, assign:
T81.82 Persistent postprocedural fistula, not elsewhere classified

Add external cause codes as appropriate.

You may wish to write a public submission to IHPA through the Australian Classification Exchange (ACE) for future improvements to the indexing of postprocedural fistula.


Query Text:
This patient was admitted with an Achilles tendon rupture.

The title on the operation report is left tendoachilles repair.

In the body of the operation report it is documented that the tear was identified and debrided. It was then repaired with PDS suture using Krakow techinique with augment repair of tendon and paratendon with 2.0 vicryl.

VICC query #3073 Debridement with repair states: “VICC considers that a code for the suture in addition to the debridement code is not required, regardless of the depth of the debridement, as the suture is a component of the procedure. This is in accordance with ACS 0016 General procedure guidelines under section titled 'Procedural components' and ACCD Coding Rules Q2880 titled Debridement of skin with suturing published in March 2015”.

As such, do we apply this advice and only assign a code for the debridement? (Repair being a procedural component of the debridement).

Or should a code for the tendoachilles repair be assigned? (As this is the title of the operation).

Can the committee please advise what procedure code(s) should be assigned for Achilles tendon repair with documentation of debridement?

Response:
VICC notes that, for the operation report supplied with this query, the procedure was documented as "Tendoachilles repair" for a ruptured Achilles tendon, so the Index lead term to follow is Repair/tendon/Achilles'. As debridement of the tendon was documented, and there are no excludes notes in the ACHI Tabular list, VICC considers that an additional code for debridement of tendon can be assigned following the Index lead term Debridement/tendon - see Debridement/soft tissue.

Therefore, the codes assigned for this scenario would be:
49718-01 [1542] Repair of Achilles' tendon
30023-00 [1566] Debridement of soft tissue


Query Text:
Can the Committee please advise the correct coding of Hypercalcaemia?

Index: Hypercalcaemia, hypocalciuric, familial E83.5
E83.5 Disorders of calcium metabolism

Do coders need to see the term “familial” or “hypocalciuric” before assigning the code? It is quite common to ONLY see the term “hypercalcaemia” documented in notes with a management plan.

Index: Calcium/metabolism disorder E83.5
E83.5 Disorders of calcium metabolism

Can we assume a metabolism disorder when we see hypercalcaemia documented with a plan to monitor electrolytes?

Response:
VICC advises that familial hypocalciuric hypercalcaemia is a specific condition, therefore the commas at the Index lead term Hypercalcaemia, hypocalciuric, familial are essential modifiers. 

VICC also notes that E83.5 Disorders of calcium metabolism excludes chondrocalcinosis and hyperparathyroidism and hypercalcaemia is a common symptom of these conditions. VICC therefore advises to clarify the documentation of hypercalcaemia with the clinician if possible, to establish more specificity of the cause of the condition. 

If there is no further specificity, VICC advises to follow the Index entry Disorder/metabolism, metabolic NEC/calcium to assign E83.5 Disorders of calcium metabolism.


