# VICC queries

Query Title:
Intra operative transoesophageal ultrasound of heart (TOE)

Query Text:
Please give us a reason to why there is no index entry in Seventh edition to code `ultrasound of the heart during cardiac surgery (TOE)'.

The code 55130-00 [1942] 2 dimensional real time transoesophageal ultrasound of heart performed during cardiac surgery - is in the tabular but no index pathway.

Response:
This query was originally published in the 2010-11 December VICC queries database release as follows:

VICC will refer this query to the NCCC to clarify whether 55130-00 [1942] 2 dimensional real time transoesophageal ultrasound of heart performed during cardiac surgery should have been removed along with the Index entry, as other intraoperative codes such as intraoperative angiograms and their Index entries have been removed in Seventh Edition.

Please note the Seventh Edition errata 1 June 2010 to ACS 0042 Procedures normally not coded, which states that intraoperative TOE 55130-00 [1942] 2 dimensional real time transoesophageal ultrasound of heart performed during cardiac surgery is no longer coded.

This response is superseded by Ninth edition ACS 0042 Procedures normally not coded point 13 Imaging services.


Query Text:
Could you please give confirmation on how to code metastatic melanoma when the site is C4-C5.

If the index is followed it takes you to codes M8720/6 C79.88 specified site NEC. 

It is believed a more specific site code can be obtained - therefore in this case C79.5 should be the site code.

Can you please confirm if this is correct?

Justification of using the more specific site code is that there is a explanation note under the Melanoma (malignant) coding pathway which states:

Melanoma (malignant) (M8720/3) C43.9 

Note: Except where otherwise indicated, the morphological varieties of melanoma in the list below should be coded by site as for 'Melanoma (malignant)', ie according to the list under 'site classification' below. Internal sites should be coded to malignant neoplasm of those sites.

Also the definition for NEC in the standard is: 
The words 'not elsewhere classified', when used in a three character category title, serve as a warning that certain specified variants of the listed conditions may appear in other parts of the classification.

Therefore, would this overide the rule of coding to follow the coding pathway in the index and provide a more specific site code.

Response:
VICC confirms that the correct code to assign for metastic melanoma at C4-C5 is C79.5 Secondary malignant neoplasm of bone and bone marrow and that coding rules are not overridden to arrive at this code.  

The logic used by VICC is to follow Index entry 'Melanoma (malignant), site classification' (as per the note), where you'll find that there is no entry for bone or vertebra.  So, you go to the entry for specified site NEC which directs you to the neoplasm table under Neoplasm, malignant.  Under this Index entry you look up terms bone or vertebra and assign the secondary malignant code C79.5 Secondary malignant neoplasm of bone and bone marrow.


Query Text:
Intra-operative TOE code has been removed from ACHI index, and instructions in ACS 0042 are to no longer code intra-operative imaging. However, the intra-op TOE code (55130-00 [1942]) still appears in the ACHI tabular, 3M Codefinder pathway and is accepted by IPM as a valid code, therefore must still be contained within the library files.

Should we be assigning it even though it cannot be reached via the index or should it have been deleted?

Search Details: 
No relevant information found as to validity of code.

Response:
This query was originally published in the 2010-11 December VICC queries database release as follows:

VICC advises to not assign 55130-00 [1942] 2 dimensional real time transoesophageal ultrasound of heart performed during cardiac surgery as per the Seventh Edition errata 1 June 2010 to ACS 0042 Procedures normally not coded.

VICC will refer this query to the NCCC to clarify whether 55130-00 [1942] 2 dimensional real time transoesophageal ultrasound of heart performed during cardiac surgery should have been removed along with the Index entry, as other intraoperative codes such as intraoperative angiograms and their Index entries have been removed in Seventh Edition.

This response is superseded by Ninth edition ACS 0042 Procedures normally not coded point 13 Imaging services.


Query Title:
Repair of right cubital fossa pseudoaneurysm

Query Text:
Can you please clarify how to code repair of right cubital fossa pseudoaneurysm. It is performed in the imaging lab under ultrasound guidance. The inpatient notes documented by the medical staff stated 'compression with probe under ultrasound guidance' and the following is a reproduction of the text on the imaging report done during the procedure:

Ultrasound guided compression right cubital fossa pseudoaneurysm 

The right cubital fossa pseudoaneurysm was identified. Compression was applied to occlude the neck. After 25 minutes of compression the pseudoaneurysm no longer filled, therefore thrombin injection was not undertaken. The patient is advised to rest his arm for 2-3 hours to reduce the risk of recanalisation. 

CONCLUSION: 

Successful occlusion of pseudoaneurysm neck with ultrasound guided compression.

According to Coding Matters Volume 12 Number 2 September 2005:

Ultrasound guided compression of a false femoral artery aneurysm
Ultrasound guided compression of a false femoral artery aneurysm, also known as duplex-guided compression therapy, is a relatively new method of treating pseudoaneurysms (Burnett, nd). 'During the procedure, the neck or tract of the pseudoaneurysm is compressed by an ultrasound transducer until there is no blood flow detected in the pathway. Compressions, lasting up to one hour, are usually applied in ten minute time intervals. Colour flow imaging confirms compression of the neck and patency of the artery and vein' (James, 2002). 
Classification
In cases where ultrasound guided compression of a false femoral artery aneurysm is documented, assign 55238-00 [1946] Duplex ultrasound of arteries or bypass grafts in lower limb, unilateral.
According to ACS 0042 Procedures normally not coded, ultrasound is not normally coded. However, in this case, it is integral to the procedure.

Surely this advice is incorrect as the ultrasound transducer is merely the equipment/tool being used to perform the compression (or intervention as it is termed in our record) which is being done under imaging guidance. The CM advice states that it is a 'procedure' not just an ultrasound. 

Therefore shouldn't we code intervention/procedure itself and as there is no specific code in ACHI, we would follow the convention to default to Procedure, artery NEC 90222-00 [720] and not assign the additional code for the ultrasound as we no longer code imaging as it is inherent with such procedures (as per ACS 0042)? 

Search Details: 
Coding Matters 12 (2) Sept 2005
Nothing found in VICC query database

Response:
This query was originally published in the March 2012 VICC queries database as follows:

VICC referred this query to the NCCC who assigned the query a low priority (see the ICD/ACHI/ACS Evaluation Criteria Definitions on the NCCC website at: http://nccc.uow.edu.au/icd10am/submitquery/index.html).  Consequently it was referred back to VICC to answer as an interim measure.

VICC considers the clinical advice in the Coding Matters article is still valid and overrides ACS 0042 Procedures normally not coded, therefore please continue to apply the advice until further advice is published by the NCCC.

Following publication of Coding Q&A June 2012 the VICC response above is superseded by the following advice titled Repair of right cubital fossa pseudoaneurysm:

The NCCC advises that ultrasound guided compression meets the definition of a procedure as per ACS 0016 General Procedure Guidelines, as it: 
carries a procedural risk 
may carry an anaesthetic (sedation) risk 
requires specialised training 

The correct code to assign for repair of cubital fossa pseudoaneurysm using ultrasound guided compression is 92205-00 [1908] Noninvasive therapeutic intervention, not elsewhere classified, following the pathway: 

Procedure 
- therapeutic NEC 92205-00 [1908] 

Where the compression is performed under sedation, an appropriate code for the ultrasound and sedation should also be assigned, as per ACS 0042 Procedures normally not coded. 

This advice supersedes the previous advice published in Coding Matters, September 2005 (Volume 12, Number 2), Ultrasound guided compression of a false femoral artery aneurysm, which will be retired on 30 June 2012. 

The classification of Interventional radiology and ultrasound is outdated in ACHI and has been flagged for review in a future edition.


Query Text:
Please instruct how to code likely systemic BCG-osis post intravesicular BCG therapy for TCC bladder. The patient was commenced on isoniazid, rifampicin and ethambutol (anti TB meds).

Inpatient notes state 'man was admitted with likely systemic BCG reaction...in view of intermittent fevers ... systemic BCGosis considered. Commenced on Anti-TB meds'.

As Immucyst uses live Mycobacterium, should we code to Systemic TB (miliary TB), and if so which code? With additional diagnosis codes for adverse reaction to chemotherapy and POO codes?

The following is a reproduction from MIMS for the BCG therapy (Immucyst) that the patient received for TCC bladder treatment:

ImmuCyst
Generic Ingredients: bcg (nonvaccine)
Use: Immunostimulant. Treatment of primary, relapse bladder carcinoma in situ (CIS) to reduce tumour recurrence frequency (+/- assoc papillary tumour); salvage therapy in CIS following failure of other treatment regimens
Contra: Congenital, acquired immune deficiency; UTI; active TB infection; systemic BCG reaction or history; gross haematuria; febrile illness; less than or equal to 1 wk following traumatic urinary tract catheterisation, biopsy, transurethral resection;
Prec: Not for TB prevention, SC, IV admin; small bladder capacity (incr bladder contracture risk); monitor for toxicity, BCG systemic reaction; assess pretreatment TB purified protein derivative (PPD) reactivity; latex hypersensitivity; immunosuppression (eg myasthenia gravis, patients awaiting organ transplantation); arterial aneurysm; prosthetics; women of childbearing age (ensure adequate contraception); pregnancy, lactation; children (should not use)
Adverse: Tuberculin sensitivity; irritative bladder symptoms; UTI; fever, flu-like symptoms; GI upset; anaemia; leucopenia; renal toxicity; myalgia; arthralgia; arthritis; granulomatous prostatitis; epididymo-orchitis; DIC; systemic BCG infection; allergic reaction, renal abscess (very rare); others, see full PI
Interact: Antimicrobial therapy; antituberculosis drugs; immunosuppressants; radiotherapy; do not mix with other medicines esp vaccines.

Response:
As BCGosis is a reaction to a drug properly administered, VICC considers it should be coded as an adverse effect in accordance with ACS 1902 Adverse effects, which states to assign a code for the manifestation followed by the external cause codes .  

In the absence of a specific code for BCGosis, assign codes for the specific symptoms (for example, fever in the case cited) or T88.7 Unspecified adverse effect of drug or medicament in the absence of any documented symptoms.

VICC considers a code for systemic TB is not appropriate because even though the patient has been treated with anti TB medication, there is no documentation to support a diagnosis of TB.


Query Title:
Coding of clinical diagnosis from test results

Query Text:
Is it appropriate to code from the 'Clinical Diagnosis/Indication'  written by the consultants/registrars on MRI, CT or pathology reports? For example, in the case of an MRI done under general anaesthetic, this may be the only place where a reason for the procedure is recorded (no progress notes). 

At our hospital a discussion took place between pathologists and HIMs/coders where it was decided that this was acceptable, since these comments are recorded by the doctors who have reviewed the patient. Although these are coded less often in seventh edition, there are still cases under anaesthesia that need coding.

Search Details: 
Clinical input from pathologists/consultants/registrars.
VICC queries 2310, 2500.

Response:
Coders should always attempt to obtain a diagnosis from the clinician, however we recognise that this may not always be possible.  

In cases where there is no documented diagnosis after study, a diagnosis has been unable to be obtained from the clinician and the only clinical documentation is the indication on the investigation report, it is appropriate to code the indication.


Query Title:
Chronic obstructive pulmonary disease (COPD) with pneumonia

Query Text:
I refer to ACS 1008 Chronic obstructive pulmonary disease (COPD).  Specifically the paragraph about COPD with pneumonia (copied below).  Given that the diabetes rules have changed it seems strange that this standard was not altered accordingly, as it is directly referred to.   I have had more than one case where COPD has been noted within the medical record, with a principal diagnosis of pneumonia but no evidence to show the COPD was treated/monitored,  just the pneumonia.  My question is, do we still code COPD in the presence of pneumonia, as we don't have to determine a cause and effect relationship?

ACS 1008 Chronic obstructive pulmonary disease (COPD) under heading COPD with pneumonia: 
Clinically, pneumonia may not always exacerbate COPD. It is often the case that clinical documentation is unclear whether pneumonia exacerbates COPD. From a classification point of view, the presence of COPD with pneumonia is sufficient to assign J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection. This is similar to diabetes mellitus coding where the 'with' rule applies and it is not necessary for clinical coders to ascertain a cause and effect relationship between the conditions.

Search Details: 
ACS 1008 Chronic obstructive pulmonary disease (COPD)

Response:
VICC advises to follow ACS 1008 Chronic obstructive pulmonary disease (COPD) and assign J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection when you have documentation of pneumonia in the presence of COPD.

VICC will suggest to the NCCC that references to diabetes mellitus in ACS 1008 be deleted as they are not relevant to this standard


Query Text:
ACS 0401 Diabetes mellitus and impaired glucose regulation states that we can code diabetes when cause and effect terms are documented including ‘diabetic’, ‘due to’, or ‘secondary to’.

If conditions are listed under a heading ‘Diabetes’ (with dashes, arrows and slashes) can we interpret this as a cause and effect relationship being documented?

For example, if the diabetes does not meet ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses and one of the following complications is treated and is documented in the following format, can we interpret this as a cause and effect relationship?

Diabetes
 -nephropathy 
 -retinopathy
 -PVD
 -HT
 -Hypercholesterolaemia
 -obesity

Does the advice in query #1658 Smoking related COPD published in the ICD Coding Newsletter June 2001 still apply?

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

"A causal relationship between diabetes mellitus and another condition cannot be assumed unless it is explicitly documented in the medical record - for example using terms such as “diabetic”, “due to” or “secondary to”. A causal relationship cannot be inferred by a list of conditions headed by the concept ‘diabetes’.  Without further clarification in the record, such a list should be interpreted as diabetes with the listed conditions. 

In accordance with the 1 July 2012 revision of ACS 0401 Diabetes mellitus and intermediate hyperglycaemia, for conditions without a documented causal relationship assign a diabetes code (Rule 1) following the index pathway Diabetes, with (Rule 3) and assign codes for complications according to Rule 4a and Rule 4b.  

Note also the clarification of ‘diabetic’ conditions detailed in Rule 2."

VICC supports the NCCC advice which is in accordance with ACS 0401, that there must be a documented causal relationship in order to follow the Index pathway 'Diabetes, diabetic'.  Dashes are not a substitute for documentation of 'diabetic' but represent a relationship to diabetes which is coded following the Index pathway 'Diabetes, with'.

In relation to your question regarding query #1658 Smoking related COPD,VICC advises that this query still applies. As with diabetes, the dashes represent a relationship between smoking and COPD which is then coded in accordance with ACS 0503 Drug, alcohol and tobacco use disorders.


Query Text:
Newborn baby with 'ear tag' - ligated during birth episode.  

There is a new code in Seventh Edition Q17.02 Ear tag, but it is not indexed under Tag, ear (only under preauricular and other entries as per the inclusion terms under the code).  

The Seventh Edition education had a query of how to code 'ear tag' and the answer is Q17.02.  

Could this be indexed please?

Response:
Thank you for bringing this deficiency in the index to our attention.  VICC will refer this to the NCCC for review of the index entry for Q17.02 Ear tag.


Query Text:
ACS 0103 Streptococcal infection was deleted in Seventh Edition.  The Education material stated that improvements were made to the index and so the ACS was deleted.  But Enterococcus is only indexed under Streptococcus, so you have to know that it is a Group D streptococcus to know to go to that index entry.  

Could an Errata be made to the index:
Infection
- Enterococcus B95.2

Search details:
Sixth Edition ACS 0103 and Seventh Edition Education Material

Response:
Thank you for bringing this deficiency in the index to our attention.  VICC will refer this to the NCCC for review of the index entry for enterococcus infection.


Query Text:
Could you please advise how to code an infected insect bite. The patient received an insect bite to the arm two days prior to admission which became infected and he presented to Emergency with cellulitis.

VICC query #2194 advises to code the cellulitis as principal diagnosis but this seems to contradict ACS 1916 Superficial injuries which advises to code the superficial injury followed by T79.3 Post traumatic wound infection, not elsewhere classified.

Using the codefinder we have coded:
T11.03 Insect bite of upper limb
T79.3   Post traumatic wound infection
L03.10  Cellulitis
and external cause codes


Search Details: 
VICC query 2194 Infected wound with cellulitis
ACS 1916 Superficial injuries

Response:
VICC advises that both the infected insect bite and the cellulitis can be coded in the same episode and the sequencing will be dependent on your documentation.  

Therefore, if your documentation supports a diagnosis of cellulitis with an infected insect bite the sequencing of codes will be:
L03.10 Cellulitis of upper limb
T11.03 Insect bite of upper limb
T79.3 Post traumatic wound infection
Appropriate external cause codes

If your documentation supports a diagnosis of an infected insect bite with cellulitis the sequencing of codes will be:
T11.03 Insect bite of upper limb
T79.3 Post traumatic wound infection
L03.10 Cellulitis of upper limb
Appropriate external cause codes

VICC query #2194 and Coding Matters Volume 17 Number 1 query titled 'Cellulitis with superficial injuries' confirm that ACS 1210 Cellulitis can't be applied to the coding of cellulitis with an insect bite because this standard only applies to cellulitis with open wounds.


Query Title:
Principal diagnosis for admission for decreased fetal movements

Query Text:
Patient who is overdue by 10 days is admitted because of 'decreased fetal movements'.  A LUSCS is then performed on day of admission. According to ACS 1537 Decreased fetal movements, we must assign O36.8 Maternal care for other specified fetal problems followed by the appropriate code from category O80–O84 Delivery.

Some coders at our hospital feel they should assign O82 Single delivery by caesarean section first as they feel that the intent of the episode/admission was to have the baby. 

Can you confirm that in fact for decreased fetal movements that is subsequently delivered that O36.8 Maternal care for other specified fetal problems should always be assigned as the principal diagnosis as per the standard?

Response:
In accordance with ACS 1537 Decreased fetal movements if the patient is admitted with a diagnosis of decreased fetal movements, no underlying cause is documented and they deliver within the episode of care, assign O36.8 Maternal care for other specified fetal problems as the principal diagnosis followed by a code from category O80–O84 Delivery.  Therefore if your documentation supports that the patient is admitted for decreased fetal movements, follow ACS 1537 and assign O36.8 as the principal diagnosis.

If however, your documentation supports that the patient was admitted for LUSCS, follow ACS 0001 Principal diagnosis under heading Obstetrics which says "Where the patient is admitted for delivery such as 'in labour', 'for induction', 'for caesarean', and the outcome is delivery, assign a code from category O80–O84 Delivery as the principal diagnosis,…"
and assign O82 Single delivery by caesarean section as the principal diagnosis.

If it is unclear from the documentation whether the patient was admitted for the decreased fetal movements or the LUSCS, follow ACS 0001 Principal diagnosis under heading Obstetrics which says "Where there is difficulty in determining the principal diagnosis in obstetric cases with an outcome of delivery, assign a code from category O80–O84  Delivery as the principal diagnosis."


Query Title:
Streptococcus pneumonia with streptococcus sepsis and organ failure

Query Text:
Female 61 year old patient presents with streptococcus pneumonia with streptococcus sepsis. Patient also has acute renal failure documented as secondary to dehydration. The main reason for admission is the pneumonia followed by the sepsis. 

After these are coded do I then code R65.1 SIRS of infectious origin with acute organ failure followed by ARF or (as the history clearly states it is secondary to dehydration) just code the ARF without R65.1?  Of course, dehydation is coded in both cases below ARF. Does SIRS have to be documented literally or do we interpret the definition of SIRS as being severe sepsis with organ failure?  Please note there is no documentation in the history of 'severe sepsis' just 'sepsis due to strep'.

Search Details: 
Clinical input has been unhelpful as the advice we have recieved from our clinicans is that this is sepsis and organ failure without SIRS.  Education from NCCH (please check workbook Clinical Record 2 with answer book) indicates that this case should be coded SIRS + organ failure. Would you please clarify how to code this case and/or offer more information regarding the coding of sepsis/severe sepsis/SIRS.

Response:
In accordance with ACS 0110 Sepsis, severe sepsis and septic shock there must be documentation in the medical record of SIRS or severe sepsis to assign an appropriate code from category R65 Systemic inflammatory response syndrome [SIRS]. 

As in the scenario cited there is no documentation of SIRS or severe sepsis with organ failure, it is not appropriate to code R65.1 Systemic inflammatory response syndrome [SIRS] of infectious origin with acute organ failure.  The documentation of acute renal failure (organ failure) alone is not sufficient to assign R65.1.


Query Title:
Coding of births under a homebirth program

Query Text:
Our hospital has recently commenced a homebirth pilot program.  We would like some guidance on the coding of these episodes.
When coding the baby Z38 Liveborn infants according to place of birth, would we code singleton, twin, other multiple born in hospital as the baby was born as an inpatient even though they were not physically in our hospital, or would we code outside of hospital?

Similarly, when coding Z39.0x Postpartum care and examination immediately after delivery for a mother that has home birth in a previous episode would we code Z39.01 Postpartum care after hospital delivery or Z39.02 Postpartum care after planned, out of hospital delivery?

Response:
Public homebirth program episodes are reported to the VAED as Accommodation Type 4 HITH and Program Identifier 5 .  The definition of Hospital in the Home in the VAED manual is 'Provision of care to hospital admitted patients in their place of residence as a substitute for traditional hospital accommodation.'

Therefore, as HITH is a direct substitute for hospital based care, the episodes should be coded as hospital based delivery and birth episodes.


Query Text:
Patient admitted to investigate slow progression of orbital pain, chemosis, proptosis, diplopia and loss of visual acuity. Thyroid function normal including TSH receptor antibodies. However a further CTB and MRI confirmed a diagnosis of thyroid ophthalmopathy (thyroid eye disease).  Treated with three day course of pulsed steroid and slow K.  Patient to return for weekly doses of IV methyl-prednisolone.

Please advise how to code thyroid ophthalmopathy (thyroid eye disease).

Search Details: 
Index
Proptosis H05.2

Index
Exophthalmos
--thyrotoxic, thyrotropic E05.0+ H06.2*

Response:
VICC advises that when the documented diagnosis cannot be found in the Index and no other documentation is available, to look up the Index under lead term Disease.  In this case follow Index entry Disease, eye which leads to H57.9 Disorder of eye and adnexa, unspecified.

The NCCC has already received a public submission requesting index improvements for coding of Thyroid eye disease (Reference number P37). 

Public submissions received by the NCCC can be viewed through the NCCC Information Portal (NIP) at:
http://nccc.uow.edu.au/productservices/nip/index.html


Query Text:
We would like some clarification on the correct way to code brachytherapy of the prostate.

15338-00 [1792] Brachytherapy, prostate has an instruction note to code first - implantation of brachytherapy applicator 37227-00 [1160] which also has note to code also when performed brachytherapy prostate.

Should we code both codes as they seem to imply that both procedures are performed at the same time?

Operation notes are not always helpful as they say seed implant performed as per protocol, and xray reports sometimes mention the presence of needles within the prostate post procedure.

Response:
Research undertaken by VICC indicates that it is normal practice for both procedures to be performed in the same episode, therefore it is correct to assign codes for both the brachytherapy and the applicator insertion.  

ACHI code 37227-00 [1160] Implantation of brachytherapy applicator, prostate should be sequenced first in accordance with ACS 0040 Conventions used in the tabular list of interventions which says 'Code first instructions assist the clinical coder in the correct sequencing of codes. This instruction appears under codes that must never be assigned alone'.


Query Text:
A patient admitted as an emergency admission with pneumonia and AF. During the admission he underwent a planned trial of void which was to have been carried out at home. This was managed by the Continence advisor and was unsuccessful with the catheter being re-inserted prior to discharge. We realise that this was not the principal reason for his admission. 

Should we simply code 'Retention of urine' with the Z97.8 Presence of other specified devices with no procedure codes or are we able to code out the trial of void codes as per ACS 1436 Admission for trial of void as it was originally planned (albeit at home).

Search Details: 
ACS 1436 Admission for trial of void

Response:
VICC advises that it is not appropriate to apply ACS 1436 Admission for trial of void to the scenario cited because the patient has not been admitted for trial of void.

It is appropriate to assign R33 Retention of urine as retention is documented and treated, however in accordance with ACS 0042 Procedures normally not coded catheterisation should not be coded.

Z97.8 Presence of other specified devices has an excludes for fitting and and adjustment of prosthetic and other devices (Z44–Z46) leading to Z46.6 Fitting and adjustment of urinary device which would be a more appropriate code, however VICC considers the assignment of the Z code is not necessary as it does not add any further information.


Query Text:
We continue to have trouble assigning a procedure code for radioablation of a kidney lesion. 

VICC query 2276 from Fifth Edition provides guidance, instructing coders to use 90354-00 [1064] Other procedures on kidney
however this query is retired/archived.

It also states that NCCH was going to be asked to create a new code for this procedure.  As we are now in Seventh Edition with no new code available, would the committee please advise if the advice in Query 2276 is still current?

Response:
VICC considers that the appropriate code to assign for radioablation of a kidney lesion is 90354-00 [1064] Other procedures on kidney and will send a public submission to the NCCC suggesting the creation of a new code for radioablation of a kidney lesion.


Query Title:
Indexing error for Lymphoblastic T-Cell Lymphoma

Query Text:
We have come across what seems to be an indexing error for Lymphoblastic T-Cell Lymphoma.
When following the look up:

Lymphoma
-lymphoblastic (diffuse)
--precursor cell 
---T-cell (M9729/3) C83.5 

we get to code C83.5 and M9729/3 which is the correct code.

However, when using T-cell as the lead look-up term through Lymphoma:

Lymphoma
-T-cell NEC
--lymphoblastic (M9837/3) C83.5 

we get to code C83.5 M9837/3.

By using this look-up, it gives you the incorrect morphology code (M9837/3 Precursor T-cell lymphoblastic leukaemia); t-cell lymphoblastic leukaemia instead of lymphoma.

Can this please be referred on to the NCCC for correction.

Search Details: 
Disease Index and Tabular entries for both Sixth and Seventh Editions

Response:
Thank you for bringing this index entry error to our attention.  VICC will refer this to the NCCC for review of the morphology code at index entry:
Lymphoma
-T-cell NEC
--lymphoblastic (M9837/3) C83.5


Query Title:
Alcoholic cirrhosis of liver with a past history of drinking

Query Text:
There has been some debate at our organisation whether F10.1 Harmful use of alcohol should be used in conjunction with code K70.3 Alcoholic cirrhosis of liver when a patient is no longer drinking alcohol.  

In VICC #2234 Harmful use of alcohol the patient is still drinking heavily and received counselling for this and hence F10.1 Harmful use of alcohol should also be coded.  

In the instance where the patient no longer drinks and has a past history of drinking should F10.1 be coded in conjunction with K70.3 Alcoholic cirrhosis of liver?  Or should we follow the same logic as F17.1 Harmful use of smoking?

Response:
VICC advises that whilst the patient has ceased drinking, in accordance with ACS 0503 Drug, alcohol and tobacco use disorders  it is correct to assign an additional code to specify the previous level of use disorder for documentation of alcoholic liver disease.

To answer your specific question, it is appropriate to assign F10.1 Harmful use of alcohol in the absence of documentation relating to the level of previous alcohol use.


Query Title:
Documentation appropriate to clinical discipline

Query Text:
We have had recent discussion regarding what diagnoses are appropriate to a nurse’s clinical discipline.
Please refer to:
ACS – Introduction - How to use this document
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.
Coding Matters Vol 15 No. 1 - Malnutrition
The NCCH and CSAC have agreed that malnutrition may be coded when it is documented by a dietitian in the clinical record. This decision is supported in the Introduction to the Australian Coding Standards (ACS) 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.”
Dieticians’ meet the definition of a clinician in the ACS and diagnosis and treatment of malnutrition is appropriate to their profession.  Malnutrition must meet the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses to be coded.

Can you please confirm if the following VICC queries/ Newsletter advice regarding coding of clinical information recorded by clinicians other than medical officers from August 2000, November 2001 & 2002 is still current advice?
- ICD Coding Newsletter – August 2000 - Coding of Clinical Information Recorded by Clinicians other than Medical Officers
- ICD Coding Newsletter – November 2001 – VICC #1735 Arrows/plus signs/question marks as adequate documentation
- ICD Coding Newsletter – November 2002 - VICC #1799 Documentation appropriate to clinical discipline

Response:
VICC considers that the advice in the queries and articles cited in this query are still current.  

As the term 'clinician' encompasses a range of health professionals including nurses, the coder must therefore use the documentation in the entire medical record when making a decision as to what diagnoses are codeable.


Query Text:
In our hospital the stem cell collection procedure involves the following steps:
1. Stem cells collected via apheresis
2. Stem cells undergo in vitro processing
3. Stem cells cryopreserved

When it comes time to for the patient to undergo the stem cell transplant, the stem cells are thawed and transfused.

To incorporate the cryopreservation I have proposed we code the collection procedure to:
13750-05 [1892] Apheresis of stem cells with cryopreservation

One of our Haematology Registrars explained that the in vitro processing takes place at the time of collection, not at transplantation. I am wondering if we should reflect this by also coding:
13760-00 [1891] In vitro processing of bone marrow or peripheral blood for autologous stem cell transplantation

I believe the apheresis code is correct but am unsure whether the processing code is required. I was trying to reflect that the cells are being in vitro processed at the time of collection.

Search Details: 
ACS 0030 Organ and Tissue Procurement and Transplantation
Coding Matters, Volume 16, Number 1
Consultation with Haematology Registrar
Review of in-house procedures

Response:
VICC considers that 13760-00 [1891] In vitro processing of bone marrow or peripheral blood for autologous stem cell transplantation should only be assigned if the in vitro processing is documented in the apheresis episode.


Query Text:
Patient is documented as having ‘transient quadriplegia’ as a result of spinal cord compression caused by C5/6 and C6/7 disc prolapse. Index entries for R29.88 Other and unspecified symptoms and signs involving the nervous system exist at:
Hemiplegia G81.9 
-transient R29.88 

Monoplegia G83.3 
-lower limb G83.1 
-- transient R29.88 
-transient R29.88 
- upper limb G83.2 
- - transient R29.88 

Paralysis, paralytic (complete) (incomplete) (see also Paresis) G83.9 
- arm G83.2 
- - transient R29.88 
- leg G83.1 
- - transient or transitory R29.88 
- limb NEC G83.3 
- - all four (see also Tetraplegia) G82.5- 
- - transient (cause unknown) R29.88 

Paraplegia (lower) G82.2- 
- transient R29.88 

There is no index entry for transient quadriplegia.  There are excludes notes for R29.88 Other and unspecified symptoms and signs involving the nervous system at blocks:
G81 Hemiplegia
Excludes: transient hemiplegia (R29.88)
and
G82 Paraplegia and Tetraplegia, and G83 Other paralytic Syndromes
Excludes: transient paresis (R29.88)

Firstly, should there be an index entry for Quadraplegia, transient R29.88?

Secondly, following the index entry for Paralysis, limb NEC,

Paralysis, paralytic (complete) (incomplete) (see also Paresis) G83.9 
-limb NEC G83.3 
- -all four (see also Tetraplegia) G82.5- 
- -transient (cause unknown) R29.88 

should there be an option for ‘transient’ under ‘all fours’? i.e.

Paralysis, paralytic (complete) (incomplete) (see also Paresis) G83.9 
- limb NEC G83.3 
- - all four (see also Tetraplegia) G82.5- 
- - - transient R29.88 *
- -transient (cause unknown) R29.88

Response:
VICC acknowledges the deficiency in the Index regarding transient quadriplegia however advises to follow the excludes note at G82 Paraplegia and Tetraplegia which says  'Excludes: acute, traumatic paraplegia and tetraplegia (S14.-, S24.-, S34, congenital cerebral palsy (G80.-), transient paresis (R29.88)' to assign R29.88 for documentation of transient quadriplegia.

You may wish to submit a public submission to NCCC requesting improvements in this area of the index.


Query Title:
Cervical disc prolapse causing spinal cord compression/myelopathy

Query Text:
Patient has cervical disc prolapse causing spinal cord compression/myelopathy.  There seems to be inconsistency in the index when looking up this condition, as only one index entry includes G99.2* Myelopathy in diseases classified elsewhere.

Compression 
- spinal (cord) G95.2 
- - by displacement of intervertebral disc NEC M51.0 
- - - cervical M50.0 Cervical disc disorder with myelopathy

Myelopathy (spinal cord) G95.9 
- in (due to) 
- - intervertebral disc disorder M51.0 
- - - cervical, cervicothoracic M50.0 Cervical disc disorder with myelopathy

Displacement, displaced 
- intervertebral disc NEC M51.2 
- - cervical, cervicothoracic (with) M50.2 
- - - with myelopathy M50.0†  G99.2* 

Is it necessary to add G99.2* Myelopathy in diseases classified elsewhere to M50.0 Cervical disc disorder with myelopathy?

Could the index entries be made consistent?

Response:
Thank you for bringing this inconsistency in the Index to our attention.  VICC will refer this to the NCCC for review of the index entry:
Displacement, displaced 
- intervertebral disc NEC M51.2 
- - cervical, cervicothoracic (with) M50.2 
- - - with myelopathy M50.0†  G99.2* 

VICC considers that it is not necessary to add G99.2 when assigning code M50.0 Cervical disc disorder with myelopathy as the code title of M50.0 fully describes the medical statement.


Query Title:
Principal diagnosis for Geriatric Evaluation and Management Program episodes

Query Text:
I have been given conflicting instructions regarding the use of Z50.9 Care involving use of rehabilitation procedure, unspecified as a principal diagnosis for patients admitted with VAED Care Type 9 Geriatric Evaluation and Management Program (GEM).

Can patients in GEM (Care Type 9) be assigned Z50.9 as a principal diagnosis?

This query assumes that the reason for admission was rehabilitation.

Can you please confirm (please answer Yes or No so its definitive).

Response:
VICC advises that if the documentation supports a principal diagnosis of rehabilitation, Z50.9 Care involving use of rehabilitation procedure, unspecified can be assigned as the principal diagnosis in a GEM (Care Type 9) episode.  

Please also refer to the Victorian Additions to the Australian Coding Standards, Vic 2104 Rehabiliation which says '...If a patient is admitted 'for rehabilitation' (even if the patient is in a bed other than a designated Rehabilitation bed or if the hospital does not have a designated Rehabilitation program), Australian Coding Standard 2104 Rehabilitation applies…'


Query Title:
Coding of 90477-00 [1343] Other procedures to assist delivery

Query Text:
When assigning O83 Other assisted delivery, do you also need to code 90477-00 [1343] Other procedures to assist delivery?

Response:
VICC advises that there is no classification guideline or coding convention that requires a procedure code to be assigned with a diagnosis of O83 Other assisted single delivery.  

Therefore when assigning O83, it is not necessary to assign 90477-00 [1343] Other procedures to assist delivery, if no procedure is performed.  If however a procedure to assist delivery is performed, the specific code should be assigned.

For further information, please refer to ICD-10-AM/ACHI/ACS Seventh Edition Education Frequently Asked Questions, question 3 available on the NCCC website.


Query Title:
Clarification of ACS 0401 Diabetes Mellitus General classification principles points 3 and 4

Query Text:
Please provide clarification on ACS 0401 Diabetes Mellitus - General classification principles in diabetes mellitus and impaired glucose regulation, points 3 and 4 as they relate to the following example:

Patient admitted from dialysis unit with catheter complications and undergoes further dialysis while an inpatient for ESRF in diabetic nephropathy.  Hypertension has also been documented but doesn't meet ACS 0002 Additional diagnoses.  The diabetes itself does not meet ACS 0002 in this admission.

Codes used as follows:
Catheter complication codes
N18.5   Chronic Kidney Disease, Stage 5
E11.22  Type 2 DM with established diabetic nephropathy  (causal link per example 8, ACS 0401).
I10       Essential Hypertension. (code also note on N18 Chronic Kidney Disease).
Procedure codes

E11.72 Type 2 diabetes mellitus with features of insulin resistance was not added as Diabetes does not meet ACS 0001 or ACS 0002.

Is this correct?

Response:
VICC advises that it is correct to assign E11.72 Type 2 diabetes mellitus with features of insulin resistance in this scenario in accordance with points 2 and 4 of the general classification principles in ACS 0401 Diabetes mellitus and impaired glucose regulation.

This is because the ESRF is described as 'in diabetic nephropathy', which indicates a causal link thus enabling the diabetes to be coded in accordance with problems and underlying conditions in ACS 0001 Principal diagnosis (point 2 of the general classification principles).  As it's been determined that the diabetes meets criteria for coding in ACS 0001, E11.72 Type 2 diabetes mellitus with features of insulin resistance is then coded to reflect the severity of the diabetes (point 4 of the general classification principles). 

Had there been no causal link between the ESRF and the diabetes, point 3 of the general classification principles would have applied, which would require the diabetes to meet ACS 0001 Principal Diagnosis or ACS 0002 Additional diagnoses criteria before it can be coded.

See also #2778 Coding of type 2 diabetes with insulin resistance.


Query Title:
Z92.22 Insulin with diabetes mellitus in pregnancy

Query Text:
The instruction relating to the use of Z92.22 Insulin is now at the headings for E11 Type 2 diabetes mellitus, E13 Other specified diabetes mellitus and E14 Unspecified diabetes mellitus codes.  But there is no such note at the diabetes in pregnancy codes O24 Diabetes mellitus in pregnancy range.  
Should we add Z92.22 to O24 codes (except Type 1, O24.0) when applicable?

Search Details: 
ACS 0401 Diabetes mellitus and impaired glucose regulation

Response:
VICC advises that it is not necessary to assign Z92.22 Insulin for code range O24.1–O24.9 because the fifth character subdivisions at O24.1–O24.9 provide information about insulin use.


Query Text:
A 15 year old patient presented to our hospital with sudden onset of left leg pain after running. The limb was cold, pale had a decreased pulse and the patient reported paraesthesi. The patient was investigated with an arterial doppler, MRA and MRI and was diagnosed with popliteal entrapment syndrome. We are unsure whether to code this to peripheral vascular disease. Could the coding committee please advise on how to code this condtion?

Search Details: 
ACS 0941 Arterial disease
Popliteal artery entrapment syndrome (PAES) is an anomalous relationship between the popliteal artery and its surrounding musculotendinous structures. PAES is an unusual but important cause of peripheral vascular insufficiency especially in young patients. Early diagnosis through a combined approach is necessary for exact diagnosis. Popliteal artery release alone or with vein bypass is the treatment of choice when intervention is indicated for good operative outcome and to prevent limb loss.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464757/

Response:
In accordance with the Conventions used in the Tabular List of Diseases under 'Other' and 'unspecified' codes, in the absence of subterm 'popliteal' under Index entry Syndrome/entrapment VICC considers the most appropriate code to assign is I77.9 Disorder of arteries and arterioles, unspecified following Index entry Disease/arterial.


Query Text:
Patient was admitted to our facility with an open fracture of the distal tibia and fibula. They underwent a reduction of the distal tibia with an IM nail and debridement of the wound (please find attached operation report). We are unsure what to code the distal tibia reduction to as there is no code to reflect this procedure in ACHI without a reduction of the fibula (which did not occur). 

Should we code it to 47566-01 [1509] Open reduction of fracture of shaft of tibia with internal fixation following the pathway:
Reduction
-fracture
--tibia,tibial
---shaft (closed)
----open
-----with internal fixation (cross) (intramedullary) 47566-01 [1509]
*This includes the IM nail 

Or,

Should we code it to open reduction of fracture of ankle (however we are unsure which index pathway to follow next):
Reduction
-fracture
--ankle
---open
----with internal fixation
-----diastasis
-----fibula
-----malleolus

Please advise us on an appropriate code for this procedure.

Response:
VICC's interpretation of the operation report is that there is no documentation to support a fracture of the ankle, therefore the correct Index entry to follow is Reduction, fracture, tibia, tibial.  As there is no default code at this level and the following essential modifiers are for 'shaft' and 'plateau' a decision must be made as to which of these is the appropriate choice.  As the tibial plateau is anatomically proximal and the documentation in the operation report says 'distal' , VICC has followed the Index entry:
 Reduction
-fracture
--tibia,tibial
---shaft (closed) 
We do however suggest that you review the X ray report and any other available documentation before assigning the code.

VICC also notes that you have selected open reduction. However with the limited documentation we have available we consider this to be a closed reduction as we found no documentation to support operative exposure of the fracture during the reduction.  Please refer to the definition of open reduction at the beginning of Chapter 15 Procedures on musculosketal system of the ACHI tabular for further information.


Query Title:
ACS 0001 Principal diagnosis, problems with underlying conditions in the perinatal period

Query Text:
Please clarify the use of ACS 0001Principal diagnosis - Problems with underlying conditions, point two 'Coding the problem as the principal diagnosis' when applied to conditions originating in the perinatal period.

ACS 1605 Conditions originating in the perinatal period, second dot point 'Conditions originating in the perinatal period still apply for infants >28 days who are discharged and subsequently readmitted with a condition documented as originating in the perinatal period'.

With a condition such as chronic lung disease due to prematurity, from which a patient can suffer into adulthood, is it appropriate to apply 'Problems with underlying conditions' when the patient is older than 28 days?

For example, five year old patient with principal diagnosis of chronic lung disease due to prematurity (patient was born at 25 weeks gestation):
P27.1  Chronic neonatal lung disease
P07.22  Extreme immaturity, 24 or more completed weeks but less than 28 completed weeks.

Is it appropriate to use a code from P07.__ in this case?

Search Details: 
ACS 0001 Principal Diagnosis
ACS 1605 Conditions originating in the perinatal period

Response:
ACS 0001 Principal diagnosis applies to all patients and as such there is no age limit to the application of the Problems and underlying conditions part of standard, therefore it can be applied to a patient who is greater than 28 days.  You must however have documentation of a condition clearly stated as being due to an underlying cause and the underlying cause still needs to be present.

ACS 0008 Sequelae provides guidance for coding the residual condition when the underlying cause is no longer present.

VICC does not consider the assignment of P07.22 Extreme immaturity, 24 or more completed weeks but less than 28 completed weeks is appropriate in the case cited because the prematurity is no longer present as an underlying condition.  As the number of sequelae codes is very limited, in the absence of an appropriate sequelae code, we suggest assigning Z87.6 Personal history of certain conditions arising in the perinatal period to describe a history of prematurity.


Query Text:
We are having some conflicting advice on whether a 'Ring Block' should be coded. It is documented as 'Ring Block lignocaine 2% for suture of wound'.

We have been interpreting this documentation to mean local anaesthetic (and therefore not coding it) - but this has been queried by one of our senior clinicians.  He states a ring block is a block of the digital nerves to a finger or thumb. It is a regional block of a digit. Local anaesthesia usually is a term that applies to local infiltration with local anaesthesia which is a different procedure.

Other clinicians disagree and state it should be classified to a LA.

Could you please advise on the correct classification?  Would clinicians need to document the ring block as a nerve block or similar for it to be coded as regional anaesthesia?

Response:
VICC research concurs with the clinical advice from your senior clinician that a ring block is a nerve block.   Therefore,  provided you have documentation that the ring block has been given to achieve anaesthesia, you can code the ring block as a nerve block by following Index entry Block, nerve, for operative anaesthesia.


Query Text:
Following the Index:
Endometritis
-puerperal, postpartum O85

Tabular entry:
O85 Puerperal sepsis ACS 0027, 0110
Puerperal:
• endometritis
• fever
• peritonitis
• septicaemia
Use additional code (A40.- – A41.-) to identify sepsis.
Use additional code (B95–B97) to identify infectious agent in localised infection.
Use additional code to identify localised infection:
• endometritis (N71.-).
• peritonitis (N73.3, N73.5).

Even though endometritis is an inclusion term in O85, the 'use additional code' instructions and ACS 0027 Multiple coding and ACS 0110 Sepsis, severe sepsis and septic shock require N71.- to be added to fully translate the medical statement into code.

Considering the endometrium is part of the genital tract (there is an Index entry Puerperal, puerperium; perimetritis O86.1) my question is whether O86.1 Other infection of genital tract following delivery, in addition to N71.-, would be more appropriate than O85.

Tabular entry:
O86.1 Other infection of genital tract following delivery
Cervicitis } following delivery
Vaginitis  } 

Of note is that Index entries for both cervicits puerperal postpartum and vaginitis puerperal (postpartum), which are inclusion terms under O86.1, both lead directly to O86.1.

Search Details:
ACS 1501Definition of puerperium 
ACS 1548 Postpartum condition or complication 
ACS 0027 Multiple coding 
ACS 0110 Sepsis, severe sepsis and septic shock

Response:
VICC considers O85 Puerperal sepsis the appropriate code for documentation of puerperal endometritis as supported by the Index and Tabular entries for this condition.   See Index entries:
Endometritis
- puerperal, postpartum O85

and

Infection, infected (opportunistic) B99 
↓
-genital organ or tract 
↓
--puerperal, postpartum, childbirth NEC O86.1 
---major or generalised O85 
---minor or localised O86.1

We note that the Classification at third and fourth character levels is mandated by the World Health Organisation (WHO) and NCCC are not able to make changes to the classification at this level.

We also note that the Classification separates major puerperal infections from other infections and has classified puerperal endometritis to a major infection. If you consider this is not appropriate, you may wish to submit a public submission to NCCC.


Query Title:
Bone destruction secondary to septic arthritis and osteomyelitis caused by MRSA

Query Text:
We had a patient admitted for a TKR, diagnosis documented as bone destruction secondary to septic arthritis & osteomyelitis caused by MRSA. During hospital stay patient had extensive swabs of knee joint to check for recurrence of MRSA - but all came back negative.

We were going to use B94.8 Sequelae of other specified infectious and parasitic disease, but the Note at the start of B90-B94 says it is to be used for codes in A00-B89, so MRSA (B95.6 & Z06.32) doesn't fit in this category.

When you look at Z86.1x for Personal History of Infectious and Parasitic disease, it says includes conditions classifiable to A00-B89, B99, and excludes sequelae of infectious and parasitic diseases (B90-B94), so again the codes for MRSA B95.6 & Z06.32 aren't included.

Is the only way to code this particular episode as MRSA carrier Z22.3?

Can you please advise of the appropriate code to assign for personal history of MRSA?

Search Details: 
Index Entry:
History
-disease or disorder
--infectious
---specified disease or disorder NEC Z86.18

Sequelae
-infectious disease
--specified NEC B94.8

Coding Commandments, Volume 16 number 3 MRSA & VRE carriers

Response:
VICC notes that it is important to differentiate between infectious agents, infectious diseases and other infections.  The classification does not contain codes for past history of infectious agents such as MRSA, however it does contain codes for past history of infectious diseases and other infections.

VICC does not consider a code for MRSA carrier is appropriate because the swabs were negative and there is no documentation of current MRSA.  Therefore there is no code that is applicable in this case to describe that the patient had a previous MRSA infection.

As you have said the sequelae code for sequelae of infectious disease excludes septic arthritis (because septic arthritis is an infection, not an infectious disease) and therefore there is no sequelae code available to describe this condition. 

If the history of septic arthritis and osteomyelitis meet criteria for coding, VICC considers it appropriate to assign Z87.3 Personal history of diseases of the musculoskeletal system and connective tissue.


Query Text:
Please clarify the use of F05.1 Delirium superimposed on dementia.

A patient with Alzheimer's disease is admitted with pneumonia and during the admission develops delirium superimposed on dementia (so described). The dementia itself is not managed or assessed during this admission.

Codes :
J18.9  Pneumonia
F05.1  Delirium superimposed on dementia

ACS 0027 Multiple Coding notes 'multiple codes may need to be assigned to reflect the various components of the disease'.

1.  Is it necessary to add G30.9† F00.9* (Alzheimer's disease, Unspecified and Dementia in Alzheimer's disease unpecified) to add specificity to F05.1, that is to identify the type of dementia?

2.  Is the terminology 'Delirium on a background of dementia' sufficient to assign F05.1, provided there is no other cause for delirium specified?

Thanks for your advice.

Search Details: ACS 0027 Multiple coding

Response:
This query was originally published in the 2011-12 March VICC queries database release as follows:

As you have stated, delirium superimposed on dementia needs to be so described in order for F05.1 Delirium superimposed on dementia to be assigned.   Therefore the terminology 'delirium on a background of dementia' is not sufficient to assign F05.1 Delirium superimposed on dementia.

In accordance with the note at the beginning of the chapter titled Organic, Including Symptomatic, Mental Disorders (F00-F09) that says to 'Use additional code to identify the underlying disease', it is correct to add codes G30.9+ F00.9* for the case cited.

Following publication of the ACCD Coding rules on 15 March 2014 the advice on the assignment of F05.1 is superseded by the following advice titled Delirium with dementia:
[Q:  How do you classify delirium in a patient with dementia?

A: Where delirium is specifically documented in a patient who also has dementia,
assign F05.1 Delirium superimposed on dementia by following the index pathways:
Delirium, delirious (acute or subacute) (not alcohol- or drug-induced) F05.9
…
- superimposed on dementia F05.1

Note: the documentation does not have to specify superimposed on dementia. The term superimposed implies delirium with dementia.

(see also Coding Rules: Confusion or delirium with dementia)]


Query Title:
Principal diagnosis selection for birth whilst on leave

Query Text:
Woman in spurious labour admitted, contractions dissipated after a couple of hours, so given prostin to induce labour and sent home on leave, to await labour.  Delivers at home.  Represents with babe in arms.

Do I use O80 Single spontaneous delivery as the principal with Z39.03 Postpartum care after unplanned, out of hospital delivery as the outcome code? She didn't plan to have the baby at home.  

Also had first degree tear sutured.  Precipitate labour (nothing done for it,  but was the reason babe delivered at home and would tell the full story).

Response:
VICC advises that the correct principal diagnosis for the case cited is O80 Single spontaneous delivery as per ACS 0001 Principal diagnosis.  This is because the woman gave birth in this episode. Although the birth occurred at home, the patient was on leave and leave is still considered to be part of the episode (see VAED manual section 4 Business rules).  

Consequently the correct outcome code to assign is Z37.0 Single live birth.  

Whilst the first degree tear clearly meets criteria for coding, a code for the precipitate labour would only be assigned if it meets ACS 0002 Additional diagnoses criteria.


Query Title:
Bleeding of oesophageal varices during banding procedure

Query Text:
Patient was admitted for variceal screening with a past history of ETOH cirrhosis and varices with previous banding. During gastroscopy, it was noted that the patient had varices with cherry red spot and banding induced ulceration. During application of variceal band, patient's varices began bleeding and it was decided that patient was for conservative management only given the severity of patient's condition. 

Question 1:
Should the banding induced ulceration be coded as a complication of gastrointestinal device T85.88 with K22.1 or postprocedural gastrointestinal complication K91.8 with K22.1?

Question 2: 
How should the variceal bleeding be coded? Is this a postprocedural complication or an extension of the patient's current disease? 

Please refer to the gastroscopy report:
Procedure Date: Date: 22/06/2011 Start Time: 3:50:00 End Time: 4:10:00 Duration: 20 minutes 
Venue: Procedure Venue: Repat Endoscopy 
Instrument :  Olympus Gastro-2705349 
Indications :  Varices screening 
Medications Used: No pre-medication used. 
Report Findings:  There was nothing precluding the gastroscopy on history or physical examination. Informed consent for the procedure was obtained. The risks and benefits were explained and the alternatives were outlined. The patient tolerated the procedure well. OESOPHAGUS 4 varices (protruding to greater than one half of the lumen) with cherry red spot and banding induced ulceration were evident. STOMACH DUODENUM The duodenum was normal to the second part. The only post operative instruction was routine post gastroscopy. 
Preliminary Diagnosis: Oesophageal Varices 
Procedures:  Variceal banding on oesophagus: 1. The patient suffered from the following complication: Variceal bleeding which was treated by medical review. 
Disposition:  Return to ward. 
General Comments: Large varices with evidence of band ulceration and red spots - see photo - single band applied which triggered active bleeding and red out. Unable to visualise bleeding site or control bleeding. D/W Gastro Ward 
Consultant - given patients overall medical condition - not a candidate for intubation/ICU/sengstaken tube - for conservative medical management only. Commence terlipressin. Con't antibiotics - likely aspirated. Ward Management only.

Response:
In answer to question one, from the information provided in the query, VICC does not consider that the banding induced ulceration meets ACS 0002 Additional diagnoses because it is pre-existing and simply noted on gastroscopy, therefore it would not be coded in this episode.  If it were to meet ACS 0002, VICC considers the appropriate codes to assign are:
T85.88 Other complications of internal prosthetic device, implant and graft, NEC 
(A code for the site of the ulceration)
Y83.1 Surgical operation with implant of artificial internal device
Y92.22 Health service area

By following Index entries:
Complication
- prosthetic device, graft or implant
-- gastrointestinal tract
--- specified NEC T85.88

Complication
-implant, implantation (of) 
--artificial 
---internal device (cardiac pacemaker) (electrodes in brain) (heart valve prosthesis) (orthopaedic) Y83.1 

In answer to question two, ACS 1904 Procedural complications defines a procedural complication as 'a condition or injury which is directly related to a surgical/procedural intervention.  From the information provided, the variceal bleeding is documented as being caused by the procedure, therefore VICC considers the correct codes to assign are:
T85.88 Other complications of internal prosthetic device, implant and graft, NEC 
(A code for the variceal bleeding)
Y60.4 During endoscopic examination 
Y92.22 Health service area

By following Index entry:
Misadventure(s) to patient(s) during surgical or medical care 
-cut, cutting, puncture, perforation or haemorrhage (accidental) (during) (inadvertent) (unintentional) 
--endoscopic examination Y60.4


Query Text:
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 (Please see below). 

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?

Search Details: 
Urethroplasty and buccal graft procedure: The urethroplasty technique involves obtaining urethral exposure transvaginally from the distal urethra to the bladder through a midline incision. An incision is then made into the urethra, opening it ventrally at the 6-o’clock position through the meatus into the healthy urethral tissue proximally. The graft is then sutured into the urethral defect with 5-0 polyglyconate sutures, with the mucosal surface facing inward toward the lumen. After the graft is in place, sounds are used to establish patency to 28F. Then, the repair is covered with mobilized periurethral soft tissue. If inadequate periurethral tissue exists, but adequate vaginal wall tissue exists for coverage, a Martius flap should be rotated to provide an adequate blood supply and prevent fistula formation. An 18F silicone urethral catheter and a 22F suprapubic tube are left in place.

NCCH Query #906 - Free buccal mucosal graft Urethroplasty with free buccal mucosal graft
Principal diagnosis: Bulbar Urethral Stricture. What code should be allocated for the free buccal mucosal graft?
Advice: Thankyou for the helpful information provided with your query. A urethroplasty generally involves excision of diseased urethral tissue and replacement with a graft using a variety of materials such as mucosa, foreskin, penile skin, scrotal skin or dermis. The procedure can be performed in a single stage or in two stages. In the case cited, assign '37342-00 [1120] Urethroplasty, single stage procedure'.

Response:
VICC advises that whilst the 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 Text:
The following VICC Query has been retired.  
#2178 PTP implants:
The above procedure is performed at our facility for the repair of either internal sphincter dysfunction or IAS - internal anal sphincter dysfunction. Both diagnoses refer specifically to sphincter dysfunction of which both result in faecal incontinence.

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

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

We have found there to be no new index entry for this code under the term Implant or Insertion and no recent advice. 

Is it correct to continue to apply this advice in query #2178 and code 90316-00 [942] Other procedures on Anus?

Response:
For coding of PTP implants, VICC advises to follow the advice in the October 2010 ICD-10-AM/ACHI/ACS Q&A, Answers to Coding Authority questions published on the NCCC website as follows:

PTQ Injections
Q. What is the correct code to assign for a PTQ injection performed for faecal incontinence?
A. A new, minimally invasive, treatment for faecal incontinence involves the injection of a liquid material (PTQ™ Implant also known as Bioplastioque™) into the anal sphincter. When injected in to the sphincter muscle it becomes solid and by its bulk improves sphincter function.

The correct code to assign for this procedure is 90344-01 [929] Administration of other therapeutic agent to anorectal region. Currently there is no suitable index entry look up for this procedure in ACHI.  Improvements to the Alphabetic Index will be considered for this procedure for a future edition of ACHI.


Query Text:
The following VICC query has been retired:
#2119: Perimenopausal Bleeding 
What is the correct code to assign for Perimenopausal bleeding?  We have been using N92.4 Excessive bleeding in the premenopausal period.  If this is the correct code, is it possible for it to be added as an inclusion term in the tabular list under N92.4, and have an index entry as well?

We have found there to be no new index entry for this code and no updated advice. 

Is it correct to continue to apply this advice and code N92.4 Excessive bleeding in the premenopausal period for documentation of perimenopausal Bleeding?

Response:
VICC considers that the advice provided in retired VICC query #2119 is still current and is reproduced below.

Perimenopause is defined as the three to five year period prior to menopause during which oestrogen levels begin to drop.  (Better Health Channel Online medical dictionary)

Postmenopause is defined as the physiological period following the menopause, the permanent cessation of the menstrual life.  (Better Health Channel Online medical dictionary)

Therefore the correct code to assign for perimenopausal bleeding is N92.4 Excessive bleeding in the premenopausal period.  See index entries as follows:

Bleeding
uterus, uterine NEC N92.6
...
- - preclimacteric or premenopausal N92.4


Query Text:
At our facility it is common to see the following qualifications in the documentation of Hepatitis C: ‘cleared’; with ‘SVR’ [sustained virological response]; ‘PCR –ve’; and ‘successfully treated’ with pegylated interferon and ribavirin. A review of the research literature indicates that some patients can be ‘cleared/cured’ of the Hepatitis C virus (HCV). This was confirmed in discussion with our Gastroenterologists.

A new treatment regime – a combination drug therapy of pegylated interferon and ribavirin – has proven itself effective in achieving a sustained virological response (SVR) across different genotypes of HCV. “The goal of treatment is to eradicate hepatitis C virus (HCV) RNA, which is predicted by the achievement of a ...SVR as defined by the absence of HCV RNA by polymerase chain reaction [PCR] six months after stopping treatment. An SVR is associated with a 99 percent chance of being HCV RNA negative during long-term follow-up.” A summary of evidence-based research on SVR and treatment outcomes support its use as a clinical indicator of viral eradication; in the words of the authors, “SVR is tantamount to cure.” 

This new scenario creates a contradiction with the definition of Hepatitis C in ACS 0104 Viral hepatitis:
'Hepatitis C differs from hepatitis B in that a patient with hepatitis C will have the virus for the rest of their lives as either an acute or chronic infection or as an asymptomatic carrier'.

Based on this information, they cannot possibly be “cleared/cured” of the virus. It is clear that ACS 0104 needs to be reviewed, particularly the section on Hepatitis C and also the directives given via Coding Matters Volume 17, no. 1, June 2010 on 'Hepatitis C Cirrhosis'. A public submission to this effect is being prepared by this hospital for the NCCC. 

As the concept of ‘cleared/cured’ Hepatitis C is not addressed in the ACS, and given the fact that viral hepatitis “should always be coded even if the criteria for additional diagnosis is not met.”, we have made some local coding decisions. We would like to submit these to the VICC for their comment:

• Potentially two situations with 'cleared' HCV infection: 
(a) HCV 'cleared' – HCV-related liver disease still present 
Example of Documentation seen: Cleared Hep C/ Hep C with SVR – HCV-related liver disease present [cirrhosis]
Code(s):
(1) HCV-related liver disease [e.g. cirrhosis K74.6]
(2) Sequelae of viral hepatitis B94.2
We have used the sequelae code given that the underlying condition (Hepatitis C) is now not present (per ACS 0008 Sequelae)

(b) HCV 'cleared' – HCV-related liver disease not present
Example of Documentation seen: Cleared Hep C/ Hep C with SVR 
Code(s):
(1) Personal history of other infectious and parasitic disease Z86.18

As the notion of ‘cleared/cured’ Hep C is not addressed in ACS 0104 we have been coding this scenario to Z86.18. We make reference to the “Cured diabetes” section in ACS 0401 Diabetes Mellitus and Impaired Glucose Regulation (p. 110). 

We acknowledge that the use of Z86.18 means taking ACS 2112 Personal History into account. It states to only assign a personal history code when the 'resolved' condition is directly relevant to the current episode of care. Does this mean Z86.18 would not be assigned when no sequelae condition is present and 'cleared' HCV is incidentally documented and is not the reason for admission.

Search Details: 
ACS 0104 VIRAL HEPATITIS
ACS 0008 SEQUELAE
ACS 0401 DIABETES MELLITUS AND IMPAIRED GLUCOSE REGULATION [see 'Cured diabetes pg 110]
ACS 2112 PERSONAL HISTORY

Coding Matters Volume 17, Number 1, June 2010 on Hepatitis C Cirrhosis

Clinical Input: Director Gastroenterology, Alfred Health.

Chopra, S., (2011). Current treatment regimens for chronic hepatitis C virus infection. Retrieved 29 June, 2011 from UpToDate: http://www.uptodate.com/contents/peginterferon-and-ribavirin-for-the-treatment-of-chronic-
hepatitis-c-virus-infection-treatment-regimens?source=search_result&selectedTitle=7%7E150

Pearlman, B. L., & Traub, N. (2011). Sustained virologic response to antiviral therapy for chronic hepatitis c virus infection: A cure and so much more. Clinical Infectious Diseases. 52(7), 889-900. Retrieved 29 June 2011 from: http://cid.oxfordjournals.org/content/52/7/889.short?rss=1

Response:
VICC acknowledges that clinical advances in this area means that ACS 0104 Viral hepatitis does not address the concept of cleared/cured hepatitis.  

Upon review of the examples provided to illustrate the two scenarios noted in the query, we consider that it is appropriate to assign B94.2 Sequelae of viral hepatitis in cases of HCV 'cleared' – HCV-related liver disease still present and Z86.18 Personal history of other infectious and parasitic disease in cases of HCV 'cleared' – HCV-related liver disease not present.

VICC is aware that a public submission has been submitted to the NCCC to address the issues with ambiguious terms and defining symptoms (Reference number P118).  Public submissions received by the NCCC can be viewed through the NCCC Information Portal (NIP) at:
http://nccc.uow.edu.au/productservices/nip/index.html


Query Text:
The following VICC query has been retired:
#1926 Bursectomy with repair of rotator cuff 
When coding arthroscopic sub-acromial decompression with repair of the rotator cuff, I have been using code:
48960-00 [1405] Arthroscopic reconstruction of shoulder
but often the operation report also says that a bursectomy is performed. Question:Should bursectomy be coded as well, or is it an integral part of the above procedure. If it does need coding, should I use:
30111-00 [1566] Excision of large bursa
or
30107-01 [1566] Excision of small bursa

The response indicates 'NCCH will consider the additon of bursectomy to the includes list in code 48960-00 [1405] for a future edition of ICD-10-AM'.  

As it is not included in the code in Seventh Edition, I assume it is still applicable but would appreciate your advice.

Response:
In the absence of an update to the classification VICC considers that the advice 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.

For Tenth Edition advice refer to #3345 Bursectomy with repair of rotator cuff published in the 2017-18 March VICC queries database.


Query Text:
What is the correct code(s) to assign for a TACE procedure?

Background Information:
TACE -Transarterial chemoembolisation
Chemotherapy is injected into the hepatic (liver) artery that supplies the liver tumor. In chemoembolization, additional material is injected to block (embolize) the small branches of the hepatic artery.

The procedure is most often done in the radiology department under either sedation or local anaesthetic.

The following codes have been suggested;
35321-05 [768] Transcatheter embolisation of blood vessel, abdomen
35317-00 [741] Percutaneous peripheral arterial or venous catheterisation of thrombolytic or chemotherapeutic agents by continious infusion
35320-00 [741]  Open peripheral arterial or venous catheterisation of thrombolytic or chemotherapeutic agents 

Search Details: VICC #1901
http://www.medicinenet.com/chemo_infusion_and_chemoembolization_of_liver/article.htm
http://en.wikipedia.org/wiki/Transcatheter_arterial_chemoembolization

Response:
VICC considers it is appropriate to assign two codes for transarterial chemoembolisation (TACE) - one for the embolisation and one for the administration of the chemotherapeutic agent.  

VICC agrees that the correct code for the embolisation is 35321-05 [768] Transcatheter embolisation of blood vessel, abdomen.


Query Text:
Please advise on how to code the following scenario.  Patient was admitted into hospital for a removal of a biliary stent.  During gastroscopy it was noted the biliary stent was no longer there.  Should this be coded to:
 Z45.89 Adjustment and management of other  implanted devices.  This groups to Z40Z (WIES 0.2371) or,
 T85.5 Mechanical complication of gastrointestinal prosthetic devices, implants and grafts with appropriate Y codes (because stent has moved?) Grouping to X63B (WIES 0.1994)

Response:
As per the advice in query #1714 published in the August 2002 ICD Coding Newsletter, the correct diagnosis code to assign for removal of biliary stent is Z46.8 Fitting and adjustment of other specified devices by following Index entry:
Adjustment
...
-device (related to) NEC Z46.9 
...
--specified NEC Z46.8

This code should be assigned as the admission was for the removal of the stent even if the stent could not be found.

T85.5 Mechanical complication of gastrointestinal prosthetic devices, implants and grafts is not appropriate in this scenario as there is no documentation to support a complication of a device, that is there is no documentation of displacement or malposition or other complication of the stent.


Query Title:
Crush # at L4 with moderate central canal stenosis

Query Text:
57 year old patient admitted with lower back pain and diarrhoea.  Patient had a fall 3 weeks prior.  
Discharge summary states: Crush # at L4 with moderate central canal stenosis.  

MRI performed - Conclusion: 
1. Crush fracture at L4 with moderate central canal stenosis at L3/L4 and minor central canal stenosis at L4/L5. 
2. Enhancing anterior epidural thickening, posterior L4 vertebral body is probably a combination of extruded disc material and haematoma.  The differential of superimposed vertebral osteomyelitis and epidural abscess is thought unlikely if there are no infective clinical symptoms.

Doctors state in the progress notes that the patient has cord compression/nerve root compression.  The patient is experiencing back pain only (no paralysis, decreased sensation etc).

Suggested codes: 
S34.1 Other injury of lumbar spinal cord [conus medullaris]
S34.2 Injury of nerve root of lumbar and sacral spine
S34.74 Functional spinal cord injury, L4
S32.04 Fracture of lumbar vertebra, L4 level
plus external cause codes. Are these the correct codes to use?  Should I also code the canal stenosis, M48.06 Spinal stenosis, lumbar region?

Search Details: 
ACS 1915 Spinal (cord) injury (includes traumatic paraplegia and quadriplegia)

Response:
Following ACS 1915 Spinal (cord) injury (includes traumatic paraplegia and quadriplegia) VICC agrees with the following codes you have assigned:
S34.1 Other injury of lumbar spinal cord [conus medullaris]
S34.2 Injury of nerve root of lumbar and sacral spine
S32.04 Fracture of lumbar vertebra, L4 level

ACS 1915 and the Tabular instruct the coder to also code the functional level of spinal cord injury.  As there is no documentation of functional level of injury provided in the query, VICC considers that S34.70 Functional spinal cord injury, lumbar level unspecified is the appropriate code to assign.

As this is a traumatic injury, it is not appropriate to assign M48.06 Spinal stenosis, lumbar region unless it meets ACS 0002 Additional diagnoses itself.


Query Text:
The Transpyloric Shuttle (TPS) is a non-surgical, non-pharmacologic weight-loss medical device that is endoscopically delivered and removed from the stomach. The TPS is designed to self-position across the pylorus and create an intermittent obstruction to outflow that may result in delayed gastric emptying. Slowing gastric emptying may enable an overall reduction in caloric intake by helping the subject feel fuller sooner (early satiation) and/or feel full longer (prolonged satiety/reduced hunger).

One of our sites has currently started performing this procedure. Can you please direct us to what the appropriate procedure codes are?

Response:
VICC advises that in the absence of a procedure code for insertion of a transpyloric shuttle you can only code the gastroscopy.  

VICC is aware of possible changes to Block 889 Procedures for morbid obesity so you may wish to submit a public submission to NCCC for creation of a new procedure code for transpyloric shuttle.


Query Title:
ACS 1908 Laceration with nerve and tendon damage

Query Text:
ACS 1908 Laceration with nerve and tendon damage

We have differences in opinion on how this standard is applied.  Our question is in regards to the paragraph:
Open wound with arterial and nerve damage
The standard states: 'The overriding factor in a vascular injury is the potential of limb loss or compromise.  In these instances where arterial and nerve damage may occur together, priority should be given to sequencing arterial damage first followed by nerve damage, followed by laceration.  Where there is no potential for loss of limb, yet both nerve and artery damage have occurred, the clinician should be consulted as to the correct sequencing.'

1. When a patient is admitted with arterial and nerve damage, can we assign the arterial damage as principal diagnosis? (i.e default to artery injury as the principal diagnosis) Or do we need documentation in the record that there is potential for limb loss in order to routinely assign the arterial damage first if nerve damage is also present?

2.  We often query cases with our clinicans to ascertain if the arterial damage has the potential for limb loss.  In the majority of cases the answer is no.  Does this mean that if there is no potential for limb loss we cannot assign the arterial injury first and have to code the nerve injury as the principal diagnosis?

Response:
ACS 1908 Laceration with nerve and tendon damage under section 'open wound with arterial and nerve damage' provides advice on sequencing when there is documented potential for limb loss or compromise.  When there is no documented potential for limb loss or compromise the standard advises coders to consult with the clinician for correct sequencing.

VICC advises that if you are unable to consult a clinician, code as the principal diagnosis the first mentioned diagnosis on the discharge summary as per advice in ACS 0001 Principal diagnosis under section 'two or more diagnoses that equally meet the definition for principal diagnosis'.


Query Text:
Patients are admitted as day cases to our Medical Day Unit for IV Vitamin K administration to reverse their warfarin in preparation for surgery in a subsequent episode.  Can you please advise the appropriate diagnosis codes to assign:

PDx  Condition necessitating the subsequent procedure
ADx  Z51.4 Preparatory care for subsequent treatment, NEC
Adx  Z92.1 PHx use of anticoagulants

OR

PDx  Z51.4 Preparatory care for subsequent treatment, NEC
Adx  Z92.1 PHx use of anticoagulants

VICC query #2402 refers to 'a patient admitted for anticoagulant stabilisation prior to surgery to be performed at another hospital' we are not sure whether this advice can be applied to scenarios where the procedure is subsequently performed at the same hospital.

Response:
VICC advises that the correct diagnosis codes to assign for the case cited are:
Z51.4 Preparatory care for subsequent treatment, not elsewhere classified
Z92.1 Personal history of long term (current) use of anticoagulants

Query #2402 Anticoagulation therapy pre and post surgery is applicable to your scenario because code assignment for preparatory care episodes does not change depending on which hospital the subsequent procedure is performed.

As this episode is not for treatment of the condition, it is not appropriate to assign a code for the condition as principal diagnosis.


Query Text:
When a patient who is paraplegic or quadriplegic is admitted into our organisation we only assign paraplegia/quadriplegia, subsequent phase when it meets the definition of additional diagnosis; as per ACS 1915 Spinal (cord) injury (includes traumatic paraplegia and quadriplegia).

"If a patient with paraplegia/quadriplegia is admitted to a hospital/facility for treatment (eg neurogenic bladder), and the paraplegia/quadriplegia meets the definition of an additional diagnosis, assign code G82.- Paraplegia and tetraplegia and other conditions as appropriate…"

However, it has been brought to my attention that other organisations code paraplegia or quadriplegia all the time, even when it does not meet additional diagnosis because they are following the example 3: 
Urinary tract infection. Incomplete paraplegia at C5 level as a result of MVA 5 years ago.

N39.0 Urinary tract infection, site not specified
G82.26 Paraplegia, unspecified, incomplete, chronic
T91.3 Sequelae of injury of spinal cord
Y85.0 Sequelae of motor vehicle accident
Y92.49 Unspecified public highway, street or road

In the above example, I cannot see where the paraplegia meets additional diagnosis, nothing was done for the patient and UTI was not linked to the paraplegia.  Is this an error in the books or should code paraplegia or quadriplegia in all admissions?

Response:
VICC advises that you are correct to follow the advice in ACS 1915 Spinal (cord) injury (includes traumatic paraplegia and quadriplegia) and only assign paraplegia/quadriplegia, subsequent phase when it meets the definition of additional diagnosis.  Examples in the standards simply demonstrate the use of codes; they do not replace the coder's obligation to make a decision about which conditions meet criteria for coding.  Example 3 in ACS 1915 illustrates the correct code assigment for paraplegia, subsequent phase.

You may wish to consider submitting a public submission to NCCC suggesting improvements to ACS 1915 Spinal (cord) injury (includes traumatic paraplegia and quadriplegia).


Query Title:
Chronic Kidney Disease with glomerulosclerosis

Query Text:
When a patient is admitted into hospital with CKD and the patient has a past history of HT and the underlying condition of CKD is glomerulosclerosis, how do we code this?

N18.- Chronic Kidney Disease, stage -
I10   Hypertension (as per ACS 1438, code also code)
N26   Glomerulosclerosis (coding underlying condition as per ACS   1438)
DRG L60C Renal Failure W/O catastastrophic or Severe CC- WIES 1.0714

Or do we follow the index:
Glomerulosclerosis (see also Sclerosis, kidney) N26
and code:
I12.9 Hypertensive Kidney Disease without kidney failure (or I12.0)and
N18.- (CKD stage 1-4)

Sclerosis, sclerotic 
-kidney N26 
--with 
---hypertension (see also Hypertension, kidney) I12.9 
DRG L67B Other Kidney and Urinary Tract Diagnosis W/O Cat. or Severe CC- WIES 0.6004

However when coding option 2 there is an includes note which states 'Includes: any condition in N00–N07, N18.-, N19 or N26 due to hypertension'.  Does this mean that there needs to be documentation that glomerulosclerosis is due to the hypertension or should we be following the index?

Response:
VICC believes that the note at I12 Hypertensive kidney disease means that there needs to be documentation that the glomerulosclerosis is due to the hypertension.  

Therefore whilst the Index may lead you to I12, if you do not have documentation of a causal relationship between the hypertension and the kidney disease, following the advice in ACS 1438 Chronic Kidney Disease which says '...Where hypertension is documented in the presence of CKD assign I10 Essential (primary) hypertension, as an additional diagnosis, except where a causal relationship has been clearly documented, for example, hypertensive kidney disease...' the correct codes to assign are:
N18.x Chronic Kidney Disease, stage -
I10   Essential (primary) Hypertension 
N26  Glomerulosclerosis


Query Title:
Excision of heterotopic ossification post total hip replacement

Query Text:
Patient admitted for excision of 'heterotopic ossification post THR'.  If you look up 'heterotopic' in the disease index it takes you to 'congenital malposition'.  If you look up 'ossification' there is no suitable option to select.

We have coded this to:
T84.8 complication due to ortho device
M89.85 (this code includes post-traumatic subperiosteal ossification but looked up 'disorder, bone, specified type NEC' to get there).

Are we able to bypass the look-up for heterotopic given that this is an acquired condition?

How do we code the excision? Excision lesion bone/soft tissue? Or exostosis?

'a large heterotopic bone block was found firmly attached to the proximal femur and the anterior aspect of the trochanteric region. Another block of bone found in the soft tissue anterior to the trachanteric and neck region of the hip. All heterotopic masses were excised.'

Search Details: 
http://en.wikipedia.org/wiki/Heterotopic_ossification

Response:
As per advice in query #1803 Heterotopic bone published in the November 2002 ICD Coding newsletter, the Index entry for 'heterotropic' does not provide for this condition and the term 'ossification' should be used as the Index lead term.  When the site is not listed under 'ossification', look up Index lead term 'disorder' by site for the appropriate diagnosis code.  

ACS 1904 Procedural complications should not be applied unless you have documentation supporting a complication of surgery.

For the excision VICC suggests assigning 48424-04 [1483] Ostectomy of proximal femur following Index entry Ostectomy, femur, proximal for the excision of bone from the proximal femur and 90572-00 [1563] Ostectomy, not elsewhere classified by following index entry Ostectomy, bone, NEC for excision of bone from soft tissue.


Query Text:
Please advise on how to code the following scenario:  Patient admitted into hospital with vasculitis, patient has a past history of CKD and hypertension both treated in this admission.  According to ACS 1438 Chronic Kidney Disease page 202, an assumption is made that vasculitis is also known as renovascular disease. Refer to the following: 

Common causes of chronic kidney disease include:
•glomerulonephritis
•diabetes
•hypertension
•renovascular disease – eg atherosclerosis, vasculitis

In this case should all patients who have vasculitis with CKD and HT be coded to the following:
I12.- with appropriate CKD code if required.

This groups to L67B- WIES 0.6004 or should we code this to:
I77.8 Vasculitis in Kidney
N18.- CKD
I10 HT

This groups to F65A -WIES 0.4269

Response:
VICC's interpretation of the information in ACS 1438 Chronic Kidney Disease is that vasculitis is one of the listed causes of renovascular disease, therefore a patient with vasculitis does not necessarily have renovascular disease.

If the patient did have renovascular disease it has to be documented as the cause of CKD in order to assign a code from I12 Hypertensive kidney disease.

Based on the information in the query there is no evidence that the vasculitis is of the kidney so VICC considers the correct code to assign is I77.6 Arteritis, which is the default at Index entry term 'Vasculitis'.  If it is determined the vasculitis is of the kidney you can assign I77.8 Other specified disorders of arteries and arterioles by following Index entry Vasculitis, kidney.


Query Text:
According to Seventh edition of ICD-10-AM, lung infection is coded to J18.9 Pneumonia, unspecified.

Infection, infected (opportunistic) 
-lung (see also Pneumonia) J18.9  
--atypical mycobacterium A31.0 
--tuberculous (see also Tuberculosis, pulmonary) A16.2 
--virus — see Pneumonia, viral 

However, when referring back to the Sixth edition, infection of lung was coded to J98.4 Other disorders of lung

Infection, infected (opportunistic)
-lung NEC J98.4 
--atypical mycobacterium A31.0 
--tuberculous (see also Tuberculosis, pulmonary) A16.2 
--virus — see Pneumonia, viral 

Is this an error in the Seventh edition or has the code for infection of lung now been altered?

Response:
VICC advises that the change was intentional for Seventh Editon.  It is part of the WHO updates and details can be found in the Seventh Edition education material 2010 under the heading WHO-URC Updates - Trieste 2007 on page 187.


Query Title:
Principal diagnosis selection in same day endoscopy cases

Query Text:
Can the VICC please give us a hierarchical decision on where the Principal Diagnosis selection should be taken from in same day endoscopy cases?

Our organisation takes the reason for admission to have an endoscopy (and therefore the PDx in cases where the indication for endoscopy is not linked in the ‘operative/preliminary diagnosis’ section of the endoscopy report) from the request form which is filled out by the clinician (when there is no referral letter). However in a recent audit, it was brought to our attention that we should be taking the reason for admission from the actual endoscopy report ‘Indication’ section instead. Is this correct? We feel that this is not always accurate, as treating clinicians are able to select the ‘Indication’ for endoscopy from a drop-down menu, which can be misleading and inaccurate and often it is a different ‘indication’/ diagnosis from the referral letter/ request form.

e.g. 1.  A patient is admitted for “Screening Colonoscopy, Family Hx”, as documented on the ‘Indications’ section of the endoscopy report, however the request form states “+ve faecal occult, screening for CRC, Family Hx”.  In this case we would code the R19.5 Other faecal abnormalities   rather than Z12.1 Special screening examination for neoplasm of intestinal tract  as the Principal Diagnosis. Is this correct?

Please advise whether there is a hierarchy for principal diagnosis selection or whether one can be developed for these types of scenarios and whether this would also apply for same day angiograms.

It was also brought to our attention when a patient is admitted for investigation of their Anaemia and the “operative/preliminary” diagnosis states “oesophagitis” we should code the “oesophagitis” as principal diagnosis as per VICC query 2444  “Principal diagnosis in same day patients when operation form has an 'operative diagnosis”'.  However, we feel this is incorrect as “oesophagitis” does not necessarily cause anaemia and do not feel that a ‘causal link’ has necessarily been established, just because there is a condition in the ‘preliminary/ operative diagnosis section on the endoscopy report.  Please advise whether we are correct to code anaemia as principal diagnosis and oesophagitis as additional diagnosis.

If we are to code the oesophagitis as the principal diagnosis in these cases (therefore assuming a link has been made), can you please confirm that in all endoscopy cases, we should be selecting the principal diagnosis from the ‘preliminary/ operative diagnosis’ on the endoscopy report; assuming that there is always a causal link provided due to the documentation of a condition in the ‘preliminary/ operative diagnosis’ section; provided of course that there has been no clear documentation that there is no causal link between the indication and operative/ preliminary diagnosis.

Response:
VICC advises that there is no hierarchy on where the principal diagnosis selection should be taken from in same day endoscopy cases when a discharge summary is not present.  Coders should first look for a preliminary or operative diagnosis and regard this as the principal diagnosis in the absence of subsequent information.  If there is no preliminary or operative diagnosis documented coders should then use the rest of the medical record for a diagnosis for example, a referral letter.

Where there is a discrepancy between the referral letter and the indication on the endoscopy report (and there is no documented operative diagnosis), consult the clinician for clarification.  

With regard to patients admitted for investigation of their anaemia, when the clinician has documented an operative diagnosis, this in itself represents a causal link and therefore a code for this condition must be assigned as the principal diagnosis.  

VICC cannot provide a directive to always use a specific form in the medical record to assign the principal diagnosis when a discharge summary is not present because as mentioned above, the whole medical record must be used.


Query Title:
Insertion of brachytherapy applicators for cervical and uterine brachytherapy

Query Text:
Can the VICC please confirm what code/s should be used for insertion of brachytherapy applicators for cervical and uterine brachytherapy.

We are seeing an increasing amount of patients being admitted for 'Insertion of Brachytherapy Applicator (Tandem and Ovoids)' under cerebral anaesthetic in theatre, without actually having the brachytherapy in that theatre visit. The patient then goes back to theatre at another time, to have the HDR brachytherapy performed.

We understand that 'Brachytherapy planning' has an includes note for 'applicator intracavitary', however this is specifically for Low Dose Rate (LDR) brachytherapy not HDR, as applies to these cases.

Response:
VICC considers that insertion of brachytherapy applicator is synonymous with brachytherapy planning, therefore it is appropriate to assign a brachytherapy planning code by following index entry Planning (of), brachytherapy (simple).  

For the case cited the correct code to assign is 15536-02 [1799] Brachytherapy planning, complex as the patient is receiving high dose rate brachytherapy. Whilst there is no includes note at this code for 'applicator intracavitary', includes notes are not exhaustive. Ttherefore the code can still be assigned in your case.


Query Text:
Can you please provide advice on the appropriate code selection for a new procedure being performed at our hospital called Renal Denervation to treat patients with Refractory Hypertension?  If we look up denervation in the index, the only options are for facet or spinal facet.

The definition we found for the renal denervation procedure is as follows: 
A brief catheter-based procedure can safely ablate renal sympathetic nerves and may provide persistent blood-pressure reduction.  Renal sympathetic efferent and afferent nerves are crucial for the initiation and maintenance of systemic hypertension. The nerves lie within and immediately adjacent to the wall of the renal artery. The catheter-based system uses radiofrequency (RF) ablation to disrupt renal sympathetic nerves without affecting other abdominal, pelvic, or lower-extremity innervations.  During the procedure, the tip of the catheter is directed into the distal renal artery and 2 minutes of RF energy is applied.  The tip is withdrawn, circumferentially rotated within the artery, and a further 2 minutes of energy is applied, and so on all the way back through the renal artery, so in the end there's usually about 4 to 6 applications of the RF energy.
An example of an operation report is as follows: 
RENAL SYMPATHETIC DENERVATION REPORT
HISTORY
53 year old man, history of resistant hypertension, allergy or inability to take multiple other medications due to side effects.  Ongoing severe hypertension.   
PROCEDURE
Renal sympathetic denervation was performed using a 6Fr IMA 55cm guide with an Ardian RF catheter.  Renal angiography was performed bilaterally, GTN given.  Multiple RF ablations were then performed in both renal arteries with a good technical result achieved.   
A 6Fr angioseal was used to close the right femoral.
CONCLUSION
Successful renal sympathetic denervation application procedure.

The title of these reports may read as 'Renal Sympathetic Ablation' or 'Renal Sympathetic Denervation'.
We have discussed the appropriate code selection with our director of CCU who performs this procedure and we selected the following codes to be most appropriate: 

39323-00 [72] Other percutaneous neurotomy by radiofrequency
and 
90222-00 [720] Other procedures on arteries

We followed the index look up:
Ablation
- nerve — see also Neurotomy 
Neurotomy 
-   peripheral 39324-01 [74] 
- - percutaneous, by 
- - - radiofrequency 39323-00 [72] 

90222-00 [720] Other procedures on arteries was selected to account for the catheter being directed into to the distal renal artery and the radiofrequency ablation energy being applied through the renal artery to the parallel renal nerve.

Response:
VICC agrees with the assignment of 39323-00 [72] Other percutaneous neurotomy by radiofrequency for the procedure cited in the query because the procedure is percutaneous as the catheter is inserted through the skin via an angiogram. 

However, VICC considers that 90222-00 [720] Other procedures on arteries should not be assigned because the catherisation is the operative approach.

Note Index entry update Denervation/renal (artery) percutaneous, by radiofrequency (endovascular) (transluminal) 39323-00 [72].


Query Text:
How do we determine whether a condition is within a nurse's discipline as per the Introduction to the 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. 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 all agree that nurses are clinicians, but the question that keeps coming up is what is relevant to their clinical discipline and therefore where does one draw the line?  

For example, nurse documents hypokalaemia (or equivalent, e.g. 'down arrow' K+) and the patient is given Slow K; nurse documents UTI and the patient is commenced on antibiotics.

We could code potentially anything from nursing documentation that is able to be backed up by an investigation report and is treated (e.g. pneumonia, atelectasis, CCF, CKD, hypokalaemia, UTI etc) - but is that right?   

Many coders state that as nursing staff cannot initiate treatment for such conditions then medical documentation is required to back it up. But they would code from a nursing wound consultant who can ‘prescribe’ dressings, or from nursing notes for other treatment such as Nilstat oral drops or Canestan vaginal cream for thrush, e.g. non S4 treatment.

I have heard from colleagues interstate too that this is an issue for them also.

Could VICC/NCCC please advise how we determine whether a condition is within a nurse's discipline?

Response:
VICC considers that if a clinician has documented a condition, coders should trust that the clinician has documented appropriately to his or her discipline.

However VICC acknowledges that the sentence …'in order to assign a code associated with a particular clinician's documentation, the documented information must be appropriate to the clinician's discipline' is difficult to apply and causes confusion and will submit a public submission to NCCC asking that the sentence is reviewed.

For Tenth Edition advice refer to #3290 - VICC Query #2752 Coding from nursing documentation retired published in the 2017-18 March VICC queries database.


Query Text:
Patient presents with a diagnosis of strain to ankle muscle from fall. By following the index you are presented with:

Strain — see also Sprain 
- muscle M62.6- 
-- traumatic — see Sprain, by site 

At this point, what is considered to be the 'site'. The muscle or the ankle? 

Sprain
-ankle S93.40 
or
Sprain
-muscle — see Injury, muscle 

Injury 
-muscle 
--ankle (level) S96.9
 

3M Codefinder assumes the 'site' is the muscle and follows the second pathway. 

Search Details: 
ACS 1921 Sprains and Strains

Response:
VICC advises that the site is considered to be the muscle as it describes which part of the ankle has been injured.

Therefore the correct Index entry to follow is:
Sprain
-muscle — see Injury, muscle 
and 
Injury 
-muscle 
--ankle (level) S96.9
to assign S96.9 Injury of unspecified muscle and tendon at ankle and foot level.  

This is supported by the excludes note: 'Excludes: sprains and strains of joint capsule (ligament)' at S93 which directs the coder to S96 for sprains and strains of other parts of the ankle.


Query Title:
When does precipitate labour meet ACS 0002 Additional diagnoses

Query Text:
Is it appropriate to assign the diagnosis code for Precipitate Labour (O62.3) in cases where a lady is GBS positive and would, under any other circumstances, have received prophylactic antibiotic coverage because of her GBS status but couldn’t because her labour was precipitate and there simply was not enough time to administer them?

Some coders believe that this diagnosis (precipitate labour) has altered the mother’s care plan and it can therefore be coded whereas others cannot see how the condition has met the specific criteria in ACS 0002 (as it is the baby who would receive extra care and/or monitoring if this was the case, not the mother.)

Search Details: 
ACS 0002 Additional Diagnoses

Response:
If it is clearly written that the mother did not receive prophylactic antibiotics because of the precipitate labour then VICC considers that the precipitate labour meets dot point 1 in ACS 0002 Additional diagnosis and is therefore coded.  

Without this documentation you would need to seek clinician clarification as there can be other reasons that antibiotics are not given.


Query Title:
Is hepatitis C cirrhosis advice applicable to hepatitis B cirrhosis

Query Text:
Should the advice given for Hepatitis C Cirrhosis, NCCH 10-AM Commandments Volume 17 Number 1, be applied to Hepatitis B Cirrhosis?

Scenario: patient admitted with acute hepatic encephalopathy in a patient with cirrhosis of the liver secondary to HBV. 

Acute hepatic failure excludes viral hepatitis (B15 – B19).

Response:
Whilst the Coding Matters (17:1) article is titled Hepatitis C cirrhosis the article says "cirrhosis of the liver is a manifestation of chronic viral hepatitis...".  VICC interprets this to mean that the advice is applicable to all types of chronic viral hepatitis.


Query Text:
We are concerned that the published NCCC advice from Q&A June 2012  “CVA deficit of facial droop” is incorrect. 

We have followed this up with the neurologists at our hospital who do not agree with the advice provided. 

They believe that facial droop in the setting of a CVA would be facial weakness with dysarthria/ visual disturbance rather than hemiplegia.  They also informed us that primary facial droop without a CVA would be considered a bells palsy.

By definition: 
monoplegia n. Complete paralysis of a single limb, muscle, or muscle group
Hemiplegia n. (Medicine / Pathology) paralysis of one side of the body

Thus can we reconsider the advice instructing coders to use hemiplegia for facial droop?

Search Details: 
NCCC Q&A June 2012 “CVA deficit of facial droop”
http://www.thefreedictionary.com
Clinical Advice from Director of Neurosciences and Continuing Care at our hospital

Response:
VICC referred this query to ACCD for further consideration.  ACCD provided the following advice:

There are no codes in ICD-10-AM to specifically classify facial droop following a cerebrovascular accident (CVA); therefore, G81.- Hemiplegia was previously determined to be the most appropriate code within the constraints of the current classification.

G51.0 Bell’s palsy (also known as facial palsy) is not an appropriate code as the mechanism for Bell's palsy is not stroke. It is a disorder of the seventh cranial nerve (facial nerve) thought to be triggered by a virus or other infection with significantly different treatment to that of facial droop following a CVA.

ACCD will consider improvements to the classification of facial droop following CVA for a future edition of ICD-10-AM.


Query Text:
Patient admitted for an elective DSA of legs for a chronic leg ulcer. The DSA showed minor disease, and a discharge letter said that the minor PVD wasn't the cause of the ulcer, and was likely caused by old age and fragile skin. 

We coded L97 Ulcer of lower limb, not elsewhere classified and relevant DSA codes, but the auditor felt we should code I70.23 Atherosclerosis of arteries of extremities with ulceration. We felt that as the discharge letter states minor PVD not explaining the ulcer, we didn't need to code the I70.2x code. 

Can the committee please provide advice on the correct coding of the above scenario?

Response:
VICC advises that if the documentation states that the PVD is not the cause of ulcer, it is not appropriate follow Index entry 'Arteriosclerosis, arteriosclerotic, extremities, with ulceration' to assign I70.23 Atherosclerosis of arteries of extremities with ulceration for the scenario described above.

VICC agrees with the enquirer that for the case cited the correct principal diagnosis is a code from L97 Ulcer of lower limb, not elsewhere classified.


Query Text:
At a recent external coding audit, we were advised to include 30566-00 [895] Resection of small intestine with anastomosis when we code: "Closure of Ileostomy", where the operation report says a small bowel resection was performed. We had assumed that a portion of the ileum would be resected to enable the two segments of bowel to be rejoined. 

From searching the internet, it seems that resecting a portion of the bowel is inherent in the ileostomy reversal procedure. Below are two sample operation reports for your reference: 

OPERATION ONE: Closure of loop ileostomy with small bowel resection and ileo-ileal anastomosis, repair of parastomal hernia. PREOPERATIVE NOTE: This woman had had a rectal cancer managed by an ultra low anterior resection with a covering loop ileostomy. A Gastrografin enema and direct inspection of the anastomosis had revealed an intact anastomosis without contrast extravasation. There was no stricturing. OPERATIVE DETAILS: Under general anaesthesia the patient’s abdomen was prepped and draped to expose the stoma. An elliptical incision was made centered on the stoma and then the ileostomy mobilized from the surrounding tissue. In performing the mobilization a large parastomal hernia was encountered. The loop ileostomy was mobilized from the parastomal hernial sac and then omentum and another loop of bowel freed up from the hernial sac. Once sufficient mobility was achieved a small bowel resection was performed to remove the loop ileostomy and at the same time a side-to-side stapled anastomosis created with the GIA-80 stapler. The second firing closed the enterotomy and resected the bowel. The staple lines were reinforced with 3/0 PDS. The anastomosis was returned to the abdominal cavity and then the parastomal hernial sac excised. Further adhesions were then removed from the posterior abdominal wall to allow the hernia to be closed in a primary repair using 1 PDS. Once the fascia had been closed the wound was thoroughly irrigated and then the skin closed with interrupted Prolene sutures. 

OPERATION TWO: Closure of loop ileostomy requiring small bowel resection and side-to-side stapled anastomosis. PREOPERATIVE NOTE: This woman had undergone a laparoscopic ultra low anterior resection with a colorectal anastomosis and a covering loop ileostomy. A Gastrografin had revealed an intact and watertight anastomosis and rigid sigmoidoscopy and digital rectal examination revealed a patent anastomosis. OPERATIVE DETAILS: Under general anaesthesia the patient was prepped and draped to expose the entire abdomen. An elliptical incision was made around the stoma and this was then mobilized from the abdominal wall down to the fascia until the peritoneum was entered. Complete circumferential mobilization then occurred allowing delivery of the ileum. The proximal ileum was thickened and mildly distended but appeared healthy. The segment of ileum was then resected and a stapled side-to-side anastomosis created using a GIA-80 blue stapler. All staple lines were reinforced with 3/0 PDS. Some bleeding from the staple line intra-luminally was dealt with by an under-running 3/0 PDS suture prior to a second firing of the stapler which closed the enterotomy and resected the bowel. The dog-ears were then buried and the cross staple line also buried. The anterior staple line was reinforced with 3/0 PDS sutures. At the end of the procedure it was necessary to enlarge the fascial opening to allow the anastomosis to return to the abdominal cavity. This was then closed using 1/0 PDS and 2/0 Prolene used to close the skin with an interrupted vertical mattress suture. 
We are now not sure if the Surgeon documents that a small bowel resection has been performed, we can also assign the code for the resection. We find the Intervention Index slightly confusing: 
Closure ileostomy (without resection) 30562-01 [899] 
- - with restorative proctectomy 32060-00 [934] 
- - following Hartmann's procedure 32033-00 [917] 
- - temporary (covering) (defunctioning) (loop) 30562-00 [899] 

30562-01 has a non-essential modifier (without resection), but when you go down to Closure, temporary ileostomy there is no modifer, so does this mean that it can be with or without resection? We realise that we aren't to use the CMBS item numbers that the Surgeon's apply, but they often seem to not include the extra code 30566-00 [895] even when they specify that a bowel resection was performed in the operation notes. 

Can the Committee please clarify what are the correct codes to assign for Closure of a Temporary Ileostomy, where the operation report states that a resection was also performed? Especially if the clinician can't be sought to clarify, as working in a private hospital makes this difficult. 


Search Details: 
http://www.hcpro.com/HIM-245886-3288/read-colostomy-ileostomy-documention 
http://www.cditalk.com/content/218-colonic-concepts Interventions Index

Response:
This query was originally published in the 2012-13 June Database as follows:

Clinical advice obtained by VICC agrees with the enquirer's research in that bowel resection can be inherent in a closure of a temporary ileostomy, however the bowel resection is not always required and therefore not always performed.  

VICC considers that when bowel resection or bowel excision is documented with closure of a temporary ileostomy, a code can be assigned for the procedure.

Following publication of ACCD Coding Rules on 15 September 2014, the VICC response is superseded by following advice titled Closure of ileostomy with resection:

Q:
Is a separate code required for resection/excision of bowel with 30562-01 [899] Closure of ileostomy with restoration of bowel continuity, without resection as without resection is a nonessential modifier in the index?

A:

30562-01 [899] Closure of ileostomy with restoration of bowel continuity, without resection includes resection of small sections (freshening) (trimming) from the end of the stoma (exteriorised bowel/doughnuts) and distal intestine prior to anastomosis. 

Resection/excision of intestine in excess of this freshening/trimming should be coded in addition to the closure of ileostomy code. This may occur if the diseased section of bowel was not resected prior to creation of the ileostomy or when further pathology is found during the closure procedure. 

Where there is no documentation of further pathology of the bowel requiring resection, a separate code for the resection should not be assigned.


Query Text:
Procedures being performed elsewhere  - there are a number of patients being admitted to this hospital, being transferred to a private hospital for balloon angioplasty with stenting and then transferred back (same day).   They are not contracted.  We are wondering whether or not we should be coding the procedure.  

As per VICC queries #2237 and #2296 the hospital is paying for these procedures, and therefore we are thinking that they should be coded.  Depending on what other procedures are being performed during the episode, coding the stents will change the DRG.

Response:
VICC advises that in accordance with the VAED manual, Section 3: Data definitions, data element Procedure Codes, procedures performed at another hospital under contract to this hospital are recorded by both hospitals (where the episode is admitted by both hospitals).  

If the episode is not a contract episode, the procedure cannot be coded at this hospital as it is coded by the hospital where the procedure was performed.

VICC queries #2296 Coding of CT scans performed off site and #2237 Medical imaging apply specifically to the coding of non admitted procedures performed elsewhere.


Query Title:
ACS 1615 Specific interventions for the sick neonate and parenteral fluid therapy

Query Text:
We would like to seek clarification of the following statement regarding the assignment of intervention codes for parenteral fluid therapy as outlined in ACS 1615 Specific interventions for the sick neonate and parenteral fluid therapy:
“...Should be assigned when used for management of carbohydrate, hydration or electrolyte disorders”.

We have sought clarification from a paediatrician who provided the following information:
IV fluids are used for:
• Carbohydrates - control of blood sugars
• Hydration - in babies not able to tolerate oral feeds or with respiratory distress or other conditions where feeding is not considered safe
• Electrolyte Balance - essentially neonates not able to feed after first day
• Resuscitation - intravenous saline to improve baby's blood pressure or circulation

1. Is documentation of a carbohydrate, hydration or electrolyte disorder and documented administration of parenteral fluid therapy sufficient to suggest the condition was managed, or do you require a direct link provided within the clinical documentation?

2. Is the administration of parenteral fluid for ‘other’ reasons, sufficient to assign a code for parenteral fluid therapy? That is, the fluid could be given to prevent the neonate from developing a carbohydrate, hydration or electrolyte disorder which has not yet developed.  For example, Feeding Establishment  -currently on IV Dextrose 30mls

Response:
VICC’s understanding is that the parental fluid therapy codes were created to inform DRG development and that it is common practice to assign these codes when the intervention is performed.

VICC is aware that in Eighth Edition the NCCC has changed the standard so that the intervention codes sit under the heading of ‘Code always when performed’, however has retained the instruction ‘when used for management of carbohydrate, hydration or electrolyte disorders’.  

VICC therefore does not consider that there must be documentation of carbohydrate, hydration or electrolyte disorders in order to assign the parental fluid therapy codes and therefore supports the assignment of these codes when the intervention is performed.

VICC will send a public submission to NCCC asking that consideration  be given to removing the instruction ‘when used for management of carbohydrate, hydration or electrolyte disorders’.


Query Title:
Arthoscopic decompression of subacromial space

Query Text:
There are includes notes under 48903-00 [1400] Decompression of subacromial space for: 
acromioplasty excision of: 
- acromioclavicular joint 
- coraco-acromial ligament 
- distal clavicle 

The Includes notes under 48951-00 [1400] Arthoscopic decompression of subacromial space only lists: 
- division of coraco-acromial ligament.

Can it be assumed that when the SAD is done via arthroscopy, that all the Includes notes under 48903-00 still apply, as it's only the approach that is different for the SAD?

Response:
ACS 0040 Conventions used in the tabular list of interventions states that an includes note on a procedure code describes procedure components inherent in the code description.  Therefore VICC advises that it cannot be assumed that when the decompression is performed via arthroscopy, that all the Includes notes under 48903-00 [1400] Decompression of subacromial space will apply.


Query Text:
Patient with past history of breast cancer with wide excision and axillary dissection admitted for excision of axillary nodule.

Operation report states that the operation performed was excision biopsy of nodule in axilla.  Body of report states 'incision through medial part of scar.  Lump excised with some surrounding tissue.  ? suture granuloma, ? recurrence.  Small pea shaped nodule.  Closed with 3.0 interrupted vicry and interrupted subcuticular monocryl to skin, steristrips and opsite'.

Histology finds the axillary nodule to be a traumatic neuroma.

Should the procedure code for the excision of the nodule be 31205-00 [1620] Excision of lesion(s) of skin and subcutaneous tissue of other site, as this fits the description of the procedure on the operation report before it was known what the nodule was, or should the procedure code be 39324-09[80] Removal of lesion from superficial peripheral nerve, following the pathway of excision, neuroma etc.

Should the histology results be used to determine the code for the procedure in this case, or should the procedure be coded as per its description, where there was no mention of any nerve.

Search Details: 
ACS 0010 General abstraction guidelines

Response:
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.  

Therefore in the case cited, VICC considers the correct procedure code to assign is 39324-09 [80] Removal of lesion from superficial peripheral nerve.

For Tenth Edition advice refer to #3333 Excision biopsy of nodule in axilla published in the 2017-18 March VICC queries database.


Query Text:
We had twin babies born at our hospital at 24 weeks gestation.   Twin 1 was born in a car in the car park directly out the front of the Emergency Department, the birth was assisted by trained hospital staff.  Twin 2 was born within the Emergency Department.  

We have assumed that because Twin 2 was born within the Emergency Department this is born ‘in hospital (Z38.3).’ 

Could you please clarify if Twin 1 should be considered to be born ‘outside hospital (Z38.4)’ or ‘in hospital (Z38.3)’. We are unsure because of the assistance provided by trained hospital staff.

Response:
VICC considers that because the birth was attended by trained hospital staff on hospital grounds that the appropriate Z code to assign is Z38.3 Twin, born in hospital.  This is also in line with the definition of Setting of Birth, Actual in the Victorian Perinatal Data Collection.


Query Title:
Acute on chronic cholecystitis not with cholelithiasis

Query Text:
Can the Committee please clarify the coding of acute on chronic cholecystitis not with cholelithiasis. When there is a final diagnosis of acute on chronic cholecystitis, can both these codes be assigned? 

There is some confusion here surrounding the advice in 10-AM Commandment Volume 12, number 4 titled Cholelithiasis with acute on chronic cholecystitis which says:
There has been confusion regarding the correct code assignment for this condition as there are no further index entries for the term 'chronic' under the lead term 'Cholecystitis'. 

Classification: 
Only one code K80.0- Calculus of gallbladder with acute cholecystitis is required for this condition. The index pathways are as follows: 

Calculus, calculi, calculous 
- gallbladder K80.2
- - - with cholecystitis (chronic) K80.1
- - - - acute K80.0- Cholelithiasis (cystic duct) (gallbladder) (impacted) (multiple) K80.2
- - with cholecystitis (chronic) K80.1
- - - acute K80.0- 

As the term 'chronic' is a nonessential modifier in the index pathways, the chronic condition need not be coded separately (ACS 0001 Principal Diagnosis, Acute and chronic conditions). 

This advice seems to apply to acute on chronic cholecystitis with cholelithiasis, but if there are no stones detected, can both K81.0 Acute cholecystitis, and K81.1 Chronic cholecystitis be assigned?  Does the committee agree with this: Cholelithiasis with acute on chronic cholecysitis – do not code the chronic cholecystitis. Acute on chronic cholecystitis (w/o stones) – then both the acute and chronic cholecystitis is to be coded.

Response:
VICC agrees to assign a code for both acute and chronic cholecystitis without cholelithiasis.  

This is in accordance with ACS 0001 Principal diagnosis under section Acute and chronic conditions which says:
If a condition is described as both acute (subacute) and chronic and separate subterms exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first.


Query Text:
Could VICC please advise on what to code for a serosal tear which is noticed during surgery and then repaired?

For example, accidental laceration of small bowel serosa with laparosope with subsequent oversewing for repair of the laceration.

We have been advised by clinicians that this is not an injury to the organ itself so we should not code out an injury to the underlying organ. Is this correct? And if so, what would you code instead?

Response:
Original response published in 2012-13 March database:

VICC notes that clinical advice and classification conventions are not always aligned. The classification advice as per the NCCC Q&A titled Intraoperative serosal tear, released 15 April 2011 is that the correct code to assign for a serosal tear which occurs during surgery and is then repaired (thus meeting ACS 0002 Additional diagnosis criteria) is T81.2 Accidental puncture and laceration during a procedure, not elsewhere classified by following Index entry: 

Complications (from) (of) 
- accidental puncture or laceration during procedure T81.2 

As in your scenario the clinician has advised that there is no injury to the organ itself, no additional code is required. 

Following a review of the above response, it has been revised as follows:

VICC notes that clinical advice and classification conventions are not always aligned and despite clinician advice, the NCCC's classification advice is that the serosa is considered to be part of the organ.  

As per the NCCC Q&A released 15 April 2011, the correct code to assign for a serosal tear which occurs during surgery and is then repaired, thus meeting ACS 0002 Additional diagnosis criteria is T81.2 Accidental puncture and laceration during a procedure, not elsewhere classified by following Index entry:

Complications (from) (of) 
- accidental puncture or laceration during procedure T81.2 

In accordance with ACS 1904 Procedural complications an additional code from Chapters 1 to 19 should be assigned to provide further specification of the condition.   

VICC further advises that when no site is documented, an additional code cannot be assigned.


Query Text:
Are you able to provide advice on how to code ERCP with washings?

There is some old NCCH database advice 2189 - ERCP with bile duct washings. It advises the following:
For documentation of 'ERCP with bile duct washing' assign:
30484-00 [957] 'Endoscopic Retrograde Cholangiopancreatography'
90323-00 [973] 'Other procedures on biliary tract'

They also advise that 'The NCCH will consider reviewing codes for brushings/washings for a future edition of ACHI'.

'Brushings' is now an includes note at ERCP, however 'washings' have not been included.

Search Details: 
NCCH Query - 2189 ERCP with bile duct washings.

Response:
VICC will send a public submission to NCCC for consideration of adding an includes note for washings at 30484-00 [957] Endoscopic retrograde cholangiopancreatography [ERCP].

In the meantime, VICC advises that when an ERCP with washings is performed, only the code for ERCP is required because there is no specific index entry for the procedure performed.  This advice is consistent with advice in VICC query #2188 Endoscopic clipping of duodenal ulcers/bleeding vessels published in the 2006-07 March VICC queries database.


Query Title:
ACS 0011 Admission for surgery not performed

Query Text:
We seek clarification on the following scenario in relation to the assignment of the codes Z53.-, which we don’t find is covered in ACS 0011 Admission for surgery not performed.

A patient admitted for a procedure is taken to theatre and anaesthetised.  Before the procedure is commenced (knife to skin) the patient becomes unstable and the procedure is abandoned.

Are we expected to assign a code from Z53.- in the string of codes to highlight the cancellation of procedure?

Response:
Although the scenario cited is not specifically covered in ACS 0011 Admission for surgery not performed, VICC considers that the surgery was cancelled due to a contraindication and it is therefore correct to assign Z53.0 Procedure not carried out.


Query Title:
Z01.8 Other specified special examinations as principal diagnosis

Query Text:
I refer to the following advice that was included in CodeXpert Q & A - October 2010 and ask for further clarification:
Coding Matters advice, June 2001
Q: 
Is the following advice in Coding Matters Vol 8, No 1, 10-AM Commandments, Coding same day endoscopy still valid ?If no diagnosis (reason for admission) is recorded in the record and clinical advice is unavailable, assign Z01.8 Other specified special examinations."
A: 
This advice is still valid for ICD-10-AM Seventh Edition. Z01.8 Other specified examinations may be assigned, in the absence of a diagnosis and where a reasonable attempt has been made to establish a diagnosis with the clinician .ACS 0046 Diagnosis selection for same day endoscopy has been flagged for review for a future edition of ICD-10-AM/ACHI/ACS."

In admissions for same day endoscopy where no indication or principal diagnosis has been provided, yet there are finding listed in the report what codes are assigned? (No further clarification can be sought from the treating doctor.)

1. Assign code for findings
Or
2. Assign Z01.8 as the principal diagnosis followed by codes for all findings

Please find example of operation report which highlights these cases.

Response:
In circumstances where there is no provisional or operative diagnosis or indication or symptom documented as the reason for the procedure, and clinician advice cannot be sought, it is correct to assign Z01.8 as the principal diagnosis. 

Findings are coded in accordance with ACS 0046 Diagnosis selection for same-day endoscopy.


Query Title:
Haemorrhoidal artery ligation and recto-anal repair

Query Text:
Patient had a HAL-RAR procedure (Haemorrhoidal artery ligation and recto-anal repair).    

I have used the following procedure codes for this:

Ligation
 - artery
   -- specified site NEC 34106-14 [697]

and

Repair
 - rectum NEC 90313-00 [940]


Could the Committee please advise on the correct coding of the HAL-RAR procedure?

Response:
This query was originally published in the 2012-13 June Database VICC queries database release as follows:

VICC agrees with the codes suggested by the enquirer and also suggests an additional code for the anal repair.  Therefore the correct codes to assign for haemorrhoidal artery ligation and recto-anal repair (HAL-RAR) are:
34106-14 [697] Interruption of other artery
90313-00 [940] Other repair of rectum
32123-00 [938] Anoplasty

Whilst there is code 43963-00 [938] Anorectoplasty via perineal approach, because in the case cited the procedure was not performed via perineal approach or laparotomy, VICC considered that this code was not appropriate and therefore assigned 32123-00 [938] Anoplasty for the anal repair.

Following publication of Coding Rules on 15 December 2014, the VICC response is superseded by the following advice titled Haemorrhoidal Artery Ligation and Rectal Anal Repair (HAL RAR):

Q:
What is the correct code for haemorrhoidal artery ligation and rectal anal repair (HAL RAR) procedure OR transanal haemorrhoidal dearterialisation (THD) with haemorrhoidopexy?
A:
Haemorrhoidal artery ligation and rectal anal repair (HAL RAR), also known as transanal haemorrhoidal dearterialisation (THD) with haemorrhoidopexy, is a minimally invasive procedure to treat haemorrhoids. The procedure usually consists of two components: haemorrhoid artery ligation (HAL) and transanal rectal repair (RAR).

HAL involves the use of a Doppler proctoscope, through which the arteries feeding the haemorrhoid are identified and ligated by placing stitches around the artery. Once all the blood vessels supplying the haemorrhoid have been tied off, the haemorrhoid shrinks and falls off.

The second part of the operation, known as RAR or haemorrhoidopexy, is performed to reduce the prolapse of the haemorrhoid and rectoanal mucosa by placing stitches to pull the haemorrhoid tissue back up into the upper anal canal.

Currently there is no specific code in ACHI for this procedure. Assign 32135-00 [941] Rubber band ligation of haemorrhoids for Doppler guided haemorrhoidal artery ligation (HAL) or transanal haemorrhoidal dearterialisation (THD), following the index pathway:

Ligation
- haemorrhoids (rubber band) 32135-00 [941]
 
If an adjunctive mucosal plication of rectal prolapse (RAR component of the procedure) or haemorrhoidopexy is performed, 32120-00 [929] Insertion of anal suture for anorectal prolapse should also be assigned, following the index pathway:

Repair
- prolapse, prolapsed
- - anorectal
- - - by insertion of anal suture (Thiersch wire) 32120-00 [929]

Improvements to ACHI will be considered for this procedure for a future edition.


Query Text:
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?

Response:
VICC considers the correct code to assign for documentation of functional decline is R53 Malaise and fatigue
following Index entry:
Decline (general) (see also Debility) R53

VICC considers it is acceptable to assign Z74.1 Need for assistance with personal care if documentation supports the assignment of this code, however please note that Z74.1 when assigned as principal diagnosis will generate PRS/2 edit 355 - Invalid principal diag - warning.

We would recommend querying with the clinician if there is an underlying cause for the functional decline if you are in a position to do so.

Note: This query has been superseded by VICC query #3529 Functional decline.


Query Text:
When coding adverse effects of clozapine the index leads to Y47.1 Benzodiazepines causing adverse effects in therapeutic use. Clozapine is an anti-psychotic used for treatment resistant schizophrenia and can have serious side effects such as myocarditis. 

Advice from our Psychiatrist is that this should be classified as an anti-psychotic not a benzodiazepine and that Y49.5 Other antipsychotics and neuroleptics would be more appropriate. The community pharmacist also agrees that clozapine should be classified as an anti-psychotic. The MIMS class for clozapine is antipsychotic agent as per below extract from MIMS Can you please advise if there is an error in the index entry. 
 
Search Details: 
Clozapine Use: Tricyclic dibenzodiazepine derivative antipsychotic. Treatment of schizophrenia in patients intolerant of, or unresponsive to, greater than or equal to 2 other antipsychotics (treatment resistant schi... Dose: Please open Abbreviated PI for Dosage MIMS Class: Antipsychotic agents Drug Interactions Pill Identifier 
submit: submit

Response:
VICC advises that MIMS often classifies drugs according to their therapeutic purpose (indication) whilst ICD-10-AM usually classifies drugs according to class.  Therefore an inconsistency between the two is not unusual and the index should be followed for code assignment.

You may wish to consider submitting a public submission to the NCCC suggesting changes to the classification of clozapine.


Query Title:
Coding of type 2 diabetes with insulin resistance

Query Text:
In regards to VICC #2611 Clarification of ACS 0401 Diabetes Mellitus General classification principles points 3 and 4:

Can you please review the response as my understanding is that E11.72 T2DM with insulin resistance would not be coded as per note on ACS 0401 3. DM and IH with features of insulin resistance regarding hypertension. 

I note that  #2611 was published 2010-2011 June database prior to the July 2012 diabetes changes were implemented, should this query now be retired?   

Search Details: 
ACS 0401 DIABETES MELLITUS AND INTERMEDIATE HYPERGLYCAEMIA  - 1 July 2012

Response:
You are correct in that query #2611 Clarification of ACS 0401 Diabetes Mellitus General classification principles points 3 and 4 published in the 2010-2011 June database has been overriden by the updated ACS 0401 Diabetes mellitus and intermediate hyperglycaemia effective 1 July 2012.  

However as VICC retires queries by edition (not by individual query), #2611 will remain in the database unretired until Eighth Edition is superseded.  As with all advice, new advice overrides old and coders need to be aware of and follow the most current advice.

Note: This query has been retired due to ICD-10-AM edition changes.


Query Title:
ACS 1103 Gastrointestinal (GI) haemorrhage

Query Text:
Could you please provide some guidance re the use of 'with haemorrhage' as per ACS 1103. The wording in the standard is very specific: 'upper GI bleeding', 'ulcer, erosions, varices'; how strictly is this wording to be adhered to?

1) Can PR bleeding be regarded in the same way as upper GI bleeding as per VICC query 2512?
2) Can FOB+ve be regarded in this way also? (Eg indication for colonoscopy is FOB+ve, Operative Diagnosis is diverticular disease, should this be coded as diverticular disease with haemorrhage?)
3) Can any finding be coded to as 'with haemorrhage' as diverticular disease is in VICC query 2512 (eg, it is not an 'ulcer, erosion or varices' specifically)?

We feel ACS 1103 may be worded too specifically if the intent is to apply it to all endoscopy cases where bleeding is present and a finding is documented in the Operative Diagnosis on the Operation Report, as per the example in VICC query 2512. Perhaps ACS 1103 should be looked at for potential re-wording for 8th edition?
 
Search details: 
ACS 1103
VICC query 2512

Response:
VICC notes that ACS 1103 Gastrointestinal (GI) haemorrhage was not applied in VICC #2512 Operative diagnosis and symptom for same day endoscopy to make a link between the PR bleeding and the diverticular disease; the documentation in that query supported a link between the operative diagnosis and the presenting symptom.  ACS 1103 was referenced to provide advice for coding conditions that do not have the 'with haemorrhage' distinction included in the code.

In answer to your specific questions:
1. PR bleeding cannot be regarded in the same way as upper GI bleeding as ACS 1103 Gastrointestinal (GI) haemorrhage differentiates on how upper and lower GI bleeding should be coded.  

2. As FOB detects tiny amounts of blood, it is not the same as haemorrhage, therefore a +ve FOB cannot be coded as a haemorrhage. This is supported by Index entry Positive, faecal occult blood R19.5 Other faecal abnormalities. 

3. No, as noted above there needs to be a causal link made between the finding and the bleeding.  In #2512 this link was made by the documentation, that is, the operative diagnosis was diverticular disease and the symptom was bleeding.   ‘Any finding’ cannot be assumed to be the cause of the haemorrhage.  ACS 0046 and ACS 1103 need to be applied to the documentation used and a decision made as to whether a causal link has been given or implied before assigning a ‘with haemorrhage’ code.

Query #2512 was retired on 1 January 2014.  Please refer to #2880 Principal diagnosis in same day endoscopy cases.


Query Title:
Hepatic encephalopathy with documentation of alcoholic cirrhosis

Query Text:
A patient was admitted with “cirrhosis secondary to ETOH with hepatic encephalopathy”.
Are we able to assume that the hepatic encephalopathy is alcohol related?

Currently depending on whether you assign K72.9 (hepatic encephalopathy) or K70.4 ( alcoholic encephalopathy) DRG assignment is affected. Can the code assignment pleased be clarified for this scenario.
 
Another scenario we have encountered is when a patient is admitted with hepatic encephalopathy with alcoholic and Hep C cirrhosis.
Currently we assign the default of K72.9 as we don’t assume the encephalopathy is due to either the alcoholic or hep C cirrhosis. Please advise the correct code assignment.

Response:
As the case cited does not have clear documentation to support that the encephalopathy is due to the alcohol, VICC suggests to seek clinical clarification.   This is because the Index entry for K70.4 has an essential modifier for alcohol, therefore it cannot be followed without supporting documentation.  

VICC agrees with the codes assigned in scenario two.


Query Title:
Acute thrombosis of aorto bifemoral bypass graft

Query Text:
What is the correct code to use for acute thrombosis of aorto bifemoral bypass graft?

The patient was admitted with an occluded aortobifemoral bypass graft, the original bypass having been performed 19 months previously. A thrombectomy and synthetic patch graft was performed on the grafted section of the artery.

Is the thrombosis considered to be a normal disease progression, and should therefore be coded as:
I74.3  Embolism and thrombosis of arteries of lower extremities,

or is it a complication of the graft:

T82.8  Other specified complications of cardiac and vascular prosthetic devices, implants and grafts.

Note: there is no documentation that the thrombosis is due to or a complication of the graft.

Search Details: 
Thrombosis
- artery
--limb
---lower I74.3

Thrombosis
-due to device, implant or graft
--arterial graft NEC T82.8

Complication 
-graft
--aterial
---specified T82.8

Response:
VICC advises that in accordance with ACS 1904 Procedural complications conditions are coded to procedural complications codes only if the condition or injury is directly related to a surgical/procedural intervention.  

As in the  scenario cited there is no documentation that the condition is directly related to the previous graft, the appropriate code to assign is I74.3 Embolism and thrombosis of arteries of lower extremities.  

Assignment of this code is also supported by the advice in ACS 0941 Arterial disease which says that thrombosis of other arteries should be assigned codes in accordance with the Alphabetic Index of Diseases.


Query Title:
Type 2 diabetes mellitus - steroid induced

Query Text:
Could you please provide guidance on which codes we should be using when there is documentation of T2DM- steroid induced?

At our facility we have used the following codes:

If the patient has T2DM- steroid induced, however the steroid has be weaned, we use E11.- Type 2 Diabetes mellitus with Y42.7 Androgens and anabolic congeners and Y92.22 Health service area to show the underlying cause.

If the patient has T2DM- steroid induced within the current admission we assign E13- Other specified diabetes mellitus
with Y42.7 Androgens and anabolic congeners and Y92.22 Health service area

Please advise if this is correct or whether we should be assigning E11.-, as it seems to be more specific than E13.-

Response:
This query was originally published in the 2013-14 September database release VICC queries database release as follows:

In order to determine the correct code assignment for the statement T2DM - Steroid induced, VICC obtained the following clinical advice:
If a patient has Type 2 diabetes before the commencement of steroid therapy, the correct diagnosis is Type 2 diabetes.  If the patient develops diabetes after induction of steroid therapy the correct diagnosis is steroid induced diabetes.  Therefore the coder will need to clarify with the clinician whether the patient had pre-existing diabetes if it is not clear in the documentation.  Where there is no evidence of pre-existing diabetes and clinician clarification is not possible, default to E13.- Steroid induced.  

VICC supports the assignment of external cause codes for E11.- Type 2 diabetes in cases where the documentation supports that the steroid therapy exacerbated the diabetes. [end of original response]

This advice has been superseded by VICC #3007 Steroid induced Type 2 diabetes which references ACCD advice published in the March 2015 Coding Rules titled E13 Other specified diabetes mellitus.


Query Title:
Principal diagnosis selection for same-day TOE admissions

Query Text:
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 current.

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 Text:
Please clarify the difference between High Flow O2 delivery via nasal cannula and via mask as NIV.

NCCC Q&A Dec 2011 states "When 'high flow', high flow therapy or high flow nasal cannula is documented in the clinical record, assign a code from block 570 Noninvasive ventilatory support..."  Our clinicians tell us that leakage around a mask renders the pressure inadequate to qualify as NIV, however ACS 1006 documents  "via mask" as a method of NIV delivery.

A patient has documented high flow O2 delivered via mask (Humidified mask circuit) at levels specified in Q&A  High Flow Nasal Cannula. Should Non-invasive ventilation be coded?

Search Details:
Management (of) 
- airway 
- - with ventilatory support  see Management, ventilatory support 
... 
- ventilatory support (nonintubated)  see block [570] 

Ventilation 
- noninvasive 
- - mask ventilation (NIMV)  see block [570] 
- - pressure ventilation (NIPV)  see block [570] 

NCCC Q&A Dec 2011  High Flow Nasal Cannula

ACS 1006 Ventilatory Support.

Response:
Original response published in the 2013-14 September Database:

Notwithstanding the clinical advice, from a classification perspective NIV can be delivered by any of the modes listed in ACS 1006 Ventilatory support under heading Noninvasive ventilation (NIV).

Therefore in accordance with the Index entry HFT (high flow therapy), assign a code from Block [570] Noninvasive ventilatory support for documentation of high flow delivered by any of the modes listed in ACS 1006 Ventilatory support under heading Noninvasive ventilation (NIV) regardless of the level of O2 delivered. The NCCC Q&A query titled High flow nasal cannula,which has now been retired, prompted the addtion of Index entries for high flow to ICD-10-AM Eighth edition and may be a useful reference for coders.

Following the publication of the Eighth edition education workshops FAQs part 2,  the original response is superseded by the following advice under heading High flow nasal cannula (HFNC):
Q:
Where high flow therapy is delivered through a mask, is it the same as high flow nasal cannula therapy?
A:
Clinical advice indicates that high flow therapy delivered through a mask is not the same as high flow nasal therapy.

High flow nasal cannula therapy depends on the nasal airways partly sealing the cannula to generate a pressure gradient to improve oxygenation and this cannot be generated with a face mask even if high flow oxygen is administered. Therefore, despite the modalities listed for NIV in ACS 1006 Ventilatory support including mask, high flow therapy must be delivered through a nasal cannula to be coded as non-invasive ventilation.


Query Text:
Could VICC please clarify if documentation of "unable to void" that meets ACS 0002 Additional diagnoses criteria can be coded as urinary retention?

An internet search on "unable to void" gives many references of "urinary retention".  If they are the same thing, does that mean I can use the internet search results to justify coding urinary retention when my documentation only states "unable to void"?

Response:
This query was originally published in the 2013-14 September Database as follows:

Whilst an internet search on 'unable to void' gives references of 'urinary retention', VICC does not consider that the term 'unable to void' is a synonymous term with 'retention'. This is because a patient's inability to void may be caused by other factors such dehydration, spinal injury, being bed bound or the physical environment.  Therefore clinical advice and supporting documentation should be sought before a code for urinary retention is assigned.  

In the absence of clinical advice and in accordance with ACS 0013 'Other' and 'unspecified' codes, VICC considers R39.1 Other difficulties with micturition an appropriate code to assign following Index entry:
Disorder
- micturition NEC R39.1


This query has been updated for Eleventh Edition as follows:

Whilst an internet search on 'unable to void' gives references of 'urinary retention', VICC does not consider that the term 'unable to void' is a synonymous term with 'retention'. This is because a patient's inability to void may be caused by other factors such dehydration, spinal injury, being bed bound or the physical environment. Therefore, clinical advice and supporting documentation should be sought before a code for urinary retention is assigned.

In the absence of clinical advice, VICC considers R39.1 Other difficulties with micturition an appropriate code to assign following Index entry:
Disorder
- micturition NEC R39.1


Query Title:
Fatty Liver and diabetes with insulin resistance

Query Text:
Could VICC please clarify if we have documentation of fatty liver, in the presence of diabetes that we can assign E1x.72? 

There seems to be contradictory statements:
1. Point 3 of the general classification rules in ACS 0401 states to refer to index entries which directs you to assign E1x.72 

2. The description under E1x.72 (features on insulin resistance section) in  ACS 0401, describes a requirement for nonalcoholic fatty liver, which is a nonessential modifier in the index.

Response:
VICC does not consider the statements to be contradictory but acknowleges that the specific terms nonalcoholic fatty (change of) liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) listed in the classification box in ACS 0401 under heading DM and IH with features of insulin resistance can cause confusion.  

As the standard does not preclude the use of the Index, for documentation of fatty liver in the presence of DM it is appropriate to follow Index entry Diabetes, diabetic (controlled) (mellitus) (without complication)/with/fatty liver (NAFLD) (non-alcoholic)  to assign E1-.72. 

Assignment of E1x.72 is also supported by the excludes note at K76.0  Fatty (change of) liver, not elsewhere classified which says 'excludes with diabetes mellitus (E1-.72)'.


Query Text:
Is the advice in the retired VICC query 1967 In-stent restenosis of coronary artery still applicable?

VICC #1967 In-stent restenosis of coronary artery 
Query:
We have a large Cardiology department at our hospital and patients are often discharged with a diagnosis of in-stent restenosis of a coronary artery. Previously, when coding in-stent restenosis that occurred more than 1 month after the original stent insertion, we have assigned only 'I25.11 Atherosclerotic heart disease of native coronary artery', assuming it was a natural progression of the disease. This is supported by NCCH #1532 'Stenosis of a stent of the heart' which states “Where 'restenosis' is documented, with no further clarification of aetiology, the following directions apply: Where the restenosis has occurred within one month of the original procedure, assign a code relating to the complication. Where the restenosis has occurred more than one month after the original procedure, and is not related to a postprocedural complication, assign a code relating to the cardiac condition requiring investigation and/or treatment”. 

But at the HIMAA Education Seminar at Moonee Valley in August this year, the answers to Case 1, which referred to in-stent restenosis of the PDA, included: 
'T82.8 Other complications of cardiac and vascular prosthetic devices, implants and grafts' 
'Y83.1 Surgical operation with implant of artificial internal device' 
'Y92.22 Health service area 

I am now confused about which codes should be assigned. 

Questions: 
1. Could you confirm what codes we should be assigning when re-stent stenosis occurs more than 1 month after the original stent insertion? If it is decided that we should assign T82.8, Y83.1 and Y92.22 in addition to I25.11, please explain the reasoning behind this. 
2. In addition, confirm whether this applies to in-stent stenosis of all arteries eg, renal artery? 

Search Details: 
NCCH #1532 
HIMAA Education Seminar at Moonee Valley in August 2003  

Response:
Question 1 
If there is a cause other than progression of disease documented for an in-stent restenosis, codes should be assigned accordingly. 
Otherwise, when in-stent restenosis occurs in a coronary artery more than one month after surgery, it is correct to follow ACS 0934 Cardiac revision/re-operation procedures, and assign a code for the cardiac condition requiring surgery. 

Patients admitted within one month of the original surgery for a revision or re-operation due to a complication of the initial procedure should have a principal diagnosis relating to the complication. 

Question 2 
This information in ACS 0934 Cardiac revision/re-operation procedures is intended for use for cardiac revision procedures only and does not apply to stenosis of all other arteries (per NCCH query 783).  

Publication Date: 2004-05 First quarter    ICD 10 AM Edition: Fourth edition

Response:
VICC advises that with updates to ACS 1904 Procedural complications that provides advice regarding the relationship between the condition and the intervention, VICC query #1967 In-stent restenosis of coronary artery is no longer applicable.

For documentation of in-stent restenosis of a coronary artery (regardless of the time frame) VICC advice is to follow Index entries Stenosis, coronary (artery) — see Arteriosclerosis, coronary and Arteriosclerosis, arteriosclerotic, coronary artery to assign I25.1-. This is supported by the advice in standards 0940 Ischaemic heart disease and 0941 Arterial disease.

VICC does acknowledge that there are some inconsistencies in standards 0940 Ischaemic heart disease and 0941 Arterial disease as well as confusion caused by the timeframe advice in ACS 0934 Cardiac revision/reoperation procedures and will send a public submission to NCCC asking that the three standards are reviewed in the context of ACS 1904 Procedural complications.


Query Text:
Could VICC please advise how to code a faecal transplant. We have had an influx of admissions to our hospital for patients undergoing a faecal transplant. Patients will undergo a faecal transplant usually to treat C. difficile Colitis, other forms of Colitis or IBS.

Faecal transplants (FMT) involves the transplantation of healthy faecal bacteria from a healthy donor, into the patient. This is done via gastroscopy.

Currently, as there is no code to capture this, we are coding the transplant component to 90560-00 [1552] Administration of other agent into soft tissue, NEC (with the addition of the gastroscopy code) as 90307-00 [903] Other procedures on small intestine takes this to a surgical DRG.

Response:
This query was originally published in the 2012-13 June VICC queries database release as follows:

VICC advises that because the faecal transplant is performed via a gastroscopy and there is no specific Index entry for procedure performed, that only the gastroscopy is coded in these cases.

Hospitals can assign an additional code if they wish to capture this activity internally but this additional code needs to be suppressed from submission to PRS2.

VICC will send a public submission to NCCC asking that consideration be given to an includes note under gastroscopy for this procedure or a new endoscopic code.

Following publication of ACCD Coding Rules on 15 March 2014 the VICC response is superseded by the following advice titled Faecal microbiota transplantation (FMT):
 
[Q:  What is the correct procedure code to assign for faecal microbiota transplantation?
A:  Faecal microbiota transplantation (FMT), also known as faecal bacteriotherapy, faecal transplant, intestinal microbiota transplantation (IMT) or human probiotic infusion, is an alternative treatment for patients who have failed standard treatment for Clostridium difficile infections (CDI). The procedure involves collecting a stool sample from a healthy donor, processing it into a liquid suspension and instilling it into the gastrointestinal
tract via various routes including nasogastric or nasoenteric tube, gastroduodenoscopy, flexible sigmoidoscopy, colonoscopy or enema. Instillation by colonoscopy to caecum is the preferred method for the vast majority of FMTs based on the results of published studies.

The correct code to assign for FMT is:
92075-00 [1895] Gastrointestinal tract instillation, except gastric gavage

An additional code should also be assigned where the microbiota installation is delivered via an endoscope as per ACS 0023 Laparoscopic/arthroscopic/endoscopic surgery. For example:
32090-00 [905] Fibreoptic colonoscopy to caecum

The classification of FMT will be reviewed for a future edition of ACHI.


Query Text:
Can the Committee please give advice on coding the following scenario that is common in our hospital:

Patient admitted with acute exacerbation of asthma.  Viral pneumonitis is documented in addition to the asthma.  

ICD-10-AM classifies viral pneumonitis as viral pneumonia.  However, our clinicians have advised us that viral pneumonitis is an inflammation of the lung tissue and in conjunction with asthma it is a symptom rather than a condition in its own right.  They have stated that in this circumstance and with the absence of lung consolidation it is not pneumonia.    

Based on this advice, we have not been coding viral pneumonitis with asthma but have only been coding the asthma.  However, this scenario came up in a recent VAED audit and we were advised not to use 'blanket' rules but to be guided by the documentation and assign a code for the viral pneumonitis in addition to the code for asthma.

Could the Committee please clarify the codes that should be assigned in this situation?

Response:
As you have noted viral pneumonitis is classified to viral pneumonia.  This is because ICD-10-AM is a statistical classification which by definition does not have a unique code for every condition; multiple conditions can be coded using the same code.  

Therefore, notwithstanding the clinical advice that viral pneumonitis is not pneumonia, if the Index leads to the code for viral pneumonia, that is the correct code to assign.

VICC advises that when asthma with viral pneumonitis is documented and both conditions meet criteria for coding, a code for both conditions should be assigned.


Query Text:
The index for pyeloscopy requires an essential modifier for antegrade or retrograde and there is no default code.

Pyeloscopy
- Antegrade - see Nephroscopy 
- Retrograde 36652-00 [1040] 

Pyeloscopies performed at our hospital are often performed with a Retrograde Pyelogram (RGP) or on their own and are never documented as being clearly a Retrograde Pyeloscopy..

We consulted our director of Urology who said: 
'About the only time an anterograde pyeloscopy would be performed, would be at the same time as a Percutaneous nephrolithotomy (PCNL).'

So, for pyloscopies performed on their own or with a RGP (without PCNL), can we code these to Retrograde Pyeloscopy 36652-00 [1040]  Retrograde pyeloscopy?

Response:
VICC research supports the clinical advice that antegrade pyeloscopy is via a percutaneous approach whereas retrograde pyeloscopy is via an endoscopic approach.  This is also supported by the classification where the Index entry for Pyeloscopy, antegrade leads to nephroscopy.  

VICC advises that unless there is documentation that the pyeloscopy was performed percutaneously, assign 36652-00 [1040] Retrograde pyeloscopy.


Query Text:
Could the committee please comment on the difference between the two statements below and how they would be applied? 

GLOMERULAR DISEASES  
(N00-N08)
Use additional code to identify presence of kidney failure, acute (N17) or unspecified (N19).
Code also associated chronic kidney disease N18.-

Search Details:
ACS 0027 - Multiple Coding: point 2 Instructional terms

Response:
According to the advice in ACS 0027 Multiple coding under heading Instructional terms, there is no real distinction between the meaning of the two instructions.  This is supported by the Coding Matters Volume 15 Number 3 advice in article titled Back to basics which says 'Code also..... and Use additional code..... – are found throughout the classification where an additional code may be required to fully describe a condition'.

The 'code also associated chronic kidney disease N18.-' note was added to GLOMERULAR DISEASES (N00-N08) with the introduction of ACS 1438 Chronic Kidney Disease. 

These notes should be followed to assign an additional code for acute renal failure, chronic kidney disease or unspecified renal failure when documented.


Query Title:
Insertion of sacral nerve electrodes for faecal incontinence

Query Text:
A 57 year old lady was admitted for insertion of sacral nerve electrodes for treatment of her faecal incontinence. The codes assigned are:
Principal diagnosis: R15 Faecal incontinence 
Principal procedure code: 32213-00 [940] Insertion of sacral nerve electrodes

The DRG groups to the 901Z (V5.1).

Is this the correct coding for insertion of sacral nerve electrodes for faecal incontinence?

Response:
VICC advises that the codes assigned by the enquirer for insertion of sacral nerve electrodes for faecal incontinence are correct and that this is a grouping issue.  

VICC notes that the issue also exists in Version 6 of the grouper but it is corrected in Version 7 of the grouper and a new code for insertion of sacral nerve electrodes has been created in Eighth edition ICD-10-AM/ACHI 36663-00 [67].


Query Text:
We require some clarification regarding the coding of antenatal admissions with conditions complicating pregnancy. We have recently had a VAED audit where we were directed that we could not use O codes for these admissions unless there was documentation of 'complicating pregnancy', etc as per VICC query# 2684 ACS 1521 Conditions Complicating Pregnancy and that they should be coded to the applicable code from another chapter with the Z34 code.

But then VICC query #2685 Iron Infusion in a pregnant lady states that 'A condition in pregnancy...which requires increased CTG monitoring is sufficient documentation to indicate the condition has complicated the pregnancy' and the use of O codes is advised.

We have an admission where an obstetric patient comes in with abdominal pain and stays overnight, has multiple CTG's and cervical exams without any other investigations into the abdominal pain (eg CT scan), but 'complicating pregnancy' is not documented. She is clearly receiving obstetric care and due to the increased CTG monitoring, could we code the O codes for complication of pregnancy?

Search Details:
VICC Queries #2684 ACS 1521 Conditions Complicating Pregnancy and #2685 Iron Infusion in a pregnant lady

Response:
In order for a code from Chapter 15 (an 'O' code) to be assigned, there needs to be documentation relating the condition to the pregnancy in some way.  

From the information provided in the query, VICC does not consider that there is sufficient documentation that the abdominal pain is the reason for the increased CTG monitoring.  Therefore VICC advises to assign a code for the abdominal pain followed by Z34.- Supervision of normal pregnancy.  The Z34.- code identifies that the patient is receiving obstetric care.

In regard to VICC #2685 Iron Infusion in a pregnant lady, this query referenced the scenario in Coding Matters Volume 15  Number 3, where the NCCH considered that there was 'sufficient documentation to indicate the condition complicated the pregnancy'.


Query Text:
Can you please advise of the correct sequencing if a patient undergoes a number of ECT treatments during the one episode of care either under a general anaesthetic or under IV sedation. 

For example,  for 4 ECT treatments in the one episode of care and given general anaesthetic two times and sedation two times would it be coded as:
93341-02 [1907] Electroconvulsive therapy [ECT], 2 treatments
92514-29 [1910] General anaesthesia, ASA 2
92514-29 [1910] General anaesthesia, ASA 2
followed by:
93341-02 [1907] Electroconvulsive therapy [ECT], 2 treatments
92515-29 [1910] Sedation, ASA 2 
92515-29 [1910] Sedation, ASA 2 
or would the sessions need to be cumulatively coded as per standard ACS 0533 Electroconvulsive therapy (ECT)
with the corresponding anaesthesia codes in hierarchical sequence?

Response:
VICC advises that in accordance with ACS 0533 Electroconvulsive therapy (ECT), one ECT code identifying the total number of ECT treatments in one episode of care is assigned followed by one anaesthetic code for each visit to theatre.  

Therefore the correct codes to assign for the case cited are:
93341-04 [1907] Electroconvulsive therapy [ECT], 4 treatments
92514-29 [1910] General anaesthesia, ASA 2
92514-29 [1910] General anaesthesia, ASA 2
92515-29 [1910] Sedation, ASA 2 
92515-29 [1910] Sedation, ASA 2


Query Text:
Can you please confirm the correct procedure code for laparoscopic ovarian tissue harvest and injection of Zoladex implant. (Pt has NHL and she presented to our organisation for fertility preservation). 

I have assigned:
13215-03 [1297] Other reproductive medicine procedure (look up: Fertilisation, In Vitro (IVF)
30390-00 [984] Laparoscopy

Response:
Research undertaken by VICC indicates that ovarian tissue harvesting involves removing part of the ovary so the patient can undergo treatment and reimplantation of the ovarian tissue at a later date, therefore this procedure is not considered an IVF procedure.

As the operation report provided with the query states that the left ovary was partially resected, VICC considers that the correct code to assign for the ovarian tissue harvest is 35638-01 [1243] Laparoscopic partial oophorectomy following index entry Oophorectomy, partial, laparoscopic 35638-01 [1243].  

VICC notes that code 14203-00 [1906] Direct subdermal hormone implantation is also required for the Zoladex implant by following index entry Implant, implantation,  hormone, subdermal 14203-00 [1906].


Query Title:
Chemotherapy drug administered for non-neoplasm conditions

Query Text:
Which procedure code should we use when an anti-neoplastic drug such as methotrexate is given intravenously to treat a non-neoplastic condition such as rheumatoid arthritis?   Is the retired VICC query #2167 IV infusion of Zometa still applicable?


Search Details:
ACS 0044 Chemotherapy
Retired VICC query #2167 IV infusion of Zometa

Response:
VICC advises that the correct procedure code for IV administration of an antineoplastic drug to treat a non-neoplastic condition such as rheumatoid arthritis is 96199-09 [1920] Intravenous administration of pharmacological agent, other and unspecified pharmacological agent.

Extension -00 Antineoplastic agent should not be assigned when the pharmacotherapy is for treatment of conditions that are not neoplasms or neoplasm related conditions.  This is in accordance with the note in Block [1920] under extension 00 Antineoplastic agent:'Agents used in the treatment of neoplasms and/or neoplasm related conditions'.


Query Title:
Patient recommenced on warfarin post op for atrial fibrillation (AF)

Query Text:
In regard to Vic Query #2716 Anticoagulation as part of the management plan for atrial fibrillation, where warfarin is adjusted or commenced for AF, can you please advise if AF should be coded where a patient is admitted for an operation and post operative care instructions include "Recommence Warfarin with loading dose tonight for underlying atrial fibrillation".  That is, the patient is on warfarin for their AF but taken off due to risk of bleeding and recommenced whilst in hospital. 

In these cases would the AF be considered meeting ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses?

Response:
VICC considers that not giving warfarin prior to an operation and recommencing warfarin post the operation is not management of the atrial fibrillation; it is management of the warfarin.  Based on this, the atrial fibrillation does not meet ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.  

Assign Z92.1 Personal history of long term (current) use of anticoagulants for the management of warfarin.


Query Text:
If a patient is admitted for an elective termination of pregnancy that is not for a cited medical indication - should this be coded as a medical abortion O04.- or unspecified abortion O06.-.

Those of us who have been coding for a while still apply advice from the 'abortion' coding feature in August 2003 that indicates O04- should be used.  Is this advice regarding an elective termination still current?

Search Details:
VICC Newsletter August 2003

Response:
VICC considers that the advice in the article regarding the elective temination code is still current, but coders need to be aware that since the article was published there have been updates to obstetrics coding including the Seventh edition delivery codes, Seventh edition ACS 1513 Induction and augmentation and VICC queries #2250 Termination of pregnancy and #2295 Spontaneous abortion.

There are several subterms under lead term Abortion that do lead to code O04.-.  An example is subterm 'operative' and VICC would consider documentation of dilation and currettage or suction allows the coder to follow that subterm to assign O04.-.

Where you have no documentation to enable you to follow any of the subterms, it is appropriate to assign O06.-.


Query Text:
Patient had cataract extraction & insertion of IOL with no mention of complication at the initial surgery. Came back seven days later with a diagnosis of residual lens fragment, and had Phaco extraction of fragments.

I've looked on internet site: http://www.revophth.com/content/d/retinal_insider/c/27709/ which says that residual lens fragments are a complication of the cataract surgery.  

We're not sure if we code this to cataract again, or as T85.81 Complication of the lens.  I've searched the query database and found no relevant queries, so please advise which are the correct codes to use.

Response:
VICC advises that in accordance with ACS 1904 Procedural complications there needs to be a relationship between the condition and the original intervention in order for the condition to be considered a complication of the intervention.  

Unless there is documentation to support that the residual lens fragment is a complication of the surgery, the correct principal diagnosis for the subsequent episode is the original cataract. However, a documentation query could be raised with your clinician to clarify if this was a complication of the surgery.


Query Title:
Stenosis of femoro-popliteal bypass graft

Query Text:
Can the VICC please review the following two episodes of the same patient and clarify whether the documentation provided meets the definition of a procedural complication and the appropriate codes to assign?

Episode 1) November 2012
Principal diagnosis documented on discharge summary: PVD 
Procedure performed: Bilateral lower limb DSA
Findings: severe short segment stenosis proximal to L) sided bypass graft with significant flow limiting effect. 
Future Management Plan: Will bring back as CAT1 for L) CFA EA & patch

Episode 2) December 2012
Principal diagnosis documented on discharge summary: Inflow stenosis L) FPBG (in CFA)
Procedure performed: Ilio- graft bypass 8mm Dacron
Past History for this patient:
PVD 
-1995 Bilateral fem-pop synthetic bypass grafts for calf/ thigh claudication
- May 2012 bilateral fem angiogram: focal L CFA/ anastomosis/ profunda femoris plaque & stenosis. Not felt appropriate for endovascular treatment. Proximal R) graft anastomosis stenosis in close proximity to but not involving R CFA or profunda.
- June 2012 Endarerectomy & patch L) CFA/ profunda/ graft
- Oct 2012 USS: More than 70% distal L) CFA stenosis proximal to graft

1. Can we assume the cause of this patients stenosis based on the documentation?

2. 
a. Is there enough documentation that the stenosis is directly related to bypass graft to assign T82.8 'Other complications of cardiac and vascular prosthetic devices, implants and grafts'?

b. Do you need to add I70.20 'Atherosclerosis of arteries of extremities, unspecified' as an additional diagnosis?

3. If this is not enough documentation that the stenosis is directly related to bypass graft, but instead disease progression, should I70.20 'Atherosclerosis of arteries of extremities, unspecified' and Z95.8 'Presence of other cardiac and vascular implants and grafts' be assigned?

Search Details:
ACS 1904 Procedural complications
ACS 0941 Arterial disease
ACS 0001 Principal Diagnosis
ACS 0002 Additional Diagnosis

Response:
VICC does not consider that documentation of 'inflow stenosis left femoro-popliteal bypass graft' supports the assignment of T82.8 Other specified complications of cardiac and vascular prosthetic devices, implants and grafts.  As per the definition of procedural complication in ACS 1904 which is 'a condition or injury which is directly related to a surgical/procedural intervention', there needs to be a documented relationship between the condition and the surgery.  The correct code to assign in your scenario is therefore I70.20 Atherosclerosis of arteries of extremities, unspecified.  As you have noted in your question 3, it is also appropriate to assign Z95.8 Presence of other cardiac and vascular implants and grafts.

In response to your question 2b, had there been documentation to support the assignment of T82.8, you could assign I70.20 in addition, to provide further specificity in accordance with ACS 1904 which says 'An additional code from Chapters 1 to 19 may be assigned to provide further specification of the condition'..  

Please note that the above sentence from ACS 1904 Procedural complications has changed in Eighth edition to read 'An additional code from Chapters 1 to 19 should be assigned where it provides further specificity'.


Query Text:
We have patients who are participating in a clinical trial of Prochymal protocol 603. The aim of this study is to evaluate the long term effectiveness and safety of Prochymal for the treatment of Crohn's disease. 

Prochymal is a stem cell drug therapy which is supported in the documentation 'patient admitted for stem cell infusion'.

Given that this is a clinical trial and we have participant information and consent form completed for these patients we have assigned:

Pdx: Z006 Examination for normal comparison and control in clinical research programme
Adx: K509 Crohn's disease, unspecified

1) Does the VICC agree with the diagnosis codes assigned?

2) Can the VICC provide guidance on the correct procedure code for the infusion? 

a. 92064-00 [1893] Administration of other blood product?

b. 13706-10 [802] Allogeneic bone marrow or stem cell transplantation, other donor, with in vitro processing?

Response:
This query was originally published in the 2013-14 September VICC queries database release as follows:

Based on the participant information and consent form that accompanied this query as well as supporting information on the internet, VICC agrees with the diagnosis codes assigned by the enquirer in accordance with ACS 0026 Admission for clinical trial, drug challenge or therapeutic drug monitoring.  

As the patient received a stem cell infusion, VICC considers the correct procedure code to assign is 13706-10 [802] Allogeneic bone marrow or stem cell transplantation, other donor, with in vitro processing.

This response is superseded by ACCD Coding Rules advice Q2926 titled Classifying a procedure under investigation in a randomised and placebo-controlled clinical trial and Q2906 Same-day chemotherapy for neoplasm; participant in clinical drug trial.


Query Text:
A patient was admitted with principal diagnosis of SND (sinus node dysfunction) for a pacemaker insertion.  Stated to have 'extensive conduction abnormalities' with 'symptomatic bradycardia/conscious collapse'.  

How should we code the above disorder? It is a conduction disorder but to get to I45.9 or I45.8 the ICD-10-AM index has very limited options. I cannot get there with 'dysfunction', 'disease' or 'disorder' but need to use the word 'defect'.  If you use 'dysfunction, heart' you have to use I51.8 or if you follow the advice in ACS 0013 you end up with I51.9.

Search Details:
VICC query database - no advice
NCCC Q&A - no advice

Response:
VICC advises to follow Index entry Dysfunction/heart to assign I51.8 Other ill-defined heart diseases for documentation of sinus node dysfunction despite this being a non-specific code.  As the main term Dysfunction exists in the Index, VICC does not consider it necessary to apply 'Other' and 'unspecified' codes in the Conventions used in the Tabular List of Diseases.

You may wish to submit a public submission to ACCD asking for a more specific code to be created for this condition or for an index entry to allow assignment of an existing code.


Query Title:
Documentation of down arrows after a result

Query Text:
I wish to clarify if we are able to code anaemia in the following example, as we are currently receiving a lot of documentation with arrows after the result.

Patient has documentation in medical record of Hb (downward arrow) and was given PRBC. When reviewing their pathology for that day, we can see that their Hb was low.  Are we able to code anaemia?

Response:
This query was originally published in the 2013-14 September database release VICC queries database release as follows:

VICC advises that there is no published advice to indicate that the position of the arrow is important.  If the arrow is positioned after the result, please follow the same advice as you would if the arrow were positioned before the result.

Coding Matters Volume 16 Number 2 advice titled Use of abbreviations and symbols should be followed and is reproduced below:
"Question:
When can coders use abbreviations and symbols documented in the clinical record to assign conditions, eg Hb or Hb 98 documented and transfusion given – can anaemia be assigned for (downward arrow) K or K2.9 documented and potassium supplements commenced – can hypokalaemia be assigned?

Clinicians sometimes use abbreviations and symbols to document conditions in the clinical record. Each case should be assessed on its own merits to determine if the documentation sufficiently describes a condition that meets the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses, in order to be coded.

When (downward arrow) Hb or (downward arrow) K is documented as the indication for an intervention such as a blood transfusion or commencement of medication, a code for the condition can be assigned if the test result or clinician confirms that the patient’s haemoglobin or potassium is below the normal range; as the criteria for code assignment in ACS 0001 or ACS 0002 has been met. See ACS 0010 General abstraction guidelines.

So, where (downward arrow)Hb is documented as the indication for a transfusion and the test results and/or clinician verifies the patient’s haemoglobin is below the normal range – follow the index pathway, Low, haemoglobin and assign D64.9 Anaemia, unspecified.

Where (downward arrow)K is documented as the indication for commencement of medication and the test results and/or clinician verifies the patient’s potassium is below the normal range, follow the index pathway Deficiency, potassium (K); Depletion, potassium; Hypokalaemia; or Hypopotassaemia and assign E87.6 Hypokalaemia.

However, if ICD-10-AM does not provide an index look up or there is uncertainty or ambiguity in relation to such abbreviated forms of documentation, they should be confirmed with the clinician prior to code assignment. Coders should not assign codes on the basis of test results alone."

March 2016 update:  Whilst the VICC response is still current, the ACCD advice referenced in the response was updated in the September 2015 Coding Rules as follows:

"Q:
When can coders use abbreviations, symbols and test result values documented in the clinical record to assign conditions, eg (downward arrow)Hb or Hb 98 documented and transfusion given - can anaemia be assigned? (downward arrow)K or K2.9 documented and potassium supplements commenced - can hypokalaemia be assigned?

A:
Clinicians may document test result values as well as abbreviations and symbols in the clinical record as shorthand to indicate conditions such as anaemia, hypokalaemia, hypercalcaemia etc.

Where such shorthand is used to document/describe a condition, each instance must be assessed on its merits and where possible confirmed with a clinician to ensure that the documentation sufficiently describes a condition that is both supported by an appropriate index entry and meets the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.

Test result values, symbols and abbreviations are not to be used in isolation to inform code assignment and coders should therefore:
•	 clarify the significance of the documented shorthand (test result, values, abbreviations and symbols) with the clinician to inform code assignment

Where this is not possible assign a code for the condition represented in shorthand (as described above) only if:
•	 test results (pathology report) verify that a result is abnormal AND 
• there is an appropriate ICD-10-AM index pathway AND 
• it meets the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.

For example, where (downward arrow)Hb or a haemoglobin level (eg.Hb 98) is documented as the indication for a transfusion and the test results (pathology report) and/or the clinician verifies the patient's haemoglobin is below the normal range, follow the index pathway:
Low
- haemoglobin 
to assign D64.9 Anaemia, unspecified.

Where (downward arrow) K or a potassium level (eg. K 2.9) is documented as the indication for commencement of medication and the test results and/or clinician verifies the patient's potassium is below the normal range, follow the index pathways:
Deficiency
- potassium (K) 

Depletion
- potassium

Hypokalaemia

Hypopotassaemia

to assign E87.6 Hypokalaemia.

However, if ICD-10-AM does not provide an index look up or there is uncertainty or ambiguity in relation to such abbreviated forms of documentation, always confirm with the clinician prior to code assignment."


Query Text:
Does VICC #2636 Debridement includes note refer only to soft tissue excisional debridements or can it also be applied to excisional debridement of the skin?

e.g. 1 excisional debridement of eyelid with suture of wound

e.g. 2 excisional debridement of eyebrow with suture of wound

Search Details:
VICC #2636 Debridement includes note
Commandments Vol 16 No 1 - Excisional debridement

Response:
VICC advises that in accordance with ACS 0016 General procedure guidelines - procedure components,  suture is inherent in debridement.  

Therefore it is not necessary to assign an additional code for suture of wound performed with excisional debridement.


Query Title:
Drug adverse effect causing hyperglycaemia in T2 diabetes patient

Query Text:
Patient is admitted with increased intracranial pressure secondary to a brain meningioma. The patient also has T2 diabetes. The patient was given dexamethasone for the intracranical pressure, however it is stated on the discharge summary the patient developed hyperglycaemia because of the dexamethasone. 

Can the hyperglycaemia be coded as an adverse effect of the dexamethasone? R73 Elevated blood glucose level has the exclusion of diabetes mellitus, so we are not sure if this code is the right code to go with.

Search Details:
R73 (exclusions in diseases tabular)
ACS 1902 Adverse effects

Response:
VICC advises that because the patient has T2 diabetes and as the classification links the hyperglyaemia to the diabetes, you must assign the appropriate diabetes mellitus code following Index entry hyperglycaemia, with diabetes: 

Hyperglycaemia, hyperglycaemic R73/with diabetes (mellitus) — see Diabetes/by type

This is reinforced by the excludes note at R73 Elevated blood glucose level.

In accordance with ACS 1902 Adverse effects, an external cause code must be assigned to indicate the drug or medicinal agent which caused the adverse effect.  VICC does acknowledge that the nature of the effect may not always be evident in the code title, for example, the hyperglycaemia is not specified in the code title of E11.- Type 2 diabetes mellitus.


Query Text:
We have patients who are electively admitted for removal of Nuss bar, which were originally inserted for pectus excavatum.

The operative procedure is noted below:
The existing scars were incised bilaterally in the subpectoral region. The pectoral muscle fibres were separated and the plates were identified. These were dissected free then bent to remove them from the main bar. The main bar was then straightened on one side and slid out. Wounds were then closed.

Can the VICC please provide the correct diagnosis and procedure codes for removal of Nuss bar? 

Z48.8 Other specified surgical follow-up care? or
Z47.0 Follow-up care involving removal of fracture plate and other internal fixation device?

90606-01 [1661] Removal of other soft tissue implant? and 
47930-00 [1554] Removal of plate, rod or nail, not elsewhere classified?

Response:
For assignment of the diagnosis code, VICC considers that because the Nuss bar is fixated with plates, it is appropriate to follow Index entry Removal, device, fixation (internal) to assign Z47.0 Follow-up care involving removal of fracture plate and other internal fixation device.  

For assignment of the procedure code, VICC advises to follow Index entry Removal, fixation device, internal, plate (with associated pin, screw or wire) to assign 47930-00 [1554] Removal of plate, rod or nail, not elsewhere classified.


Query Text:
In reference to VICC query #2364 Initiation of CPAP sleep clinic patients we have had a recent coding audit and have subsequently been advised to use the code 11503-16 [1849] Continuous monitoring of pulmonary function for ≥ 6 hours duration to identify Sleep Study patients having CPAP titration. 

We currently use a CPAP code to reflect this and want to clarify if the directive previously given (in accordance with a previous (5th) edition of ICD-10-AM) is still relevant?

Search Details:
VICC # 2364 Initiation of CPAP sleep clinic patients
5th Edition ACS 1006 Ventilatory support

Response:
VICC considers that for documentation of CPAP titration or monitoring of CPAP ≥ 6 hours, it is appropriate to assign 11503-16 [1849] Continuous monitoring of pulmonary function for ≥ 6 hours duration.  

VICC followed Index entry Monitoring, pulmonary, function, continuous for >= 6 hours duration to arrive at the code as our research indicates that CPAP titration involves the monitoring of CPAP levels to find the right amount of air pressure.


Query Text:
There is some confusion over when to apply point 3 of ACS 0012 Suspected conditions.  If investigations were undertaken and the results indicated a probable diagnosis, yet no specific treatment was initiated during the episode of care, assign a code for the suspected condition.

Our issue is that some interpret the wording of a probable diagnosis to mean any of the terms indicating uncertainty that are mentioned at the beginning of the standard probable, suspected, possible. Whereas others interpret this to mean that you need the documentation of a term which indicates more certainty about the diagnosis such as probable or likely rather than suspected or possible.

If the consensus is that it can include any of the terms mentioned within the standard, can you please clarify how point 3 of the standard differs from point 1.

Can you also please provide advice on what would be coded and what part of the standard would be applied for the following cases?

CASE 1
Diagnosis on discharge: # L) arm paraesthesia FI ? Conversion disorder
Investigations: CTB/c spine, MRI brain all normal
Neurology and psychiatry reviews
Treatment:  Nil
Follow up with GP in 1/52 for review
 
CASE 2
Diagnosis on discharge:  PR bleed and lower abdo pain - Possible colitis
Investigations:  Bloods NAD Abdo ultrasound NAD
Treatment : Morphine & Buscopan
Follow up: GP follow up in one week to chase faecal specimen culture

CASE 3
Diagnosis on discharge: ? Ruptured ovarian cyst  L)IF pain 
Investigations: Bloods  NAD Pelvic U/S some fluid seen around the ovary, rupture of ovarian cyst suspected
Treatment: Morphine
Follow up : Referral made to gynaecologist

Response:
VICC referred this query to ACCD who has acknowledged some ambiguity in the standard but would like to maintain the status quo for Eighth and Ninth Edition rather than publish advice that could result in a major change to current coding practice. Instead ACCD has created a task to review the standard and welcomes a Public Submission on this subject.

VICC considers that the terms in ACS 0012 Suspected conditions listed under the heading of Discharged home are interchangeable. VICC also considers that the difference between example 1 and example 3 in the standard is that example 3 illustrates a condition for which there is no treatment. 

With respect to the examples in the query, VICC acknowledges the difficulty in interpreting whether treatment was given for the condition and advises to seek clinical clarification if there is capacity to do so.  VICC further considers it is not the role of the coder to determine whether treatment has been given for a specific condition. If the documentation does not support the decision to code the condition, VICC advises to default to coding the symptom.

VICC also suggests to consider ACS 1802 Signs and Symptoms and ACS 0001 Principal diagnosis when making a decision.


Query Text:
We would like some guidance on the correct coding of a rotational vacuum when it is only used to rotate the baby not deliver the baby. The vacuum is attached, baby turned, then removed. 

We don't consider this a failed vacuum as the purpose was only ever to turn the baby and that has been successfully achieved.   The index does take you to 90469-00 [1338] Vacuum extraction with delivery but the description includes with delivery/extraction. 

There is an option for rotation with forceps but not with vacuum. This is common to help move things along especially in cases of POP etc. Block 1342 looks like better options but this is not where the index takes us.

Response:
VICC advises that regardless of the code title including delivery, you have followed the Index under Rotation/vacuum to correctly to assign 90469-00 [1338] Vacuum extraction with delivery.

NCCH has previously advised that a term appearing in a code title does not have to be an essential modifier in the Index.


Query Text:
Can you advise on what code should be used for forceps unspecified. 

There are occasions the type is not specified and further querying to the doctor adds no further information or description of where the forceps are in use - low, high, mid. 

Currently we are defaulting to Mid cavity if we have no further information.

Response:
VICC advises that because there is no default code for unspecified forceps, it is not appropriate to select a code as your default.  

In the absence of documentation of the type of forceps and no clinical documentation to support the assignment of a code as per the advice in ACS 1534 Forceps delivery, VICC suggests to seek clarification from a midwife.  If the response is unsatisfactory, VICC suggests to seek support from your management and to also give consideration to modifying forms in the medical record to assist in the capture of this information.


Query Text:
I have been trying to code a patient admitted two years post cervical cancer for a laparoscopic ovarian tissue graft. 

The operation report has the tissue being grafted into the abdominal wall bilaterally. There are no codes when using the graft pathway that seem appropriate. Not sure if 14203-01 [1906] Direct living tissue implantation is an appropriate code. 

Otherwise do we just use 90331-00 [1004] Other procedures on abdomen, peritoneum or omentum
or  90431-00 [1247] Other procedures on ovary?

Response:
VICC considers that it is appropriate to follow Index entry Implant/implantation/ living tissue/by/direct implantation to assign 14203-01 [1906] Direct living tissue implantation for the procedure cited.  Assign an additional code for the laparoscopic approach in accordance with ACS 0023 Laparoscopic/arthroscopic/endoscopic surgery.

If your hospital is performing many of these procedures, please submit a public submission to the ACCD for a specific code for living tissue grafting.


Query Title:
Mechanical ventilation in emergency department prior to admission

Query Text:
From 1 July 2013, admission time for patients admitted via an Emergency Department (ED) is the time the patient leaves the ED.  Page 6 of the Admissions Policy Fact Sheets states 'treatment provided in the ED is not considered part of the admitted episode of care'.

Patients may be mechanically ventilated (invasive or non-invasive) in ED for several hours prior to transfer to ICU or ward.  In terms of ACHI coding, can you please advise whether MV in ED is to be excluded from the calculation when determining the correct procedure code?  This has the potential to impact on ARDRG assignment.

Response:
In accordance with the change in Admission Time to be the time of departure from the ED, the hours of any mode of ventilation provided in the emergency department must be excluded from the calculation for determining the appropriate procedure code.  

This is supported by ACS 1006 Ventilatory support section – Calculating the duration of CVS under 'begin with' dot point Admission of a ventilated patient that says 'For those patients who are admitted with continuous ventilatory support in place, begin counting the duration at the time of admission.'

VICC acknowledges the potential impact on AR-DRG assignment.  For public hospitals the cost associated with providing ventilatory support in emergency will now be used to inform the ED funding model.


Query Title:
Coding of diseases and procedures in emergency departments

Query Text:
Can the VICC please clarify the coding of the below scenarios, given that the admission time from 1 July 2013 is the time the patient leaves the clinical area of the Emergency Department?

1. Can you code the procedure code for transfusion of blood products that are commenced in ED and continue on the ward?

2. a. When do you start calculating mechanical ventilation hours?
    b. Can you include the mechanical ventilation hours commenced in ED to the calculation of total MV hours?

3. a. If patient had a fracture/ dislocation and the dislocation is reduced in ED can you code the diagnosis code for the dislocation? 
   b. Can you code a procedure code for a reduction of the dislocation that is reduced in ED?

4. Can minor injuries, such as abrasions, contusions, lacerations that are managed only in ED be coded when a patient is admitted for a trauma episode?

5. Can suture of lacerations performed in ED be coded?

6. Can you code diabetes with hypoglycaemia and/or unstable diabetes that is only managed in ED?

Response:
As the Admission Time for patients admitted from the emergency department (ED) is now the departure time from the ED, the ED component of the patient's care is no longer considered to be part of the admitted episode.  

VICC advises the following in answer to your specific questions:
1.  Transfusions of blood products commenced in ED and continued on the ward are to be coded because the blood product continues to be administered.  This is supported by ACS 0302 Blood transfusions that says that the administration of blood and blood products should be coded whenever performed.

2. Presuming the patient is already ventilated on transfer from the ED, mechanical ventilation hours are calculated from the time of admission.  This is in accordance with ACS 1006 Ventilatory support section Calculation the duration of CVS under 'begin with' dot point Admission of a ventilated patient that says 'For those patients who are admitted with continuous ventilatory support in place, begin counting the duration at the time of admission.'  Mechanical ventilation hours that occurred in the ED cannot be included for assignment of the code.

3. If the patient is admitted via the ED for ongoing treatment or management of the fracture/dislocation then the dislocation can be coded.  This will be supported, either by documentation stating that the dislocation is requiring ongoing management/monitoring or by the advice provided in Coding Matters Volume 17 Number 1 query titled Multiple trauma which says that for the initial presentation for multiple trauma all the injuries should be coded out. 

Even if the dislocation component is treated in the ED, if the admission is the patient's first admission following the initial injury, codes should be assigned for both the fracture and the dislocation. 

However, the procedure code for the reduction of the dislocation performed in ED, cannot be assigned as this was not performed in the admitted episode of care.

4. The Coding Matters advice above also applies to the coding of minor injuries, such as abrasions, contusions, lacerations that are managed only in ED when a patient is admitted for a trauma episode.

5. Sutures performed in ED for lacerations cannot be coded as the suture was performed prior to the patient's admission.

6.  Diabetes with hypoglycaemia or unstable diabetes that is only managed in ED cannot be coded as the complication did not occur in the admitted episode of care.


Query Text:
Our query is in regards to ACS 0401 Diabetes mellitus and intermediate hyperglycaemia and coding diabetes with features of insulin resistance.  The standard says we can code this if we have dyslipidaemia/hypercholesterolaemia/high cholesterol/hyperlipidaemia documented and if we can confirm they have elevated fasting triglycerides or depressed HDL-cholesterol.

We are wanting to know when coding diabetes with dyslipidaemia/hypercholestrolaemia if we have to use pathology results from within the current episode of care we are coding or if we can go back and use old pathology results from previous episodes (from within a reasonable time frame but what would be a reasonable time frame)?  

We understand lipids change all the time with medication but it is also unlikely for lipids to be done again if the patient was in the week prior and had them done.  Using older results means we are using the entire record when coding but may also not be accurate to the patients current conditions.  We have sought advice from other hospitals and discovered they apply this differently.

Search Details:
ACS 0401  Diabetes mellitus and intermediate hyperglycaemia
NCCC 1 July 2012 workshop handouts

Response:
VICC considers that provided the dyslipidaemia is documented as a current condition within the episode, it is appropriate to refer to test results from any part of the record regardless of the time frame to support the assignment of E1-.72 Diabetes mellitus with features of insulin resistance.  However, coders are advised to use only the most recent information available.


Query Text:
There is some confusion at our hospital when a single neoplasm has multiple morphologies found within it. There are instructions for when a morphological diagnosis contains two qualifying adjectives that go to different codes (Appendix A, Morphology of Neoplasms) but nothing, as far as we can tell, for when multiple morphologies - which each have their own code - are found within the one neoplasm. 

Please confirm which morphology code/s VICC would use for the following ovarian cancer based on clinician documentation of: "Ovarian Cancer, High grade serous cancer - mixed pattern with undifferentiated ca." and the provided pathology report below. Please also include reasoning.

DIAGNOSIS
1. Left tube ovary and appendix - high grade carcinoma of the ovary, with a mixture of serous, endometrioid and undifferentiated patterns with lymphatic space invasion but no definite involvement of the serosal surface. The ovary and fallopian tubes show features of torsion but there is no evidence of malignancy within the fallopian tube.

Tumour type - 84% serous, 1% endometrioid, 15% undifferentiated

Response:
NCCC Q&A December 2011 advice titled Morphology of recurrent mediastinal tumour says that the statement in ACS 0233 Morphology - "If a morphological diagnosis contains two histological terms which have different M codes, select the highest number as it is usually more specific" - applies to one histological sample which describes a neoplasm using more than one histological term for which there are separate morphology codes. It does not apply to multiple histological diagnoses from different timeframes or different episodes of care, even if in reference to the same tumour.

VICC considers that the single neoplasm documented in your query is, as per the above advice, one histological sample which describes a neoplasm using more than one histological term for which there are separate morphology codes.  Therefore, apply ACS 0233 Morphology and select the morphology with the highest number.


Query Text:
We have a patient referred from outpatients to HITH for inpatient VAC dressings.  The VAC dressings were applied by our HITH initially and then daily “VAC dressing” for a total LOS of 18 days.  Part way throughout the admission the patient began receiving treatment from HITH in a regional area.  
 
According to VICC query 2454 “if the initial application or change of VAC dressing requires anaesthetic and no other procedure is performed, the correct code to assign is 90686-01 [1628]….”. ACS 0042 Procedures normally not coded dot point two states that the listed procedures should be coded if cerebral anaesthesia is required in order for the procedure to be performed.   In this case there is no evidence of cerebral anaesthesia being used to apply the dressing so my interpretation is that a code for this procedure should not be added.
 
My questions are:
 
1.Does a multi-day HITH episode of care for VAC dressings meet the criterion for admission? 
2.Should a procedure code for VAC dressing be assigned for this multi-day episode of care to provide information about the treatment required?

Response:
This query was originally published in the 2013-14 September VICC queries database release as follows:

VICC advises that because the episode is a multi day episode, it does meet Criterion For Admission O Overnight.  

Your interpretation of ACS 0042 Procedures normally not coded is correct - a code for the VAC dressing would only be assigned if cerebral anaesthesia was required in order to perform the procedure.  As the VAC dressing was not performed under cerebral anaesthesia in your scenario, a procedure code for the VAC dressing is not assigned.

Following publication of December 2015 Coding Rules the original response is superseded by the following advice titled Vacuum assisted wound closure (VAC) Dressings

Q: 
Should VAC dressings be coded and if so, how many times should the code be assigned?

A: 
Vacuum assisted wound closure (VAC) is a type of wound dressing which uses negative pressure to promote wound healing. The wound is covered with open cell foam or gauze dressing that moulds to the wound bed. A drainage tube is attached, the wound is then sealed and vacuum or negative pressure is applied via a pump. The suction pressure removes or 'debrides' loose tissue and has been shown to reduce swelling, aid wound closure and promote formulation of granulation tissue.

Dressings are routine treatment for burns, wounds and ulcers, however vacuum dressings are not, nor are they a routine part of any significant procedure being performed. ACHI classifies vacuum dressings as nonexcisional debridement:

90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue
or
90686-00 [1627] Nonexcisional debridement of burn. 

Do not apply the guidelines in ACS 0020 Multiple/bilateral procedures, ACS 1203 Debridement or ACS 1911 Burns when coding vacuum dressings, instead apply the following guidelines for their application or replacement (change):
- when performed with cerebral anaesthesia (including that with excisional debridement), assign once for each operating theatre session. 

For example:
Day 1 - excisional debridement of soft tissue of ulcer and application of vacuum dressing performed in theatre under general anaesthetic, assign:
90665-00 [1628] Excisional debridement of skin and subcutaneous tissue 
and
90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue
and the appropriate anaesthetic code.

Day 5 – change of vacuum dressing performed in theatre under general anaesthesia, assign:
90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue and the appropriate anaesthetic code. 

- when performed without cerebral anaesthesia, assign once only for the episode of care 
For example:
Day 1 – patient transferred with vacuum dressing in situ:
No code is assigned.

Day 2 – change of vacuum dressing performed on the ward, assign:
90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue, once only.

Day 4 – change of vacuum dressing performed on the ward.

As 90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue has already been assigned for this episode, no additional code is required.
 
- when vacuum dressings are performed with cerebral anaesthesia in an operating theatre and without cerebral anaesthesia on the ward in the same episode of care, assign once for each operating theatre session.

A code for any change of dressings undertaken on the ward is not required.
For example:
Day 1 – vacuum dressing applied in operating theatre under general anaesthetic, assign:
90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue 
and the appropriate anaesthetic code.

Day 3 – change of vacuum dressing undertaken on the ward.
As 90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue has already been assigned for this episode, no additional code is required.

Day 5 – change of vacuum dressing undertaken on the ward.
As 90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue has already been assigned for this episode, no additional code is required.

Day 6 – excisional debridement and application of new vacuum dressing in operating theatre under general anaesthetic, assign:
90665-00 [1628] Excisional debridement of skin and subcutaneous tissue and
90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue
and the appropriate anaesthetic code.

Day 9 – change of vacuum dressing undertaken on the ward.
As 90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue has already been assigned for this episode, no additional code is required. 

As VAC dressings are classified to nonexcisional debridement, ACS 0042 Procedures normally not coded, point 7 – Dressings, does not apply.

This will be clarified in ACS 0042 Procedures normally not coded, point 7 – Dressings and the classification of wound dressings has been highlighted for review in a future edition of ACHI.


Query Text:
Would you please advise on the appropriate code assignment for mesenteric panniculitis in the following scenario: 

A patient had a discharge diagnosis of mesenteric panniculitis following a three day history of abdominal pain radiating to his back.  CT abdomen/pelvis revealed an enlarged mesentery with inflammatory stranding, ? mesentery panniculitis.

The patient was treated with IV pantoprazole and simple analgesia.  Pain improved.  Length of stay was two days.  Patient was discharged on oral pantoprazole (new medication for this patient).

Should this scenario be coded as:
K66.8 Other specified disorders of peritoneum:  the coder has followed the lead of mesenteric inflammation, peritoneum to try to describe the digestive symptoms and nature of the condition treated.
Or
M79.38 Panniculitis, unspecified, other site:  the coder has followed the lead panniculitis but the code is for other soft tissue disorders which does not accurately describe the digestive nature of this condition.

Search Details
Index and tabular entries:-
- mesenteric inflammation, peritoneum
- panniculitis, unspecified, other site

Response:
The correct lead term to follow in the Index is panniculitis to assign M79.38 Panniculitis, unspecified, other site.  

VICC research suggests that panniculitis is a soft tissue disorder, which in this patient, happens to be located in the mesenteric area.

Note: This query was originally published in December 2013 and retired 30 June 2020.  The committee has determined that the advice is current and the query has been reinstated.


Query Title:
Prolapsing haemorrhoid without specification of degree

Query Text:
Colonoscopy report details 'large, prolapsing anterior haemorrhoid - band x1'. 

We have discussed three possible codes to use:
K64.9 Haemorrhoids, unspecified (as it is without mention of degree)

K64.1 Second degree haemorrhoid (as it is the smallest denominator of a haemorrhoidal prolapse) 

K64.8 Other specified haemorrhoid (as it lists strangulated,thrombosed & ulcerated haemorrhoids NEC and we thought maybe an unspecified prolapsed haemorrhoid could be included here) 

Which code does the committee think would best capture a prolapsing haemorrhoid without specification of degree?

Response:
Without documentation of the degree of the prolapse, VICC advises that the correct code to assign for documentation of prolapsing haemorrhoid is K64.8 Other specified haemorrhoids following Index entry:
Haemorrhoids (bleeding) (external) (internal) (without mention of degree)/specified NEC K64.8

This is in accordance with the Conventions used in the Tabular List of Diseases 'Other' and 'unspecified' codes example 45, but in this case there is a 'specified NEC' Index entry enabling the assignment of K64.8.  

It is not possible to assign K64.1 Second degree haemorrhoid because the degree is an essential modifier in the Index.


Query Text:
Can you please clarify if the prefix should be a P or a C on neonates admitted for Neonatal Abstinence Syndrome (NAS) scoring where no symptoms are observed and NAS is not confirmed. 

We have been using prefix P as the exposure to the drug/medication is while the neonate is in utero. But since the issues won't arise until after birth is it a C? 

Alternatively if the neonate is NAS scored and has symptoms or NAS develops should the prefix then be a C since the exposure was in utero but the symptoms/NAS are now occurring after delivery?

Search Details:
Vic Additions to ACS
COF education material 8th edition workshops

Response:
Exposure during pregnancy is a risk factor and is therefore not relevant to the coding or prefixing decision.  However conditions that arise in utero whether suspected or proven would be prefixed with a P Primary condition.

The correct prefix for the observation code, the symptoms codes or the Neonatal Abstinence Syndrome (NAS) code is P Primary Condition.  This is in accordance with ACS 0048 Condition onset flag definition of COF 2. Condition not noted as arising during the episode of admitted patient care:
'A condition previously existing or suspected on admission such as the presenting problem, a comorbidity or chronic disease.'


Query Text:
Can you please clarify what was the final consensus was on the coding of POTS?
 
I'm aware that VICC sent a request for a new code. Will there be a new code? And, should we still be coding it as per ACS 0005 Syndromes?

Response:
VICC advises that Postural Orthostatic Tachycardia Syndrome (POTS) should be coded in accordance with ACS 0005 Syndromes.  There does not appear to be a public submission relating to POTS on the ACCD website and VICC is unaware of any pending tasks for development of a code for POTS.  

You may wish to submit a public submission to ACCD asking for a more specific code to be created for this condition.


Query Title:
Antibiotics for premature rupture of membranes (PROM)

Query Text:
If an obstetric patient is admitted in labour having already had PROM 18 hours prior to onset of labour, is not GBS positive and is given antibiotics during the labour, is the administration of antibiotics coded or is this considered routine treatment and not coded?

Response:
As per ACS 0042 Procedures normally not coded point 8, Drug treatment/pharmacotherapy, administration of antibiotics is not coded unless the substance is given as the principal treatment in same-day episodes of care or the drug treatment is specifically addressed in a coding standard.  As neither of these points appear to apply to your scenario, do not code the administration of antibiotics in this case.


Query Text:
Are Maternity hospitals permitted to code from information in the BOS Summaries without any other written notes within the admission episodes?

For example, vacuum delivery for delay in second stage documented on the BOS but not documented anywhere else in the partogram or progress notes.

Response:
VICC advises that a BOS summary must be treated like a discharge summary, therefore any information contained in it must have supporting documentation in the body of the record.  

This is in accordance with ACS 0010 Clinical documentation and general abstraction guidelines which says '...Before coding any diagnosis/procedure recorded, the clinical coder must verify information recorded on the front sheet and/or the discharge summary by reviewing pertinent documents in the body of the clinical record.'

So, for example, if a second degree tear is documented in the summary, there must be documentation of the tear and how it meets criteria for coding in the body of the record.


Query Title:
Coding of pneumonia with positive sputum culture

Query Text:
Could VICC please provide advice on the coding of pneumonia where there is an organism grown on sputum culture (eg. streptococcus pneumoniae, or haemophilus influenzae).

Can coders assume that the organism grown on sputum culture is the causative organism to use the essential modifiers under lead term Pneumonia for the bacteria:
eg. Pneumonia - streptococcus pneumoniae J13, or Pneumonia - haemophilus influenze J14

Or would there need to be documentation in the medical record that the pneumonia is Haemophilus influenzae pneumonia (for example) before coder can assign J14?

ACS 0010 General abstraction guidelines in example 2 " Code the following ....J21.0 Acute bronchiolitis due to respiratory syncytial virus where documentation shows bronchiolitis and cytology confirms RSV as causative agent" and ACS 1004 Pneumonia last paragraph "Microbiological reports, particularly sputum and blood cultures, will describe the organism (if any) thought to be the cause" seem to indicate that coders can make the link, however the opinion of our Infectious Diseases consultant is that "sputum has little predicative value of causative organism and  I would ignore".

It seems inconsistent that coders cannot assign codes for antibiotic resistance based on microbiology sensitivity reports alone (ACS 0112 Infection with drug resistant microorganisms and Coding Matters September 2009 volume 16 no. 2), yet the standards appear to allow coders to assume the causative organism of pneumonia.

Search Details:
ACS 0010 General abstraction guidelines
ACS 1004 Pneumonia
ACS 0112 Infection with drug resistant microorganisms
Coding Matters Vol 16 no 2

Response:
When there is a documented condition, in this case the pneumonia, in accordance with ACS 0010 General abstraction guidelines, the causative organism grown on the sputum can be used to access the essential modifiers under lead term Pneumonia unless the clinician documents otherwise in the body of the record.

VICC acknowledges that it may seem inconsistent that coders cannot assign codes for antibiotic resistance based on microbiology sensitivity reports alone however ACS 0112 Infection with drug resistant microorganisms advises that resistance must be documented in the record by the clinician.


Query Text:
Can you please provide guidance on the coding of VIN as the gradings 1,2,3 in the classification are no longer the recognised terminology for VIN. 

We have spoken with our vulval clinic team at our hospital and they say that VIN 1, 2, 3 are no longer acceptable terms in this specialty and terms such as warty, basaloid, mixed, differentiated are now used.

Response:
As the terms described do not appear as essential modifiers in the Index, VICC advises to assign the default code N90.3 Dysplasia of vulva, unspecified at Index entry Neoplasia, vulva (VIN).

You may wish to consider submitting a public submission to ACCD suggesting changes to the indexing of VIN.


Query Title:
Example 1 in ACS 0001 Principal diagnosis

Query Text:
Example 1 in ACS 0001 Principal Diagnosis, instructs coders to select the myocardial infarction as Principal Diagnosis, from a list of 3 diagnoses on the front sheet (reproduced below). 

Can VICC please provide clarification on what information was used in this example to make this decision? 

EXAMPLE 1:
Diagnoses as listed on the front sheet:
Diabetes mellitus
Coronary artery disease
Myocardial infarction

History of present illness:
Patient experienced severe chest pain on the morning of admission and was transported by ambulance to hospital and admitted to the coronary care unit.

In this example, the information from the clinical record indicates that myocardial infarction is the principal diagnosis.

Search Details
ACS 0001 - Principal Diagnosis

Response:
VICC advises that the example is illustrating the concept of 'after study' in the principal diagnosis definition, rather than the concept of two or more diagnoses that equally meet the definition for principal diagnosis.

Coders should interpret the example as illustrating that the full record was referenced and that after study it was determined that the myocardial infarction was the principal diagnosis.


Query Text:
I would like clarification on the use of the codes convalescent care and aftercare (surgical) in conjunction with step down care.  Does convalescent care or aftercare have to be documented to code them?

Is step down care considered synonymous with the above when dealing with patients transferring from one hospital to another for after care?

I work at two small rural hospitals that receive patients from larger regional and metro hospitals for post operative and/or medical care following a condition.  Through recent VAED coding audits many of these cases that were audited resulted in a DRG change due to step down care being documented as the principal diagnosis.   The auditors changed the coding to code the condition the patient had, as there was no index entry for step down care.  There was inconsistency amongst the auditors with some tending to code from the principal diagnosis rather than a review of the whole medical record and appreciating the logistics of coding in a small rural hospital.

The VMOs at my health services routinely document step down care post the condition (e.g. TKR, fracture NOF, cholecystectomy) for patients being transferred back from another hospital.  In most cases the patients are coming back for general nursing care with some allied health intervention prior to going home. There are however some that are receiving active treatment.  Majority of admissions are for between 4-6 days.  In some cases if the patients are not ready to go home they will transfer onto Transitional Care.

I believe the whole record should be used to make the decision of principal diagnosis assignment rather than what is documented solely as the principal diagnosis.  The term step down implies the patient is having a less active form of care at the receiving hospital.

Search Details
VICC #2128 Post operative care versus convalescence (retired)
Post surgery care after orthopaedic surgery (NCCH) 
ACS 2103 Admission for convalescence/aftercare

Response:
VICC acknowledges that whilst in some cases the reason for the transfer may be aftercare, VICC does not consider 'step down care' to be synonymous with convalescence or aftercare.

In order to apply ACS 2103 Admission for convalescence/aftercare, you need to have documentation of convalescence or aftercare. In the absence of documentation supporting the application of ACS 2103 VICC advises to code the condition that occasioned the episode of care as principal diagnosis, when documented.

VICC considers this to be a documentation issue and suggests seeking the support from your hospital management to engage with the clinicians to document the reason the patient is being admitted to your hospital.  This is because there are many reasons a patient can be transferred such as respite, palliation, continuing care, to be closer to home, convalescence or aftercare and the term step down care does not differentiate between these reasons.


Query Text:
We would like a review of previous coding advice query #2620 Subgaleal haematoma in newborns. 

We code this but question the advice to code following the pathway haematoma, see contusion, scalp P12.3. We believe that a subgaleal haematoma is more involved than this and believe the correct pathway to follow is Haematoma, Birth trauma P15.8. The information has already made the link that it is a birth trauma. Since subgaleal is not an option on either pathway we do not feel choosing scalp is correct.

Response:
As subgaleal is the space between the scalp and the skull, it is appropriate to search under lead term Haematoma for subterm scalp.  As there is no subterm for scalp under lead term Haematoma, coding convention is to follow the 'see also' note at Haematoma which says 'see also Contusion'.  At lead term Contusion, there are subterms, scalp, due to birth trauma leading to P12.3 Bruising of scalp due to birth trauma.  

We do not consider P15.8 is the appropriate code to assign for documentation of subgaleal haematoma in newborns because the Index entry is for Haematoma/Birth trauma NEC.


Query Text:
We note your response to  query #2759 regarding closure of temporary ileostomy and the scenarios where it is appropriate to code a bowel resection -  "VICC considers that when bowel resection or bowel excision is documented with closure of a temporary ileostomy, a code can be assigned for the procedure".

Our private hospital group has hospitals in Western Australia, Victoria and NSW and is keen to ensure that coding quality and consistency and coding standard application is of a high standard across our hospitals.  

We recently received the following advice from the Western Australian Coding committee regarding closure of temporary ileostomy and when it is appropriate to code a bowel resection. 

See following query and response from WA Coding Committee published 26 October 2012:-
Closure of Ileostomy -   Coding Committee WA     26th October 2012 

Query: With reference to an old WA database query W1733, is this query still valid and what constitutes an extensive resection. In the operation notes for closure of ileostomy we are given the measurement in centimetres and therefore don't know when to consider it extensive. 

Query W1733 reads: 

Q. The index for closure of ileostomy (without resection) 30562-01 [899] has the non-essential modifier without resection, however, the code in the tabular list actually includes the 'without resection' in the code description. 

Does this exclude the tidying up of the ileostomy ends before re-joining them? 

A. Code 30562-01 [899] includes the tidying up of the colostomy prior to closure, this may involve some trimming and resection of the ends before re-anastomosis. However, if there is documentation of more extensive resection as well as re-anastomosis it should be coded separately. 

Recommendation: 

Pieces of intestine removed with colostomy closure or ileostomy closure are part of the operation and coders should not report either separately. If documentation indicates the surgeon has simply removed the small segment of bowel that has been exteriorised or examined the doughnuts associated with an end to end stapled anastomosis do not code a resection. When a true bowel resection is documented, i.e. when the surgeon has found further pathology at the time of closure, a resection code should also be assigned. There is no need to code a re-anastomosis separately as previously advised in W1733. Coders should clarify with the clinician if there is any ambiguity. 

Decision: Coders must read the operation report and determine if a true resection has been performed before assigning a separate resection code. Clarify with the clinician if there is any ambiguity. 

Given the inconsistencies in the response, is it possible for this query to be raised via the National Coding Committee to ensure uniform coding of this particular procedure across Australia.

Response:
This query was originally published in the 2013-14 December Database as follows:

VICC considers that in essence the responses are the same, that is, the resection should be coded if it is documented as such.  VICC has based its answer on documentation of resection whereas WA draws a distinction between true resection and tidying up of the ends.  In both cases there must be documentation that a resection has been performed. Therefore, VICC does not consider the query needs referral to the Australian Consortium for Classification Development (ACCD).

Following publication of ACCD Coding Rules on 15 September 2014, the VICC response is superseded by following advice titled Closure of ileostomy with resection:

Q:
Is a separate code required for resection/excision of bowel with 30562-01 [899] Closure of ileostomy with restoration of bowel continuity, without resection as without resection is a nonessential modifier in the index?

A:

30562-01 [899] Closure of ileostomy with restoration of bowel continuity, without resection includes resection of small sections (freshening) (trimming) from the end of the stoma (exteriorised bowel/doughnuts) and distal intestine prior to anastomosis. 

Resection/excision of intestine in excess of this freshening/trimming should be coded in addition to the closure of ileostomy code. This may occur if the diseased section of bowel was not resected prior to creation of the ileostomy or when further pathology is found during the closure procedure. 

Where there is no documentation of further pathology of the bowel requiring resection, a separate code for the resection should not be assigned.


Query Text:
Is query #1955 ACS 1204 Plastic surgery still valid or did it retire in June 2010? 
 
The reason I am asking is because in the standards book, page 143, example 2, in this example they have not added the Z41.1 as an additional code. Shouldn’t they have added the Z41.1 into example 2 if the above query was still valid?

Response:
VICC advises that query #1955 ACS 1204 Plastic surgery was retired on 30 June 2010 and that revisions to ACS 1204 in Fourth edition included the deletion of Z41.1 Other plastic surgery for unacceptable cosmetic appearance in example 2. 

Please follow the advice in the current standard as it supersedes any other published information including advice titled Abdominal apron/overhang in Coding Matters Volume 8 Number 2 September 2001.


Query Title:
Foot debridement of a diabetic patient by allied health

Query Text:
As VICC query #2215 Foot debridement of diabetic patient has been retired and the Victorian ICD Coding Committee (VICC) Queries Database instructions state that coders must submit a new query to VICC if they consider the advice in a retired query to be still current or in need of updating. 

I now wish to check if the advice in this retired query can still be applied and is currently correct.

Response:
VICC advises that the advice in the retired query #2215 Foot debridement of diabetic patient is consistent with current standards ACS 1203 Debridement, which instructs that debridement should be coded as excisional in the absence of documentation of non-excisional and ACS 0032 Allied health interventions which advises that a combination of the specific code and a general code may be assigned. Therefore please follow the advice in the standards.


Query Text:
A patient has a cephalic-basilic vein DVT - what is the correct code for this?

If I look up Thrombosis, deep - I80.2 - the code descriptor indicates this code is for the lower limb, but includes 'Deep Vein Thrombosis NOS' and there is no essential modifier for lower limb in the index.

There is a subterm at 'thrombosis, deep' of 'specified site NEC' but I am not sure if I should use this.  

Also if the DVT was of a specified vein of the lower limb, should I82.8 be used instead of I80.2?  I don't think the indexing is very consistent when coding out DVT.

Response:
VICC acknowledges that the Index is problematic, however agrees that for the case cited the correct code to assign is I82.8 Embolism and thrombosis of other specified veins following Index entry Thrombosis/Deep/Specified site as the DVT in this case is not of the lower extremities.

If the DVT is of a specified vein of the lower limb (excluding femoral), the correct code to assign is I80.2 as the Tabular has an excludes note at I82 for lower extremities (I80.-).


Query Title:
Example 1 in ACS 1905 Closed Head Injury/Loss of Consciousness/Concussion

Query Text:
Example 1 in ACS 1905 is a scenario that is very common at our hospital.  We have many trauma patients with skull fractures and intracranial injuries.  The documentation on the discharge summary can vary sometimes the fracture is listed first, sometimes it is the intracranial injury.  The sequencing of these codes affects the DRG.

In the instances where the skull fracture is the first listed diagnosis on the summary and the intracranial injury is second, some coders believe that they can assign the intracranial injury first as that is how the codes are sequenced in example 1.  

However, I believe this scenario is contradictory to the advice provided in ACS 0001 Two or more diagnoses that equally meet the definition for Principal Diagnosis.

Should the codes be assigned in the order as listed on the discharge summary as per ACS 0001?
Or should the codes be assigned as per example 1 (haemorhage before fracture) no matter what order they appear in on the discharge summary?

Search Details:
ACS 0001 Principal Diagnosis
ACS 1905 Closed Head Injury/Loss of Consciousness/Concussion

Response:
VICC advises that examples in standards are designed to illustrate the particular advice the standard is providing.  

In the case of example 1 in ACS 1905, this example is illustrating the need to assign codes for each type of injury for example, fracture,  intracranial injury and loss of consciousness.  The example is not attempting to provide advice on sequencing.  

Standards ACS 1907 Multiple injuries and ACS 0001 Principal diagnosis should be applied for sequencing advice.


Query Text:
When a keloid scar is removed prior to the entry into the uterus for a LUSCS, is code O34.2 Maternal care due to uterine scar from previous surgery sufficient or is a code from the Skin chapter (L Code) also required?

Response:
VICC advises that the keloid scar meets criteria in ACS 0002 Additional diagnoses because it was documented as being excised prior to entry into the uterus.

Therefore, if the keloid scar is due to a previous uterine scar, assign an L code in addition to O34.2 Maternal care due to uterine scar from previous surgery to provide further specificity of the scar.

If the keloid scar is not related to a previous uterine scar, assign O99.7 Diseases of the skin and subcutaneous tissue complicating pregnancy, childbirth and the puerperium and the appropriate L code as per ACS 1500 diagnosis sequencing in obstetric episodes of care/Other additional diagnoses in obstetric episodes of care, second dot point. O34.2 Maternal care due to uterine scar from previous surgery would be assigned in addition in this instance if it meets the criteria in ACS 1506 Malpresentation, disproportion and abnormality of maternal pelvic organs.


Query Title:
SSU admission post fracture reduction in ED

Query Text:
We have had a couple of patients admitted to our SSU post treatment of a fracture in ED.  For example patient with # radius - reduction done in ED under sedation - patient then admitted to SSU for observation and pain relief.  

What should we be coding as principal diagnosis?  The fracture has already been treated, in which case should we be coding Z47.8 Other specified orthopaedic follow-up care as the principal diagnosis with the fracture code after this?  

We have gone in circles with these scenarios as to what is the best reflection of what happened during the inpatient component of the episode.

Response:
VICC advises that provided there is documentation supporting that the patient is admitted to a SSU for ongoing treatment, observation, assessment or re-assessment of the fracture, the principal diagnosis will be the fracture.


Query Text:
To look up a percutaneous cholecystostomy, done by ultrasound in radiology, it appears as though you need the essential modifier of 'trocar' to select 'Cholecystostomy, trocar (percutaneous) 90348-00 [961] Percutaneous aspiration of gallbladder. 

This seems inconsistent with other entries in the ACHI index in which the term 'percutaneous' would be the essential modifier.  

If a patient has a percutaneous cholecystostomy should we use the default code of 30375-05 [969] Cholecystostomy
or ignore the essential modifier of 'trocar' if we don't have that documented and select the percutaneous option?

You can also get to 90348-00 looking up 'Aspiration/ gallbladder/ percutaneous'.

Response:
VICC considers that without documentation of the essential modifier of trocar, the correct code to assign is the default code 30375-05 [969] Cholecystostomy.

You may wish to submit a public submission to ACCD requesting an Index entry for percutaneous cholecystostomy.


Query Title:
Combined Ventilatory Support >96 hrs in neonates

Query Text:
Neonate patient has:
100 hours of CMV 13382-02 [569] Management of continuous ventilatory support, >= 96 hours
40 hours of CPAP 92209-01 [570] Management of noninvasive ventilatory support, > 24 and < 96 hours
Total combined hours of 140.
 
My question is, do we need to code the additional code to indicate there is a combined total of >96 hours 92211-00 [571] Management of combined ventilatory support, >= 96 hours? 

Given that it has already been identified that the CMV is > 96 hours (100 hours), is it required to code the additional code to explain the combined >96 hours?

Response:
VICC advises that in accordance with the 'Code also when performed note' at Blocks [569] Ventilatory support and [570] Noninvasive ventilatory support,  92211-00 [571] Management of combined ventilatory support, >= 96 hours must be assigned in neonate episodes when combined invasive and noninvasive ventilatory support is >= 96 hours.


Query Title:
Clarification of coding for 2013-14 Victorian Admission Policy

Query Text:
Seeking clarification regarding Victorian Hospital Admission Policy: 2013-14 changes regarding use of ED notes for coding of inpatient episodes. 

Note these cases refer to ED attendances and not EOU admissions. 

1. Can we include MV/NIV hours in ED in the codeable count? 
Eg. 6 hours MV in ED, 19 hours MV in ICU (non surgical patient). Do we assign 13882-00 Management of continuous ventilator support, <= 24 hours or 13882-01 Management of continuous ventilator support, > 24 hours <96 hours?

2. Can we use documentation from the ED notes to support coding conditions that are still being treated once the patient is transferred to the ward? 

Eg. Patient admitted to ward via ED.  In ED hypokalaemia is documented and IV KCL is ordered. Patient is transferred to the ward and IV KCL is commenced for K2.8 as per ED orders. 

Can we code the hypokalaemia as the treatment was given once the patient was admitted?  Do we need to submit a coding query to have hypokalaemia documented by the ward doctor or can we use the documentation of hypokalaemia from the ED notes?

Eg. Patient presents to ED in acute respiratory failure (ARF) due to infective exacerbation of COPD. Patient is commenced on continuous oxygen therapy and transferred to the ward. Oxygen therapy continues on the ward until 02 sats reach acceptable level. Inpatient notes state patient was admitted for infective exacerbation of COPD. 

Can we use ED documentation to code ARF as treatment is still being administered on ward?  Do we need to submit a coding query to have ARF documented by the ward doctor or can we use the documentation of ARF from the ED notes?

3. Patient is transferred from ward to HITH for ongoing management of coagulation therapy, becomes unwell during HITH admission at home, starts haemorrhaging and is brought in to ED via ambulance and from ED readmitted to the ward. 

Can we use the ED notes as part of the continuous admission for coding purposes?

4. Patient presents to ED in septic shock, required intubation and MV commenced. Patient has intra-osseous line inserted into tibia for fluid resuscitation and blood transfusion as they are too dehydrated to be able to get an IV line in. CVC inserted into jugular vein once patient rehydrated enough to enable IV cannulation.  No ICU bed available at presenting hospital so patient kept in ED resus bay for 7 hours until an ICU bed can be obtained at another hospital and patient transferred. 

According to the admission policy changes this patient does not meet admission policy criteria as they were not admitted to an EOU bed due to their need to remain in the resus bay in ED due to their acuity. Yet a patient that presents with chest pain, is on a chest pain care plan and is well enough to be admitted to an EOU bed and goes home 4 hours later with antacids prescribed does meet admission criteria.  Can the committee confirm that this is not an admission?

5. Patient presents to ED with thrombotic cerebral infarct and has TPA given whilst in ED for clot thrombolysis. TPA causes intracerebral haemorrhage.  Patient transferred to ward from ED with diagnosis of intracerebral haemorrhage documented on discharge summary from ward.  Can we code the original infarct as the treatment for same was given in ED?  If we can code it, do we need to submit a coding query to have it documented by ward doctor or can we use the documentation of same from the ED notes?

6. Patient BIBA to ED found on floor at home, having sustained #NOF, several lacerations, rhabdomyolysis and in acute urinary retention. Ward bed not available for several hours post arrival in ED. Patients lacerations cleaned and sutured and IDC inserted for retention in ED. Fluid resus and electrolyte monitoring for rhabdomyolysis performed in ED.  

Can we code the lacerations and rhabdomyolysis if only care for same during inpatient episode is removal of dressing and daily U&Es (not stated as being performed for monitoring of electrolytes to determine if rhabdomyolysis resolved)?

Can we code the urinary retention based on removal of IDC?

Can we use the ED notes to code these conditions if they are not documented in the ward notes or do we need to submit a coding query to have conditions and monitoring/treatment of same documented by ward doctor?

7. MVA patient BIBA to ED with LOC at scene, assorted lacerations, abrasions, and tender RUQ abdo. 4 hours of HI obs, CT brain, chest, abdo, pelvis performed in ED.  No head injury on review by neurology in ED. General Surgery registrar review in ED "liver laceration" for admission to ward.

Can we code the LOC and other traumatic injuries? Only evidence of care to other lacerations and abrasions is wound chart in inpatient record and no further head injuries observations performed as head injury ruled out in ED. 

8. Patient presents to ED in AF with SOB & decreased 02 sats (84% on arterial blood gases) attributed to acute respiratory failure (ARF) and also fluid overloaded.  Patient is reviewed by General Medical registrar (1900 hours) and is for admission to ward when bed becomes available.  Whilst in ED patient is given 02 therapy, IV lasix and is given IV Amiodarone.  On transfer to ward (0300 hours following morning) patient has returned to normal heart rhythm and 02 sats are at target (> 90% on room air). Inpatient notes " PDx CCF, ADx AF".
 
Can we code the ARF based on a repeat arterial blood gas being performed once the patient is on the ward? No documentation of ARF in inpatient notes, only in ED notes.

Can we code the AF? It is documented on the inpatient discharge summary but only documented evidence it was treated is in the ED notes.

Response:
With the change to Admission Time definition, the admitted episode now begins at the time the patient departs from the emergency department.  This change has impacted on the way emergency department notes are considered when coding the admitted episode. 

The following principles may assist coders in determining how emergency department notes should be considered and will provide guidance in each of the above scenarios:

- Emergency department notes are to be regarded like any other documentation outside the admission (for example, GP referring letters, outpatient notes or transfer documentation) to provide further specificity to a documented condition in the admitted episode or to support the coding of conditions requiring ongoing treatment on the ward

- Procedures performed in the emergency department are not coded in the admitted episode

- Conditions completely resolved or fully treated in the emergency department are not coded in the admitted episode

Other specific points to note are:
- Mechanical ventilation hours that occurred in the emergency department cannot be included for assignment of the code

- Emergency department notes, like any other documentation outside the admitted episode, can be used to support the coding of a condition that requires ongoing treatment on the ward. However, the notes need to link the treatment to the condition.  Therefore with respect to the acute respiratory failure (ARF) example, there needs to be clear documentation that the ongoing treatment in the admitted episode is for the ARF and not the COAD

- When a patient is transferred to the emergency department from Hospital In The Home (HITH) and then transferred to the ward, this is a continuous admission and therefore the ED notes are part of the admitted episode.  This is because HITH is considered to be admitted care and the emergency department component of this case is viewed as a ward transfer

- Traumatic injuries can be coded in accordance with the Coding Matters Volume 17:1 article titled Multiple trauma which says:
[Q:  When a patient is admitted with multiple trauma should all of the injuries be coded or only those that meet ACS
0001 or ACS 0002 (or other specialty standards)? For example, patient admitted with fractured ankle, punctured lung and contusions to the head and arm. Contusions to the head and arm don’t meet ACS 0002 i.e. no treatment, observation etc. Should they be coded?

A: The NCCH advises that when coding multiple trauma admissions, coders should code out all injuries, including contusions and abrasions, documented as part of the totality of multiple trauma.  

Clinical advice recommended continuation of the practice to code abrasions and contusions in a multiple trauma as they are not always trivial injuries and may be significant in their own right; such as abrasions a motor cycle rider suffers in an accident when not wearing protective clothing.  

This advice applies to the initial presentation for multiple trauma and not to subsequent admissions where the injuries would need to meet the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.

The only exception to this rule is in ACS 1916 Superficial injuries which states:
“Superficial injuries, such as abrasions or contusions, are not coded when associated with more severe injuries of the same site.”]`


Query Title:
Diagnostic coronary angiograms leading to intervention

Query Text:
We are having trouble deciding the correct code to assign for patients who present with chest pain, have a coronary angiogram, and at the same Cath Lab visit proceed to either a stent or balloon of diseased vessels.

Most of our patients have IV sedation for these procedures, so they are able to be coded.

We're not sure if we code 38215-00 [668] Coronary Angiography or 38218-00 [668] Coronary angiography with left heart catheterisation.

We feel that we should be using 38218-00 [668] for patients initially presenting with symptoms, where the angiogram and  PTCA are performed within the same visit to the Cath Lab, but are not sure if previous advice leads us to 38215-00 [668] for all intra-operative coronary angiography.

Your advice would be appreciated.

Search Details:
VICC queries #2311 states to use 38215-00, but that query was related to Non-diagnostic angiograms

Response:
VICC advises that #2311 Non-diagnostic coronary angiography with PTCA and stenting has been superseded with developments in the classification.  Regardless of whether a Percutaneous transluminal coronary angioplasty (PTCA) or stent insertion is performed, you can assign 38215-00 [668] Coronary Angiography or 38218-00 [668] Coronary angiography with left heart catheterisation in accordance with the documentation in your record.

With respect to your comment regarding these patients having IV sedation, cardiac catheterisation blocks [667] and [668] are excluded from ACS 0042 Procedures normally not coded, therefore these codes can be assigned regardless of IV sedation being administered.


Query Title:
Cerebrospinal fluid (CSF) seeping / seepage / ooze

Query Text:
Could the committee please provide clinical coding advice on the following two scenarios?

1. Following a gross total resection of a midline intradural tumour at L3/4, the following was documented on the operation report: "Watertight dural closure although CSF seeping through suture holes. Surgicel with Tisseel applied. Haemostasis. Wound closure".  Should code/s be assigned to represent that CSF was seeping through the suture holes, and if so, what codes should be assigned?  

2. Two days post-operatively following spinal surgery the following was documented in the progress notes: " ? small CSF ooze from back wound. Plan: Remain flat, await Neurosurgery review."  Should code/s for the ? CSF ooze be assigned, and if so, what codes should be assigned?

Search Details:
1. ICD-10-AM Alphabetic Index: No index entry listed for the following terms: Seeping, Seepage or Ooze.
2. Victorian ICD Coding Committee (VICC) Queries Database.
3. ACCD (previously NCCC) ICD-10-AM/ACHI/ACS Published Coding Advice.

Response:
With respect to scenario one, VICC sought clinical advice that indicates that testing of wound closure is standard practice and additional sutures may be routine.  You would therefore need to seek clinical advice as to whether the CSF seeping through the suture holes in your scenario is considered a complication of the surgical intervention requiring additional clinical care and monitoring in order for the CSF seeping to be coded as a procedural complication in accordance with ACS 1904 Procedural complication and ACS 0002 Additional diagnoses.  

If you are not able to get clinical advice, VICC advises to follow the part of ACS 1904 which says 'If it cannot be determined whether a condition meets the definition of a procedural complication, it should not be coded as such...'

In regard to your second question, VICC notes that there was no documentation provided of the neurosurgery review and therefore suggests to seek clinical advice.  If the clinician documents that it is a CSF leak, the correct code to assign is G97.0 Cerebrospinal fluid leak from spinal puncture.  If the clinician does not confirm that the wound ooze is CSF, VICC suggests to refer to VICC query #2725 Wound ooze for advice reproduced below:

#2725 Wound ooze
Q:
In reference to VICC query #2508 Wound ooze, the response that states 'wound observation/monitoring and dressing management are routine post-operative care... you would need documentation of care or management of the wound that is beyond routine care'.  
Can you please provide some advice on whether or not wound ooze should be coded in the following examples:

1. Nursing notes 9/7 0610: POP L) leg – oozing on plaster marked.
Nursing notes 9/7 1440: L leg plaster insitu, has old ooze, elevated on pillow LMO notified on 7232 to review patient regarding old ooze and ?D/C.
Ortho Res 9/7 2130: “ATRP re slight ooze in plaster. S/B Registrar (ortho) patient okay for discharge.”

2. Nursing notes: Moderate ooze from graft site. Reinforced. No more ooze.

3. Nursing notes 9/12 1750: L) groin Dx – slightly oozing and marked. Small further oozing. Nil further oozing after 2nd time marking.
Nursing notes 10/12 0345: Dx to L) groin has old ooze – marked @ 2200.

4. Nursing notes: For change of dressing as wound is oozing.

Search Details: 
VICC Query #2508 Wound Ooze

A:
VICC referred this query to ACCD who provided the following advice published in the December 2014 Coding Rules:

Postoperative wound ooze may refer to:
- Serous exudate – drainage of a clear, thin, watery fluid from a surgical wound. This type of wound ooze is a normal and expected part of the healing process
- Haemoserous (serosanguinous) exudate – drainage of a thin, watery, pink coloured fluid composed of blood and serum. This type of wound ooze is also a normal and expected part of the healing process
- Sanguinous exudate or haemorrhage – indicates a trauma to blood vessels
- Purulent (pussy) exudate – a yellow, grey or green odiferous discharge – indicates infection.

While small amounts of serous or serosanguinous exudate from a postprocedural wound is considered normal, excessive or increasing discharge may indicate a postprocedural complication.

The ACCD agrees that wound observation/monitoring and dressing management are routine postprocedural care and that wound ooze should only be coded when there is documentation of care or management of the wound that is beyond routine care.

Evidence that wound ooze has met the criteria for code assignment in ACS 0002 Additional diagnoses includes:
- Consultation/treatment by a clinician, including a wound specialist or stoma therapist (if this is outside of routine wound management in your facility)
- Application of vacuum dressing or other dressing/device outside of the routine type of dressing material (for example, stoma bags may be used in place of conventional dressings where there is excessive discharge of exudate)
- Unexpected/unplanned return to theatre for wound exploration/insertion of a drain.

The above list should not be considered exhaustive and each case must be considered on its own merits. Where there is uncertainty as to whether wound ooze is in excess of the normal healing process or is indicative of haemorrhage or infection (and these terms are not documented), confirmation should be sought from the treating clinician.

When the above guidelines have been followed and criteria have been met, assign the following codes for wound ooze NOS:

T81.8 Other complications of procedures, not elsewhere classified
Y83-Y84 Surgical and other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure
Y92.22 (Place of occurrence) Health service area

Assign codes for postoperative haemorrhage or infection by following the guidelines in ACS 1904 Procedural complications. [end of ACCD response]

In addition to the ACCD response, VICC has developed the following additional instructions to clarify what constitutes routine care and beyond routine care.   This advice is to be followed for documentation of an intervention for wound ooze.

1. Routine care – Wound ooze must not be coded
- Dressings
- - scheduled changes of existing dressing e.g. third or fourth daily
- - non-scheduled changes of existing dressing
- - reinforcing of existing dressing
- - change of dressing from one type to another  - see point 2 below for exclusion
- icing 
- marking
- cleaning/cleansing
- wound swab
- elevation

Note:  The types of care detailed above cannot be queried with clinicians to gain advice that these are beyond routine care.

2. Beyond routine care – Wound ooze should be coded
- Debridement of wound 
- Theatre management 
- Change of dressing TO negative pressure wound therapy (vacuum) or stoma bag
- Consultation with clinician resulting in change of patient management e.g. commencement of antibiotics, delayed discharge


Query Text:
I have an ED/SSU scenario which I would like to get some clarification on in terms of coding.

We had a patient present to ED in SVT where they had DCR under sedation. Patient transfer to SSU under the careplan titled Post Procedure/Sedation Observation. They also received IV fluids in SSU.

My thoughts were SVT as that is what the procedure was for. We would not code the DCR or sedation.

I have discussed this with another health service whose thoughts were along the same lines as mine and to code the SVT as the diagnosis rather than observation.

Is the diagnosis SVT, or observation?

Response:
VICC agrees that the principal diagnosis in the case cited is the SVT as it was the diagnosis established after study  that was chiefly responsible for occasioning the episode of care (ACS 0001 Principal diagnosis).  

VICC agrees with your comment not to code the DCR or sedation.


Query Title:
Enterococcus faecalis septicaemia secondary to port-line infection

Query Text:
Can the VICC please provide guidance on the correct code assignment and sequencing for the following episode? 

Patient diagnosis on discharge summary states enterococcus faecalis septicaemia secondary to port-line infection. 

Documentation in progress notes state sepsis and enterococcus faecalis bacteraemia from permacath.

1. Can A40.2 Sepsis due to streptococcus, group D (generalised sepsis) be coded as the principal diagnosis? 

2. Can T82.7 Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts  OR T80.2 Infections following infusion, transfusion and therapeutic injection be coded as the principal diagnosis WITH A40.2 Sepsis due to streptococcus, group D coded as an additional diagnosis?

Search Details:
ACS 1904 Procedural complication, Infected intravenous (IV) site
ACS 0110 Sepsis, severe sepsis and septic shock.

Response:
As your documentation links the sepsis to the port-line, VICC considers that the correct principal diagnosis is T82.7 Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts following Index entry Sepsis/due to/device, implant or graft /infusion NEC and ACS 1904 Procedural complications.  

Also, in accordance with ACS 1904 an additional code from Chapters 1 to 19 should be assigned where it provides further specificity.   Therefore assign A40.2 Sepsis due to streptococcus, group D as an additional code to identify the bacterial agent and the generalised nature of the sepsis.


Query Text:
When coding subcutaneous emphysema that is secondary to surgery - are we able to add T79.7 Traumatic subcutaneous emphysema to add specificity to code T81.8 Other complications of procedures NEC? 

We are able to add injury codes to T81.2 to indicate the site of a perforation or other intra-operative injury, but the exclusion notes seem to indicate that perhaps you can't (depending on what type of exclusion note it is).

Response:
This query was originally published in the 2013-14 VICC queries database as follows:

For documentation of  surgical subcutaneous emphysema, VICC considers it is appropriate to add T79.7 Traumatic subcutaneous emphysema to add specificity to code T81.8 other complications of procedures NEC.  

This is supported by example 15 in the Conventions used in the Tabular list of diseases under heading excludes notes, to translate medical statement into code and ACS 1904 Procedural complications which says that an additional code from Chapters 1 to 19 should be assigned where it provides further specificity.

The response has been updated for Tenth Edition as follows:

For documentation of surgical subcutaneous emphysema, follow the Index pathway Emphysema/surgical to assign T81.84 Post procedural emphysema. As the clinical concept has been fully described by code T81.84 an additional code is not required.


Query Text:
We are seeking clarification on coding from pathology results versus interpreting pathology results. We understand that if a urine culture grows a bacteria, we can't code a UTI unless UTI is documented by a clinician in the notes.

If however a haemtology result shows an abnormal Hb level, and in the comments section on the Haematology report it says anaemia, can we code anaemia?

Often we see that in the medical record it will say Hb 7.1 (for example), and blood transfusion ordered, but anaemia is not written.  However when we check the pathology results it often says either of these comments:
Clinical context and instrument parameters have been reviewed. A blood film is not required on this occasion; or anaemia (usually normochromic normocytic anaemia).

If there is documentation on the pathology result of anaemia, is that enough to code D64.9?

Search Details:
ACS 0010 General Abstraction Guidelines doesn't specifically comment on the above scenario.

Response:
VICC advises that if the only documentation of anaemia is in the haematology report, then the anaemia would not be coded. This is because the haematology report is an interpretation of a laboratory reference range and not necessarily an interpretation of the clinical relevance of the result in the current episode of care.

If however, anaemia is documented in other parts of the record and there is evidence of treatment or monitoring of the anaemia, the haematology result can be used to provide further specificity of the type of anaemia.  This is in accordance with ACS 0010 General abstraction guidelines under heading 'findings that provide more specificity about a diagnosis'.


Query Text:
Patient underwent diagnostic laparoscopy for abdominal pain.  Laparoscopy showed necrotic appendix and adhesions.  Open appendicectomy and lysis of adhesions performed.

It was never the intention to perform a laparoscopic appendicectomy.  The intention of the laparoscopy was to identify the source of the pain.

Do you code appendicectomy followed by laparoscopic procedure proceeding to open procedure or do you code laparoscopy and appendicectomy ? (as well as lysis of adhesions)

Search Details:
VICC #2559 Exploratory laparotomy in trauma episodes 
ACS 0019 Procedure not completed or interrupted

Response:
This query was originally published in the 2013-14 March Database as follows:

VICC advises that because the patient underwent diagnostic laparoscopy for abdominal pain prior to the appendicectomy, it is not appropriate to assign 90343-01 [1011] Laparoscopic procedure proceeding to open procedure in the case cited. This is in accordance with the second note in ACS 0019 Procedure not completed or interrupted which says 'These codes should not be used for diagnostic endoscopy/laparoscopy/arthroscopy'.

Therefore, the correct codes to assign for the case cited are:
30571-00 [926] Appendicectomy
30390-00 [984] Laparoscopy


This query has been updated for Eleventh Edition as follows:

ACS 0019 Intervention abandoned, interrupted or not completed states ‘When an intended minimally invasive intervention proceeds to an open intervention, assign first a code for the open intervention followed by an appropriate code below:
•	90343-00 [1011] Endoscopic procedure proceeding to open procedure
•	90343-01 [1011] Laparoscopic procedure proceeding to open procedure
•	90613-00 [1579] Arthroscopic procedure proceeding to open procedure.’

Therefore, VICC advises as the patient underwent diagnostic laparoscopy for abdominal pain prior to the appendicectomy, and the appendicectomy never intended to be performed laparoscopically, it is not appropriate to assign 90343-01 [1011] Laparoscopic procedure proceeding to open procedure in the case cited.

Therefore, the correct codes to assign for the case cited are:
30571-00 [926] Appendicectomy
30390-00 [984] Laparoscopy


Query Title:
ACS 0012 Suspected Conditions and transfers

Query Text:
Patient presents to Hospital A with chest pain.  Having met admission criteria at Hospital A, the patient is transferred to Hospital B for CTPA with the transferring letter stating this is "to exclude PE" (pulmonary embolism) - note Hospital A does not have the equipment to perform this procedure.  There is no documentation in the clinical notes other than chest pain.

Is the terminology "to exclude PE" synonymous with "? PE".  That is, does a transfer to rule out a condition out mean it is suspected?  In the scenario described does Hospital A code I26.9 Pulmonary embolism without mention of acute cor pulmonal
with Z75.3 Unavailability and inaccessibility of health-care facilities or R07.4 Chest pain?

Response:
For the case cited, VICC advises that the correct code to assign is R07.4 Chest pain.

As ACS 0012 Suspected conditions under heading 'Transferred to another hospital' specifically refers to a suspected condition, VICC considers that there must be documentation in the record of 'suspected PE' or '?PE' in order for hospital A to assign a code for pulmonary embolism. VICC does not consider documentation of 'to exclude PE' to be synonymous with 'suspected PE'.


Query Text:
With the Eighth edition coding changes to Hepatitis, please advise on how to code the condition during a delivery episode.  

ACS 0104 Viral Hepatitis, Classification 2. Hepatitis complicating pregnancy, childbirth or the puerperium states "when viral hepatitis complicates pregnancy, childbirth or the puerperium, assign O98.4 Viral hepatitis complicating pregnancy, childbirth and the puerperium and a code for the specific type of hepatitis.  

The article in Coding Matters Volume 15 Number 3 December 2008, ACS 1521 Conditions Complicating Pregnancy states, "The rule of thumb for many coders appears to have been to assign a code from O98 or O99 as appropriate for nonobstetric conditions in this period and then to assign a code for the condition based on ACS 0027 Multiple coding.  We advise that this practice should continue... where there is a nonobstetric condition in the postpartum period of the delivery episode of care."

If a lady has been documented as being Hepatitis C positive during her uncomplicated delivery episode, do we assign:

(a) (P) O80
     (P) Z37.0
     (A) B18.2  or,

(b) (P) O80
     (P) Z37.0
     (A) O98.4
     (A) B18.2

Search Details:
ACS 0104
Coding Matters 15(3)
VICC #2392

Response:
This query was originally published in the 2013-14 March database as follows:

VICC notes that the Coding Matters article titled ACS 1521 Conditions Complicating Pregnancy in Volume 15 Number 3 December 2008, was retired by NCCC on 30 June 2013.

Therefore, VICC advises that in accordance with the statement in ACS 0104 Viral hepatitis, if there is documentation that the viral hepatitis has complicated the delivery episode, assign O98.4 Viral hepatitis complicating pregnancy, childbirth and the puerperium and a code for the hepatitis.  In the absence of such documentation, assign only the hepatitis code.

On 1 May 2014 ACCD advised jurisdictions that the advice in the Coding Matters article has been updated for Eighth edition and incorporated into Coding Rules.  Consequently the original response is superseded by the following advice:

VICC advises that the correct codes to assign for the scenario cited are the codes listed under option (b).  This is in accordance with the advice in the Coding rules titled ACS 1521 Conditions complicating pregnancy (2 of 2).

Please note that the advice titled ACS 1521 Conditions Complicating Pregnancy was originally published as an article in Coding Matters article Volume 15 Number 3, December 2008 but coders should now reference the Coding Rules on the ACCD website.


Query Title:
Subcutaneous injection of hypoglycaemic agents for Type 2 diabetes

Query Text:
We have a patient who is on long term use of subcutaneous Byetta (Exenatide) for his Type 2 diabetes. On discussion with the pharmacist, this is a measure used before the need for insulin which is often very effective and reduces the incidence of hypoglycaemic episodes. 

Should this be coded as Z92.28 Past history of long term use of other medicaments to reflect the severity or progression of the diabetes?

Response:
VICC notes that there is no specific instruction regarding the coding of long term use of medication other than insulin.  The diabetes codes will reflect the severity and progression of the diabetes as per ACS 0401 Diabetes mellitus and intermediate hyperglycaemia (rule 4a). 

VICC advises that Z92.28 Past history of long term use of other medicaments can only be assigned if it meets criteria for coding such as ACS 0002 Additional diagnoses.


Query Title:
Principal Diagnosis in same day endoscopy cases

Query Text:
VICC query #2444 states if the condition has been documented under the heading of operative diagnosis (as opposed to a heading of operative findings), this means that the clinician has made a diagnosis after study and therefore documentation of a link between the symptom and the finding is not required.

VICC query #2671 provides advice for the example where a patient is admitted for investigation of their anaemia and the operative/ preliminary diagnosis states oesophagitis,, that this in itself represents a causal link and therefore a code for this condition (oesophagitis) must be assigned as the principal diagnosis.

Our Director of Gastroenterology has advised that the endoscopic diagnosis field on our endoscopy reports (which I assume is considered the same as operative/ preliminary diagnosis) is more commonly used to list the incidental findings rather than the underlying cause of the indication.  He stated that the title endoscopic diagnosis does not indicate a final diagnosis or an established causal link.  He also stated that in general, the endoscopist does not make the established causal link between the indication and findings, as it is the treating clinician that should make the link.

Here is an example of a colonoscopy and gastroscopy performed on a patient in the one admission.  The endoscopy referral and consent form states the indication is chronic abdominal pain and the pathology states mild chronic gastritis.

PROCEDURE PERFORMED
Colonoscopy
INDICATIONS FOR EXAMINATION
Chronic Abdominal pain
EXTENT OF EXAMINATION
Caecum
FINDINGS
Minor sigmoid diverticular disease. Very difficult passage through sigmoid colon, probably due to adhesions from previous total hysterectomy
ENDOSCOPIC DIAGNOSIS
Minor Diverticulosis
? adhesions
PATHOLOGY
None
FOLLOW UP/RECALL
Follow up as planned.
Consider diagnostic laparoscopy

PROCEDURE PERFORMED
Gastroscopy
INDICATIONS FOR EXAMINATION
EXTENT OF EXAMINATION
Second part of duodenum
FINDINGS
Normal upper GI endoscopy to the second part of duodenum.
ENDOSCOPIC DIAGNOSIS
Normal Gastroscopy
PATHOLOGY
Stomach biopsies
FOLLOW UP/RECALL
Follow up with Referring Doctor

Q1. Should we code the diverticulosis as principal diagnosis as it is documented under the Endoscopic Diagnosis field on the colonoscopy report or should we code the chronic abdominal pain as principal diagnosis because normal gastroscopy is documented under the Endoscopic Diagnosis field on the gastroscopy report?

Following advice above from the Director of Gastroenterology, it seems we should not make the causal link between the chronic abdominal pain and diverticulosis as endoscopists generally do not use the Endoscopic Diagnosis field to indicate an established causal link.

Q2. If there were several conditions listed under the Endoscopic Diagnosis field, then do we code all of them as principal diagnosis listing them in the same order as the clinician or do we go back to coding the indication as principal diagnosis?

Q3. Should we follow advice in VICC queries #2444 and #2671 which states when the clinician has documented an operative/ preliminary diagnosis ( in our case endoscopic diagnosis), this in itself represents a causal link and therefore a code for this condition must be assigned as the principal diagnosis?  Or should we follow advice provided by our Director of Gastroenterology who states that the title endoscopic diagnosis does not indicate a final diagnosis or an established causal link and therefore code the indication as principal diagnosis (applying ACS 0046 Diagnosis Selection For Same Day Endoscopy).

Search Details:
VICC queries #2444, #2512, #2671, #2704, #2432

Response:
VICC advice is to apply the following points in ACS 0046 Diagnosis selection for same day endoscopy to the documentation in the record to determine the principal diagnosis assignment in same day endoscopy cases:

- If a causal link is established between the symptom and one of the findings (that is, either the clinician documents the link, or a standard directs coders to assume a link), this finding should be assigned as principal diagnosis. The symptom should not be coded (unless it meets criteria in ACS 1802 Signs and symptoms) and the other findings, if any, should be assigned as additional diagnoses
- If a causal link is not established, code the symptom as the principal diagnosis and code all the findings as additional diagnoses
- A computer generated report of the findings does not constitute establishment of a link, unless that report clearly demonstrates that one of the findings is the cause of the symptom and the other findings are incidental

VICC has decided to retire queries #2444 Principal diagnosis in same day patients, #2512 Operative diagnosis and symptom for same day endoscopy, #2704 Principal diagnosis in same day patients and #2671 Principal diagnosis selection in same day endoscopy cases from 1 January 2014 so that coders can apply their understanding and knowledge of their documentation when following ACS 0046 rather than having the coding decision being influenced by variations in forms design and various computer generated reports.


Query Text:
The following query was retired on 30 June 2013:

#2391   Femoro-acetabular impingement (FAI)  
Question:
What is the correct diagnosis code to assign for Femoro-acetabular impingement (FAI)? 

Patients with FAI are now being admitted for an orthopaedic procedure to correct this. 

The procedure is documented as surgical hip dislocation with femoral head 'bumpectomy'and lateral tear debridement. Can the VICC please advise on the correct codes to assign for this procedure?  

Response:
From the operation reports provided, femoro-acetabular impingement is documented as labral tear, therefore the VICC suggests assigning diagnosis code M24.15 Other articular cartilage disorders, pelvic region and thigh by following index entry: 
Tear, torn 
-articular cartilage, old M24.1- 

For documentation of tear debridement, assign 90574-01[1561] Excision of joint, not elsewhere classified by following the index entry Debridement, joint, specific joint NEC. 

For documentation of bumpectomy, assign 48424-04 [1483] Ostectomy of proximal femur by following the index entry Ostectomy, femur, proximal.  

Currently there is no advice to support the coding of FAI. Does the committee still consider this advice current?

Response:
VICC advises that the information in query #2391 Femoro-acetabular impingement (FAI) is still current, however notes that the response is specific to the query and the operation report provided.  

For documentation of femoro-acetabular impingement without mention of a tear, the correct code to assign is M25.95  Unspecified joint disorder, pelvic region and thigh following Index entry Disorder/joint or Lesion/joint.


Query Text:
Should cam lesions be coded in addition to femoro-acetabular impingement (FAI) of the hip?  If yes, what is the code for a cam lesion?

Research: Cam type impingement describes a bump on the surface of the femoral head (ball) which jams on the rim of the (acetabulum) socket.

Search Details:
http://www.hiparthroscopy-ireland.com/fai.html

Response:
VICC advises that a cam lesion is a type of femoro-acetabular impingement.

For documentation of cam lesion, assign M25.95  Unspecified joint disorder, pelvic region and thigh following Index entry Disorder/joint or Lesion/joint.

See also VICC query #2882 Femoro-acetabular impingement (FAI) for further information.


Query Text:
VICC #2384 Skin sparing mastectomy was retired on 30 June 2013.

There is currently no index updates or advice to support the coding of skin sparing mastectomy. Is this advice still current?

Response:
VICC advises that the information in retired query #2384 Skin sparing mastectomy is still current and is reproduced below:

Question:
How do you code skin sparing mastectomy as there is no index entry for this type of mastectomy?  

Response:
Research undertaken by VICC indicates that skin sparing mastectomy is a subcutaneous mastectomy. Therefore follow index entry: 
Mastectomy 
-subcutaneous (unilateral) 31524-00 [1747] 
--bilateral 31524-01 [1747] 

to assign the appropriate code.

VICC notes that this information is supported by the note at Block [1747] Subcutaneous mastectomy.


Query Title:
Preservation of ovarian tissue and sperm

Query Text:
30 year old male with bowel cancer admitted for a testicular biopsy to preserve sperm. I have assigned:
Z31.3 Other assisted fertilisation methods
Z85.0 Personal history of malignant neoplasm of digestive organs
37605-01 [1177] Percutaneous aspiration of testis

I was looking for a preservation code or a cryotherapy prior to chemotherapy or for future use, but all I can find is a Prophylactic code Z40.8 Other prophylactic surgery. 

16 year old girl with Hodgkins Lymphoma, who came in for ovarian preservation again I am not able to find a code for her apart from Z40.08 Prophylactic surgery for risk-factors related to malignant neoplasms, Other and Z85. 7 Personal history of other malignant neoplasms of lymphoid, haematopoietic and related tissues.

I don't believe this is correct.  Can you please advise?

Response:
VICC considers that the correct principal diagnosis code to assign for the two cases cited is Z31.8 Other procreative management following Index entries Admission/Management - see Management and Management/procreative/specified.  This is because the procedures undertaken are to manage procreation for future fertility as opposed to current IVF treatment.   

Z31.2 In vitro fertilisation and Z31.3 Other assisted fertilisation methods are assigned specifically for harvesting or implantation of ova and aspiration of sperm respectively. Similarly, Z40.8 is assigned for prophylactic surgery performed to reduce the risk of developing cancer or other diseases.  As infertility is not a disease (but rather an outcome), ACS 2114 Prophylactic surgery does not apply.  

As the cancer appears to be a current condition in your scenarios, and if it meets ACS 0002 Additional diagnoses, it may be appropriate to assign a current cancer code rather than a history code.


Query Title:
PR bleeding and multiple operative diagnoses

Query Text:
Can the VICC please provide some clarification on the following scenario? 

Patient presents for same day colonoscopy to investigate PR bleeding. Documentation under operative diagnosis lists multiple diagnosis including, diverticular disease, colonic polyp and ulcer of intestine. 

1.Can all these conditions listed under operative diagnosis be assumed to be the cause of the haemorrhage?

2.If so, does the VICC agree with the below codes?

K57.31 Diverticular disease of large intestine without perforation or abscess, with haemorrhage
K63.50 Polyp of colon, unspecified
K633 Ulcer of intestine
K922 Gastrointestinal haemorrhage, unspecified

Search Details:
VICC query 2512 Operative diagnosis and symptom for same day endoscopy 
VICC query 2779 ACS 1103 Gastrointestinal (GI) haemorrhage
ACS 1103 Gastrointestinal (GI) haemorrhage
ACS 0046 Diagnosis selection for same-day endoscopy

Response:
If the documentation in the case cited has established a causal link between the PR bleeding and the findings,  the link is made to all the findings (unless otherwise documented).  However as the 'with haemorrhage' convention can only be applied to the diverticular disease, it is correct to assign K92.2 Gastrointestinal haemorrhage, unspecified as an additional code.

If a causal link cannot be established, follow the guidelines in the ACS 0046 Diagnosis selection for same-day endoscopy and code the presenting problem/symptom as the principal diagnosis.

VICC query #2880 Principal Diagnosis in same day endoscopy cases provides further advice on coding of same day endoscopy episodes.


Query Text:
Reflux nephropathy is a condition in which the kidneys are damaged by the backward flow of urine into the kidney. 

At our hospital this condition is frequently documented as the underlying cause of  patient's end-stage renal failure. Could the Committee please advise how to code reflux nephropathy?

Uropathy
- vesicoureteral, reflux associated N13.7

Nephropathy
- specified NEC N28.8

Response:
Following Index entry Nephropathy/specified NEC, the correct code to assign is N28.8 Other specified disorders of kidney and ureter.

VICC acknowledges that in the Tabular N13.7 Vesicoureteral-reflux-associated uropathy may appear to be the correct code for reflux nephropathy, however you cannot get to this code in the Index because your lead term is nephropathy.

You may wish to send a public submission suggesting the creation of an Index entry for reflux under lead term Nephropathy.


Query Title:
Coding H2O injection into the lower back

Query Text:
When H2O injections are administered to maternity patients for pain relief should this be coded as 96205-09 [1920] Other administration of pharmacological agent, other and unspecified pharmacological agent or does this come under ACS 0042 Procedures not normally coded.

Response:
VICC advises that in accordance with ACS 0042 Procedures normally not coded point 8 Drug treatment/pharmacotherapy, a code for the H2O injection would not normally be assigned in the case cited.


Query Text:
Our respiratory department intends to categorise/document humidified oxygen therapy that was previously described only as high flow, as medium flow (40L/min) or high flow (50L+/min).

The December 2011 NCCC Coding Q&A clinical information is that generally 30L/min is considered high flow, but instructs that a code from block [570] Noninvasive ventilatory support could only be assigned if 'high flow' is documented.

We seek your advice as to whether documentation of medium flow respiratory support can be classified as NIV, given that it meets the clinical criteria for high flow?

Search Details:
NCCC ICD-10-AM/ACHI/ACS Seventh Edition Coding Q&A - December 2011

Response:
VICC advises that documentation of medium flow respiratory support cannot be classified as NIV as there needs to be documentation of high flow therapy to follow the Index entries HFNC (high flow nasal cannula) (heated) (humidified) — see block [570] or 
HFT (high flow therapy) (heated) (humidified) — see block [570].

VICC notes that NCCC Q&A query titled High flow nasal cannula published in December 2011 was retired on 30 June 2013 as high flow was added to Eighth edition ACS 1006 Ventilatory support.


Query Text:
Can the committee please clarify the use of test results when the result is not transposed/documented in the medical record?

For example: if a patient was to have surgery and it was noted on test results post surgery that the Hb is below the normal range and there is no documented Hb within the notes.

ACS 0010 General abstraction guidelines tells us that results can be used to add specificity to already documented conditions or unless a clinician can indicate that a test result is significant and/or indicates the relationship between an unclear test result and a condition, such test results should not be coded.

1) Is it reasonable to query this when there is nothing documented to support the query?
2) Can this be applied to radiology report findings?
3) Is the answered query enough to support ACS 0002 Additional diagnoses if there is nothing in the body of the record?

Search Details:
Other VICC queries researched are #2819, #2310, #2582, #1944, #2152
All the responses in these queries suggest there must be documentation in the medical record to support the test result.

Response:
In response to your questions: 

1. Yes, as results form part of the medical record, it is reasonable to clarify the with the clinician the presence of a condition in relation to the result, as their response provides the supporting documentation.

2. As per question 1, yes, radiology report findings can be clarified with a clinician.

3. Even if the diagnosis is confirmed by the clinician response to a query, there must be adequate documentation in the answered query or body of the record of how the condition meets ACS 0002 Additional diagnoses.


Query Text:
We are looking for advice on how to code Toxic effect of synthetic THC (tetrahydrocannabinol).

As this drug is synthetic, we are unsure whether to look up tetrahydrocannabinol T40.7 or unspecified drug poisoning T50.9?

Search details:
Synthetic marijuana is a designer drug in which herbs, incense or other leafy materials are sprayed with lab-synthesized liquid chemicals to mimic the effect of tetrahydrocannabinol (THC), the psychoactive ingredient in the naturally grown marijuana plant (cannabis sativa)

http://www.drugs.com/synthetic-marijuana.html

Response:
As the lead term tetrahydrocannabinol in the Table of drugs and chemicals section of the Index does not have a subterm for 'synthetic', VICC advises that the correct code to assign for documentation of synthetic tetrahydrocannabinol (THC) is T40.7 using the default code at the Index entry.

VICC notes that synthetic narcotics are classified to the narcotic range of codes supporting our advice that synthetic versions of drugs are coded to the specific drug range rather than unspecified drug.


Query Title:
Rectus sheath haematoma secondary to anticoagulation

Query Text:
1. How should 'rectus sheath haematoma secondary to anticoagulation' be  coded please?
There is an index entry: Haematoma, nontraumatic due to circulating anticoagulants D68.3
So is it D68.3 only (plus ext cause codes)?
Or
Index: Haematoma, muscle - see Contusion, by site
Contusion, abdominal (muscle)(wall) S30.1
So is it S30.1, D68.3 etc?
Or
Index: Haematoma, internal organ NEC - see Injury, by site
Injury, muscle, abdominal S39.0
So is it S39.0, D68.3, etc?

Each of these give a different DRG and this is not an uncommon diagnosis so would like to have a reference as to the correct coding.

2. Why does the index entry at Haematoma, abdominal (muscle)(wall) S30.1 have a non-essential modifier for muscle, when there is a specific code for abdominal muscle injury (S39.0)?

Response:
VICC advises that for the case cited the correct codes to assign are S30.1 Contusion of abdominal wall following the Index entry noted in the query and D68.3 Haemorrhagic disorder due to circulating anticoagulants.  

Both codes are required to describe the site of the haematoma and the haemorrhagic component, which is in accordance with ACS 0303 Abnormal coagulation profile due to anticoagulants and ACS 1902 Adverse effects.

The sequencing of the codes is in accordance with example 2 of ACS 0303 Abnormal coagulation profile due to anticoagulants.   

As the rectus sheath is not an internal organ, it is incorrect to follow Index entry Haematoma/internal organ NEC - see Injury, by site.


Query Text:
Is there a code to reflect the use of a robot during surgery?

Please see attached operation report of a robotic assisted laparoscopic partial nephrectomy as an example of the use of a robot.  The patient has three normal port sites and a fourth created for the use  of the robot. The use of the robot is not routine in performing a nephrectomy.

Response:
VICC advises that there is currently no ACHI code for the use of a robot during surgery. 

The procedure identified in this query should be coded to Partial nephrectomy 36522-00 [1048].

You may wish to consider a public submission to the ACCD to request a code/s for robotic assisted surgeries.


Query Text:
We have patients present for a clinical trial which is titled "A Multicenter, Randomised, Double-Blind, Placebo-Controlled Study to evaluate the efficacy, safety and tolerability of BIIB023 in subjects with Lupus Nephritis.

As this study is Double-Blind, Placebo-Controlled, does the committee agree that the principal diagnosis should be Z00.6 rather than Lupus Nephritis?

The principal diagnosis of Z00.6 Examination for normal comparison and control in clinical research programme has been chosen as it is unknown if the patient receives the placebo or treatment drug.

Search Details:
VICC #2366 Admission for clinical drug trial (now retired)
VICC #2711 Principal diagnosis selection in clinical trials 
ACS 0026 Admission for clinical trial, drug challenge or therapeutic drug monitoring

Response:
This query was originally published in the 2013-14 June VICC queries database release as follows:

When documentation exists to support the fact that the patient is a participant in a clinical trial for research purposes coders must follow ACS 0026 Admission for clinical trial, drug challenge or therapeutic drug monitoring and assign Z00.6 Examination for normal comparison and control in clinical research programme as principal diagnosis.

Whether the patient receives a placebo versus the treatment drug is not relevant to the principal diagnosis decision.

If you are unsure about whether the patient is participating in a clinical trial or not, identify and investigate the documentation that applies to the clinical trial before you refer to ACS 0026 Admission for clinical trial, drug challenge or therapeutic drug monitoring.[end of response].

This response is superseded by ACCD Coding Rules advice Q2926 titled Classifying a procedure under investigation in a randomised and placebo-controlled clinical trial and Q2906 Same-day chemotherapy for neoplasm; participant in clinical drug trial.


Query Title:
Principal diagnosis for same day endoscopy

Query Text:
Regarding the response to  VICC query #2880 we were very pleased to see a new query created to replace previous multiple queries for same day coding but in putting this into practise we are a little confused.  Your response refers to "Symptom" and "Findings" - where does "Diagnosis" fit into this?

An example:
Diagnosis
Moderate oesophagitis (probable candidiasis)
Fundic gland gastric polyps

Indication
Heartburn

Pre procedure preparation - nil orally
Scope insertion
Endoscope passed into the duodenum with no difficulty

Findings
Oesophagitis (probable candidiasis) was observed
A few polyps (pedunculated) (size small <5mm) observed in the fundus of 
the stomach

Interventions
Biopsy 1 taken from the antrum of the stomach x 1 HUTT
Biopsy 2 taken from the lower third of the oesophagus x 2

Follow up
Follow up with the referring Doctor L Thompson 5-7 days

Specimens to Pathology
YES

The pathology indicated chronic reflux oesophagitis with no fungal elements.  As per your response should the heartburn still be coded as the principal diagnosis or should the diagnosis of oesophagitis be used as the principal diagnosis?

We welcome the opportunity to keep coding of day procedures simpler than it has been in the past.

Response:
The wording in response to query #2880 is in line with the wording in ACS 0046 Diagnosis selection for same day endoscopy.  

VICC advises that irrespective of the words used in your documentation, you need to establish if a causal link exists between the symptom and one of the findings with the documentation available.  If this cannot be done, follow the guidelines in the standard and code the presenting problem/symptom as the principal diagnosis.


Query Text:
Can the committee please confirm whether it is acceptable to code debridement of wound in the following scenario, where the only documentation of the debridement is on this form (attached wound chart).

The first page of the wound chart describes the wound management plan, with the second page describing the progress and treatment. 

We often have patients either admitted with wounds, or develop wounds/ pressure ulcers etc, where the only documentation regarding the type, stage and depth of the wound (pressure/ surgical etc) is on a wound chart in the medical record, under the appropriate admission. When we have asked a wound nurse and treating clinician, both have confirmed the use of this form to document the treatment performed.

Response:
VICC advises that you can code debridement of wound from documentation on a wound chart as the chart forms part of the clinical record.

However in the wound chart example you have provided, the documentation identifies autolytic debridement by dressings only.  As per ACS 0042 Procedures normally not coded point 7, dressings are not coded (unless one of the dot points under the note is met), therefore no code is assigned for debridement by dressings in this case.


Query Text:
Query #2286 Cyclops lesion of the knee has been retired on the 30.6.2013.  The  advice in this query was that Cyclops lesion is a complication of previous reconstruction surgery to the knee and the correct code to assign was T84.4 Mechanical complication of other internal orthopaedic devices, implants and grafts, with an additional code, if required, to further specify the specific disorder and reflect the condition of the ligament, for example, ‘disorder of ligament’.

Can you give me an update on this query and can this query be republished with the correct answer?

Response:
VICC advises that #2286 Cyclops lesion of the knee was published prior to the updating of ACS 1904 Procedural complications. 

VICC research indicates that the exact aetiology of a cyclops lesion is uncertain, and may be related to gradual fraying and bunching up of ACL or graft fibres, excessive fibrosis, or alternatively due to uplifting of fibrocartilaginous tissue during drilling of the tibia for anterior cruciate ligament reconstruction which serves as a nidus for fibrous tissue deposition.  The end result, regardless of cause, is a rounded fibrous ball sitting in the intercondylar notch. Pathologically, the lesion consists of central granulation tissue surrounded by dense fibrous tissue.

Coders must therefore establish if the cyclops lesion is a complication from a surgical intervention in order to code as a procedural complication as per the definition in ACS 1904 Procedural complications.

If it is documented as a procedural complication, follow ACS 1904.  If it is not documented as a complication from a surgical intervention, follow Index entry Lesion/joint to assign M25.96 Unspecified joint disorder, lower leg.


Query Text:
If a patient has a laparoscopic assisted hemicolectomy, do we code this as a laparoscopic hemicolectomy, or do we code it as an open procedure, and also laparoscopy.

Search Details:
VICC  #2563, Laparoscopic hemicolectomy and laparoscopic adhesionolysis

Response:
A laparoscopically assisted right hemicolectectomy is different to a laparoscopic right hemicolectomy because the laparoscopic assisted procedure requires an abdominal incision whereas a laparoscopic procedure does not - only port holes are made.

As in your scenario laparoscopic assisted is documented, assign a code for the open procedure followed by the laparoscopic code.

Follow the Index entry Hemicolectomy/right/via laparoscopy only when the right hemicolectomy is performed entirely via the laparoscope.


Query Text:
One of our surgeons often documents ostectomy (osteectomy) of bone spur at the time of removal of metal.  Sites include patella and olecranon. Example of olecranon operation report attached.

The Index provides for ostectomy of a site, e.g. patella, but it goes to 49503-04 [1504] Patellectomy which doesn't sound right.  In the case of olecranon, the index only provides a code for with reduction of fracture. 

The only 'excision of spur' is for calcaneus 49818-00 [1534] Excision of calcaneal spur.

How should an ostectomy of a bone spur be coded?

Response:
VICC advises that to code ostectomy of a bone spur you should look up lead term 'Ostectomy' in the ACHI Interventions Index.  

If there is a subterm for the site of the ostectomy, in this case patella, it is correct to assign 49503-04 [1504] Patellectomy.

If there is no subterm for the site, assign the default code at lead term 'Ostectomy' 90572-00 [1563] Ostectomy, not elsewhere classified. 

Ostectomy of olecranon without reduction of fracture should be assigned 90572-00 [1563] Ostectomy, not elsewhere classified as there is no default code at Ostectomy, olecranon.


Query Title:
Respiratory acidosis in a diabetic patient

Query Text:
Note this is not documented as "diabetic acidosis"

Is E1x.11 correct for respiratory acidosis in a diabetic patient (no coma)? Following the codefinder you get this code, however if you follow the index you do not.

Codefinder Selection History
Enter Key Work: - ACID
ACID  Acidosis (lactic)(respiratory)
Acidosis (lactic) (respiratory)  With diabetes [coded as diabetes, with, acidosis][includes metabolic acidosis]
Diabetes, diabetic (mellitus) (controlled) (famililial) (severe)  Type II [NIDDM] [adult/maturity-onset]
Diabetes with acidosis  Other/unspecified [coded as diabetes, 
with, ketoacidosis].......

Index entry:
Acidosis (lactic)(respiratory) E87.2
-Diabetic -See Diabetes/with/acidosis   (*note it says Diabetic, as opposed to with Diabetes,  the codefinder selection defaults to "with diabetes")

If you treat the term Diabetic the same as you would "with diabetes" and go to Diabetes in the index it leads you to:
acidosis - see also Diabetes/with/ketoacidosis
-lactic
-with coma
There is no mention of "respiratory".

Search details:
ACS 0401
VIC queries 2125, 2544

Response:
This query was originally published in the 2013-14 June VICC queries database release as follows:

VICC advises that as the acidosis has not been described as diabetic acidosis, it is not necessary to start with the lead term Acidosis to assign the diabetes code -see Rule 2 of ACS 0401 Diabetes mellitus and intermediate hyperglycaemia.  

VICC advises to apply rule 3 of ACS 0401 and follow Index entry Diabetes/with/acidosis - see also Diabetes/with/ketoacidosis.

As there is no subterm for 'respiratory' or default code under Index entry  Diabetes/with/acidosis,  follow the 'see also' note which says 'see also Diabetes/with/ketoacidosis' to assign E1-.11 Diabetes mellitus with ketoacidosis, without coma.

You may wish to submit a public submission to ACCD if you consider that the Index entry needs improvement to reflect respiratory acidosis.

Following publication of ACCD Coding Rules in March 2016 the original response is superseded by the following advice titled Respiratory acidosis in a diabetes mellitus patient:

Q: 
What is the correct code assignment for respiratory acidosis in a patient with diabetes mellitus?

A:
Respiratory acidosis is a metabolic derangement of acid-base  balance  where the  blood  pH  is abnormally  low. Respiratory acidosis  will occur if the  lungs  are not ventilating properly resulting in an excess  of carbon dioxide  in the  body (Mondofacto, 1999).

Respiratory acidosis may have a variety of different causes, including:
•COPD 
•Neuromuscular diseases 
•Chest wall disorders 
•Obesity-hypoventilation syndrome
•Obstructive sleep apnoea (OSA)
•Central nervous system (CNS) depression 
•Other lung and airway diseases (Medscape, 2015).

ICD-10-AM does not assume a causal link between diabetes mellitus and respiratory acidosis when both are documented. 

ICD-10-AM does however assume a causal link where there is documentation of lactic acidosis or ketoacidosis as per the index pathway below: 

Diabetes, diabetic 
- with
- - acidosis — see also Diabetes/with/ketoacidosis
- - - lactic (without coma) E1-.13
- - - - with coma E1-.14
- - - - and ketoacidosis (without coma) E1-.15
- - - - - with coma E1-.16

For a patient with respiratory acidosis and diabetes mellitus assign:
E87.2 Acidosis following the index below with the appropriate diabetes mellitus code and sequence according to ACS 0001 Principal diagnosis and ACS 0002 Additional diagnoses. 

Acidosis (lactic) (respiratory) E87.2 

See also Coding Rule, Metabolic acidosis in a diabetes mellitus patient, published 15 September 2015.


Query Text:
Prothrombinex contains concentrated factor IX, factor II, factor X and low level of factor VII. These proteins are essential for the normal blood clotting process.

Can the committee please advise on the correct code to use for a  prothrombinex transfusion?

Response:
As Prothrombinex contain factors noted in the query, VICC considers that the correct code to sign for Prothrombinex transfusion is 92061-00 [1893] Administration of coagulation factors, following Index entry Administration/coagulation factors.


Query Title:
Insertion of haemostatic clip/endoclip during endoscopy

Query Text:
An endoclip is a metallic mechanical device used in endoscopy in order to close two mucosal surfaces without the need for surgery and suturing.  

Endoclips have found use in treating gastrointestinal bleeding (both in the upper and lower GI tract), in preventing bleeding after therapeutic procedures such as polypectomy, and in closing gastrointestinal perforations.

Is it appropriate to assign 90295-00 Endoscopic insertion of colonic prosthesis, for the insertion of a haemostatic clip during a colonoscopy?

Colonoscopy
-with
insertion of prosthesis
-colon 90295-00 [906]

Search Details:
http://en.wikipedia.org/wiki/Endoclip

Response:
VICC advises that when an endoclip is used as a haemostatic clip, that is, as a closure method to achieve haemostasis, a code for insertion of the endoclip is not required.  This is accordance with ACS 0042 Procedures not normally coded point 18 Procedure components (see also ACS 0016 General procedure guidelines).


Query Text:
A patient presented to us with a tumour of the 'meso-colon'.  They had surgery in which the tumour was removed. In this procedure the omentum was removed from the transverse colon, then the tumour was dissected off the colon, but no colon was removed, just the 'superior leaf of the meso-colon'.  In Wikipedia the 'meso-colon' is defined as a fold of peritoneum.

The patient is female and we feel that the most appropriate code for the procedure performed is 90328-00 [989] Excision of lesion of peritoneal tissue which has no exclusions or edits on it, but it is impossible to get there unless the patient is a male. 

We don't believe that this is a gynaecological procedure which is the way you are forced to go following the index - to use 35713-14 [1299] Excision of lesion of pelvic cavity.

Could you please advise if the split on male/female is intentional for these codes? Should we be able to allocate 90328-00 [989] Excision of lesion of peritoneal tissue for this episode?

Response:
As you have noted, the classification leads to different codes depending on whether the patient is male or female.  VICC notes that this is one of many examples in the classification where there is a male/female split on surgery.

VICC presumes this is intentional and that it is a consequence of the classification being developed from MBS. Therefore in your case VICC considers the correct code to assign is 35713-14 [1299] following Index entry Excision/lesion/peritoneal tissue/female (open).

You may wish to submit a public submission to ACCD suggesting the split on male and female is removed for excision of mesentery.


Query Text:
We often have "static fundal height" documented as a reason for induction of labour or documented as reason for admission to special care nursery.  

In the baby's record I considered using a supervision code but it is not really a suspected condition. Their growth has not progressed so the condition is present but is this enough to code intrauterine growth retardation (IUGR) . At the moment I try to find anything else I can to code (symptoms etc) and often send the clinician a query asking if it is IUGR and often receive an unhelpful response.

In the mother's record we code it currently to O36.8 Maternal care for other specified fetal problem but I feel maybe a O36.5 Maternal care for poor growth code is better as internet searching it is an indication of IUGR or poor fetal growth.

Can we code this statement to P05.9 IUGR/ Poor growth?

Response:
Whilst your research indicates that static fundal height can be an indication of IUGR/poor fetal growth, it is not necessarily a synonymous term for these conditions.

VICC acknowledges that clinical advice or documentation is not always possible to obtain but in the absence of documentation of IUGR/poor fetal growth, O36.5 Maternal care for poor growth cannot be assigned.

VICC advises that a code from the O28 range may be appropriate in the mother's record by following Index entry Abnormal/finding/antenatal screening, mother to capture the reason for the induction of labour in accordance with ACS 0002 Additional diagnoses.

VICC also advises that Z03.79 Observation of newborn for other suspected condition may be assigned in the baby's record if there is documentation of observation for static fundal height following Index entry Observation/newborn (for)/specified condition NEC.


Query Text:
Patient had a history of a right sided orbital exenteration (Orbital exenteration is the removal of all the orbital contents including the periorbita and eyelids) as treatment for melanoma of their iris.

They are admitted twice for staged osseointegration procedures.

Admission one Stage 1: 45794-02[1698] Osseointegration procedure, implantation of titanium fixture for attachment of prosthetic orbit

Admission two Stage 2: 45797-02 [1697] Osseointegration procedure, fixation of transcutaneous abutment for attachment of prosthetic orbit

Can you please confirm the correct principal diagnosis for these admissions?

Can they be coded to admissions for insertion of device, prosthetic artificial eye, Z44.2 Fitting and adjustment of artificial eye?

Search Details:
ACS 1220 Extraoral osseointegrated implants
ACS 1204 Plastic Surgery
ACS 0236 Neoplasm coding and sequencing

Response:
VICC considers that the correct principal diagnosis for both admissions is Z42.0 following Index entry Surgery/reconstructive/head and neck.  This is in accordance with ACS 1204 Plastic surgery which says that in the absence of a documented condition or a deformity, assign  Z42.- Follow-up care involving plastic surgery.

VICC also considers it appropriate to assign Z85.8 Personal history of malignant neoplasms of other organs and systems as an additional diagnosis for history of melanoma in accordance with example 3 of ACS 1204.

VICC does not consider Z44.2 Fitting and adjustment of artificial eye is the correct principal diagnosis because it is not the artificial eye that is being inserted - it is the implant to which the prosthetic eye will be attached.


Query Text:
Patient admitted for insertion of a stent to treat a left false popliteal aneurysm.

The stent was inserted via angiography. Given that angiography is an endovascular procedure, can the endovascular repair pathway be followed to assign the procedure code?

Insertion
-stent
- - artery
- - -specified NEC
- - -endovascular repair (aneurysm) 33116-00 [762]

Alternatively should this be coded to balloon angioplasty with stent following index classification

Insertion
-stent
- -artery
- - -specified
- - -single stent (percutaneous) 35309-06 [754]

Response:
VICC advises that whilst an angiography with stent insertion could be described as an endovascular procedure, this is not the same as an endovascular repair.  This is because an endovascular repair is a tube graft or endovascular graft and is commonly documented as a stent graft or endovascular repair.

As your documentation describes a stent insertion rather than a stent/endovascular repair or graft, VICC advises that the correct code to assign in this case is 35309-06 [754] Percutaneous transluminal balloon angioplasty with stenting, single stent following Index entry Insertion/stent/artery/specified (for) NEC/single stent (percutaneous).


Query Text:
Patient admitted for embolisation of cerebellar aneurysm.  A cerebellar artery is an artery that provides blood to the cerebellum which is part of the brain.

1. Is the cerebellar artery classified as a cerebral or intracranial artery?

2.
a) Is the use of cerebral reserved exclusively for the actual cerebral arteries including the anterior, middle, posterior arteries?
OR
b) Can it be used for other arteries that supply blood to the brain such as the internal carotid and the vertebral arteries?

3. Should embolisation of cerebral or intracranial aneurysm be coded for a cerebellar aneurysm? Please see index classification below.

-Embolisation
-aneurysm (see embolisation blood vessel)
-blood vessel, transcatheter
- -cerebral
- - -aneurysm 35412-00 [11]
35412-00 [11] Endovascular occlusion of cerebral aneurysm or arteriovenous malformation

OR

Embolisation
-aneurysm (see embolisation blood vessel)
-blood vessel, transcatheter
- -intracranial
- - -arteries NEC 35321-02 [768]
35321-02 [768] Transcatheter embolisation of intracranial arteries, not elsewhere classified

4
a) Should embolisation of cerebral aneurysm index ONLY be followed for the cerebral aneurysm?

OR

b) Can it be used for aneurysms to other arteries of the brain such as the basilar, internal carotid, anterior choroidal, pontine arteries?

Response:
VICC notes that although there are different subterms for cerebral and intracranial under Index entry Embolisation/blood vessel, the classification differentiates on the condition requiring embolisation rather than the artery on which the procedure is performed.  That is, the code for embolisation of cerebral aneurysm and AVM is the same and the code for embolisation of cerebral arteries NEC and intracranial arteries NEC is the same.  Therefore, in answer to your specific questions:
1. The cerebellar artery is classified as both a cerebral and intracranial artery.

2. Given that the essential modifier differentiates on the reason for the embolisation rather than the artery, the use of cerebral is not reserved exclusively for the actual cerebral arteries.

3. Embolisation of cerebral or intracranial aneurysm should be coded to 35412-00 [11] Endovascular occlusion of cerebral aneurysm or arteriovenous malformation following Index entry Embolisation/blood vessel transcatheter NEC/cerebral/aneurysm.  This is supported by the excludes note at 35321-02 [768] Transcatheter embolisation of intracranial arteries, not elsewhere classified which says 'Excludes: endovascular occlusion of cerebral aneurysm or arteriovenous malformation (35412-00 [11])'.

4. The embolisation of cerebral aneurysm Index entry can be used for aneurysms of other arteries of the brain, not just the cerebral artery.


Query Text:
Principal diagnosis on summary is 'Adhesions secondary to hemicolectomy'.  Patient had laparoscopic division of adhesions.  Past history: Hemicolectomy approximately one year ago. 

I am unsure which code to assign as principal diagnosis - K66.0 Peritoneal adhesions or K91.8 Other postprocedural disorders of digestive system, not elsewhere classified (with additional diagnosis K66.0).

Following ACS 1904 Procedural complications coders should look up Adhesion, postprocedural.  There is an Index entry at this point but there is no default and none of the essential modifiers apply to this case.  The ACS goes on to say 'If there is no subterm for postprocedural in the Index, follow the look up for Complication.  But as there is a subterm (but no code), should I then assign the default at Adhesions K66.0?

The Index seems to be inconsistent as there is an entry for Adhesions, postprocedural, pelvic peritoneal, N99.4 but not Adhesions, postprocedural, abdominal or peritoneal.

Search Details:
ACS 1904 Procedural complications
Diseases Index

Response:
VICC considers that because the adhesions have been described as 'secondary to', it represents a causal link. It is therefore correct to follow ACS 1904 Procedural complications and to follow the Index entry Complication/digestive/postprocedural/specified to assign K91.8 Other postprocedural disorders of digestive system, not elsewhere classified.

VICC acknowledges the lack of default code at subterm 'postprocedural' under the Index entry Adhesions/postprocedural and the absence of an essential modifier for abdominal and suggests you may wish to consider a public submission to ACCD asking for improvements to the Index in this area.


Query Text:
A patient presented to our hospital with heavy PV bleeding and suprapubic pain after having a surgical termination of pregnancy (10/52) and Mirena insertion earlier that day. She received an obstetric review and the impression was that she had post-op bleeding due to her STOP and Mirena insertion, she then remained in hospital overnight for observation. The 
principal diagnosis recorded on the discharge summary is 'post Mirena insertion pain and bleed'.

It is noted that there is an index entry for complication of intrauterine contraceptive device, specified NEC which assigns the code T83.8. However there is an excludes notes at T80-T88 which excludes complications of surgical procedures during pregnancy, childbirth and the puerperium.

Given the recorded diagnosis on the discharge summary, what code should be assigned as principal diagnosis?
Is it appropriate to assign O08.1 Delayed or excessive haemorrhage following abortion and etopic and molar pregnancy as the principal diagnosis? We also note that for this particular admission, further clinical advice is not possible.

Search Details:
- Index: Complications, -intrauterine, contraceptive device, -specified NEC T83.8
- Index: Abortion, -complicated (by), haemorrhage (delayed) (excessive) O08.1
-Excludes note at T81.0:
(Excludes haemorrhage due to or associated with 
prosthetic devices, implants and grafts T82.8, T83.8, T84.8, T85.8-)
- Excludes note at T80-88:
(Excludes: complications of surgical procedures during pregnancy, childbirth and the puerperium O00-O99)

Response:
VICC considers that the qualifying term 'post' in the principal diagnosis recorded on the discharge summary does not represent a cause and effect relationship and as such the episode should not be coded as a post procedural complication.

In accordance with ACS 1904 Procedural complications, in the absence of documentation directly relating a condition to the surgery, VICC considers that the appropriate codes to assign in this case are:
R10.4  Other and unspecified abdominal pain
N93.9 Abnormal uterine and vaginal bleeding, unspecified

On review of clinical notes accompanying this query, VICC considers that retained products of conception and uterine perforation were ruled out as a cause of the bleeding and pain.


Query Text:
Patient is admitted with a principal diagnosis of 'R pleural tap & chemotherapy'. The body of the summary goes on to explain that the patient is having drainage of large malignant pleural effusion from DLBC Lymphoma.  For most malignancies we code pleural effusion to C78.2 but we cannot do this with that caused by lymphoma. In this scenario, should the principal diagnosis be:
J90 Pleural effusion with C83.3
OR
C83.3 Diffuse large B-cell lymphoma with J90
OR
C83.3 Diffuse large B-cell lymphoma with J90?

The lymphoma is a pre-existing condition and the patient is being frequently admitted for pleural drainage.

Response:
VICC advises that in accordance with example 1 of ACS 0222 Lymphoma, the correct principal diagnosis is C83.3 Diffuse large B-cell lymphoma.

It is not appropriate to assign J90 Pleural effusion, not elsewhere classified as an additional code because the effusion in this case is documented as malignant.

As you have noted, a metastatic site cannot be coded for lymphoma therefore C78.2 Secondary malignant neoplasm of pleura does not apply in this case.


Query Text:
A patient was admitted to our hospital for an interval appendicectomy. In September 2012 she had an appendiceal phlegmon which was managed with antibiotics and settled conservatively.  In December 2012 she was placed on the waitlist for an interval appendicectomy as a category 2 patient. 

Since that time she has remained asymptomatic and the appendix was removed in April 2014 via a laparoscopic approach. 

Histology of the appendix showed no evidence of inflammation or malignancy the appearances were most consistent with a resolved phlegmon.

How should this scenario be coded? Is it appropriate to consider an interval appendicectomy as a staged procedure and therefore assign the condition for which the patient first presented (i.e. appendiceal phlegmon) as the principal diagnosis?

Response:
The documentation provided with this query states that the patient had a resolved appendiceal phlegmon and now presents for an interval appendicectomy as treatment of this condition. Therefore VICC considers that it is correct to assign K35.3  Acute appendicitis with localised peritonitis as the principal diagnosis following Index entries Phlegmon — see Abscess and Abscess/appendix.


Query Text:
A patient presented to our hospital with a swollen red thigh 4 days after having been bitten in the area by a white tail spider. He was treated with intravenous antibiotics and analgesia, the cellulitis decreased in size and severity and he was discharged after days. The principal diagnosis was cellulitis (secondary to spider bite).

ACS 1923 Contact with Venomous/Nonvenomous creatures states that spiders are almost exclusively venomous and that in cases of envenomation from spider bite, T63.3 Venom of spider should be coded.  However for the scenario described above, there was no evidence that  envenomation occurred.

1) Should T63.3 Venom of spider be assigned when there is no evidence of envenomation? Or is it acceptable to assign:
L03.11 Cellulitis of lower limb
X21.2 Contact with white-tailed and other necrotising spider
Y92.9 Unspecified place of occurrence
U73.9 Injury or poisoning occurring while engaged in unspecified activity

2 a) Is the bite from a spider considered a superficial injury? 
   b) Can T79.3 Post traumatic wound infection, not elsewhere classified be added to the string of codes as per ACS 1916 Superficial Injuries?

Search Details:
ACS 1923 Contact with Venomous/Nonvenomous creatures
ACS 1916 Superficial Injuries

Response:
VICC advises that it is correct to assign T63.3 Toxic effect of contact with venomous animals, venom of spider for the scenario cited following Index entry Bite/spider (venomous) in accordance with ACS 1923 Contact with Venomous/Nonvenomous creatures.  Additionally, 'venomous' is a non essential modifier in the Index, therefore documentation of envenomation in the clinical record is not required.

In answer to the specific questions:
1.  L03.11 Cellulitis of lower limb can be assigned as principal diagnosis if supported by the documentation. T63.3 Toxic effect of contact with venomous animals, venom of spider would then be assigned as an additional code.

2 a. A code for superficial injury can only be assigned when the spider is documented as nonvenomous as per Index entry Bite/spider/nonvenomous (see also Injury/superficial).
   B. Once it is determined to be a superficial injury, T79.3 Post traumatic wound infection can be assigned as an additional code if the bite is described as infected.


Query Text:
Advice in VICC query #2722 is to code greenlight laser ablation of prostate to 37203-02 [1165] Transurethral electrical vaporisation of prostate.  

Advice from theatre manager at this hospital is that, although ablation and vaporisation of prostate are the same (as stated in query #2722)  they can be performed either by laser or electric current i.e
37207-00 [1166] Endoscopic laser ablation of prostate is performed with a laser.
37203-02 [1166] Transurethral electrical vaporisation of prostate is performed with electrical current and not laser.

Index entry for prostatectomy, by laser is 37207-00 [1166]
Index entry for prostatectomy, by electrical vaporisation, transurethral, is 37203-02 [1165]

Would you please confirm advice in VICC #2722 that we should be using 37203-02 [1165] for both of these procedures and explain the reasons the index shouldn't be followed?

Response:
VICC advises that the correct code selection will be determined by the documentation available in the clinical record.

In query #2722 titled Greenlight laser of the prostate, the enquirer did not have documentation of ablation, only green light laser which was confirmed by clinical research to be the same as vaporisation.  Therefore in that scenario, the appropriate code to assign was 37203-02 [1165] Transurethral electrical vaporisation of prostate, following lead term Vaporisation.  

If you were to have documentation of laser ablation, the correct lead term to look up would be Ablation to assign 37207-00 [1166] Endoscopic laser ablation of prostate.


Query Text:
We are seeking clarification of ACS 0635 Sleep apnoea and related disorders.  Specifically we would like clarification of the directive contained in this standard which states 'Assign R06.5 Mouth Breathing, if there is no documentation of Obstructive Sleep Apnoea Syndrome (OSAS).  If OSAS is documented with snoring assgon only G47.32 Obstructive Sleep Apnoea Syndrome'.

We often have patients admitted to our sleep study unit for investigation of snoring.  Following sleep study, the doctors final report will indicate that the patient has "Sleep apnoea" or "Mild sleep apnoea", however there is no indication that the patient has OSAS.

For these cases is it correct to code snoring as the principal diagnosis with sleep apnoea as an additional diagnosis given that the sleep apnoea is not specifically described as "obstructive".

Response:
VICC advises that ACS 0635 Sleep apnoea and related disorders does not provide advice for documentation of sleep apnoea unspecified as opposed to obstructive sleep apneoa. Therefore the standard does not apply to your scenario.  

As in the case cited the clinician has documented 'sleep apnoea' or 'mild sleep apnoea', it is correct to follow Index entry Apnoea, apnoeic (spells)/sleep to assign G47.30 Sleep apnoea, unspecified as the principal diagnosis.


Query Text:
A patient presented to our facility with sudden swelling and paraesthesia of left forearm and hand after injecting heroin. The patient was treated with antihistamine and analgesia and transferred to Short Stay Unit for observation. 

The patient was discharged the following day after the swelling had subsided.  It was felt that the patient had inadvertently injected the heroin intra-arterially rather than intravenously. The final diagnosis was likely localised allergic reaction to heroin (intra-arterial injection).

Can VICC please provide guidance as to how this scenario should be coded?

Response:
VICC considers that for the case cited ACS 1901 Poisoning applies as the substance was wrongly injected into the artery (rather than the vein) indicating improper use. 

Therefore in accordance with the standard, follow Index entry Allergy/drug, medicament and biological (any) (correct medicinal substance properly administered) (external) (internal)/wrong substance given or taken NEC/specified drug or substance — see Table of drugs and chemicals to assign the following codes:
T40.1 Heroin
X42 Accidental poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified
(appropriate place of occurrence and activity codes)


Query Title:
Delivery while on leave to other hospital

Query Text:
We have a maternity patient admitted to our Hospital A for antenatal care related to a maternal heart condition, treatment is given for the heart condition in the hope of prolonging the pregnancy as long as possible. 

The patient is booked for a caesarean section at another hospital due to this heart condition and the need for cardiothoracic surgeons at delivery. At 34 weeks the decision is made to deliver the baby. They are transferred to Hospital B for the delivery and 24 hrs ICU care. Following this they are transferred back to us in Hospital A for post surgical/delivery care and continued treatment of the heart condition. The patient is admitted with a leave episode to Hospital B as per HDSS helpdesk confirmation and VAED rules.

Is the correct coding of this:
O99.4 Diseases of the circulatory system complicating pregnancy, childbirth and the puerperium
I09.1 Rheumatic diseases of endocardium, valve unspecified
Z39.01 Postpartum care after hospital delivery
Z48.8 Other specified surgical follow-up care

If so this groups to a Postpartum DRG O61Z which seems wrong. Can you offer guidance on this situation?

Search Details:
VICC #2653 Principal diagnosis selection for birth whilst on leave
Hospital Admission policy

Response:
VICC considers the codes assigned are correct for the antenatal and postnatal care provided at Hospital A and therefore the DRG allocated is also correct in this scenario.

VICC considers that in this scenario the assignment of prefix C Complicating condition to Z39.01 and Z48.8 would help to reflect that the patient was not postpartum when the episode of care commenced, acknowledging that currently the Victorian Additions to the Australian Coding Standards instruct Z39.0- codes to be assigned prefix P Primary condition.  VICC will revise the prefix instruction with regard to Z39.01 in the next release of the Victorian additions.


Query Title:
Updates in CLIP Conditions complicating pregnancy

Query Text:
This is confusing as we have a case of a pregnant lady who fell and came in for observation (no injuries found) so we coded it as per Coding Matters 12:1:
Z04.3 Examination and observation following other accident 
Z34.8 Supervision of other normal pregnancy 
W18.9 Unspecified fall on same level
Y92.22 Place of occurrence, health service area
U73.8 Other specified activity

This patient is also Hepatitis C positive so we coded B18.2 Chronic viral hepatitis C. 

Following the changes to the Conditions complicating pregnancy recently we can put the O98.4 Viral hepatitis complicating pregnancy, childbirth and the puerperium before the Hepatitis C code without a link. Obviously this isn't correct coding as you don't code a supervision code Z34.8 with an O code. Should we not code the Z34.8 in the first part of the coding as we have an O code further down? How should we code this?

Search Details:
Coding Matter Vol 12 No1
Email HDSS Update to CLIP
ACS 1521 Conditions complicating pregnancy

Response:
VICC advises that the Coding Rules advice titled ACS 1521 Conditions complicating pregnancy (2 of 2) applies to delivery episodes only.  As the episode described is not the delivery episode, in accordance with ACS 1521 Conditions complicating pregnancy, there must be documentation that the viral hepatitis complicates pregnancy in order for O98.4 to be assigned.  

Therefore VICC considers, based on the information provided, that the correct codes to assign to your scenario are:
Z04.3 Examination and observation following other accident
Z34.8  Supervision of other normal pregnancy
B18.2 Chronic viral hepatitis 
(and external cause codes as per your documentation).


Query Text:
Please provide clarification of ACS 1904 and Excludes notes at T81 of the Tabular List in relation to the coding of wound dehiscence following insertion of a prosthetic device, implant or graft.

If a patient has any complication listed at T81x, (including wound dehiscence), post a procedure involving a prosthetic device, implant or graft, does the excludes note at the begining of T81 require you to automatically apply codes from T82-T85 ahead of codes from block T81?

I note that there is an excludes note at "T814x  Wound infection following a procedure, not elsewhere classified",  which specifically requires documentation that the infection is "due to" the prosthetic device, implant or graft before you can proceed to use codes from T82-T85 however there is no such note at "T81.3. Disruption of operation wound, not elsewhere classified".

Coders at our hospital are currently using the code T81.3 for wound dehiscence in preference to codes at T82-T85 as it seems more specific given that the term "dehiscence" does not appear in any of the descriptions under T82-T85.
However if we follow the instructions under ACS 1904,  which states "Where the complication relates to a prosthetic device, implant or graft... look up the main term 'Complication(s)' and then by device" it would seem that the more appropriate code/s for a wound dehiscence following insertion of a prosthetic device, implant or graft should be codes from blocks T82-T85.

Could you please advise us of the most appropriate code to use in the case of a patient with wound dehiscence following insertion of a prosthetic device, implant or graft.  Should we continue to use T81.3 or codes from blocks T82-T85, or a combination of both if we are to provide greater specificity?

Search Details:
ACS 1904, Exclusion notes at T81, Coding advice.

Response:
VICC advises that the excludes note at the rubric T81 Complications of procedures, not elsewhere classified excludes complications of prosthetic devices, implants and grafts where documentation supports that the complication is due to the prosthetic device, implant or graft (in accordance with ACS 1904 Procedural complications).

The only exception to the above statement is at T81.0 which has an excludes note that says 'excludes a haemorrhage due to or associated with prosthetic devices, implants and grafts' which allows coders to assign the T82 - T85 range of codes when haemorrhage is documented without a link between the haemorrhage (condition) and the device.

In answer to your specific questions in relation to wound dehiscence, there needs to be a documented link between the dehiscence and the prosthetic device to be able to assign a code from the T82 - T85 range of codes.  In the absence of this documentation, the correct code to assign is T81.3 Disruption of operation wound, not elsewhere classified.  The external cause code will indicate that the procedure involved a prosthesis.


Query Text:
Re: VICC #2514 Kidney transplant status with kidney transplant failure

Given that ACS 0027 Multiple coding has been removed in ACS 8th edition, can we still follow the advice in VICC #2514 to "...assign an additional code to identify the stage of chronic kidney disease in patients who have received a kidney transplant"?

Search Details:
VICC #2514 Kidney transplant status with kidney transplant failure

Response:
VICC advises that whilst ACS 0027 Multiple coding has been deleted, the advice in that standard which was referenced in query #2514 has been incorporated into the Conventions used in the Tabular list of diseases and therefore the logic used to respond to #2514 still applies.

In addition, VICC considers that point 3 of the classification box of ACS 1438 Chronic kidney disease, under kidney replacement therapy applies to transplant failure as well as transplant status and therefore you would assign an additional code for the chronic kidney failure with transplant failure.


Query Title:
Ruptured breast implant sustained in MVA

Query Text:
Can you please advise the correct code assignment for a patient who presented with ruptured breast implants due to a motor vehicle accident?

Can this be coded to S29.9 Unspecified injury of thorax together with appropriate external cause codes, following Index classification:
Rupture (see also injury by site)

Injury
- breast NEC S29.9

Response:
VICC advises that because the breast implant has ruptured, follow Index entry Complication/breast implant (prosthetic)/mechanical, to assign T85.4 Mechanical complication of breast prosthesis and implant as the principal diagnosis for the case cited.   

As the cause of the rupture is the motor vehicle accident, assign the appropriate external cause code from the V00-V99 code range followed by Y92.4x Place of occurrence, street and highway and U73.9 Unspecified activity.

S29.9 Unspecified injury of thorax would only be assigned if there was documentation of injury to the chest wall or the breast itself in the case described.


Query Title:
Principal Diagnosis sequencing in same day endoscopy

Query Text:
With the introduction of the new VICC query 2880 Principal Diagnosis in same day endoscopy cases our organisation has been presented with an old problem.

If a patient comes into our hospital for a gastroscopy and a colonoscopy there are sometimes different indications for each. We then also have an endoscopy request form that may have another indication.

We were wondering in these situations when no causal link has been established which symptom/indication should we be coding as Principal Diagnosis?

There are many symptoms a patient may present with that influence the DRG from the norm such as Anaemia, Weight loss, Iron deficiency etc. or if the colonoscopy is a follow-up and the gastroscopy is for a symptom.

As per VICC query #2484 Selection of Principal Diagnosis-first mentioned, we do not have a discharge summary for our day endoscopy cases and there is no instruction as to which part of the record the decision should be based on. By applying the ACS 0001 Principal diagnosis definition there are many opinions in our organisation as to which should be followed as 'first mentioned', the first endoscope that has been scanned/put in the record, the scope that was performed first, the symptom documented first on the endoscopy request form?

Can you please give us some guidance where we should be taking the Principal diagnosis from in these cases?

Response:
VICC acknowledges that this is an ongoing issue that has not changed by the introduction of #2880 Principal Diagnosis in same day endoscopy cases.  VICC advice is that ‘first mentioned’ only applies to documentation of the principal diagnosis on the discharge summary.  When no discharge summary exists, the principal diagnosis can be taken from any relevant documentation including that on the endoscopy reports.  There is no hierarchy regarding which endoscopy report takes precedence.


Query Title:
Cancelled intended procedure but stayed for another procedure

Query Text:
Patient admitted for sameday IV chemotherapy, admission bloods taken and chemotherapy cancelled because they are found to be anaemic.  Patient then stayed in the day ward for a transfusion for their anaemia and was discharged later in the day (ie still a same day stay).

ACS 0011 Admission for surgery not performed seems to have 2 parts.
Part 1:
"If a patient is admitted to hospital for surgery which for some reason has not been performed and the patient is discharged, code as follows:
A.  If surgery was not carried out due to an administrative problem:
B.  Where a Z code would normally be assigned to capture the reason for hospitalisation and the surgery is cancelled:
C.  If surgery was not carried out due to another condition or complication being present on admission:

Then Part 2:
"If a patient is admitted to hospital for surgery which is not carried out due to a condition present on admission which requires ongoing inpatient care, sequence this condition as the principal diagnosis....."

There is confusion because the patient was not discharged after it was decided to cancel the chemotherapy (so Part 1 doesn't seem to apply) but we are unsure if the wording of 'ongoing inpatient care' in Part 2 means the patient stayed overnight (which would mean that Part 2 doesn't apply either).

Should the principal diagnosis be Z51.1 (chemotherapy) or D64.9 (anaemia)?

Search Details:
ACS 0011 Admission for surgery not performed
VICC 2208 Principal diagnosis for cancelled chemotherapy (retired)

Response:
VICC considers that the wording 'ongoing inpatient care' in ACS 0011 Admssion for surgery not performed is not limited to overnight episodes.  Therefore example 5 of the standard can be applied to any episode where the patient remains in hospital for ongoing inpatient care (treatment and/or monitoring) of the condition that caused the original intended treatment to be cancelled.

VICC therefore considers that for the case cited the correct principal diagnosis is D64.9 Anaemia, unspecified.


Query Text:
Surgery start 13/6/14 08:32, surgery end 13/6/14 11:39.  Patient entered ICU 13/6/14 11:50 EXTUBATED 14/6/14 09:08.

Mechanical ventilation is less than 24 hours after surgery.

Which is correct?

1. Calculating mechanical ventilation from time of surgery?

or

2.  Calculating from end of surgery until extubation which is less than 24 hours and hence not coded?

Response:
VICC advises that for the scenario cited, option 2 stated in the query is correct.  This is in accordance with ACS 1006 Ventilatory support point f under heading Classification which says 'the ventilatory support that is provided to a patient during surgery is associated with anaesthesia and is considered an integral part of the surgical procedure. The patient may remain on ventilatory support for some hours while recovering following surgery. Ventilation of less than 24 hours post surgery should not be coded in these cases'.  Therefore, no ACHI code is assigned in the case described in this query.

Please note however that the ventilated hours (rounded up) that occur in ICU are reported to the VAED in the Duration of Mechanical Ventilation in ICU field.  In this case, 22 hours (21.18 hours rounded up) would be reported in this field.  Please refer to the current Victorian Admitted Episodes Dataset (VAED) manual, Section 3 – Data definitions Duration of Mechanical Ventilation in ICU for further information.


Query Text:
VICC #2351 Category T78 was retired 30/06/2013.  Can VICC please advise if the advice is still applicable?

Response:
This query was originally published in the 2014-15 December VICC queries database release as follows:

VICC advises that the advice provided in #2351 Category T78 is still applicable in Eighth edition and is reproduced below with minor wording amendments:

Query:
Please clarify application/interpretation of the Note in category T78 

T78 Adverse effects, not elsewhere classified 
Note: This category is to be used to identify the effects, not elsewhere classifiable, of unknown, undetermined or ill-defined causes. For multiple coding purposes this category may be used as an additional code to identify the effects of conditions classified elsewhere. 

Excludes: complications of surgical and medical care NEC (T80-T88) 

Is it correct to interpret this note to mean that if the nature of the adverse effect is documented, that a code for the effect should be assigned, before a T78 code (specifically T78.0, T78.1, T78.2 and T78.3)? Is it optional to assign T78 as an additional diagnosis? 

What does the reference to 'unknown, undetermined or ill-defined causes' mean? Does this note only apply if the cause is unknown, undetermined or ill-defined? For example, if the cause of the allergic reaction is known such as seafood, is it appropriate to assume this note does not apply? 

Patient diagnosed with lip swelling as a result of an allergic reaction to seafood. How should this be coded? 

Patient presents with swelling of the lips, face and tongue. Discharge summary states angioedema as the principal diagnosis. Should T78.3 be assigned as principal diagnosis or R22.0 Localised swelling, mass and lump, head? 

Response:
In response to your questions, the VICC advises that it is correct to interpret the note at Category T78 to mean that if the nature of the adverse effect is documented, a code for the effect should be assigned before a T78 code and that it is optional to assign T78 as an additional diagnosis code. 

The reference to 'unknown, undetermined or ill-defined causes' is applicable to countries with single condition coding where for example, the adverse effect or allergy was known but not the cause so only a code from the T78 range would be assigned. Therefore this note is not relevant in Australia. 

For scenario one where the patient diagnosed with lip swelling as a result of an allergic reaction to seafood assign: 
R22.9 Localised swelling, mass and lump, unspecified 
T78.1 Other adverse food reactions, not elsewhere classified 
Y57.9 Drug or medicament, unspecified 

For scenario two, the VICC considers that the only codes required are T78.3 Angioneurotic oedema and the external cause codes as the discharge summary states angioedema as the principal diagnosis.[end of response]

Following publication of the September 2015 Coding Rules the original response is superseded by the following advice under heading Coding of allergic reactions NOS and anaphylactic reactions:
Q:
How should allergic reactions not otherwise specified (NOS) and anaphylactic reactions be coded? Should symptom codes be assigned for allergic reactions?
A:
The correct code assignment for allergic reactions NOS and anaphylactic reactions are outlined below.
Allergic reaction NOS:
T78.4 Allergy, unspecified following the guidelines in ACS 2004 Allergic reaction NOS and the index pathway:
Allergy, allergic (reaction) T78.4

Allergic reaction NOS to food:
T78.1 Other adverse food reactions, not elsewhere classified following the index pathway:
Allergy, allergic (reaction) 
- food (any) (ingested) NEC T78.1

Anaphylaxis due to food:
T78.0 Anaphylactic shock due to adverse food reaction following the index pathway:
Allergy, allergic (reaction) 
- food (any) (ingested) NEC 
- - anaphylactic shock T78.0 

When assigning a code classified to category T63 Toxic effect of contact with venomous animals additional codes should be assigned for any associated allergic reaction as per the instructional note at this category.

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 allergic reaction following the guidelines in ACS 1802 Signs and symptoms.

Assign external cause codes as appropriate.


Query Title:
Loss of greater than 10 percent birth weight

Query Text:
Could VICC please advise how to code the following scenario:

Baby born at our hospital and is transferred to our SCN or baby readmitted to our hospital but still in the perinatal period (<28 days) with a diagnosis of "loss of greater than 10 percent birth weight".

Baby will usually be admitted to SCN to observe feeding (breast, bottle) and may be given NGT feeding.  Very rarely will a diagnosis be made eg tongue tie.

We are unsure how to code this condition?  We have identified some codes that may be suitable:

1. P92.x Feeding problem of newborn
2. R63.4 Abnormal weight loss (note this code excludes any P00-P96 codes)
3. R62.8 Other lack of expected normal physiological development or 
failure to thrive (note this code excludes any P00-P96 codes)

Could VICC please provide advice on the correct coding of "loss of greater than 10 percent birth weight"

Response:
VICC considers that for documentation of loss of greater than 10 percent birth weight it is appropriate to look up lead terms 'Loss' or 'Weight' to assign R63.4 Abnormal weight loss following Index entries Loss/weight or Weight/loss.  

The excludes note 'certain conditions originating in the perinatal period (P00–P96)' at the start of Chapter 18 means that if a P chapter code is accessible by the Index it should be assigned in preference to a code from another chapter.  It does not prevent you from assigning a code outside of the P00-P96 range in the perinatal period if no appropriate P chapter code can be assigned.

This is in accordance with ACS 1605 Conditions originating in the perinatal period which says that some conditions that can occur in the perinatal period, such as bronchiolitis, are not categorised within Chapter 16. When such a condition occurs in the birth episode, it is acceptable to assign a code from other chapters of ICD-10-AM without a code from Chapter 16.


Query Title:
Use of infective organism from other cultures for sepsis

Query Text:
Patient admitted with UTI (E. Coli on MSU) and developed sepsis (documented as such and sick patient) - no growth on blood culture.  Should the same infective organism as found on the MSU be used to assign the sepsis code?  Should my codes be:

N39.0 UTI
B96.2 E. coli
A41.51 Sepsis due to Escherichia coli [E. coli]
or
N39.0 UTI
B96.2 E. coli
A41.9 Sepsis unspecified.

Would the same logic apply to a patient with other infective conditions, for example pneumonia, strep on sputum culture, no growth on blood culture but a diagnosis of sepsis?

Response:
VICC advises that as the blood culture was negative, a urine culture cannot be used to identify the infective organism of the sepsis.  There needs to be documentation in the record that links the sepsis to the infective organism in order to assign a specific sepsis code.

As in this scenario there is no documentation to support that the E. coli UTI and sepsis are linked, VICC considers the appropriate codes to assign are:
N39.0 Urinary tract infection, site not specified
B96.2 Escherichia coli [E. coli] as the cause of diseases classified to other chapters
A41.9 Sepsis, unspecified

VICC considers that the same logic would apply to sepsis occurring with other infective conditions.


Query Text:
Can you please clarify how fever in the postpartum period (but not the delivery episode) should be coded?

Principal diagnosis on discharge summary: Admitted 8 days postpartum with febrile illness.

Admission notes state febrile illness postpartum.  Notes on day 2 of admission state febrile illness ?cause, vomiting with dehydration and on day 3 of admission admitted with febrile illness FI likely endometritis. Notes written on the day 
of discharge (day 3) state admitted 8 days postpartum with febrile illness. Treated with IV and oral antibiotics.

There was no documentation of fever in the prior delivery episode.

Although the fever arose in the postpartum period there is no documentation that it complicated the postpartum period or that it was linked to the delivery. In this case the use of the term postpartum just seems to be referring to the time period since delivery.

Question:
Should we follow Index:
1. Fever  R50.9 and not assign any O or Z39.0- codes
OR

2. Fever
   -Puerperal O85
    (with Z39.0-)

Search Details:
ACS 1501 DEFINITION OF PUERPERIUM
ACS 1521 CONDITIONS COMPLICATING PREGNANCY
ACS 1548 POSTPARTUM CONDITION OR COMPLICATION

Response:
VICC agrees that the postpartum period is a period of time and that in the case cited there is no documentation that the condition has complicated the postpartum period.

VICC considers that in accordance with ACS 1548 Postpartum condition or complication, the condition needs to be documented as a puerperal complication to enable a code from the obstetrics chapter or Z39.0- Postpartum care and examination immediately after delivery to be assigned.  

Therefore in the case cited, VICC advises that the correct principal diagnosis is R50.9 Fever, unspecified, as the essential modifiers under the lead term Fever cannot be followed without documentation of the condition complicating the postpartum period.


Query Text:
If a patient undergoes hysteroscopy with cervical biopsy, should a code for Biopsy, cervix 35608-02 [1276] be assigned in addition the code for hysteroscopy 35630-00 [1259]?

Index:
Hysteroscopy
-with biopsy (endometrium) 35630-00 [1259]

Is biopsy referring only to biopsy of the endometrium/ uterus as both are indexed to hysteroscopy 35630-00 [1259]?

Biopsy
-endometrium
with hysteroscopy 35630-00 [1259]

Biopsy
-uterus, uterine (closed) (endometrium) 35630-00 [1259]

However, biopsy of cervix is indexed to:
Biopsy
-cervix 35608-02 [1276]

VICC query 2196 (retired 30 June 2010) instructs the coder to assign a code for biopsy of pancreas when coding a gastroscopy with biopsy of pancreas because the biopsy is not of the gastrointestinal tract. Can this logic be applied to biopsy of cervix?  Procedures on the uterus are located in blocks 1259-1273, while procedures on the cervix are located in blocks 1274-1278? This appears to indicate that hysteroscopy 35630-00 [1259] does not include biopsy of cervix.

This has DRG implications as hysteroscopy with biopsy groups to DRG N10Z Diagnostic Curettage or Diagnostic Hysteroscopy, but the addition of the cervical biopsy code groups to N09Z Conisation, Vagina, Cervix and Vulva procedures.

Search Details:
#2196 Gastroscopy with pancreas biopsy

Response:
VICC research indicates that hysteroscopy is the visual examination of the canal of the cervix and the interior of the uterus. VICC also notes that  'endometrium' is a non-essential modifier at Index entry Hysteroscopy/with biopsy (endometrium).  Therefore, VICC considers it correct to follow this Index entry for documentation of hysteroscopy with cervical biopsy to assign 35630-00 [1259] Diagnostic hysteroscopy.

VICC does not consider that #2196 Gastroscopy with pancreas biopsy applies to this scenario.


Query Text:
VICC Query #2912 states that Prothrombinex contains particular coagulation factors, however it also includes human plasma proteins.  

Would it then be correct to assign both 92061-00 [1893] Administration of coagulation factors and 92062-00 [1893] Transfusion of other serum when Prothrombinex is administered?

Search Details:
VICC #2912
MIMS: Prothrombinex-VF (screenshot of MIMS page will be sent via email).

Response:
In accordance with ACS 0302 Blood transfusions a code is assigned for each type of blood product administered, not for each component of a blood product.  As Prothrombinex is used as a coagulation treatment, only one code is required and VICC confirms that the correct code is 92061-00 [1893] Administration of coagulation factors.


Query Text:
We often get terms 'slough' or 'sloughy' documented in the medical record to describe wounds that are often debrided on the ward or in theatre.  

Could VICC advise if we can follow the index entry under Sloughing to assign R02 Gangrene in these cases?

Sloughing (multiple) (phagedaena) (skin) (see also Gangrene) R02
- abscess (see also Abscess) L02.9
- appendix K38.8
- fascia M79.8-
- scrotum N50.8
- ulcer (see also Ulcer/skin) L98.4

Response:
VICC notes that the Introduction section of the Index under General arrangement of the alphabetical index of diseases says 'In some diagnostic statements, the disease condition is expressed in adjectival form. Sometimes, the index lists both forms but often only the noun form will be found and the clinical coder must make the necessary transformation'.

VICC considers that the terms 'slough' or 'sloughy' are variations of the lead term Sloughing and therefore this lead term can be followed when those variations are documented. Please note however that R02 Gangrene is only assigned when none of the essential modifiers under lead term Sloughing apply to your case and that this also applies to any other lead term to which the 'see also' convention may take you.


Query Text:
We note your advice to assign S30.1 as the principal diagnosis in this situation following the index entry Haematoma (see also Contusion).

Noting that a haematoma is an encapsulated haemorrhage and endeavouring to show the non-traumatic nature of the condition we have been assigning M62.88 as the PDx for this condition following the index entry
Haemorrhage
- muscle M62.8-

There is a DRG variance between S30.1 and M62.88 as the PDx.  Your advice on the regarding choice of code is appreciated.

10. Search Details
VICC # 2896 Rectus sheath haematoma secondary to anticoagulation

Response:
VICC advises that the terms haemorrhage and haematoma are not interchangeable in the classification.  Also, the lead term Haematoma has a 'see also' note for contusion (not haemorrhage).  Consequently the Index entry Haemorrhage/muscle M62.8- cannot be followed for documentation of rectus sheath haematoma.  Therefore VICC maintains that the correct code is S30.1 Contusion of abdominal wall.


Query Text:
A patient was admitted for gastroscopy and colonoscopy (same day) with an indication of Torre Muir Syndrome.  Both scopes were normal (nothing found).  There is no information in the patient's record to indicate how this syndrome was diagnosed, but research into the syndrome has identified "Muir-Torre syndrome is diagnosed if a person has one or more of the skin changes (sebaceous adenomas, sebaceous epitheliomas, sebaceous carcinomas, and keratocanthomas) and one or more of the internal cancers (colorectal, endometrial (uterine), stomach, ovarian, small bowel (intestinal), urinary tract, prostate, and hepatobiliary (liver or bile duct) cancers). A person diagnosed with Muir-Torre syndrome can have a blood test to see if they have a mutation in the MLH1 or MSH2 genes. However, not everyone with Muir-Torre syndrome will have a detectable mutation in one of these two genes" (from www.cancer.net).

I have coded this episode as:
Z09.9 Follow-up examination after surgery for other conditions
Z86.0 Personal history of other neoplasms

Is this correct, or can you recommend a better way to code it?

Response:
VICC has reviewed the documentation of this case and notes that the principal diagnosis on the discharge summary is documented as Torre Muir Syndrome, for which there is no Index entry in the classification.  VICC advises that in the first instance clarification and documentation from the clinician should be sought with regard to the patient's manifestations.  Once clinical advice has been obtained, apply ACS 0005 Syndromes for sequencing guidelines.  

If it is not possible to obtain clinical advice and supporting documentation of the patient's manifestations and as the Torre Muir Syndrome is not indexed, VICC advises to assign Z03.8 Observation for other suspected diseases and conditions as per the advice in ACS 0001 Principal diagnosis section 'Codes from the Z03.0–Z03.9 series, medical observation and evaluation for suspected diseases and conditions' which says  "Codes from category Z03 are assigned as principal diagnoses for admissions to evaluate the patient's condition when there is some evidence to suggest the existence of an abnormal condition...and where no supporting evidence for the suspected condition is found and no treatment is currently required." 

VICC notes that there needs to be documentation in the medical record to support the codes Z09.9 Follow-up examination after surgery for other conditions and Z86.0 Personal history of other neoplasms suggested in the query.


Query Title:
Principal diagnosis for removal of laparoscopic gastric band

Query Text:
A patient is admitted for removal of laparoscopic gastric band with weight loss or patient choice documented as the indication for surgery, with no documented complication of the gastric band.  We note that the Index can lead to two different codes:

Management
-implanted device
--specified NEC Z45.89

OR

Adjustment
-device
--abdominal Z46.5

Could you please advise what the diagnosis code should be for the scenario listed above when further documentation is not available from the treating clinician?

We have reviewed the query #2661 Removal of biliary stent published in December 2011 and the ICD Coding Newsletter (August 2002) that the query references, for advice on indexing logic which instructs the look up for biliary stent removal to be:
Adjustment
-device
--specified NEC Z46.8

Should the same logic be applied to the removal of laparoscopic gastric band?

Response:
VICC advises that the documentation in the record should be followed in all cases in the absence of any further clarification from the clinician.

For cases where weight loss is documented, VICC considers R63.4 Abnormal weight loss should be assigned following Index entry Loss/weight (abnormal), (cause unknown).

For documentation of patient choice or in the absence of any other documented reason for the removal of the gastric band, VICC considers the appropriate diagnosis code to assign is Z45.89 Adjustment and management of other implanted devices following Index entry Management/implanted device/specified NEC.  This Index entry was followed because there is no Index entry applicable for this case under the lead term Removal and VICC considered that lead term Management is more appropriate to follow than Adjustment because the device is being removed.

VICC notes that this advice is consistent with WA Clinical Coding Advisory Group advice.
 
Please note that the advice in #2661 Removal of biliary stent is specific to removal of biliary stents.


Query Text:
An eight year old girl is admitted for soft tissue SEMLS (bilateral hamstring releases, bilateral semi-T, semi-M, biceps releases, bilateral adductor releases, bilateral pectineus and psoas releases).  The principal diagnosis on the discharge summary is "bilateral hip dysplasia".

The diagnosis on the operation report is "unstable hip, bilateral".  (Note: this patient also has spastic quadriplegic cerebral palsy and a metabolic disorder).

There is no documentation of the hip condition as "congenital" anywhere throughout this admission.  This is not an unusual scenario.

What code should be used as the principal diagnosis?

Response:
As the term 'congenital' is an essential modifier at Index entry Dysplasia/hip, congenital, in the absence of the term being documented, VICC advises to follow the 'see also' note at the lead term Dysplasia - see also Anomaly.  

Following Index entry Anomaly/hip NEC, assign Q74.21 Other congenital malformations of pelvis, not elsewhere classified for the scenario cited.
 
This is in accordance with the Conventions used in the Alphabetical Index of Diseases in Volume 2 which says 'When a term has a number of modifiers which might be listed beneath more than one term, the cross-reference (see also…) is used.

In reference to the comment regarding no documentation in this admission of the hip condition being congenital, VICC notes that documentation of 'congenital' can be found in any part of the medical record.


Query Text:
Can VICC please advise how to code curettage of a chalazion / meibomian cyst?

VICC query #2747 Incision and curettage of meibomian cyst refers to incision and curettage in the question but only addresses incision in the answer.

Response:
As curettage is defined as removal of tissue, VICC considers it appropriate to look up lead term Removal for documentation of curettage of chalazion.  However there is no essential modifier for chalazion under this lead term, so follow the 'see also' note at Removal - see also Excision which leads to Index entry Excision/lesion(s)/eyelid/chalazion to assign 42575-00 [233] Excision of cyst of tarsal plate.


Query Text:
Following an audit it was stated by the auditor that a patient should always be coded as having severe depression when receiving ECT. Therefore according to the auditor an episode that was coded as F32.90 Depression, unspecified should actually be coded as F32.20. However, there was no documentation in the record to support coding it as a severe/major depression,  only depression was documented. There was also no reference that could be found in the standards that indicated it should be coded in this way.

Can you please clarify if an episode should be coded as severe depression F32.20 whenever a patient receives ECT, even when there is no documentation to support this or whether it is permissible to use the F32.90 Depression, unspecified in these cases where clarification with a clinician is not possible.

Response:
VICC advises to follow the Index based on the documentation available.  Therefore if the documentation states depression, assign F32.90 as per the default code at lead term Depression.  

VICC notes that ACS 0506 Adjustment/depressive reaction includes information which implies that a patient receives ECT for major depression. However major depression needs to be documented in order to follow the essential modifier of major at lead term Depression.


Query Title:
Liver disease and manifestations/disease components

Query Text:
When coding a patient with chronic liver disease, whether it be alcoholic or other cause, should we be coding out all manifestations of the liver disease such as portal hypertension, cirrhosis, ascites to indicate the severity of the disease? Or should each component of the liver disease individually meet ACS 0002 Additional diagnoses in terms of clinical treatment/investigation etc before they can be coded out (this is not always easy to determine)?

In ACS 0002 in the multiple coding section it states "There are situations which require the assignment of additional codes to reflect the various components of a disease, which may themselves not meet the above criteria of an additional diagnosis" and that an example of this is 'aetiology and manifestations'.

Search Details:
VICC #2234 Harmful use of alcohol retired 30/6/2013 
VICC #2288 Coding of manifestations of multiple sclerosis retired 30/6/2013

Response:
VICC advises that the components of the liver disease that are coded must be either the underlying cause of a condition meeting criteria for coding or must meet ACS 0002 Additional diagnoses in their own right. Codes should not be assigned to indicate the severity of the disease unless they meet a specialty standard such as ACS 0401 Diabetes mellitus and intermediate hyperglycaemia.

VICC also notes that the multiple coding section in ACS 0002 is not intended to mean that all components of a disease can be coded but rather it refers to conventions such as 'dagger and asterisk' and 'code also' where mulitple coding is used.


Query Title:
Assignment of drug resistance to microorganisms code from electronic discharge summary

Query Text:
ACS 0112 Infection with drug resistant microorganisms states "If the clinician has documented in the record that the organism causing the infection is resistant to an antibiotic or other antimicrobial drugs, then the appropriate code from Z06.- Resistance to antimicrobial drugs must be assigned as an additional code to identify the antibiotic or other antimicrobial agent to which the organism is resistant.  

Does this apply when a clinician, using a scanned/electronic medical record, copies the Microbiology results from the Investigations folder and pastes it into the electronic discharge summary?  Some clinical coders believe that this is the same as the clinician writing the drug resistance results in the medical record, as would have been done with a paper-based discharge summary in the past.  With the implementation of electronic medical records, more clinicians are using this method (copy/paste) of results to communicate with GPs and other persons.

Is this enough evidence to support the assignment of Z06.-?  Does there have to be documented evidence in the progress notes also?

Response:
VICC considers that from the coder's perspective, an electronic discharge summary must be viewed in the same way as a handwritten discharge summary.  The discharge summary is the clinician's responsibility and if there is concern with the content of the summary it should be queried with the clinician.

With respect to the specific questions, VICC does consider that the sentence from ACS 0112 Infection with drug resistant microorganisms referred to in the query, applies to when a clinician uses any type of (paper, scanned or electronic) medical record.  Therefore VICC agrees that Z06.- can be assigned in the scenario cited. The coding decision is based on coding rules rather than the format of the medical record.

For Tenth Edition advice, refer to VICC query #3240 Ethical query re VICC #2966.


Query Text:
Could the committee please advise whether code E46 Unspecified protein-energy malnutrition can be coded from documentation of malnourishment and malnourished?

In the Introduction of the Alphabetical Index of disease, it states users should therefore look up the disease or condition as a lead term.

Currently there is no index entry or lead term in the classification under malnourishment or malnourished.  Therefore, by assigning E46, coders are assuming that these terms, malnutrition, malnourishment and malnourished are inter-changeable.

ACS 1909 Adult and child abuse example 1. Assigns E46 for documentation of general malnourishment, yet there is no index entry for this.

Some might say that coders are using their clinical knowledge to identify that malnourished and malnourishment clinically equal malnutrition however there are examples where we are instructed not to use clinical advice/knowledge to allocate a code, it needs to be documented in the clinical record/notes.

Example VICC query #2733, VICC response - VICC advises that the size of the suture material cannot be used to assign codes for microsurgical repair. There needs to be documentation in the medical record of microsurgical repair in order for the repair to be coded as such.  VICC acknowledges that microsurgical repair is widely practiced and suggests you consider submitting a public submission to the NCCC to default repair of artery and vein to microsurgical repair.

While coders should be aware of the Clinical Coders Creed, VICC advises that the Creed is about using the clinical documentation to confirm a diagnosis rather than allowing coders to make their own interpretation.

Could the committee please advise do we follow the lead of the NCCC and allocate E46 when terms such as malnourished and malnourishment are used in the clinical notes as per the example in ACS1909 Adult and child abuse? Or do we seek further clarification from the clinician (including the dietician) to confirm ?

Search Details:
VICC query #2733, VICC query #2263 (retired), VICC query #2693 
Alphabetical Index of Diseases, page ix ACS 1909 Adult and Child abuse

Response:
VICC notes that the Conventions and General Arrangement of ICD-10-AM Alphabetic Index says 'An index entry may list the adjectival or noun form of a condition, or both. If only the noun form is listed, the clinical coder must make the necessary translation'.

VICC considers that the terms 'malnourishment' or 'malnourished' are variations of the lead term Malnutrition and therefore this lead term can be followed when those variations are documented.


Query Text:
Please advise in cases where the clinician has documented a test result but not documented the condition being treated, and the test result indicates an abnormal result, is this sufficient documentation to assign a code for the condition.

For example: Progress notes documentation "K 5.3 given resonium" Can hyperkalaemia be assigned?

Search Details:
VICC query 2819 Documentation of down arrows after a result.
Coding Committee of WA - Meeting Minutes 2009 (Ref 6.4)

Response:
This query was originally published in the 2014-15 December database release VICC queries database release as follows:

VICC notes that the WA advice is from 2009, however there is current Coding Rules advice titled Use of abbreviations and symbols, which was originally published in Coding Matters Volume 16 Number 2 and is referenced in VICC query #2819 Documentation of down arrows after a result.  

Therefore with respect to the example in the query, hyperkalaemia can only be assigned if the clinician has verified that the patient has hyperkalaemia through documentation of the condition.

Following the release of an update to ACCD Coding Rules TN199 titled Use of abbreviations, symbols and test result values to inform code assignment for abnormal pathology results, the original response is superseded by the following ACCD advice:
Q:
When can coders use abbreviations, symbols and test result values documented in the clinical record to assign conditions, eg ↓Hb or Hb 98 documented and transfusion given - can anaemia be assigned? ↓K or K2.9 documented and potassium supplements commenced - can hypokalaemia be assigned?

A:
Clinicians may document test result values as well as abbreviations and symbols in the clinical record as shorthand to indicate conditions such as anaemia, hypokalaemia, hypercalcaemia etc.

Where such shorthand is used to document/describe a condition, each instance must be assessed on its merits and where possible confirmed with a clinician to ensure that the documentation sufficiently describes a condition that is both supported by an appropriate index entry and meets the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.

Test result values, symbols and abbreviations are not to be used in isolation to inform code assignment and coders should therefore:
 - clarify the significance of the documented shorthand (test result, values, abbreviations and symbols) with the clinician to inform code assignment

Where this is not possible assign a code for the condition represented in shorthand (as described above) only if:
- test results (pathology report) verify that a result is abnormal AND
- there is an appropriate ICD-10-AM index pathway AND
- it meets the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.

For example, where ↓Hb or a haemoglobin level (eg.Hb 98) is documented as the indication for a transfusion and the test results (pathology report) and/or the clinician verifies the patient's haemoglobin is below the normal range, follow the index pathway:

Low

- haemoglobin 

to assign D64.9 Anaemia, unspecified.

Where ↓K or a potassium level (eg.K 2.9) is documented as the indication for commencement of medication and the test results and/or clinician verifies the patient's potassium is below the normal range, follow the index pathways:
Deficiency
- potassium (K) 

Depletion
- potassium

Hypokalaemia

Hypopotassaemia

to assign E87.6 Hypokalaemia.

However, if ICD-10-AM does not provide an index look up or there is uncertainty or ambiguity in relation to such abbreviated forms of documentation, always confirm with the clinician prior to code assignment.


Query Text:
When a patient presents as STEMI/AMI, but myocardial damage is completely averted by prompt revascularization, and there is documentation of averted or aborted MI in the patient record, what is the correct code to assign?

Would  I24.0 Coronary thrombosis not resulting in myocardial infarction be the correct code to assign?

Definition:
Abortion of myocardial infarction is thought to follow rapid early reperfusion of a thrombotic occlusion of an epicardial coronary artery such that myocardial necrosis cannot be detected by classical plasma enzyme analyses.
Verheugt et al, Eur Heart J, 2006

Response:
VICC understands that with early intervention of reperfusion therapy, myocardial necrosis can be prevented in some patients and this is referred to as 'aborting' the myocardial infarction.  

As there is no essential modifier for documentation of 'aborted' under Index entry Infarction/myocardium/STEMI NEC, VICC considers that the correct code to assign is the default code I21.3 Acute transmural myocardial infarction of unspecified site. This is supported by the clinical notes provided with this query, which states the principal diagnosis as STEMI.


Query Title:
Manual rotation of fetal head to assist delivery

Query Text:
Could the committee please confirm if the appropriate delivery diagnosis code when manual rotation of fetal head is performed is O83 Other assisted single delivery?

The includes note at O83 lists 'version with extraction'.  This query is for cases when manual rotation of fetal head is performed to assist delivery, and patient goes on to deliver the baby spontaneously (without forceps or vacuum).

Our confusion is surrounding when the rotation is performed to manoeuvre the baby, but the rotation is not used to deliver/extract the baby.  Is this still considered 'assisted vaginal delivery'?

Clinical advice indicates to perform a manual rotation successfully, significant expertise and ability is required.

Response:
VICC considers that O83 Other assisted single delivery is the appropriate code to assign in this scenario because assistance is required to safely deliver the baby.  

This is supported by previous ACCD advice which classifies delivery episodes involving McRoberts manoeuvre and manual removal of placenta to O83 Other assisted single delivery.


Query Title:
Borderline or low grade tumours with invasive implants, metastases

Query Text:
Could the committee please advise the correct code assignment for tumours classified to the neoplasm of uncertain or unknown behaviour categories (D37 - D48 codes) that have invasive implants/metastases?

We have a case where a patient's diagnosis was a borderline ovarian tumour with an invasive implant in the pouch of douglas.  The histopathology stated that the tumour type was micropapillary seromucinous borderline (low grade intraepithelial carcinoma) and there were invasive implants in the pouch of douglas and rectosigmoid peritoneum.  The clinician documented these invasive implants as metastases and she was treated with chemotherapy.

After discussion with the treating clinician, he confirmed that it was a rare case, however the patient definitely did have metastatic deposits, and she was treated as though she had a primary malignancy of the ovary even though the pathology stated otherwise.

In this case, is it correct to code:
C56 Malignant neoplasm of ovary
M8010/3 Carcinoma NOS
C78.6 Secondary malignant neoplasm of retroperitoneum and peritoneum
C78.5 Secondary malignant neoplasm of large intestine and rectum
M8010/6 Carcinoma metastatic NOS

Similarly we have also had a case of an ovarian juvenile granulosa cell tumour that has two tumour deposits in the omentum, which has also been documented in the histopathology as intraperitoneal metastases. 
This patient was also treated with chemotherapy.

Would this case be correct to code:
C56 Malignant neoplasm of ovary
M8620/3 Granulosa cell tumour, malignant
C78.6 Secondary malignant neoplasm of retroperitoneum and peritoneum
M8620/6 Granulosa cell tumour, malignant, metastatic

If there is documentation of invasive implants or metastases, can we assume that the primary is malignant?

Response:
VICC notes that invasive implants are the same as metastases and if a tumour has metastasised it is considered to be malignant.  There must however be a documented link between the tumor and the invasive implants or metastases in order for that tumour to be considered the malignant primary.

With regard to case one, provided there is clinical documentation supporting the discussion with the treating clinician that this case is clinically considered to be a primary malignancy of the ovary, VICC agrees that the correct diagnosis codes to assign are:
C56 Malignant neoplasm of ovary
C78.6 Secondary malignant neoplasm of retroperitoneum and peritoneum; and 
C78.5 Secondary malignant neoplasm of large intestine and rectum

VICC notes that the histopathology 'micropapillary seromucinous borderline (low grade intraepithelial carcinoma)' contains two histological terms.  Therefore in accordance with ACS 0233 Morphology which says if a morphological diagnosis contains two histological terms which have different M codes, select the highest number as it is usually more specific, VICC considers the correct morphology is M8460/3 Papillary serous cystadenocarcinoma and M8640/6 Papillary serous cystadenocarcinoma, metastatic following Index entry Carcinoma/serous/micropapillary.

With regard to case two, if there is no documentation that the ovarian tumor is clinically considered to be a primary malignancy or the metastases are not linked to the ovarian tumor or any other primary malignancy, VICC considers the correct codes to assign would be:
D39.1 Neoplasm of uncertain or unknown behaviour of ovary
M8622/1 Granulosa cell tumour, juvenile
C80.0  Malignant neoplasm, primary site unknown, so stated
M8010/3 Carcinoma NOS
C78.6  Secondary malignant neoplasm of retroperitoneum and peritoneum
M8010/6 Carcinoma, NOS, metastatic

However, VICC considers that documentation of a tumour that has tumour deposits, which are metastases on histopathology (as in case two) provides a link between the primary and the metastases and therefore advises to assign the following codes:
C56 Malignant neoplasm of ovary
M8622/3 Granulosa cell tumour, juvenile
C78.6 Secondary malignant neoplasm of retroperitoneum and peritoneum
M8622/6 Granulosa cell tumour, juvenile, metastatic

The morphology code has been assigned following Index entry Tumour/granulosa cell/juvenile M8622/1 and changing the behaviour to /3 malignant  in accordance with the instruction in Appendix A of the Tabular which says '...this behaviour code should be changed if the other reported information makes this appropriate'.


Query Text:
A patient presented in cardiac arrest.  Documentation on the resuscitation chart indicates 'difficult intubation due to cleft palate'. All reference to the 'difficult intubation' code appears to apply to anaesthesia only.

Can we code the difficult intubation in this case or do we code the cleft palate only?

Inclusion of the difficult intubation code changes the DRG.

Response:
VICC advises that difficult intubation is not limited to anaesthesia, it is applicable to intubation for other reasons.

Coding Rules advice Q2667 titled T88.4 Failed/difficult intubation published 15 December 2014 provides the following advice regarding the assignment of T88.4 Failed or difficult intubation:
T88.4 Failed or difficult intubation should be assigned for difficult intubation when: 
• difficult intubation is specifically documented AND  
• there is documentation of a Cormack-Lehane or Mallampati score of grade 2 or higher. 

Use of advanced techniques (video-laryngoscopy or introducers) may indicate difficult intubation, but for classification purposes the above criteria must first be met before T88.4 is assigned. Where documentation is unclear, coders should seek clinical advice. 

The above advice also applies to: 
• O29.6 Failed or difficult intubation during pregnancy
• O74.7 Failed or difficult intubation during labour and delivery 
• O89.6 Failed or difficult intubation during the puerperium. 

Therefore VICC advises that based on the information provided in the query a code for difficult intubation would not be assigned for this case.

VICC also notes that the cleft palate would need to meet ACS 0002 Additional diagnoses before a code for this condition can be assigned.


Query Text:
How do we code hernias which are repaired separately through the same incision? The operation details stated "large omental umbilical hernia smaller hernia located superiorly". Separate repairs were clearly documented on the operation report. Do we code the procedure twice?

Response:
VICC advises that in accordance with ACS 0020 Bilateral/Multiple procedures under section Multiple procedures point 2, titled The SAME PROCEDURE repeated during a visit to theatre involving ONE ENTRY POINT/APPROACH and similar/same lesions, assign one code for these procedures.


Query Text:
Patient had a fistula plug inserted under GA. Unsure of how this should be coded.

Operation report states: Plug inserted into tract, sutured. Plug cut flush with skin.

Search Details:
Further research has found the insertion of a plug involves: plugging the fistula with a device made from small intestinal submucosa. The fistula plug is positioned from the inside of the anus and secured with suture.

Response:
On review of the operation report provided with the query, VICC notes that the plug used is a 'Cook' biotech product indicating that the plug is a biological sealant.  

Therefore VICC considers that for the case cited, the correct code to assign for insertion of fistula plug into anus is 90344-00 [929] Administration of biological sealant to anorectal region following Index entry Closure(of)/fistula/with biological sealant (fibrin sealant)(glue)/anorectal.


Query Text:
We have a patient who required a pacemaker to treat 'chronotropic incompetence with documented failure in heart rate rise' for which we cannot find a code.  Could you please suggest a code that we could use? We did find the advice below from NZ but realise we cannot apply this.

Chronotropic incompetence.  Created Aug 2012:

Query
What diagnosis code should be assigned for the condition Chronotropic incompetence?

On researching this condition it is defined as:
Chronotropic incompetence refers to the inability of the heart to increase its rate commensurate with increased activity or demand of the patient.  Website reference  http://www.texasheartinstitute.org/HIC/HeartDoctor/answer_145.cfm

As there is no ICD-10-AM index entry we've chosen I49.8 Other specified cardiac arrhythmias in the meantime, but would like confirmation.

Response
Based on clinical advice chronotropic incompetence is usually due to sinus node dysfunction and the clinicians consulted have advised the most appropriate diagnosis code to assign is I49.5 Sick sinus syndrome.  Free text should be used on the code description to specify the condition.

Response:
In the absence of further clinical advice, VICC suggests to apply the Conventions used in the 
ICD-10-AM Tabular List section 'Other' and 'unspecified' codes and follow Index entry Disease/heart (organic) and assign I51.9 Heart disease, unspecified.


Query Text:
Could you please advise the correct code assignment for 'Painful Bladder Syndrome' (PBS)?

We have been informed by our urogynaecologists that these patients would most likely have previously been diagnosed with 'Interstitial cystitis'.

As there is no index look up for PBS, could you please advise?

Search Details:
Pain, bladder - R39.8 - which groups to signs and symptom DRG L65B

Cystitis, interstitial - N30.1 - groups to infection of bladder DRG L63B

Response:
VICC agrees that the correct code for documentation of painful bladder syndrome is R39.8 Other and unspecified symptoms and signs involving the urinary system, following Index entry Pain/bladder, in the absence of an Index entry under the lead term Syndrome.  This is in accordance with ACS 0005 Syndromes which advises that if no one code describes the syndrome, to code the manifestation(s).

Whilst advice from the urogynaecologists indicates that these patients would most likely have previously been diagnosed with Interstitial cystitis, there needs to be documentation that the interstitial cystitis is the cause of the painful bladder syndrome in order to assign N30.1 Interstitial cystitis (chronic).


Query Text:
Could you please confirm the correct Y83.x code to be used for a post-procedural complication following a tonsillectomy. (Y83.6 vs Y83.8)

Discussion at our organisation has determined that some coders consider the tonsil to be an organ, where as others do not.

Search Details:
Mosby's Medical Dictionary, 8th edition 2009, Elsevier - defines an organ as a structural part of a system of the body that is composed of tissues and cells that enable it to perform a particular function.
Mosby's Medical Dictionary, 8th edition 2009, Elsevier. Defines tonsil as a small rounded mass of tissue, especially lymphoid tissue,

Response:
As tonsils are an organ, the correct external cause code to assign for a postprocedural complication following a tonsillectomy is Y83.6 Removal of other organ (partial)(total).


Query Text:
Please advise the correct procedure code for decannulation of an ECMO? 

There are pathways in the Index which provide procedure codes for initial insertion and adjustment of the cannula for ECMO, but not for complete removal/decannulation.

ACHI code 38627-02 [642] Adjustment of cannula for extracorporeal membrane oxygenation includes  adjustment or repositioning of the cannula, whereas in our case it is being removed entirely (please see attached operation report).

Please advise if this code 38627-02 is still appropriate, or whether another code is more suitable for the procedure performed.

Response:
As the terms catheterisation and cannulation are used interchangeably, VICC considers that the appropriate ACHI code to assign for documentation of decannulation of ECMO is 34530-04 [738] Removal of venous catheter following Index entry Removal/catheter/vein as the cannula is being removed entirely rather than being adjusted.


Query Text:
Could you please advise the best codes to use for unstable pelvis complicating pregnancy. We have had several patients admitted for this lately. Some coders assign:
O34.8 Maternal care for other abnormalities of pelvic organs
M25.35 Other instability of joint, pelvic region and thigh
(to add specificity). 

Others have assigned:
O26.88 Other specified pregnancy-related conditions
M25.35 Other instability of joint, pelvic region and thigh

There is no direct Index look up for this and we cannot find any previous advice.

Response:
VICC agrees with the assignment of M25.35 Other instability of joint, pelvic region and thigh to describe the pelvic instability in the scenario cited.  However, VICC considers that the correct code from Chapter 15 is O99.8 Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium following Index entry Pregnancy/complicated by/conditions in M00–M82 NEC O99.8 Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium.


Query Text:
Can the committee please provide advice on the appropriate codes to use for the following scenario?

Patient with liver cirrhosis is admitted for follow-up/surveillance of oesophageal varices.  As the varices are a complication of a chronic condition does ACS 2113 Follow-up examinations for specific disorders apply?

For example: Patient with cirrhosis of the liver admitted for surveillance of previous banded oesophageal varices. Further varices are found and banded. Should this be coded as:
I98.2 Oesophageal varices
K74.6 Other and unspecified cirrhosis of liver
OR
I98.2 Oesophageal varices
K74.6 Other and unspecified cirrhosis of liver
Z09.0 Follow-up examination after surgery for other conditions

If varices are not found should this be coded as:
K74.6 Cirrhosis of the liver
OR
Z09.0 Follow-up examination after surgery for other conditions
Z86.7 Personal History of disease of the circulatory system.

For the scenario where patients are admitted for screening or follow-up of varices with no underlying condition does ACS 2113 Follow-up examinations for specific disorders and/or ACS 2111 Screening for specific disorders apply?

Search Details:
ACS 2113 Follow-up examinations for specific disorders

Response:
VICC advises that ACS 2113 Follow up examinations for specific disorders applies when there is follow up, regardless of whether the condition being followed up is a complication of a chronic condition.

The example provided in the query of the patient with cirrhosis of the liver admitted for surveillance of previous banded oesophageal varices is a follow up episode and therefore ACS 2113 applies.  If further varices are found and banded, VICC advises that the correct diagnosis codes to assign are:.
I98.2 Oesophageal varices
K74.6 Other and unspecified cirrhosis of liver
Z09.0 Follow-up examination after surgery for other conditions

If varices are not found, VICC advises to assign diagnosis codes as follows:
Z09.0 Follow-up examination after surgery for other conditions
Z86.7 Personal history of disease of the circulatory system

In regard to the last question, when there is no underlying condition documented, for a patient admitted for screening follow ACS 2111 Screening for specific disorders and for a patient admitted for follow up, follow ACS 2113  Follow-up examinations for specific disorders.


Query Title:
BBA with delivery of placenta in birthing suite

Query Text:
Two part question:
1. Can you please advise on the correct coding for unplanned baby born before arrival at home (or in ambulance), and the placenta was delivered in the birth suite once arrived at the hospital?

Recent ACCD advice 'Coding Rules - June 2014 - Manual removal of placenta in a single vaginal delivery', advises that:
" For classification purposes the O80-O84 range of codes describe the delivery component of an obstetric episode of care, including expulsion of the placenta."

Therefore, is it correct to code O80 and Z37.x for this scenario?  As the delivery of the placenta is considered part of the delivery?  Rather than Z39.03, as only the baby was BBA, not the placenta also.

2. Can you please advise on the correct coding for  baby born before arrival at home (or in ambulance), and the placenta was delivered in emergency department?

Is it correct to code these scenarios to Z39.03 Postpartum care after unplanned, out of hospital delivery as the placenta was delivered in the emergency department, and not considered part of the hospital?

Response:
VICC referred this query to ACCD who advised to apply the advice titled 'Baby born prior to admission with placenta delivered in hospital' published 15 June 2015 as follows:

"The period between the delivery of the fetus and the expulsion of the placenta and fetal membranes is the third and final stage of labour/delivery. 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).

The reference to the delivery of ‘a baby prior to admission to hospital’ in ACS 1519 Delivery prior to admission should be considered to also include the delivery of the placenta. The wording in this standard and ACS 1548 Postpartum condition or complication will be reviewed for a future edition of the Australian Coding Standards (ACS) to clarify ‘delivery’".[end of ACCD response].

With regard to question two, VICC agrees that the correct principal diagnosis is Z39.03 Postpartum care after unplanned, out of hospital delivery as the delivery was completed prior to admission.  Whilst the emergency department is part of the hospital, care and/or treatment received in the emergency department is not part of the admitted episode.

For Tenth Edition advice refer to #3317 ACS 1548 vs VICC query #2985 Delivered at Home, Placenta Delivered in Birthing Suite published in the 2017-18 March VICC queries database.


Query Text:
Could the committee please assist with the interpretation of advice provided in the ACS 1808 which states that incontinence should be coded when it 'persists for at least seven days'.

Does this need to be consecutive days, for example, if a patient has one day of continence in between 8 days of overall incontinence, can this be considered as persisting for 7 days and hence coded? Can the concept of 'persistent incontinence' also apply in a cumulative sense over the course of a patients admission.

Search Details:
ACS 1808 Incontinence
VICC #2464

Response:
ACS 1808 Incontinence does not define persistent and it is silent on whether days must be consecutive. As persistent does not mean continuous, if over eight days, the patient is incontinent for seven days, VICC considers that it is appropriate to assign a code for incontinence.

VICC also agrees that the term 'persistent incontinence' can be cumulative over the admitted episode.


Query Text:
Hoping you can clarify the way in which  “Hepatitis Carrier” should be coded.  There is definitely some ambiguity in ACS 0104 that requires clarification.
 
Example:
Patient admitted with OA of the knee for a total knee replacement.  Anaesthetist indicated on the anaesthetic chart that the patient was “Hep B Carrier”.  Patient history and all other documentation does not indicate any active or chronic hepatitis – only the “Hep B Carrier” documented by anaesthetist.
 
In reading ACS 0104 it states that the “Concept of 'carrier (state) of viral hepatitis' is no longer clinically correct; therefore, Z22.52 Carrier of viral hepatitis C should never be assigned”.  I read this that we do not code a ‘Z’ code or a ‘B’ when documented as ‘Carrier of Hepatitis’.  The ambiguous nature of the standard does justifiably lead coders to allocate a ‘B’ code to indicate “Carrier of Hepatitis”, my only issue is that coding a ‘B’ code for carrier (in my example B18.1) has a CCL value of 3, which in most instances will generate a higher funded DRG.
 
I look forward to your response and guidance on how “Hepatitis Carrier” should be coded, if at all.

Response:
VICC interprets the advice in ACS 0104 Viral hepatitis under heading classification that states that viral hepatitis should always be coded when documented except when hepatitis C is documented with terms such as 'cured', 'cleared' or 'with SVR to mean that documentation of 'carrier (state) of viral hepatitis' is coded to B18.- Chronic viral hepatitis.

This is supported by a DRG Technical Group (DTG) meeting paper which states that where documentation is insufficient, the coding standard will set the default code to B18._ for the chronic hepatitis, in line with the clinical advice.


Query Text:
In regard to advice in VICC query #1618 from November 2000, can this advice (see below) still be applied?

Query #1618 Opioid dependence
If a patient is admitted with a past history of IV drug use and they are currently on a methadone program, can we assume that the patient is opioid dependent? The patient will not cope without a daily dose of methadone.

Our clinical knowledge tells us that only opioid dependent people are accepted into the methadone program, therefore it is appropriate to assume that the patient is opioid dependent.

Search Details:
VICC newsletter November 2000 & August 2002

Response:
VICC advises the advice in retired query #1618 Opioid dependence is no longer applicable.  The opioid dependence must be documented and meet ACS 0002 Additional diagnoses for it to be coded.


Query Title:
ACS 0001 Principal diagnosis problems and underlying conditions

Query Text:
ACS 0001 Principal Diagnosis, sub-heading Problems and underlying conditions, point 2, Coding the problem as the principal diagnosis.

Scenario: patient with previously diagnosed secondary neoplasm to bone, admitted for MANAGEMENT OF BONE PAIN.

We have coders and auditors developing material for students and would appreciate clarification.  This has been discussed with more than 20 individuals and the response vary 50/50 between the answers provided so there is clearly a need for clarity.

We are split between coding the bone pain as the PDx (justification that this is the same as Example 3 in the ACS) and coding the cancer as the PDx and not coding the bone pain (justification that this is a symptom of the cancer).  Which rule is to be applied as the example implies one option while normal symptom rules imply another.

This issue has occurred many times in different situations - it does not relate to an individual case.

Search Details:
All of the above have been consulted.  In addition coding groups in Queensland and NSW have had discussions on the issue but not agreement.

Response:
Whilst ACS 0001 Principal diagnosis provides advice for coding the problem as the principal diagnosis, the scenario cited is of a patient previously diagnosed with secondary neoplasm to bone, admitted for management of bone pain. Accordingly, VICC considers that specialty standard ACS 1807 Pain diagnoses and pain management procedures applies to this scenario.  

ACS 1807 states that when pain is directly associated with another condition, assign only the code(s) for the condition(s) causing the pain.  Therefore the correct principal diagnosis in this scenario is C79.5 Secondary malignant neoplasm of bone and bone marrow.


Query Text:
When a patient is admitted for a follow up colonoscopy for polyps should a polyp of a different histopathology be regarded as a residual condition or recurrence?

Volume 13 Number 2, September 2006 Retired 30 June 2013 States a polyp or tumour of a different histopathology should not be regarded as a residual condition or recurrence unless there is clinical advice to the contrary.

Response:
ACCD has undertaken a review of ACS 0046 Diagnosis selection for same-day endoscopy, ACS 2111 Screening for specific disorders and ACS 2113 Follow-up examinations for specific disorders for ICD-10-AM/ACHI/ACS Tenth Edition in consultation with the ICD Technical Group (ITG) to ensure the accuracy and usefulness of the coding guidelines. Investigation revealed that there were differences in coding practice and interpretation of these standards by clinical coders.

It must be noted that many of the issues with same-day endoscopy episodes of care are due to a lack of documentation and interchangeable terminology used such as follow-up, screening or surveillance and the overlaps between these for certain conditions. Revised guidelines will be implemented in the Tenth Edition. As these guidelines will have a significant impact on coding practice, ACCD advised that a Coding Rule will not be published. 

VICC advises that, until these new guidelines are implemented,  a polyp or tumour of a different histopathology should not be regarded as a residual condition or recurrence unless there is clinical advice to the contrary.


Query Title:
Closure of ileostomy with small bowel resection

Query Text:
We are seeking clarification regarding VICC and ACCD advice surrounding Closure of a temporary ileostomy. VICC queries #2759 and #2852 which are not retired and ACCD Coding Rule closure of ileostomy with resection seem to differ in the advice they provide. The two VICC  queries state that if the bowel resection or excision is documented, we can assign a code for the procedure however the ACCD Coding Rule states there needs to be documentation of further pathology before we can assign a code for the resection.

We understand in this procedure there will always be freshening/trimming of the ends before re-anastomosis occurs, however we believe there is still some confusion when we are able to add another code for the resection/excision of the intestine in excess of the freshening/trimming.  How do we classify bowel pathology in order to add an additional code for the resection?

If the clinician has written in the title of the op-report 'closure of ileostomy with small bowel resection and anastomosis' and it is backed up within the body of the report that there was a resection, is this enough documentation for us to add a separate code?

Search Details:
VICC #2759, #2852
Coding Rule: Closure of ileostomy with resection

Response:
VICC notes that the ACCD advice was published subsequent to VICC queries #2759 and #2852, therefore the ACCD advice stands.

Regarding your question about classifying bowel pathology, VICC interprets the term bowel pathology used in the ACCD response to mean bowel disease or abnormality rather than the fact that a specimen was sent to pathology.  Therefore there must be documentation in the operation report that the resection was performed for abnormal or diseased bowel.

In answer to your second question, a code for bowel resection cannot be assigned on the basis that bowel resection with closure of ileostomy is documented on the title of the operation report or body of the report alone.


