# VICC queries

Query Text:
When a woman has an episiotomy, is this considered a procedure to assist delivery, and therefore should the principal diagnosis be O83 (except with  forceps/vacuum/c section)?

See information from one of our obstetricians:
Use of episiotomy is no longer routine for vaginal births, either term or pre-term.  The decision to perform an episiotomy is based on individual needs.   An episiotomy is a surgical intervention. Where a woman has had an episiotomy there should always be an indication for the procedure.

Indications for episiotomy include:
- To facilitate delivery in cases of non-reassuring fetal heart rate
- Facilitate delivery in case of failure to progress in second stage (maternal exhaustion)
- Rigid perineum, rigid musculature may cause prolonged delay in second stage
- Preventing perineal trauma when associated with a history of  surgical repair of the pelvic floor, bladder or fistula, including previous obstetric  trauma repair and in cases where the perineal body is unusually short
- Reducing maternal effort for example  pre existing  condition such as cardiac disease, epilepsy or hypertension
- Facilitate safe delivery in cases of shoulder dystocia (allows space for manoeuvres such as Mc Robert's to assist delivery)

Response:
Following ICD-10-AM classification conventions, O80 must be assigned for spontaneous delivery with episiotomy because of the includes note at O80 in the Tabular list.  

VICC suggests that as your clinical advice differs, you may wish to submit a public submission to ACCD to review the includes note at O80 Single spontaneous delivery.


Query Text:
We have been reviewing our PICQ data and have come up with some questions relating to the coding of Acute Pulmonary Oedema which is causing us some confusion.

1) The standard states that if the underlying cause is not known then we should code I50.1 Left ventricular failure, however if we do have an underlying cause such as pulmonary hypertension should we then code J81 Pulmonary oedema?  

2 a) Are there instances where the underlying cause would mean that I50.1 should be used, such as cardiomyopathy being the underlying cause? 
   b) Is APO on a background of COAD enough for us to consider this an underlying cause and assign J81?

3) Additionally if a patient is documented as having 'pulmonary oedema' with no qualification that it is 'acute' does ACS 0920 still apply?

Response:
In answer to question 1, if the underlying cause is a heart condition or failure, VICC advises to follow the Index entry Oedema/lung/with heart condition or failure (see also Failure/ventricular/left) and assign I50.1 Left ventricular failure.  This is supported by the excludes note at J81 Pulmonary oedema which says 'excludes pulmonary oedema with mention of heart disease or heart failure'.  VICC considers pulmonary hypertension to be a cardiac condition as it is classified to Pulmonary heart disease and diseases of pulmonary circulation and would therefore assign I50.1. If however, the known underlying condition is not a heart condition or failure, assign J81.

In answer to question 2a, if cardiomyopathy has been identified as the underlying cause of the acute pulmonary oedema, as per the Index entry above, it is correct to assign I50.1 Left ventricular failure.  In answer to question 2b, VICC considers that 'on a background of' is not the same as underlying cause, therefore follow ACS 0920 and assign I50.1.

In answer to question 3, ACS 0920 does not apply if the qualifying term 'acute' is not documented.  Therefore you would follow Index entry Oedema/lung (acute) to assign the appropriate code according to your documentation.


Query Text:
Can the Committee please advise on whether “PPH secondary to poor tone” or “PPH due to tone” can be taken to mean “PPH secondary to atonic uterus” and therefore O62.2 Other uterine inertia can be assigned in addition to O72.1 Other immediate postpartum haemorrhage?

Our Director of O&G has advised us that the standard acceptable clinical term that medical students are taught at medical school is “tone” rather than “atonic uterus”. After much discussion, I cannot convince him to encourage medical officers to change how they document. 

Could the Committee please investigate further and advise whether the terms “PPH due to poor tone” or “PPH due to tone” could be interpreted as being synonymous with “PPH due to atonic uterus”? If not, what codes does the Committee suggest to assign to describe these terms?

Response:
VICC sought clinical advice which indicates that poor tone or tone of uterus are synonymous with uterine atony or an atonic uterus.

Therefore, VICC considers it appropriate to follow Index entry Atonia, atony, atonic/uterus (during labour) to assign O62.2 Other uterine inertia for documentation of poor tone or tone of uterus if it meets ACS 0002 Additional diagnoses. Also assign a code for the PPH as per the ‘code also if applicable’ note at O62.2 Other uterine inertia. 

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


Query Text:
In the last couple of years we have seen diagnoses of BRUE in our Paediatric records. Our paediatricians have advised this means "Brief Resolved Unexplained Event". It is updated terminology for what used to be known as ALTE (Apparent/Acute Life Threatening Event).

ACS 1610 Sudden Infant Death Syndrome directs that ALTE should be coded to R68.1 nonspecific symptoms peculiar to infancy" when no cause has been determined.

We have been coding BRUE to ALTE only after querying with the clinicians that their diagnoses of BRUE mean the same thing as ALTE. They have been happy to confirm this, albeit are becoming tired of answering the same question! They are not willing to document ALTE in the discharge summaries as it is outdated terminology. They have asked if the coding classification could be updated to include an index entry for BRUE.
Would the committee please advise if this could be done?

In the meantime, can diagnoses of BRUE be coded to ALTE without having to query this?

Search Details
ACS 1610 Sudden Infant Death Syndrome/Apparent Life Threatening Event
Discussion with Paediatrics consultants at our hospital.

Response:
VICC research indicates that BRUE (Brief Resolved Unexplained Events) is the updated terminology for ALTE (Apparent Life Threatening Event) and is supported by the enquirer’s clinical advice.

Therefore, VICC advises that BRUE without an identified underlying cause should be assigned R68.1 Nonspecific symptoms peculiar to infancy. If an underlying cause is identified, only the underlying cause should be coded as per ACS 1610 Sudden Infant Death Syndrome/Apparent Life Threatening Event.

You may wish to submit a public submission to IHPA to create an Index entry for BRUE and to update ACS 1610 terminology to BRUE.


Query Text:
A patient with a previous aortic valve replacement was admitted with a final diagnosis of "paravalvular leak".

We are having trouble finding an appropriate code for the procedure of "open repair of paravalvular leak". 
We have viewed ACCD advice regarding the coding of "percutaneous paravalvular leak closure with vascular plug device", however, this is not applicable to our scenario as it was an open repair. 

Our operation report details:
"Central cannulation for CPB. The previous aortotomy was re-opened. The aortic root was seen to be small and relatively frozen with the aortic valve prosthesis posts along its outer surface adhered to the side walls of the aorta. The aortic valve prosthesis itself appeared entirely normal. Following a great deal of searching we finally found the paravalvular leak defect. Two lots of 2/0 ethibond plegetted sutures were placed from underneath the valve sewing ring in the LVOT to exit along the superior surface of the sewing ring. These were tied down over a counter pledget to repair the defect."

We have coded this to:
38653-00 [666] Other intrathoracic procedures on heart with cardiopulmonary bypass.

We note the exclusion note under this code "excludes aortic valve", however, the leak was above the valve and the valve itself was normal.
We would appreciate your advice. Thanking you

Would the committee please advise how we should code the procedure of "open repair of a paravalvular leak"?

Response:
VICC research indicates that a paravalvular leak is caused by a space between the patient’s natural heart tissue and the prosthesis and is most commonly related to a lack of appropriate sealing or a disruption to the sewing ring sutures. This is usually corrected percutaneously with the insertion of a device to block the leak, however, in the scenario cited the leak was repaired as an open procedure with resuturing of the ring. 

Even though, in the scenario cited, the leak was above the valve and the valve itself was normal, VICC considers a repair of a paravalvular leak to be a repair of the valve as the original valve replacement has not sealed correctly. This is consistent with IHPA Coding Rule Q3174 Percutaneous paravalvular leak closure with vascular plug device which advises to code percutaneous closure of a paravalvular leak as a valvuloplasty which is a valve repair.  

VICC notes the Index entry Repair/valve/heart – see Valvuloplasty. However in this scenario, the Index entry for Valvuloplasty cannot be followed, as there is no default option for an ‘open’ procedure and the documentation does not support following any of the essential modifiers.

Therefore, VICC considers it is appropriate to follow Index entry Procedure/aortic valve (intrathoracic) (without cardiopulmonary bypass) NEC/with cardiopulmonary bypass to assign 38653-04 [624] Other intrathoracic procedures on aortic valve with cardiopulmonary bypass.

You may wish to make a public submission to IHPA to improve the ACHI indexing and classification for open repair of paravalvular leak.


Query Title:
Pancreaticoduodenectomy without formation of stoma

Query Text:
A patient with malignant neoplasm underwent an open pancreatico-duodenectomy, cholecystectomy and right hemi-colectomy. Reconstruction was with:
- roux en y anastomosis
-end to side pancreatic-jejunal anastomosis
-end to side hepatic-jejunal anastomosis
-gastro-jejunal anastomosis

The index entry for Pancreaticoduodenectomy contains a non-essential modifier (with formation of stoma) and leads to code 30584-00 [978] Pancreaticoduodenectomy with formation of stoma.
In our case, no stoma was formed and anastomoses as outlined above were performed.
Would you please clarify if the presence of the non-essential modifier in the index means it is still correct to use 30584-00 [978] despite the fact that no stoma was formed?
If not, what is the correct code for pancreatico-duodenectomy without stoma and with anastomosis?

Search Details:
VICC data base
ACHI index
Google - pancreatico-duodenectomy is also called "whipple's procedure". Index entry for Whipple's also leads to 30584-00 [978]

Response:
VICC advises the correct code to assign for pancreaticoduodenectomy without formation of a stoma is 30584-00 [978] Pancreaticoduodenectomy with formation of stoma. Notwithstanding the code descriptor, VICC considers this is the correct code to assign as per the Index entry Pancreaticoduodenectomy (with formation of stoma), because ‘with formation of stoma’ is a nonessential modifier in the Index.


Query Text:
Can you please provide advice on what codes should be assigned for documentation of ‘Fungal Tongue Infection’?

Search Details
Coding Rule Q3321

Response:
VICC advises the correct code to assign for documentation of fungal tongue infection not otherwise specified is B37.0 Candidal stomatitis following Index entry Mycosis, mycotic/mouth. 

This is consistent with the logic in IHPA Coding Rule Q3321 Fungal pneumonia which advises ‘Fungal infections are classified in ICD-10-AM to category B35–B49 Mycoses’ and to follow lead term Mycosis for fungal infection. 

As B37.0 Candidal stomatitis captures both the site and the infection, VICC advises only one code is required for documentation of fungal tongue infection. This is supported by IHPA Coding Rule TN196 Candida urinary tract infection (UTI) where only one code is assigned for candida UTI.

You may wish to make a public submission to IHPA to improve the classification of fungal tongue infection.


Query Text:
We are seeking clarification on how to code vocal cord medialization using surgical technique.

We have seen this performed for vocal cord palsy and our research indicates that during this procedure, the paralyzed vocal fold is pushed to the middle so that the functioning vocal fold can close as necessary for normal voice and swallowing. There are two ways a vocal cord medialization can be performed:
•	 Injection of material into the paralyzed vocal fold – either through the mouth or through the neck skin – that fills the vocal fold and pushes it to the middle. This can be done as an inpatient or outpatient procedure. 
•	 Surgery in which thyroplasty involves permanently placing an implant through an external incision to move the vocal fold into proper position. This is usually performed under local anaesthesia as an outpatient procedure.

Some websites describe vocal cord medialization as ‘laryngoplasty’.

In the example we have submitted there is documentation in the Details of Operation:
‘…TV incision, straps di separated, lower edge thyroid cartilage identified, 1cm window, PTFE graft..’  

There is no lead term for Medialization nor an Index entry for Graft of vocal cord/larynx in the ACHI Index. We have considered the following codes options to classify vocal cord medialization involving PTFE graft:  

41876-02 [526] Laryngoplasty
90160-00 [531] Other procedures on larynx
90150-00 [531] Thyroplasty

Advice sought from one of our surgeons indicated that this should be classified as thyroplasty.

1.	Can you please advise on the correct ACHI Index pathways and codes for vocal cord medialization:
a)	Involving PTFE graft 
b)	Not otherwise specified

Query Search:
VICC 3620 Coding convention for ‘other’ procedures (June 2020)

Response:
VICC research supports the enquirer's clinical advice indicating the appropriate code to assign for vocal cord medialization performed by surgical technique is 90150-00 [531] Thyroplasty following Index entry Thyroplasty. This code would be correct to use with or without the placement of PTFE graft. 

For vocal cord medialization performed by injection VICC advises the correct code to assign is 41870-01 [521] Administration of agent into larynx or vocal cord following Index entry Administration (around) (into) (local) (of) (therapeutic agent) NEC/specified site/vocal cord (collagen) (fat) (Gelfoam) (Teflon).


Query Text:
Please advise how to code a reduction of spermatic cord lipoma given there is no appropriate option under lead term ‘Reduction’ in the ACHI Index. 
 
Typically we see this procedure performed with inguinal hernia repairs. Our research suggests that ‘A spermatic cord lipoma is found in 20–70% of all inguinal hernia repairs’ and that the operative technique can be described as reduction, resection or dissection as below:
‘Operative Technique
Surgical reduction or resection is technically demanding. As explained above, the spermatic cord lipoma originates from preperitoneal fatty tissue within the spermatic cord…….. The lipoma must be bluntly dissected from the deferent duct, arteries, veins, lymphatics, and nerves while preserving the surrounding fatty tissue….’  

Advice sought from one of our clinicians indicates that this procedure should be classified as excision of lesion of spermatic cord. 

Search details:
VICC 3620 Coding convention for ‘other’ procedures (June 2020)

Response:
VICC agrees with the clinical advice provided in the query that a reduction of spermatic cord lipoma is also known as an excision of lipoma.

VICC therefore, advises to assign 30644-08 [1181] Excision of lesion of spermatic cord or epididymis for reduction of spermatic cord lipoma following Index entry Excision/lesion(s)/spermatic cord.


Query Text:
This patient was admitted to our health service for oversewing of his left eye bleb.

In the episode notes his condition is documented only as left eye bleb, although there is documentation in correspondence that he has previously had a trabeculectomy on this eye. There is no documentation, however, linking the bleb to the previous trabeculectomy surgery.

We note VICC query #3426 Repair of trabeculectomy bleb leak which provides advice on which procedure code to assign for repair of trabeculectomy bleb leak. It also advises that ‘trabeculectomy blebs are formed in the subconjunctival space, leading to an elevation of the conjunctiva’.

Can VICC please advise:
1) What code should be assigned for a diagnosis of eye bleb?
2) What diagnosis code(s) should be assigned for trabeculectomy bleb leak? Is it correct to assume that this is a postprocedural complication?
3) What procedure code should be assigned for oversewing of an eye bleb?

Search Details
VICC query #3426 Repair of trabeculectomy bleb leak

Response:
Clinical advice obtained by VICC advised an eye bleb is a space made under the conjunctiva to assist the aqueous flow to reduce eye pressure. The clinical advice confirmed that an eye bleb is usually surgically created (e.g with a trabeulectomy or other glaucoma procedure), but can occasionally also be caused by trauma. 

VICC therefore advises that the documentation of eye bleb as a principal diagnosis is not a documented condition but a status.  Therefore, clinical clarification would be needed from the clinician to determine the condition requiring treatment, i.e if it is a complication of a surgically created eye bleb, continued management of the original condition that required the creation of the eye bleb or a traumatic injury. If  clinical clarification cannot be sought, assign H57.9 Disorder of eye and adnexa, unspecified following Index entry Disease, diseased/eye as per Example 44 of the Conventions used in the Tabular List of Diseases. An additional code for eye bleb status can be assigned following the Index entry Bleb(s)/filtering, eye (postglaucoma) (status) to assign Z98.8 Other specified postprocedural states. This is as per ACS 0002 Additional diagnoses, section titled Family and personal history and certain conditions influencing health status (Z80-Z99) which advises an additional code from categories Z80-Z99 can be assigned when they are relevant to a condition being managed or an intervention being performed in the current episode of care. 

VICC’s clinical advice also confirmed an eye bleb leak is usually a procedural complication. Therefore, VICC advises a bleb leak of a surgically created bleb would be considered a complication, and for documentation of a trabeculectomy bleb leak, to assign H59.89 Other intraoperative and postprocedural disorders of eye and adnexa, not else classified following Index entry Complication(s) (from) (of)/eye/intraoperative or postprocedural/specified NEC. 

VICC also notes that coders may see documention of ‘failed bleb’. VICC advises ‘failed bleb’ would not be considered a complication of a surgically created eye bleb. Clinical clarification would need to be sought to determine the reason for the failed bleb. 

VICC advises to assign 90089-00 [256] Other procedures on conjunctiva for oversewing of an eye bleb following the Index entry Repair/conjunctiva (superficial).


Query Text:
This patient was admitted with haematemesis. He was taken to theatre where a gastroscopy revealed erosions in the gastric body and altered blood pooling in the stomach. 200ml of blood was suctioned and EndoClot applied over the erosions.

Can the committee please advise what code should be assigned for the EndoClot application?

Response:
VICC research indicates that an EndoClot is a ‘novel topical hemostatic powder approved for use in non-variceal upper gastrointestinal bleeding. It can be administered as a primary hemostatic agent or as an adjunct alongside other modalities. EndoClot consists of a white powder that combines with blood when applied to a bleeding lesion. It draws out water to form a gel matrix that adheres to the mucosa, creating a physical barrier’.  
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4683139/ 

VICC acknowledges there is no default code for arrest of gastrointestinal haemorrhage and therefore  advises the most appropriate code to assign for application of EndoClot to treat a bleeding upper gastrointestinal lesion (due to any cause) is 90296-00 [887] Endoscopic control of peptic ulcer or bleeding following Index entry Control/haemorrhage (see Arrest/haemorrhage); Arrest (of)/haemorrhage/ gastrointestinal/from peptic ulcer/via endoscopy. 

VICC research also indicates that EndoClot can be routinely used during surgical procedures for haemostasis or prophylactically to prevent post-endoscopic surgical bleeding. VICC notes, in these instances EndoClot would not be coded as it would be considered a component of the procedure as per ACS 0016 General procedure guidelines.


Query Text:
A patient at our hospital was recently discharged with the diagnosis of proctocolitis.

There is an index entry for Proctocolitis, mucosal - however we do not have documentation of mucosal.

As such, we are unsure of how to code proctocolitis.

Do we consider the condition as a type of colitis and use the lead term colitis to assign A09.9 Gastroenteritis and colitis of unspecified origin?

Do we consider the term as two conditions and use the lead terms proctitis and colitis to assign K62.8 Other specified diseases of anus and rectum, and A09.9 Gastroenteritis and colitis of unspecified origin?

Or do we follow the convention for when a clinician uses terminology that is not listed in the ICD-10-AM Alphabetic Index and use the index entry Disease, alimentary canal to assign K63.9 Disease of intestine, unspecified?

Can VICC please advise how proctocolitis should be coded?

Response:
VICC research indicates that proctocolitis is a general term for inflammation of the rectum and colon. VICC therefore advises for documentation of proctocolitis without further specification, to assign both K62.8 Other specified diseases of anus and rectum and A09.9 Gastroenteritis and colitis of unspecified origin following Index entries: 
Proctitis K62.8
and
Colitis (acute) (catarrhal) (haemorrhagic) A09.9.


Query Text:
Patient transferred to our hospital with Discharge Summary Principal Diagnosis of ’right iliac stent occlusion’ following recent right iliac stent for AAA. EVAR undertaken 14 days prior, complicated by Type 2b endoleak. CT angiogram result from transferring hospital documented on admission to our hospital: occlusion of post right common iliac artery graft with reconstitution in right common femoral artery.

As the patient was transferred, there is minimal documentation with nothing to further advise the nature of the occlusion, eg. thrombosis or embolism

Can the Committee please advise:

1.	What code should be assigned for occlusion of stent graft with no documentation to further specify the nature of this and when the graft has been performed recently, ie. within recent -14 days of insertion?

Search details:
Q3503, Sept 2020 Eleventh Edition ACS 1904 Procedural complications –due to/related to prosthetic devices, implants or grafts
- Reference to causal relationships specific to prosthetic devices, implants and grafts including mechanical complication, infection, pain, thrombosis,   and so on, classified to block T82-T85 
- Causal relationships do not need to be documented to assign a procedural complication, block T82-T85 unless directed otherwise by a specific coding rule or ACS
- Post-operative medical conditions are an exception to the rule of assuming a causal relationship in code series T82-T85.  However, thrombosis, for example, has not been documented in our scenario.

ACS 0941 Arterial disease, Section 7. Occlusion:  ‘Occlusion of arteries that is not documented as due to another cause should be assigned the appropriate atherosclerosis code

Response:
VICC advises for occlusion of stent graft without further specification of the nature or underlying cause of the occlusion to assign a code for atherosclerosis of the site of the occlusion. This is in accordance with ACS 0941 Arterial disease, Section 7. Occlusion which states ‘The term 'occlusion' is used to describe complete blockage or obstruction of a vessel, usually due to atherosclerosis. Occlusion of arteries that is not documented as due to another cause should be assigned the appropriate atherosclerosis code (see 2. Atherosclerosis)’.

This is also suppported by IHPA Coding Rule Q3361 Restenosis of previous vascular bypass, graft or stent which states ‘where documentation specifies that restenosis of a peripheral (vascular) bypass graft/in-stent stenosis is due to recurrent atherosclerosis or the cause is unspecified, assign a code from category I70.2- Atherosclerosis of arteries of extremities’. 

Therefore, for the scenario cited, as the occlusion is of an iliac stent, this should be coded as atherosclerosis of the iliac artery. Assign I70.8 Atherosclerosis of other arteries following Index entry Arteriosclerosis, arteriosclerotic/specified artery NEC as per VICC query #2542 Stenosis of iliac artery. 

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

VICC considers it is appropriate to seek clarification regarding the underlying cause of the occlusion.


Query Text:
Could the committee please assist with providing the correct ACHI code assignment for insertion of temporary sacral nerve stimulator for faecal incontinence? This procedure is performed under GA approx 2-3 weeks prior to the patient returning for permanent implantation of the sacral nerve stimulator.

Search Details
retired VICC query #2053 Sacral neuromodulation

Response:
VICC advises that temporary sacral nerve stimulation usually involves insertion of sacral electrodes connected to an external neurostimulator. 

VICC advises that the correct code to assign for temporary sacral nerve stimulation is 36663-00 [67] Insertion of sacral nerve electrodes following Index entry Insertion/electrode(s) lead(s)/sacral nerve.

VICC advises that 39134-01 [1604] Insertion of subcutaneously implanted neurostimulator, following Index entry Insertion/neurostimulator (epidural) (intracranial) (peripheral) (sacral), can only be assigned if a neurostimulator is inserted and would not be assigned if the neurostimulator is attached externally.


Query Title:
Rectus muscle endometriosis complicating LUSCS

Query Text:
We would appreciate advice on the best way to code endometriosis of rectus muscle where the endometriosis has been excised during LUSCS. 

A patient underwent repeat LUSCS due to her past history of LUSCS. She had a known rectus abdominis soft tissue mass, diagnosed after her previous LUSCS and this was excised during her second LUSCS in the current admission. Histology: "Left rectus muscle mass - features in keeping with endometriosis".
Should the rectus muscle be considered a "pelvic organ" in order to follow the index:
'Pregnancy, complicated by, endometriosis NEC O34.8’?
O34.8 Maternal care for other abnormalities of pelvic organs directs to use O65.5 Llabour and delivery affected by abnormality of maternal pelvic organs when labour and delivery has been affected. Therefore, we have coded this case to O65.5 with an additional code to further describe the endometriosis, however, are also unsure if this should be coded to:

N80.6 Endometriosis in cutaneous scar
N80.8 Other endometriosis

Intramuscular endometriosis has been described as “a rare condition that usually develops in a surgical scar resulting from a caesarian section. While commonly seen in the cutaneous and subcutaneous fat tissue at the caesarean scar level, intramuscular localization is quite rare. (CMR -Clinical Medicine and Research Journal v. 12(3-4) 2014 Dec.)

Search Details
ICD-10 AM Index
VICC database - endometriosis

Response:
VICC advises for the scenario cited, the correct codes to assign are O65.5 Labour and delivery affected by abnormality of maternal pelvic organs and N80.8 Other endometriosis.

Following Index entry Pregnancy (single) (uterine)/complicated by/endometriosis NEC O34.8 Maternal care for other abnormalities of pelvic organs is assigned. As the endometriosis of rectus muscle affected labour and delivery follow the Excludes note at O34.8 Maternal care for other abnormalities of pelvic organs and assign O65.5 Labour and delivery affected by abnormality of maternal pelvic organs.

An additional code can be assigned as per ACS 1521 Conditions and injuries in pregnancy section titled Nonobstetric conditions complicating pregnancy classification dot point two which states ‘Assign as an additional diagnosis a code from another chapter to add specificity to the Chapter 15 code’.

As the endometriosis is of the muscle, not cutaneous, VICC advises to assign N80.8 Other endometriosis following Index entry Endometriosis (with endosalpingioma)/specified site NEC.


Query Text:
We are seeking clarification on the coding of coiling when the procedure is not performed for an aneurysm. 

In the ACHI Index at lead term ‘Coiling’ there is no default code, but rather one subterm ‘aneurysm’ with a cross reference to see Embolisation: 
Coiling
-aneurysm – see Embolisation 

We note that at the lead term ‘Embolisation’ in the ACHI Index there is no default code. However a default exists at one of the subterms ‘blood vessel, transcatheter NEC’, where there are further subterms to differentiate particular sites: 
Embolisation – see also Control/haemorrhage/by site. 
….
-blood vessel, transcatheter NEC 35321-10 [768]
--abdomen 35321-5 [768]…

We note IHPA Q3072 Basilar artery coding [Coding Rules, December 2016] provides a best fit code and advises to follow the subterm ‘blood vessel, transcatheter NEC’ in the index: 
‘Coiling of a basilar artery aneurysm is classified in ACHI to 35321-03 [768] Transcatheter embolisation of blood vessels, face and neck (as a best fit) following the ACHI Alphabetic Index:
Coiling
- aneurysm — see Embolisation
Embolisation
- aneurysm via surgical peripheral catheterisation — see Embolisation/blood vessel, transcatheter/by site
…
- blood vessel, transcatheter NEC
- - neck 35321-03 [768]’


We have seen coiling performed for conditions other than aneurysms, such as knee haemarthrosis where the medial + lat geniculate were coiled, and testicular vein incompetence – varicocele. Clarification from the clinician was sought and the clinician further specified / advised alternative terminology which best reflects the procedure is embolisation. 

We have also seen coiling performed for varicose veins of the leg. Clarification from the clinician was sought and the clinician advised alternative terminology which best reflects the procedure is perforator ligation. 

1. Can VICC please advise the correct ACHI Index pathway and code to assign for coiling of varicose veins of the leg:
• Is it correct to follow Index pathway: Ligation / vein / varicose / lower limb NEC and assign the default code 32508-00 [727] Interruption of varicose veins of great (long) and/or small (short) saphenous veins or select a further subterm in the Index for a specific site if known,
or
• Is clarification on the procedure required to be sought from the clinician? If so, please provide advice on code assignment where an attempt to seek clarification has failed.

2. Can VICC please advise the correct ACHI Index pathway and code to assign for coiling when the procedure is performed for other conditions, excluding for aneurysm and varicose veins of the leg: 
• Is it correct to follow Index pathway: Embolisation / blood vessel, transcather NEC and assign the default code 35321-10 [768] Transcatheter embolisation of other blood vessels or select a further subterm in the Index for a specific site if known, 
or 
• Is clarification on the procedure required to be sought from the clinician? If so, please provide advice on code assignment where an attempt to seek clarification has failed.

Search Details
IHPA Q3072 Basilar artery coiling [Coding Rules, December 2016]
VICC 2292 Uterine fibroid embolisation (Retired 30/6/13)

Response:
VICC research indicates that embolisation can be performed for many conditions including aneurysms, varicose veins and haemarthrosis. Once the catheter has been passed into the blood vessel to be treated, an embolic agent such as plastic particles, glue, metal coils, foam, or a balloon is used to seal off the faulty blood vessel. Embolisation using coils is often termed ‘coiling’. 

VICC therefore advises that the most appropriate code to assign for coiling is 35321-10 [768] Transcatheter embolisation of other blood vessels following the Index entry Embolisation/blood vessel, transcatheter NEC, or to select a further subterm in the Index for a specific site if known.
In the examples cited, for coiling of:
- lateral and medial genicular artery for haemarthrosis, assign 35321-07 [768] Transcatheter embolisation of blood vessels of limbs
- testicular vein incompetence – varicocele, assign 35321-10 [768] Transcatheter embolisation of other blood vessels
- varicose veins of the legs, assign 35321-07 [768] Transcatheter embolisation of blood vessels of limbs.

VICC notes that the terms division, excision, injection, ligation and stripping are indexed to Block 727 Interruption of varicose veins of lower limb includes terms but coiling and embolisation are not. Therefore VICC does not consider it appropriate to follow lead term Ligation to assign 32508-00 [727] Interruption of varicose veins of great (long) and/or small (short) saphenous veins, for coiling of varicose veins. 

You may wish to make a public submission to IHPA to delete the essential modifier of aneurysm from the Index entry at Coiling/aneurysm – see Embolisation.


Query Title:
Retirement of VICC Query #3314 'Documented BMI to enable code assignment of E11.72'

Query Text:
Could the Committee please provide clarification regarding the retirement of query #3314 Documented BMI to enable code assignment of E11.72 (retired 30/06/2020)?

There is some confusion as to whether this advice may still be applicable, ie. That E11.72 may be assigned based on documentation of Type II Diabetes and a BMI score alone. For example, can E11.72 be assigned where there is documentation of Type II Diabetes and a recorded BMI of 27?

Search Details
VICC Query #3314
ACCD TN1248 Tenth Edition FAQs Part 1
ACCD Query Q3384

Response:
VICC advises as there are Index entries which assign codes for overweight or obesity based on the BMI score, Index entry Diabetes/with/obesity or Diabetes, diabetic/with/overweight can be followed to assign E1-.72 [type of] diabetes mellitus with features of insulin resistance based on the documented BMI score alone.

VICC also advises VICC query #3314 Documented BMI to enable code assignment of E11.72 was retired in line with the retirement of ACCD TN1248 Tenth Edition FAQs Part 1 on 30 June 2019 as the information is now incorporated into the Index.


Query Text:
Recently we had a patient discharged with the diagnosis ‘urinary tract infection due to suprapubic catheter’. We are not sure how to code this condition.

Initially we followed the index entry:
Complication(s)/catheter (device) NEC/urinary (indwelling) - see Complication(s)/urethral catheter (indwelling)/ infection or inflammation, and assigned T83.5 Infection and inflammatory reaction due to prosthetic device, implant and graft in urinary system.

However, in ACS 1904 Procedural complications, Example 13, a leaking gastrostomy tube is coded to K91.43 Leak from stoma of the digestive system. The example then states that ‘a gastrostomy tube is a digestive system stoma, not a prosthetic device, implant or graft’.

Does the same logic apply for a suprapubic catheter and other tubes/catheters of stomas? (i.e. is an infection due to a suprapubic catheter a complication of the catheter, or a complication of the stoma?).

Can the committee please advise what complication and external cause codes should be assigned for urinary tract infection due to suprapubic catheter’?

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

Therefore, VICC does not consider it is correct to follow Index entries Complication(s) (from) (of)/catheter (device) NEC/urinary (indwelling) – see Complication(s)/urethral catheter (indwelling) or Complication(s) (from) (of)/urethral catheter (indwelling) NEC/infection or inflammation T83.5 for documentation of infection due to suprapubic catheter (SPC)/cystostomy. VICC notes T83.5 Infection and inflammatory reaction due to prosthetic device, implant and graft in urinary system would be assigned for infection of an indwelling catheter. 

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

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

VICC also advises to assign N39.0 Urinary tract infection, site not specified to add specificity of the condition. 

The correct external cause code to assign is Y83.36 Surgical operation with formation of external stoma, cystostomy following Index entry External causes of injury/Complication(s) (delayed) (medical or surgical procedure) (of or following)/cystostomy.

Please also refer to VICC query #3654 Infection due to suprapubic catheter (SPC)/cystostomy.


Query Text:
Can VICC please confirm whether the advice in retired VICC query #2042 Conditions arising in the perinatal period and retired VICC query #2411 Conditions in neonates is still valid?

Should codes for neonates and interventions related to the sick neonate be assigned for babies admitted to our facility at > 28 days of age if the baby has remained in hospital since their birth episode (i.e. the baby has not been discharged home)?

Response:
VICC advises that the advice in the abovementioned retired VICC queries has been superseded by changes to ACS 1605 Conditions originating in the perinatal period and ACS 1615 Specific diseases and interventions related to the sick neonate  .

Whilst the queries are retired, ACS 1605 and ACS 1615 confirm that codes for neonates and interventions related to the sick neonate should be assigned for babies admitted at > 28 days of age if the baby has remained in hospital since their birth episode.
ACS 1605 Conditions originating in the perinatal period states:
 ‘Codes from ICD-10-AM Chapter 16 Certain conditions originating in the perinatal period:
•	will still apply for infants > 28 days who are still in the birth episode and
•	will still apply for infants > 28 days who are discharged and subsequently readmitted with a condition documented as originating in the perinatal period.
….
Most conditions originating in the perinatal period disappear after a short time. Some, however, can persist throughout life and should be classified to the codes in this chapter regardless of the patient's age.’

ACS 1615 Specific diseases and interventions related to the sick neonate states:
‘These interventions should also be coded when used in the ongoing care of sick infants, who, after 28 days are still in the birth episode (see ACS 1607 Newborn/Neonate). For any infants who have been separated and then readmitted, interventions for the sick neonate may still be assigned, if documentation indicates that the condition requiring intervention, originated in the perinatal period.’


Query Text:
ACS 0010 CLINICAL DOCUMENTATION AND GENERAL ABSTRACTION GUIDELINES 

"Before classifying any documented clinical concept, the clinical coder must verify information on the front sheet and/or the discharge summary (or equivalent) by reviewing pertinent documents/data within the body of the current episode of care.”

“If, after following the above guidelines, the documentation within the health care record is inadequate for complete and accurate classification, the clinical coder should seek information from the clinician.”

Question

1.	If a query is to be done in the above scenario, why does it not contain the ACS 0001 more specific definitions of a Principal Diagnosis relevant to the query as I have included in as numbered below?   

Without these more specific definitions being included on the principal diagnosis query, the assignment of principal diagnosis based on ACS 0001 is questionable due to the lack of knowledge by the MO of ACS 0001 Principal Diagnosis multiple scenarios.

This may leave it open to revenue optimization by not adding context to Principal diagnosis queries regarding the Principal diagnosis definitions ACS 0001.

Currently reference for Principal  diagnosis on discharge summaries and queries usually only relates to the following:

“The phrase after study in the definition means evaluation of findings to establish the condition that was chiefly responsible for occasioning the episode of care. The condition established after study may or may not confirm the admitting diagnosis.”

To enhance the quality of Principal diagnosis queries, would it be of benefit to link the query to each of the principal dx scenarios as per ACS 0001 to which the diagnoses relates? Not only would data quality be improved better reflecting accurate casemix as per ACS, a better understanding of ACS 0001 would be gained from both the Medical Officers and HIMs and Clinical Coders. 

2.	In the case of a Principal Diagnosis Query, should the Principal Diagnosis options be listed from the earliest date to the latest date documented in the current episode to avoid the incidence of placing the diagnosis with the highest cost weight as the first option?
 

For example, if the queries were written in the context of the scenarios outlined in ACS 0001.

1.	PROBLEMS AND UNDERLYING CONDITIONS PRINCIPAL DIAGNOSIS QUERY

•	Coding the underlying condition as the principal diagnosis - When a patient presents with a problem, and during the episode of care the underlying condition is identified.

Which of the following is the principal diagnosis after study etc 
a)	TIA, 
b)	Occlusion cerebral artery 
c)	Other:____________________



2.	PROBLEMS AND UNDERLYING CONDITIONS PRINCIPAL DIAGNOSIS QUERY

•	Coding the problem as the principal diagnosis - underlying condition is known at the time of admission.
Which of the following is the principal diagnosis after study etc 
a)	TIA, 
b)	occlusion cerebral artery 
c)	Other:____________________

3.	CODES FOR SYMPTOMS, SIGNS AND ILL-DEFINED CONDITIONS 
Codes for symptoms, signs and ill-defined conditions from Chapter 18 Symptoms signs and abnormal clinical and laboratory findings are not to be used as principal diagnosis when a related definitive diagnosis has been established.

Which of the following is the principal diagnosis after study etc
a)	Syncope
b)	Dizziness
c)	2nd Degree AV Block
d)	Other: _______________________

4.	TWO OR MORE INTERRELATED CONDITIONS, EACH POTENTIALLY MEETING THE DEFINITION FOR PRINCIPAL DIAGNOSIS 
When there are two or more interrelated conditions (such as diseases in the same ICD-10-AM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, the clinician should be asked to indicate which diagnosis best meets the principal diagnosis definition.
Which of the following is the principal diagnosis after study etc
a)	COAD
b)	PNEUMONIA
c)	Other: _______________________

5.	TWO OR MORE DIAGNOSES THAT EQUALLY MEET THE DEFINITION FOR PRINCIPAL DIAGNOSIS 
When two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic work-up and/or therapy provided, and the Alphabetic Index, Tabular List or the standard does not provide sequencing direction, the clinician should be asked to indicate which diagnosis best meets the principal diagnosis definition.
Which of the following is the principal diagnosis after study etc
a)	Dementia
b)	UTI
c)	Pneumonia_______________________

Response:
As per the Introduction of the Australian Coding Standards “A combined effort between the clinician and clinical coder (and the CDIS) is essential to achieve complete and accurate documentation and code assignment using ICD-10-AM and ACHI classification conventions and the ACS”.

As per ACS 0010 Clinical documentation and abstraction guidelines, section titled Appropriately formulated queries to clinicians, the query should include information about the patient, with direct reference to the documentation that has prompted the query. There is nothing to preclude the coder from adding information from an ACS to a documentation query where it will enable the clinician to understand why the documentation requires clarification. Bear in mind that clinicians may not be familiar with the ICD-10-AM structure and terminology, therefore it is advisable to avoid references to volumes, chapters, or other classification specifics. 

VICC considers that if a documentation query is necessary to determine which diagnosis meets the definition of principal diagnosis, then it is important to include the definition so that the clinician has all the information required to answer the query. It may be appropriate to include other parts of ACS 0001 Principal diagnosis where it could explain the reason for the query without confusing the clinician. For example, the clinician may not understand what is meant by ‘problem and underlying condition’.
 
A query must never instruct or indicate to a clinician how to respond, and this includes multiple-choice format queries. To avoid a leading question, it would be appropriate to directly refer to the documentation that has prompted the query in a similar way to how it was documented by the clinician. Example 5 of ACS 0010 Clinical documentation and abstraction guidelines is an example of using the definition of principal diagnosis in a query, and of quoting the documentation as documented by the clinician.

VICC notes the purpose of a documentation query is to clarify the documentation so that the coder can then apply classification rules to the query answer and therefore coders should be careful to avoid using a documentation query to teach the clinician about coding rather than to clarify documentation.


Query Title:
Excludes at T82.82 Embolism and thrombosis following insertion of cardiac and vascular prosthetic devices, implants and grafts

Query Text:
IHPA Coding Rule Q3610 Vena cava thrombus or pulmonary embolism due to central or peripheral vascular catheter.

Just wanting to clarify in what circumstances would the following Excludes note be used at T82.82.

postprocedural:
•deep venous thrombosis (I80.-)
•pulmonary embolism (I26.-)

Having the Excludes at this code is confusing.

Response:
VICC advises the Excludes note at T82.82 Embolism and thrombosis following insertion of cardiac and vascular prosthetic devices, implants and grafts applies when a causal link is not documented between the deep vein thrombosis (DVT) or pulmonary embolism (PE) and the procedure. 

VICC notes that as per ACS 1904 Procedural complications DVT and PE are examples of medical conditions that are commonly seen in the postoperative period, not solely related to the procedure performed, but related to the complex interaction between the disease process and the procedure (that is, the cause of the condition is multifactorial). Therefore, VICC advises when DVT or PE is documented as postprocedural but there is no causal link between the DVT or PE and a vascular device then the Excludes note at T82.82 Embolism and thrombosis following insertion of cardiac and vascular prosthetic devices, implants and grafts should be followed to assign a code from category I80 Phlebitis and thrombophlebitis alone.

However, if there is a documented link, between the DVT or PE and the vascular device (e.g. ‘due to’), assign T82.82 Embolism and thrombosis following insertion of cardiac and vascular prosthetic devices, implants and grafts following Index entry Complication(s) (from) (of)/vascular/device, implant or graft/thrombosis. The Excludes note would not be followed in this scenario.

Please also refer to VICC query #3734 Deep vein thrombosis (DVT) due to arm port.


Query Title:
Drug induced acute kidney impairment (AKI)

Query Text:
Could VICC please confirm the correct codes to assign for drug induced AKI?

Following the Index you arrive at N17.9 for AKI with no option for drug induced or toxic in the pathway. Does the Excludes note under Kidney Failure (N17-N19) which states ‘Excludes: drug- and heavy-metal-induced tubulo-interstitial and tubular conditions (N14.-)’ apply to drug induced AKI?

Please also refer to the advice in Q2768 Contrast induced acute kidney failure (injury). 


Search Details
Index pathway
Q2768 Contrast induced acute kidney failure (injury)

Response:
VICC notes the Excludes note at N17-N19 Excludes drug- and heavy-metal-induced tubulo-interstitial and tubular conditions (N14.-), however codes in category N14 can only be reached through the lead term Nephropathy in the Alphabetic Index. 

VICC also notes the advice in IHPA Coding Rule Q2768 Contrast induced acute kidney failure (injury) which states ‘However, assignment of N17.9 is incorrect if the Excludes note (which is consistent with ICD-10) at N17–N19 Kidney failure is followed:
“Excludes: drug- and heavy-metal-induced tubulo-interstitial and tubular conditions (N14.-)”
Analysis of code assignment in the data suggests it would be a major change in coding practice to assign N14.1 Nephropathy induced by other drugs, medicaments and biological substances rather than N17.9 Acute kidney failure, unspecified for contrast induced acute kidney failure (injury), therefore clinical coders should continue to assign N17.9 until further notice.’

Therefore, VICC advises, for documentation of drug-induced acute kidney failure, the correct code is N17.9 Acute kidney failure, unspecified following the Index entry Failure, failed/kidney/acute. Appropriate external cause codes should also be assigned.

Please also refer to VICC query #3768 Diabetes Mellitus with ARF due to colchicine (or other drug). 

You may wish to make a public submission to IHPA to improve the classification of drug-induced acute renal failure.

 


Query Text:
Can you please provide advice on what code(s) should be assigned for documentation of Fracture of proximal radius and ulna?

Response:
VICC advises the correct code to assign for fractures of proximal radius and ulna without further specification is S52.7 Multiple fractures of forearm following Index entry Fracture/radius/with ulna or Fracture/ulna (shaft)/with radius. 

In accordance with ACS 0010 Clinical documentation and general abstraction guidelines section titled Findings that provide more specificity about a diagnosis, a more specific code should be assigned if further specificity of the fracture is documented or if a test result adds specificity to a documented condition. For example if an x-ray shows proximal shaft fractures of the radius and ulna, S52.4 Fracture of shafts of both ulna and radius would be assigned following Index entry Fracture/radius/with ulna/shafts or Fracture/ulna (shaft)/with radius/shafts.


Query Text:
Could you please assist with code assignment for a Keystone flap? The indexing appears to lead to quite a complex 'island flap' code for what appears to be essentially a fascio-cutaneous flap, consisting of multiple V-Y advancements.

We see this type of flap repair done with excision of skin cancers, the procedures appear to be quite simple and do not involve raising of vascular pedicles.

See definition:
The Keystone Flap is an island flap that is very useful for repairing skin defects of the integument. Described as a keystone, this arc-shaped flap in fact consists of a schematically designed, perforator-based reconstructive unit which serendipitously resembles two conjoined VY flaps. This facilitates closure because of the multiple VY points at the extremes, where the surrounding tissue is advanced to close the defect while the flap size remains basically static.
http://www.ncbi.nlm.nih.gov/pubmed/16768705

We don't feel that we can use any of the 'island flap' codes as we don't have enough information to get past the essential modifiers required. In the absence of 'pedicles' what should we be coding?

Response:
VICC research concurs that a Keystone flap is an island flap and as such must be vascularised. 

VICC considers that in the absence of any further clarification, it is correct to follow the essential modifier 'vascular pedicle (noninnervated)' at Index entry Flap/island/with/vascular pedicle (noninnervated) to assign 45563-00 [1673] Island flap with vascular pedicle for documentation of Keystone flap without further qualification.


Query Title:
Graves' cardiomyopathy with specified type of thyrotoxicosis

Query Text:
ACCD Coding Rules Ref No: Q2866 (December 2014) instructs coders to classify Graves' cardiomyopathy / cardiomyopathy secondary to Graves' disease to:
E05.9+Thyrotoxicosis, unspecified
I43.8* Cardiomyopathy in other diseases classified elsewhere

Following index entry:
Cardiomyopathy (familial) (idiopathic)
- thyrotoxic E05.9+  I43.8*

The advice also states:
An additional code may be assigned to specify the type of thyrotoxicosis, if documented. For example: Graves' disease E05.0
E05.0 Thyrotoxicosis with diffuse goitre

Sequencing of the above codes is determined by the Conventions Used in the Tabular List of Diseases. For example, where documentation supports the assignment of Graves' disease as the principal diagnosis, sequence as:
E05.0 Thyrotoxicosis with diffuse goitre
E05.9+ Thyrotoxicosis, unspecified
I43.8* Cardiomyopathy in other diseases classified elsewhere

Question:
Is it correct to assign codes for both:
E05.0 Thyrotoxicosis with diffuse goitre
AND
E05.9+ Thyrotoxicosis, unspecified

OR

In order to translate the medical statement into code should E05.9+ Thyrotoxicosis unspecified be replaced by the more specific code E05.0 Thyrotoxicosis with diffuse goitre?

VICC 2474 Anaemia in neoplastic disease with myelodysplastic syndromes ( 2009-10 March Database, Sixth edition) states that for conditions indexed to D48.9 Neoplasm of uncertain or unknown behaviour, unspecified, follow the advice in Coding Matters Volume 7 Number 2 and assign the specific neoplasm code instead of D48.9 when the neoplasm is known.

Whilst the condition in VICC 2474 and Coding Matters Volume 7 Number 2 is not thyrotoxicosis, can this same logic of assigning a code for the more specific condition be applied to E05.9+ Thyrotoxicosis, unspecified when the type of thyrotoxicosis is documented?

Search Details:
ACCD Coding Rules Ref No: Q2866
VICC 2474
Coding Matters Volume 7 Number 2

Response:
Whilst it may seem odd to assign both E05.0 Thyrotoxicosis with diffuse goitre and E05.9+ Thyrotoxicosis, unspecified in the scenario cited, the ACCD response reflects a limitation in the Index whereby there is no 'see also' note that allows a more specific thyrotoxicosis code to be assigned.

ACCD did say in their response that amendments would be considered to simplify the classification of these conditions for a future edition of ICD-10-AM, so in the meantime VICC advises to follow the ACCD advice.


Query Text:
Could the Committee please provide some clarification on the diagnosis coding of the following scenario:
Patient admitted for vaginal repair and cystoscopy.
Operative diagnosis of the following:
Vaginal vault prolapse
Grade 3 cystocele
Grade 2 cystocele
Deficient Perineum

There is no evidence or documented history that the patient has previously had a hysterectomy.

We note the index look-up for vaginal vault prolapse as the following:
Prolapse
-vagina, vaginal
vault (post-hysterectomy) N99.3

As the post-hysterectomy is a non-essential modifier, the index leads the coder to assign:
N99.3 Prolapse of vaginal vault after hysterectomy

For vaginal vault prolapse, when there is no indication of the patient previously having an hysterectomy should the code N99.3 still be assigned?

If not, could you please provide the correct code assignment for vaginal vault prolapse, when the patient had not previously had a hysterectomy or there is no documented evidence that they have had a hysterectomy?

We have reviewed VICC query 2136, Vaginal vault prolapse and cystocele after hysterectomy which advises that N99.3 should only be assigned when there is documentation of vaginal vault prolapse after hysterectomy, however we note that this query has been retired.

Response:
VICC advises the advice in retired query #2136 Vaginal vault prolapse and cystocele after hysterectomy is no longer applicable.

As you have noted, posthysterectomy is a non essential modifier at Index entry Prolapse/vagina, vaginal (anterior) (wall)/vault (posthysterectomy), therefore documentation of a previous hysterectomy is not required to assign N99.3.

VICC therefore considers it is correct to assign N99.3 Prolapse of vaginal vault after hysterectomy for documentation of vaginal vault prolapse without further qualification.


Query Text:
Could the Committee please provide some clarification on the diagnosis coding of the following scenario:

If a patient has an intraoperative complication, for example an accidental intraoperative puncture or laceration, but there is no documentation of it being repaired or requiring any additional care should the intraoperative complication be coded (when further clarification from the treating clinician is not available)?

If a condition meets the definition of a procedural complication in ACS 1904 Procedural Complications, does it first need to meet ACS 0002 Additional Diagnoses in order to be coded?

We note ACS 1904 Procedural Complications is not listed as one of the additional diagnosis reporting referred to in other standards in ACS 0002 Additional Diagnoses.

Also we note that there is a similar VICC query 2134 Accidental punctures and lacerations which has since been retired and cannot locate any further advice from NCCH / ACCD.

10. Search Details
ACS 1904
ACS 0002
VICC query 2134

Response:
#2134 Accidental punctures and lacerations has been retired, it is no longer applicable.

VICC advises to follow ACCD advice titled Procedural complications (Ref no: TN202 Published on: 15 Dec 2008 Status: Current) reproduced in part below:

Q:
The following issues were raised regarding the coding of procedural complications:
- Coding of CVAs, MI, haemorrhages, hypertension which occur during a procedure (ie intra-operatively) - are these classified to T81.8 Other complications of procedures, not elsewhere classified then the external cause being a misadventure or is the condition really a result of an existing condition and therefore just use the specific chapter code without an external cause code?
- If the condition doesn't meet the definition for a procedural complication then should the condition be coded in its own right and therefore a T code is not assigned?
- What codes should be assigned for an intra-operative haemorrhage? - a T code plus a Misadventure external cause code as per ACS 1904 Procedural complications, Definition of a misadventure.
A:
If the intraoperative event e.g. haemorrhage, MI, CVA etc meets:
- the definition of an additional diagnosis as per ACS 0002 Additional diagnoses and
- the definition for a procedural complication as per ACS 1904, (ie is directly related to the surgical/procedural intervention)
then for the diagnosis code, apply ACS 1904 and follow the index lookups. This means that the first diagnosis code could come from either the end of chapter codes or the T code section. The next code in the string will indicate the condition/problem ie MI, CVA etc and an external cause code will be assigned from Y60-Y69 Misadventures to patients during surgical and medical care, refer to examples 17 and 18 in ACS 1904.[end of ACCD advice]

ACS 1904 Procedural complications is not listed in ACS 0002 Additional diagnoses under heading 'Additional diagnosis reporting referred to in other standards' because the list is of standards that contain advice to code a condition that would not normally meet ACS 0002 or that should always be coded.  ACS 1904 does not contain advice about coding certain conditions that do not meet ACS 0002.


Query Text:
VICC query #2953 Hysteroscopy with cervical biopsy.

After our own research and in consultation with our O&G Director, we disagree with your response.  A cervical biopsy is performed without the use of a hysteroscope for a condition specific to the cervix.  The ACHI code is 35608-02 Biopsy of cervix and is located in block [1276] in the procedures performed on the cervix section.  Some common indications for a cervical biopsy are: cervical ectropion/extropion, cervicitis as in the example provided, for post-coital bleeding as in the other example provided and to test for abnormal or precancerous conditions, or cervical cancer.  Therefore, when you follow the Index:

Biopsy
- cervix 35608-02 [1276]

This is the only option you have.  There are no excludes note on this code.  One cannot be incorrect in assigning this code when this intervention has been performed, with or without a hysteroscopy.

Index entry for hysteroscopy:
Hysteroscopy
- with biopsy (endometrium) 35630-00 [1259]

This ACHI code is located in the Uterus section of the Tabular.

The indication for hysteroscopy differs to the indications for cervical biopsy.  If we were to stop assigning a code for biopsy of cervix, it could read back as no intervention being performed for the cervical abnormality.

As our O&G Director stated, the uterus and cervix are two separate anatomical locations and a hysteroscope is not used to perform the cervical bx.  These interventions are performed for different conditions. Therefore, we should follow the Index to assign codes separately.  The includes note on 35630-00 [1259] Diagnostic hysteroscopy should only mean 
biopsy of uterus as the code is allocated in the Uterus section of Tabular.  Codes relating to the cervix are located in their own section under Cervix and start at block [1274].

In the event a biopsy is performed WITH a hysteroscopy (via the hysteroscope), then we agree that only one code is assigned - 35630-00 Diagnostic Hysteroscopy.

Search Details:
ACHI Index and Tabular: Biopsy cervix, Hysteroscopy with biopsy, Biopsy of endometrium

Response:
Notwithstanding the clinical advice that a hysteroscope is not used to perform the cervical biospy, VICC answered #2953 Hysteroscopy with cervical biopsy based on the information in that query and the classification conventions.  Therefore VICC confirms that when the only documentation in the record is hysteroscopy with cervical biopsy, the advice in #2953 is correct according to classification conventions.  

VICC agrees that if the documentation supports that the cervical biopsy was performed separately to the hysteroscopy, then it would be correct to code both the cervical biopsy and the hysteroscopy.


Query Title:
Other complications of intravenous catheters

Query Text:
Is it appropriate to assign T82.8 Other specified complications of cardiac and vascular prosthetic devices, implants and grafts for intravenous catheters that are documented as painful, red, swollen odematous or have a haematoma?

Interventions for these conditions usually include resiting, icing and elevation, thus appearing to meet ACS 0002 Additional diagnoses.

Search Details:
Q2825 Dislodged and leaking intravenous cannulas ACCD Coding Rules December 2014
#2629 IV tissue VICC queries database 2011-12 September database 7th edition

Response:
ACS 0002 Additional diagnoses states that 'the national morbidity data collection is not intended to describe the current disease status of the inpatient population but rather, the conditions that are significant in terms of treatment required, investigations needed and resources used in each episode of care'.  VICC considers that in this context 'significant' means a condition requiring more than routine care. As such does not support the coding of complications of care when only routine interventions are performed.

VICC has therefore developed the following instructions to clarify what constitutes routine care and beyond routine care for management of intravenous catheters. This advice must be followed for documentation of an intervention for conditions coded to T82.8 Other specified complications of cardiac and vascular prosthetic devices, implants and grafts and is effective for separations on or after 1 April 2015.

1. Routine care - T82.8 Other specified complications of cardiac and vascular prosthetic devices, implants and grafts must not be coded when only routine interventions are performed, for example:
- Resiting
- - routine 
- - elective
- - according to protocol
- - for any reason with no subsequent change to patient management
- removal
- icing
- swabbing
- elevation
- dressings or bandage (including compression)
- marking
- cleaning/cleansing
- pressure

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 - T82.8 Other specified complications of cardiac and vascular prosthetic devices, implants and grafts should be coded when the condition requires consultation with a clinician resulting in a change of patient management, for example: 
- commencement of antibiotics
- withholding of anticoagulants
- delayed discharge

IV complications requiring consultation with a clinician resulting in any of the interventions in point 1 must not be coded.


Query Text:
Could you please clarify the coding of "Type 2 diabetes - steroid induced". This was noted as being diagnosed some years ago on the medical history from the local Dr letter. We feel that there was a directive some years ago but on scanning the Standard and checking coding query websites, we are unable to find it. The cases in question were not admitted for their diabetes - it was previously diagnosed and part of their medical history.

Our feeeling is that the drug-induced status is only flagged in the initial diagnosis stage and in subsequent admissions only the type of diabetes is coded.

Search Details:
ACS 0401/VICC queries website/Capture Consulting website

Response:
VICC advises to follow the Coding Rule Q2887 published in March 2015 and updated in June 2019 titled E13 Other specified diabetes mellitus which is reproduced below:
Q:
Can you assign multiple codes when documentation indicates that a patient has type 1 or type 2 diabetes mellitus AND diabetes mellitus classifiable to E13?

A:
ICD-10-AM classifies diabetes mellitus to the following categories:
E10 Type 1 diabetes mellitus
E11 Type 2 diabetes mellitus
E13 Other specified diabetes mellitus
E14 Unspecified diabetes mellitus

E13 Other specified diabetes mellitus cannot be assigned in addition to E10 Type 1 diabetes mellitus or E11 Type 2 diabetes mellitus, as these codes are mutually exclusive.  

E13.- is assigned by following the index pathway Diabetes/specified NEC. The NEC (not elsewhere classified) indicates that if the diabetes is classifiable to a specified category (E10 or E11), that category takes precedence over the ‘other’ (residual) category (E13).

Therefore, E13 should never be assigned when documentation confirms diabetes mellitus as type 1 or type 2.

See Conventions  and general arrangement of the ICD-10-AM Alphabetic Index/ NEC (not elsewhere classified).

Documentation issues

The above advice is applicable to cases where type 1 or type 2 diabetes mellitus are correctly identified and documented in the clinical record.

Clinicians may incorrectly document the type of diabetes and/or use terms interchangeably, especially in relation to insulin use. For example:

patient with type 2 diabetes mellitus (T2DM) on insulin, incorrectly documented as IDDM (insulin dependent diabetes mellitus) or type 1 diabetes mellitus (T1DM)
patient with T2DM on insulin, inconsistently documented as T1DM or T2DM within the one episode
patient with diabetes mellitus due to a specified cause treated with insulin, incorrectly documented as T1DM or IDDM.

The following should be noted:

IDDM and NIDDM (noninsulin dependent diabetes mellitus) are outdated terminology
IDDM and NIDDM are not types of diabetes; they are descriptors of insulin usage
IDDM does not always mean T1DM; it may mean T2DM treated with insulin or DM due to a specified cause (eg post pancreatectomy) treated with insulin.
 
Where documentation is conflicting or inconsistent within the current episode regarding the type of diabetes mellitus, coders should check previous admissions and/or correspondence and/or consult with the treating clinician to determine if the patient has T1DM, T2DM or diabetes mellitus due to a specified cause (meaning not type 1 or type 2). 

See also ACS 0401 Diabetes mellitus and intermediate hyperglycaemia, 2. Specific classification principles for DM and IH.


Query Title:
Excision of fimbrial or parafimbrial cyst

Query Text:
Please advise the correct procedure code for excision of a unilateral fimbrial or parafimbrial cyst via laparoscopy.

We have been using 35638-07 [1251] Laparoscopic partial salpingectomy, unilateral and there is some debate as to whether this is the correct code.

Response:
As a fimbrial cyst is a cyst of the fallopian tube, VICC agrees with the code assigned in the query following Index entries:

Excision/cyst — see also Excision/lesion(s) and Excision/lesion/fallopian tube (laparoscopic)(unilateral) 35638-07 Laparoscopic partial salpingectomy, unilateral.


Query Text:
I recently coded bilateral inguinal repair (recurrent) with adhesions.  The adhesions are included in the diagnosis code as Obstruction  K40.01 Bilateral inguinal hernia, with obstruction, without gangrene, recurrent.

However I am unsure if the procedure code for repair of hernia with obstruction 30615-00 [997] Repair of incarcerated, obstructed or strangulated hernia includes the adhesiolysis.  Can you please advise if procedure code 30615-00 [997] includes adhesiolysis?

Response:
VICC advises that because there is no includes note for adhesiolysis at Block [997], adhesiolysis is not included in procedure code 30615-00 [997].  Therefore a code for the adhesiolysis can be added, if performed.

Note that the presence of adhesions does not equate to obstruction; assignment of K40.01 Bilateral inguinal hernia, with obstruction, without gangrene, recurrent must be supported by documentation of obstruction.


Query Text:
Can documentation of Diabetic foot ulcer without any other criteria listed under the Diabetic Foot section of ACS 0401 Diabetes mellitus and intermediate hyperglycaemia,  be coded to E1-.73 Diabetes mellitus with foot ulcer due to multiple causes?

Response:
VICC advises that as the medical statement contains the term 'diabetic foot', E1-.73 Diabetes mellitus with foot ulcer due to multiple causes can be assigned.  This is in accordance with the classification box under point 6. Diabetic foot in ACS 0401 Diabetes mellitus and intermediate hyperglycaemia, which says 'Assign E1-.73 Diabetes mellitus with foot ulcer due to multiple causes when 'diabetic foot' is documented in the clinical record…'.


Query Text:
Can VICC please clarify whether the following advice from query #2251 Multiple behaviours in same morphology at same site retired 30 June 2013 is still current?

Response:
VICC advises that whilst VICC query #2251 is retired, the information in that query is still current.  There is however current ACCD that can be applied - Q2862 titled Invasive and in-situ neoplasms of the prostate published in the March 2015 Coding Rules reproduced below:

Q:
If a trans-rectal ultrasound (TRUS) guided biopsy of the prostate identifies adenocarcinoma (M8140/3) and high grade intraepithelial neoplasia (M8148/2), do you code both or just the adenocarcinoma?

A:
Where a histopathology report details both in situ and invasive cancer within the prostate, the behaviour takes precedence over the histological type and only the morphology and site code for the invasive cancer should be coded.

The sentence 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.”
 
is referring to multiple histological types found within a lesion in one organ, and does not provide guidance with respect to differing morphological behaviours.

In the scenario cited where multiple histological terms/morphologies with different behaviours are reported in a TRUS biopsy of the prostate, only assign codes for the invasive neoplasm (i.e. adenocarcinoma).

This will be clarified in ACS 0233 Morphology in a future edition.


Query Text:
Are we obliged to code a baby born in ED as born before arrival, and code the mother as postpartum care? 

The mother delivered in ED (precipitate labour, arrived pushing, had an episiotomy cut by ED doctor, midwife arrived from delivery suite with syntocin for placental delivery).  It seems wrong that we code it that way, given that she wasn't meaning to be an ED presentation but had to enter the hospital through ED and just didn't make it over the line, she was booked to deliver here.

The episiotomy was repaired later in the delivery suite, and I wonder the correct way to code that out, given the episiotomy was done in ED.

Response:
VICC advises that as the delivery was completed outside of admission, the correct principal diagnosis for the mother's record is a code from Z39.0 range.  In this case VICC considers that Z39.01 Postpartum care after hospital delivery is the correct code principal diagnosis because the baby was born in hospital.

VICC advises to assign 90472-00 [1343] Episiotomy following index entry Repair/Episiotomy for repair of episiotomy. 

With regard to the baby’s record, VICC considers it is correct to assign Z38.0 Singleton born in hospital as the baby was born in hospital even though administratively it was not part of the admitted episode.  This is supported by the advice in #2765 Place of birth published in the 2012-13 March Database VICC queries database and ACS 1607 Newborn/neonate.


Query Title:
Obstetric patient with previous GBS positive status, now GBS negative

Query Text:
Obstetric patients who have been GBS positive in previous pregnancies, but are now GBS negative, are being given antibiotics in labour.

Should Z22.3 Carrier of other specified bacterial disease and/or Z29.2 Other prophylactic pharmacotherapy be coded in these cases?

If an obstetric patient with an unknown GBS positive status, is given antibiotics in labour, should Z29.2 Other prophylactic pharmacotherapy be coded?

Search details:
#2145 GBS positive status in pregnancy retired 30/6/2010

Response:
VICC advises that for patients who are now GBS negative, ACS 1549 Streptoccocal group B infection/carrier in pregnancy does not apply and therefore Z22.3 Carrier of other specified bacterial diseases is not assigned for these patients.

With respect to the assignment of Z29.2 Other prophylactic pharmacotherapy in patients with a now GBS negative status or an unknown GBS status, there would need to be documentation that the antibiotics were given in labour for prophylactic purposes in order to assign the code.


Query Text:
Please advise on the correct code assignment of rhabdomyolysis following a fall in the two scenarios below.  Case 1 did not result in any acute injury, whereas in Case 2, the patient suffered a # NOF. Case 3 is an example of rhabdomyolysis due to strenuous exercise.  Please provide code assignment advice on this scenario also.

CASE 1 Discharge Summary - Principal Diagnosis:
Urosepsis
Rhabdomyolysis
Fall

69 year old male presenting with fall + 3 days on floor unable to get up on b/g metastatic colorectal cancer

HOPC
- had fall at home, unable to get back up
- ?seizures vs presyncopal, pt has poor recollection of event, fell out of bed
- dysuria 3-4 days prior

Progress
#Urosepsis
- BC - E coli sensitive to penicillin, pt has allergy to penicillin (rash), given ceftriaxone, cefazolin 2g TDS (5 days IV total), changed to PO antibiotics on 7/11/14 
- Urine-  E coli sensitive to penicillin
- initially had mild delirium, now settled

#rhabdomyolysis + Acute renal impairment
- was on floor for 3 days
- CK 2000-3000 on arrival, now normalised
- responded well to IVT

#rehab
- recommended by allied health for rehab before d/c home to improve mobility

Follow up
- defer chemo until well + r/v in oncology clinic approx 2 weeks

CASE 2 Discharge Summary - Principal Diagnosis:
Left subcapital NOF
Rhabdomyolysis:
- Cr 1712
- Dehydrated
- Tx with IVT

AoCRF
- IDC inserted
- Treated with IV hydration
- Nephrotoxics withheld

Fall from bed
- XRays reviewed- nil fracture
- Neuro obs stable

Summary of Inpatient Management:
87 yo female with L hip # post fall off bed:
- L hemiarthroplasty  (18/11/2014)
- DVT prophylaxis
- IV antibiotics
- Analgesia
- For subacute transfer to improve mobility/function
- For wound review in 2 weeks

Progress notes
87 yo female with # NOF
- Rhabdomyolysis
- Mild AoCRF (Cr 102 - 110)

Patient lives at home alone and this pm was found by visiting relative on floor.  Patient unable to recall how she got there or how long she was there.

CASE 3
Principal Diagnosis: Rhabdomyolysis

Summary of Inpatient Management:
43 year old male referred from GP with high CK

HOPC:
- Underwent 1/2 hour exercise at gym
- Felt pain in legs, muscular aches and pain
- Noticed dark urine
- Presented to GP - CK shown to be 80 000
- GP sent patient to emergency department
- CK on admission to hospital found to be 123 000

O/E:
- Appears well
- No myopathy symptoms,
- normal neurologic examination

Bloods otherwise normal

- Treated with IV hydration
- CK carefully monitored. Initial decrease in same and then rebound increase. ? cause.
- Reviewed by rheumatology team during admission- likely rhabdomyolysis.  No current indication for muscle biopsy
- Patient well throughout admission

Plan:
- Discharge home
- Outpatients clinic with repeat bloods in 4-6 weeks, including vasculitic, metabolic, and myositis work up

Progress Notes:
ATSP re: CK 15000 today (9000 yesterday).  43 yo presents with rhabdo post exercise on Sunday and Monday,pain tonight.

Imp:
Not overloaded, no evidence of compartment syndrome, CK high 1.5 days later, likely still elevated from muscle damage 2/7 ago, however still at risk of AKI. (P) cont IVT and check CK.

The default code in the Index leads to the nontraumatic M code.  Can VICC please advise on when it is appropriate to assign the code for traumatic rhabdomyolysis?  Is it enough to select this option when it is following a fall or due to other external cause, or does traumatic need to be documented?

In Case 1 and 2, documentation supports rhabdomyolysis due to immobility. Should the M code be assigned?  

In Case 3, rhabdomyolysis is post exercise and muscle damage.  Is this enough to assign T79.6 Traumatic ischaemia of muscle?

Also, please refer to Pain versus injury post trauma, December 2006 Coding Matters Vol 13, No 3.  This advice instructs the coder to assign an injury code as it could be argued that pain signifies an underlying injury.  Could we apply similar logic to the above scenarios? If rhabdomyolysis results following an external cause, can we assume traumatic?

Search details:
Rhabdomyolysis is a serious syndrome due to a direct or indirect muscle injury.  It results from the death of muscle fibers and release of their content into the bloodstream.  This can lead to complications such as renal failure.  The most common causes are:
- The use of alcohol or illegal drugs
- Extreme muscle strain
- A crush injury such as from an auto accident, fall, or building collapse
- Long-lasting muscle compression such as that caused by prolonged immobilization after a fall or lying unconscious on a hard surface during illness or while under the influence of alcohol or medication.

The ICD-10-AM Alphabetic Index entry is:
Rhabdomyolysis (idiopathic) NEC M62.8-
-traumatic T79.6

Response:
VICC advises that in order to follow the essential modifier 'traumatic' under Index entry Rhabdomyolysis (idiopathic) NEC /traumatic, there needs to be documentation of a causal relationship between the trauma and the rhabdomyolysis.  

If you are in doubt or unable to seek clinical clarification, assign the default code at lead term Rhabdomyolysis.

In respect to the scenarios cited, VICC does not consider that there is a documented causal relationship in any of the scenarios to allow the assignment of T79.6 Traumatic ischaemia of muscle and would therefore assign M62.8-Other specified disorders of muscle.


Query Text:
Our hospital is seeking clarification of coding Hospital in the home (HITH) episodes.

Can you please confirm if it is correct to code HITH episodes the following way:

Patient admitted and discharged to HITH on the same day - code both diagnosis and procedure codes e.g. clexane, antibiotics etc.

Multi day patient - coded as an inpatient, only diagnosis coded as ACS0042 procedures not normally coded applies to the procedure codes (clexane, antibiotics).

Search Details:
HITH section of Victorian hospital admission policy 2014

Response:
VICC advises that Hospital in the Home (HITH) is provision of care to admitted patients in their place of residence as a substitute for traditional hospital accommodation (ward).  Therefore the same coding rules that apply to in hospital episodes apply to HITH episodes.


Query Text:
I am confused as how to code a scenario where a patient is transferred back to hospital for diagnosis of stabilization of INR.  The documentation indicates underwarfarinisation or subtherapeutic and warfarin is increased and levels monitored until therapeutic level reached and maintained. There is documentation of history of DVT as reason for warfarin and there is no investigation or treatment or recurrence of DVT.   As there is no acute, current DVT and warfarin is prophylactic how do I code this? 

I have looked at queries #2268 and #2721 but neither really give clear guidance in this case and Z92.1 Personal history of long term (current) use of anticoagulant cannot be a principal diagnosis.  I have used D68.3 in the interim as ACS 0303 does mention stabilisation however I feel this is when overwarfarinisation is present.

Search Details:
ACS 0303 Abnormal coagulation profile due to anticoagulants
ICD coding queries #2268 ACS 0303 Abnormal coagulation profile and #2721 Underwarfarinisation

Response:
VICC advises to follow the ACCD advice titled ‘Admission for subtherapeutic INR (underwarfarinisation) and bridging therapy for temporary cessation of an anticoagulant’ Q1, published in the June 2015 Coding Rules reproduced below:

Assign R79.8 Other specified abnormal findings of blood chemistry as the principal diagnosis where underwarfarinisation or subtherapeutic INR (without a resultant condition) is documented as being the primary reason for occasioning the admission, following the index pathway:
Abnormal, abnormality, abnormalities
- chemistry, blood
- - specified NEC R79.8

Assign Z92.1 Personal history of long term (current) use of anticoagulant as an additional diagnosis.


Query Text:
Can the committee please provide advice in relation to assigning procedure codes for IV therapy for SSU admissions?

Scenario:
A patient is admitted to a Short Stay Unit on a same day basis for hypokalaemia and was treated with IV saline.

In this scenario, some of our coders would not assign a procedure code for the IV saline, while others would assign 96199-08 [1920] Intravenous administration of pharmacologic agent, electrolyte

We note the following taken from the Department of Health 2010 IV Factsheet: The Department acknowledges that in some circumstances there will be no appropriate ACHI code assigned for IV therapy (for example IV saline).

Can the committee please advise what procedure code (if any) to use in this scenario.

Search Details:
Factsheet: IV therapy, Department of Health, effective July 1, 2010

Response:
ACS 0042 Procedures normally not coded states that 'These procedures are normally not coded because they are usually routine in nature, performed for most patients and/or can occur multiple times during an episode. Most importantly, the resources used to perform these procedures are often reflected in the diagnosis or in an associated procedure. That is, for a particular diagnosis or procedure there is a standard treatment which is unnecessary to code.'  Specifically, point 8 Drug treatment/pharmacotherapy states that ‘Drug treatment should not be coded except if: the substance is given as the principal treatment in same-day episodes of care’.
 
In light of this, VICC advises that for the scenario cited, a procedure code for the IV saline is not to be assigned as the transfer to SSU is for the continuation of treatment commenced in the emergency department and is not a same day episode of care for drug treatment.

VICC advises that the Department of Health, 2010 Factsheet: IV therapy, has been superseded and is no longer relevant.


Query Text:
Can you please advise us if the advice from Hepatitis C cirrhosis (Volume 17 Number 1, June 2010) is still current?  It has been retired as of the 30 June 2013.

Response:
VICC advises that the Coding Matters advice relating to viral hepatitis C cirrhosis has been retired.  Coders should follow the advice in ACS 0104 Viral Hepatitis - point 3. Manifestations of hepatitis which was introduced in Eighth edition.

The sequencing of the codes is in accordance with ACS 0001 Principal diagnosis and ACS 0002 Additional diagnoses as noted in the standard.

For documentation of hepatitis C cirrhosis, VICC advises to assign K74.6 Other and unspecified cirrhosis of liver followed by B18.2 Chronic viral hepatitis C as per example 1 of point 3 Manifestations of hepatitis in ACS 0104 Viral hepatitis.  

If coders consider that documentation supports Chronic viral hepatitis C as the principal diagnosis, VICC advises to seek clinical advice.


Query Title:
External cause code for angioplasty complications

Query Text:
Please advise if closed vascular angioplasties (e.g. coronary angioplasty with or without stenting via cardiac catheterisation, peripheral angioplasty with or without stenting under radiological guidance) should be considered as medical or surgical procedures.

Some of the coders at our organisation consider the "interventional" nature of the procedure makes it surgical, and therefore would assign Y83.8 (angioplasty) or Y83.1 (with stent).

Others conclude that as cardiac catheterisation is "medical", related procedures such as angioplasties should be assigned Y84.0 ( angioplasties involving cardiac catheterisation) or Y84.8.( peripheral angioplasties).

We were unable to find any advice on this subject.

Response:
This query was originally published in the 2014-15 June database release VICC queries database release as follows:

VICC advises that for documentation of angioplasty complications, following Index entry Complication/catheterisation the correct code to assign is either Y84.0 or Y84.8 from the range Y84 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.

Following the release of  ACCD Coding Rules Q3070 in September 2016 titled External cause code for complication of percutaneous angioplasty with stenting of coronary arteries, the original response is superseded by the following ACCD advice:

Q:
What is the external cause code assigned for complication of percutaneous angioplasty with stenting of coronary arteries?

A:
As per the Coding Rule Catheter based cardiac intervention with angiogram (September 2014) cardiac catheterisation may be:
- performed alone as a diagnostic procedure, where the catheter is inserted into the heart chambers and valves to perform various tests 
- inserted into the coronary arteries to evaluate coronary artery disease (ie coronary angiography)
- performed with a catheter based interventional procedure, where the cardiac catheterisation serves as a guiding catheter (eg percutaneous coronary angioplasty with stenting).

Where the external cause of a procedural complication is diagnostic cardiac catheterisation (ie cardiac catheterisation performed alone or with coronary angiography for purely diagnostic purposes), assign Y84.0 Cardiac catheterisation by following the Alphabetic Index:

 Complication (delayed) (medical or surgical procedure) (of or following)
- catheterisation
- - cardiac Y84.0

Where the external cause is a catheter based interventional procedure (ie where cardiac catheterisation has been performed as a guiding catheter), assign a code from category Y83 Surgical operation and other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure.

For example, where the external cause is percutaneous coronary angioplasty with stenting, assign Y83.1 Surgical operation with implant of artificial internal device by following the Alphabetic Index: 

Complication (delayed) (medical or surgical procedure) (of or following)
- implant, implantation (of)
- - artificial
- - - internal device (cardiac pacemaker) (electrodes in brain) (heart valve prosthesis) (orthopaedic) Y83.1


Query Text:
Can you please clarify if previous advice regarding admission for creation of AVF and preparatory care for dialysis is still correct? This is in relation to the scenario for those admissions where the intention is for creation of a new fistula in preparation to commence dialysis treatment. 

The advice I refer to is from Coding Matters Vol 15 No 4 March 2009 and Coding Matters Vol 16 No 2 September 2009.  This advice is now retired. Our concern is that VICC query #2361 references this retired advice. Is it still correct to assign Z49.0 preparatory care for dialysis as principal diagnosis for those admissions where the intention is for creation of a new fistula in preparation to commence dialysis treatment?

As a private hospital, our Hospital Purchaser-Provider Agreements (HPPAs) state we must adhere to national advice however we cannot query ACCD directly.  Can you please forward this query to the ACCD?

Search Details:
NCCH March 2009 10-AM Volume 15 Number 4 Commandments
NCCH September 2009 10-AM Volume 16 Number 2 Commandments
VICC #2361 2008-09 June Database

Response:
VICC advises that as the retired Coding Matters and VICC advice has been incorporated in the Classification, the query does not require a referral to ACCD.

Z49.0 Preparatory care for dialysis is assigned by following Index entry Admission (for)/creation of arteriovenous fistula for dialysis (graft) Z49.0. There is an excludes note in the Tabular at Z49.0 which says Excludes:  admission for creation of new fistula due to complication of existing fistula (even when new fistula is created at different site) — see Alphabetic Index: Complications/dialysis/catheter, which is also supported by the Index.


Query Title:
Chronic kidney disease as additional diagnosis

Query Text:
Patient has been admitted with CCF due to cessation of Frusemide.  Frusemide had been ceased in an admission 10 days prior as he had acute on chronic renal impairment at the time.  In the current admission the pharmacist has commented on the patient's creatinine clearance rate when considering the Frusemide dose applicable for treatment of the CCF.

On this basis I submitted the following query to the clinician:
Query:
In the previous admission Frusemide was stopped as the patient has acute on chronic kidney injury. Patient now admitted with CCF due to Frusemide being stopped.  Did the chronic renal impairment have an impact in the current admission? E.g did it need to be taken into consideration when Frusemide was being introduced?  (medication reconciliation form notes egfr 28 cr 150)

Response:  
Yes, Frusemide is nephrotoxic and not usually used in people with renal impairment unless absolutely necessary or under special circumstances.

I'm not sure if this is enough in order to code CKD.  Does this meet the requirements of dot point 3 of ACS 0002 "increased clinical care and/or monitoring"?

Response:
Whilst the clinician has responded by saying that the CKD has had an impact on the management of the CCF, based on the information provided VICC considers that there is not enough evidence in the query documentation of increased monitoring or clinical care of the CKD itself to meet the criteria in ACS 0002 Additional diagnoses. 

VICC suggests that queries to clinicians should be based on the wording in ACS 0002 Additional diagnoses and include evidence from the record to support the question being asked.

VICC also notes that Ninth Edition ACS 0003 Supplementary codes for chronic conditions applies to chronic conditions, therefore if the CKD does not meet ACS 0002, it may appropriate to assign U87.1 Chronic kidney disease, stage 3 - 5, as per ACS 0003.


Query Text:
34/40 pregnant lady with pre-existing type 1 diabetes admitted with 2 week history of nausea and vomiting and unstable blood sugars.  She was positive for blood ketones but not acidotic.  Insulin was adjusted and IV dextrose given and patient stabilised.

Discharge diagnosis was "Starvation ketosis" (not ketoacidosis).

What is the correct way to code this?

O24.0 Pre-existing diabetes mellitus, Type 1, in pregnancy does not alone adequately describe the condition.
E10.11 Type 1 diabetes mellitus with ketoacidosis, without coma seems to be incorrect as patient did not have acidosis and as the patient is pregnant, O24.0 seems more accurate
E88.8 Other specified metabolic disorders if "diabetic", the Index directs to see Diabetes with ketoacidosis.  Documentation does not refer to "diabetic ketosis", rather "diabetes with starvation ketosis"

Do I need a code for starvation T73.0 Effects of hunger?

Response:
This query was originally published in the 2015-16 June Database as follows:

VICC advises that the correct code to assign for starvation ketosis is E88.8 Other specified metabolic disorders which is the default code at Lead term Ketosis.  As you have noted, the Index entry for 'diabetic' should not be followed because your documentation does not specify 'diabetic'. In this scenario, E88.8 is the principal diagnosis as it is documented as such on the discharge summary.

The term 'starvation' refers to the type of ketosis rather than a clinical diagnosis of starvation, therefore VICC does not support the assignment of a code for starvation.

With respect to the coding of the diabetes, VICC agrees that it is incorrect to assign E10.11 Type 1 diabetes mellitus with ketoacidosis, without coma because the patient does not have ketoacidosis.

VICC referred the coding of O24.0 in this case to the ACCD who provided the following advice:

"When a pregnant patient is admitted with diabetes mellitus, assign an appropriate code from O24 Diabetes mellitus in pregnancy; there does not need to be documentation that the diabetes mellitus is complicating the pregnancy.

See ACS 0001 Principal diagnosis/Obstetrics for guidelines regarding sequencing in antepartum and delivery episodes.

The classification of complications of pregnancy is being reviewed for Tenth Edition".[end of original response]

VICC has updated the response (third paragraph) to clarify that E10.11 Type 1 diabetes mellitus with ketoacidosis, without coma is not assigned in this scenario because there is no documentation of diabetic ketosis.  The updated response is below:

VICC advises that the correct code to assign for starvation ketosis is E88.8 Other specified metabolic disorders which is the default code at Lead term Ketosis.  As you have noted, the Index entry for 'diabetic' should not be followed because your documentation does not specify 'diabetic'. In this scenario, E88.8 is the principal diagnosis as it is documented as such on the discharge summary.

The term 'starvation' refers to the type of ketosis rather than a clinical diagnosis of starvation, therefore VICC does not support the assignment of a code for starvation.

With respect to the coding of the diabetes, VICC agrees that it is incorrect to assign E10.11 Type 1 diabetes mellitus with ketoacidosis, without coma because there is no documentation of diabetic ketosis.

VICC referred the coding of O24.0 in this case to the ACCD who provided the following advice:

"When a pregnant patient is admitted with diabetes mellitus, assign an appropriate code from O24 Diabetes mellitus in pregnancy; there does not need to be documentation that the diabetes mellitus is complicating the pregnancy.

See ACS 0001 Principal diagnosis/Pregnancy, childbirth and the puerperium for guidelines regarding sequencing in antepartum and delivery episodes.

The classification of complications of pregnancy is being reviewed for Tenth Edition".


Query Text:
Can the code F17.1 Harmful use of tobacco be assigned when the condition it is related to does not meet additional diagnosis?

Should the smoking code assigned be F17.1 Harmful use of tobacco or Z86.43 Personal history of tobacco use disorder?

Lady 71 years old admitted for Malignant hypertension. Past history of COPD  - Ex - smoker

Response:
VICC advises that F17.1 Harmful use of tobacco can be assigned when the condition it is related to (in this case COPD) does not meet the criteria in ACS 0002 Additional diagnoses. 

The code identifies the smoking status not the condition so the decision about how to code the smoking status is independent of the decision to code the condition.


Query Text:
We have an episode where the only diagnosis that is made is 'borderline personality traits'.  The index takes you to Z73.1 Accentuation of personality traits, under "Traits, Personality" which is not an acceptable principal diagnosis.  We have checked with other agencies and some don't code traits at all and some only as additional diagnoses.

The standards do say to seek clarification from the clinician when we are unsure but we are wondering what to code if clarification cannot be sought? Is F60.31 Borderline personality disorder appropriate to code or can we not assume this?  

The only other option we can see is to code R69 Unknown and unspecified causes of morbidity.

Response:
ACS 0512 Personality trait/disorder states that 'where a diagnosis of personality trait (eg paranoid trait) is made, the clinician should be asked to confirm whether the diagnosis is actually a disorder or a trait. If it is a disorder, then it should be coded.'  

If it cannot be determined if it is a disorder, VICC advises to code the symptoms with which the patient has been admitted.

VICC notes that in order to assign Z73.1 Accentuation of personality traits, there must be documentation of accentuation as per the Index entries leading to this code.  VICC also notes that this code is not an unacceptable principal diagnosis in Ninth edition ICD-10-AM/ACHI/ACS.


Query Text:
Diagnosis on discharge summary:  right subtrochanteric fracture neck of femur due to bisphosphonates.
Progress notes state: HOPC tripped on footpath. Patient on bisphosphonates appearance of fracture characteristic of bisphosphonate fracture.

There is no index entry for Fracture due to drug or Fracture drug induced. Therefore, this would be coded as a traumatic fracture following index:
Fracture
-femur
- - subtrochanteric S72.2
together with Y54.7 adverse effect of bisphosphonates in therapeutic use and other applicable external cause codes.

Research indicates that a bisphosphonate fracture is a type of insufficiency fracture and that an insufficiency fracture is a type of stress fracture (which is the result of normal stresses on abnormal bone).

Question:
Can we code fractures due to bisphosphonates to stress fractures?

Response:
VICC advises that in order to assign M84.3- Stress fracture, not elsewhere classified, the term 'stress' needs to be documented.  

As you have noted, there is no Index entry for fracture due to drugs, therefore VICC agrees that the correct diagnosis code for the fracture is S72.2 Subtrochanteric fracture.


Query Text:
32 year old woman admitted following FDIU at 14 weeks.  Admission was originally planned for suction evacuation but the patient passed the fetus (intact, without placenta) prior to being admitted.  The patient was taken to theatre for MROP and suction curettage.
Operation report states:
Pre-Op Diagnosis: 2nd trimester delivery
Procedure: Retained placenta manual removal/Suction curettage
Details: Manual removal - polyp forceps - size 12.  Suction curettage to remove placenta.

I have coded the procedures as:
90482-00 [1345] Manual removal of placenta
16564-01 [1345] Postpartum evacuation of uterus by suction curettage

However, should the suction curettage be coded as: 16564-01 [1345] Postpartum evacuation of uterus by suction curettage (given that the patient had delivered the fetus prior to admission), or 35640-03 [1265] Suction curettage of uterus (given that the patient was only 14 weeks and therefore the fetus was not viable)?

Search Details:
Index: Curettage/Uterus/Suction 35640-03
Tabular entry for 35640-03 Excludes: That following delivery (16564-01)

Response:
ACS 1510 Pregnancy with abortive outcome defines abortion as expulsion or extraction of the products of conception by any means, before fetal viability, that being less than the 20th week of pregnancy.

As the FDIU occurred at 14 weeks, it is classified as an abortion, not a delivery.  Therefore the correct curettage code to assign is 35640-03 [1265] Suction curettage of uterus.


Query Text:
A patient admitted with subacute endocarditis. Patient was taken to theatre for TOE but the probe was unable to be passed either under sedation or under GA. There was no problem with the intubation only the procedure. How do I capture and should I be capturing the GA when that was as far as the procedure went? The codefinder indicates an error as the GA should be preceded by a procedure.

Response:
VICC advises that in the case cited it is appropriate to assign a code only for the GA as this was the extent of the procedure performed.  VICC therefore suggests to refer this query to 3M for investigation.


Query Title:
Transoesophageal echocardiogram (TOE)  during surgery

Query Text:
Do we allocate a code for TOE 55118-00 [1942] when performed during surgery?

Response:
VICC advises that 55118-00 [1942] 2 dimensional real time transoesophageal ultrasound of heart can be assigned when performed during surgery.  This is in accordance with the exception in ACS 0042 Procedures normally not coded point 11 which lists Imaging services – all codes in ACHI Chapter 20 Imaging services and block [451] Dental radiological examination and interpretation except: 
- transoesophageal echocardiogram (TOE) (55118-00 [1942])
- when instructed to do so


Query Text:
What is the correct principal diagnosis code to assign for removal of a cardiac event monitor?

VICC query 1979 (retired 30/6/2010) suggests Z45.0 Adjustment and management of cardiac device is an appropriate principal diagnosis.  Is this advice still current?

Index entry: Removal/cardiac device

Response:
VICC advises that whilst #1979 is retired, the advice is still current.  

Follow Index entry Removal/cardiac device (automatic implantable defibrillator) (battery) (electrode) (end-of-life) (pacemaker) (pulse generator) to assign Z45.0  Adjustment and management of cardiac device.


Query Title:
Diabetes in pregnancy - Excludes notes for E code assignment

Query Text:
We seek clarification on coding of additional E codes when O pregnancy diabetes codes are coded. 

When coding a pregnant patient with diabetes should we be coding out the E codes in addition to O24.X to add specificity. There are excludes notes at E09 - E13 for O24.X which some coders interpret to mean we can't. 

If you look at the definition of a Type 1 excludes note it could be interpreted that you can code these out. If the directive is to code these out to add specificity then the PICQ fatal error needs to be amended. At the moment as the coding of both O codes and E codes together creates this fatal error it does drive how some sites interpret/apply these codes.

Search details:
ACS 0401, Type 1 exclusion notes definition, PICQ Glossary error 101991, VAED Audit report feedback

Response:
VICC obtained the codes assigned in this case: O24.42 DM arising in pregnancy, insulin treated and E13.65 Other specified DM with poor control.

VICC advises that additional E codes for complications of diabetes can be assigned with pre-existing diabetes codes but not with gestational diabetes codes.  This is supported by the instruction in ACS 0401 Diabetes mellitus and intermediate hyperglycaemia under heading 'Pregnancy and pre-existing DM and IH' which says 'additional codes for complications of DM or IH should be assigned in accordance with Rule 4a and Rule 4b'.  This instruction does not apply to gestational diabetes.  

VICC therefore considers that PICQ indicator 101991 is correct.


Query Title:
Missed dose of drug with resultant admission

Query Text:
Patient admitted with seizures on background of glioblastoma multiforme.  He had missed one dose of his antiepileptic medication which resulted in a two day stay in ICU with intractable seizures. 

Y63.6 Nonadministration of necessary drug, medicament or biological substance appears appropriate but that seems applicable only to omission by clinical staff, not the patient. The clinical staff are not happy with the non-compliance code as they feel that implies intent which is inappropriate for this scenario. Poisoning also appears inappropriate because it is underdosing not overdosing or wrong drug.

Response:
VICC considers that Z91.1 Personal history of noncompliance with medical treatment and regimen, can be assigned as an additional diagnosis for documentation of noncompliance or failed compliance. Please note that this code does not convey intent, attribute blame or make any judgement on the reason for noncompliance.

VICC does not support the assignment of Y63.6 Nonadministration of necessary drug, medicament or biological substance because this is a misadventure code, and the case cited is not about a misadventure during medical or surgical care (as per ACS 1904 Procedural complications).


Query Title:
Same day endoscopy flow chart VICC feature article

Query Text:
Scenario number 2 ACS 0046 - endoscopic investigation of any body system.  When no causal link between symptoms and findings is made do I code any (or all) of findings made?  For example positive FOBT and single finding of diverticulosis.  Should I code diverticulosis?  I know I can code findings from a histotology report such as gastritis or polyps but as the diverticulosis is not treated, it did not lengthen the stay but is a significant problem - which may even have caused the FOBT can I code it?  

Another confusion is that each of the other scenarios says 'other findings only coded if they meet ACS 0002' but scenario 2 does not have this statement.  Does this not apply?

Response:
The same day endoscopy flowchart is a representation of various standards relating to same-day endoscopy. It does not contain any information other than what is already published in those standards.

VICC advises that ACS 0046 Diagnosis selection for sameday endoscopy allows the coding of all findings both clinical and histological.  It is the exception to the other standards noted in the flow chart where ACS 0002 Additional diagnoses does apply. 

Therefore in the case cited, when ACS 0046 is applied, it is correct to assign diagnosis codes for both the positive faecal occult blood test and the diverticulosis.


Query Title:
Coding from documentation in previous episodes

Query Text:
In regard to the June 2015 ACCD Coding Rules query titled 'Coding from documentation in previous admissions', what are we able to do when there is a change of care type? We often have a patient change from acute to Rehab or GEM and sometimes there can be three or four care types changes as a patient's condition fluctuates. 

Despite continued efforts to encourage documentation for each episode, the clinical staff regard this as simply administrative changes of care type as the care is often in the same ward by the same staff and medication/observation charts are simply continued on from time of admission to separation from the hospital. Diagnoses such as malnutrition, leg ulcers, injuries are often only documented as such in the initial episode even though intervention continues throughout the entire hospital stay.

Response:
VICC acknowledges that the documentation format causes difficulty for clinical coders but is an artefact of statistical separations.

VICC advises that for a condition to be coded in each episode of care, it must be either documented in each episode of care or documented on a discharge summary covering dates of the relevant episodes and that the condition must meet ACS 0002 Additional diagnoses or a specialty standard.


Query Title:
Sickle cell anaemia with crisis and beta thalassaemia

Query Text:
Patient presents with both sickle cell anaemia with crisis AND beta thalassaemia.  What is the correct code assignment?

We have come up with the following coding options:

Option 1:
Anaemia
- sickle-cell
- - with crisis D57.0

Thalassaemia (anaemia) (disease)
- beta (severe) D56.1
- - sickle-cell (beta) D57.2

D57.0 Sickle-cell anaemia with crisis and D57.2 Sickle-cell (beta) thalassaemia

Option 2:
Anaemia
- sickle-cell
- - with crisis D57.0

Thalassaemia (anaemia) (disease)
- beta (severe) D56.1

D57.0 Sickle-cell anaemia with crisis and D56.1 Beta thalassaemia

Option 3:
Thalassaemia (anaemia) (disease)
- beta (severe) D56.1
- - sickle-cell (beta) D57.2

D57.2 Sickle-cell (beta) thalassaemia

Our clinicians feel that option 3 is not sufficient as it does not show the "crisis" stage.  Our clinicians prefer option 2.  Please advise on the correct code assignment.

Response:
VICC advises that as in this case the conditions have been documented as two separate conditions, they should be coded separately.  Therefore VICC considers the Index entries under option 2 of the query are the correct entries to follow to assign D57.0 Sickle-cell anaemia with crisis and D56.1 Beta thalassaemia.


Query Text:
Should we code local anaesthetic continuous infusions that are set up for post-operative pain relief?

Normally we do not code local anaesthetic administration but in this case the setup and maintenance of a L.A infusion is much the same as an epidural infusion, in fact it often uses the same drug (Ropivacaine).

Response:
VICC advises that whilst infiltration of local anaesthetic is not coded, continuous infusion of local anaesthesia can be coded as per ACS 0031 Anaesthesia under section titled Postprocedural analgesia.  

Provided the infusion is commenced in theatre and is continued for post procedural analgesia, the correct code to assign is 92518-01 Intravenous post procedural analgesic infusion from block [1912].


Query Text:
Can you please clarify which of T81.0 Haemorrhage and haematoma complicating a procedure, not elsewhere classified or T82.8  Other specified complications of cardiac and vascular prosthetic devices, implants and grafts is the correct code to assign for a groin haematoma at (cardiac) (vascular) catheterisation site post procedurally? 

Treated with manual compression for 20 minutes, addition compression required bed rest for four hours, marked, monitored and reviewed by cardiologist.  Documentation in record meets ACS 0002 Additional diagnoses and ACS 1904 Post procedural complications.

Response:
This query was originally published in the 2015-16 December VICC queries database release as follows:

VICC advises that the correct code to assign for groin haematoma at the catheterisation site post procedurally is T82.8 Other specified complications of cardiac and vascular prosthetic devices, implants and grafts following the Coding Rules advice titled Conventions used in the Tabular List of Diseases, under section 'Postprocedural complications - haemorrhage/haematoma' updated June 2015 and the Excludes note at T81.0 Haemorrhage and haematoma complicating a procedure, not elsewhere classified.

ACS 0002 Additional diagnoses states that 'the national morbidity data collection is not intended to describe the current disease status of the inpatient population but rather, the conditions that are significant in terms of treatment required, investigations needed and resources used in each episode of care'. VICC considers that in this context 'significant' means a condition requiring more than routine care. As such VICC does not support the assignment of procedural complication codes when only routine interventions are performed.

Based on the information provided in the query VICC cannot confirm that the groin haematoma meets ACS 0002 Additional diagnoses.  Please refer to HDSS Bulletin 195 item 195.4 titled Routine care versus non routine care for instructions on coding of complications of care based on routine clinical interventions.

Following publication of March 2017 Coding Rules the original response is superseded by the following advice titled Complications of prosthetic devices, implants and grafts/haematoma following cardiac catheterisation:

Q:
How do you code haematoma following cardiac catheterisation? Is code assignment different if a device (eg stent) has been inserted via cardiac catheterisation?

A:
For post procedural groin haematoma following cardiac catheterisation, assign:
T81.0 Haemorrhage and haematoma complicating a procedure, not elsewhere classified 
Y84.0 Cardiac catheterisation (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

For post procedural groin haematoma following cardiac catheterisation with insertion of cardiac stent, assign:
T82.8 Other specified complications of cardiac and vascular prosthetic devices, implants and grafts 
Y83.1 Surgical operation with implant of artificial internal device
Y92.22 Place of occurrence, health service area

The following should also be noted:
- There is a difference between cardiac catheterisation as operative approach for insertion of a device and as a diagnostic procedure (see also Coding Rule (Q3070): External cause code for complication of percutaneous angioplasty with stenting of coronary arteries)
- Haemorrhage/haematoma is classified similar to complications such as embolism, fibrosis etc, and as per the guidelines in ACS 1904 Procedural complications 
- Assign T82-T85 Complications of prosthetic devices, implants and grafts regardless of whether a cause and effect relationship is stated between the complication and the prosthetic device, implant or graft. However, where documentation specifies that a complication is related to a specific cause, assign codes for complications of the documented cause not the prosthetic device, implant or graft. For example:

- shoulder pain from laparoscopy gas following insertion of Filshie clips;  code the pain as a complication of the laparoscopy, not a complication of the Filshie clips

- bleeding from endotracheal (ET) tube post general anaesthetic for joint replacement; code the bleeding as a complication of the endotracheal tube, not the joint replacement.

(See also Coding Rule (Q2736): Conventions used in the Tabular List of Diseases).

Following publication of September 2018 Coding Rules and in line with Tenth Edition the original response is superseded by the following advice titled Haematoma following cardiac catheterisation:

Q: How do you code haematoma following cardiac catheterisation? Is code assignment different if a device (eg stent) has been inserted via cardiac catheterisation?

A: Cardiac catheterisation may be performed:
- alone, as a diagnostic procedure, where the catheter is inserted into the heart chambers and valves to perform various tests
- with insertion of dye into the coronary arteries to evaluate coronary artery disease (ie coronary angiography)
- with a catheter based intervention, where the cardiac catheterisation serves as a guiding catheter (eg percutaneous coronary angioplasty with stenting).

For post procedural groin haematoma following cardiac catheterisation performed as a diagnostic procedure or with coronary angiography, assign:

T81.0 Haemorrhage and haematoma complicating a procedure, not elsewhere classified
Y84.0 Cardiac catheterisation (as the cause of abnormal reaction, or of later complication, without mention of unintentional events at the time of the procedure)
Y92.24 Health service area, this facility

For post procedural groin haematoma following cardiac catheterisation performed with a catheter based cardiac intervention (eg insertion of cardiac stent), assign:

T82.81 Haemorrhage and haematoma following insertion of cardiac and vascular prosthetic devices, implants and grafts
Y83.1 Surgical operation with implant of artificial internal device
Y92.24 Health service area, this facility

Published 15 September 2018, for implementation 01 October 2018.


Query Text:
Coders are seeking clarification in regards to anaemia and myelofibrosis (osteomyelofibrosis).

Scenario:
Patient is admitted for transfusion of packed red blood cells
Diagnosis: Myelofibrosis
Presenting complaint: low Hb, anaemia, myelofibrosis
Treatment: Blood transfusion
Query: should anaemia be coded as an additional diagnosis or would it be considered a symptom of myelofibrosis?

Search Details:
#2474 Anaemia in neoplastic disease with myelodysplastic syndromes states that "Refractory anaemia is symptomatic of myelodysplastic syndrome and therefore it is unnecessary to assign D63.0* Anaemia in neoplastic disease where refractory anaemia in myelodysplasia is assigned to D46.- Myelodysplastic syndromes"  

However the dagger asterisk codes are obsolete.

Response:
Based on the information provided where myelofibrosis is documented as the final diagnosis, VICC considers that only a code for the myelofibrosis is required.


Query Text:
Does overweight equal obesity? The word overweight is not indexed in ACS 0003 for supplementary codes but overweight in both the Alphabetical index and on Codefinder leads to 'Obesity'. 

Our clinicians seem loath to use the term obesity (unless admitted for bariatric surgery) but 'overweight' is often documented and often with a significantly abnormal BMI charted. If  the intention of 'U' codes is to capture co-morbidities for hospital admissions, it seems remiss not to be able to include clinically overweight patients.

Can U78.1 be assigned following Index entry Supplementary/ codes for chronic conditions/obesity?

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

In accordance with the Ninth Edition Education FAQ titled ACS 0003 Supplementary codes for chronic conditions (September 2015), U78.1 Obesity can be assigned for documentation of overweight as the term overweight is a synonymous term which is indexed and classified to obesity.

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


Query Text:
Does a patient who has an episode of hypotension following a procedure and is treated with fluids meet the criteria to be classified as a post operative complication?  The patient had only one episode so it could be argued that hypotension is one of those transient conditions that are not normally coded as a complication but a code to identify the condition is used.

Search details:
ACS 1904 states that many conditions may arise during or in the period following a procedure and some are considered to be procedural complications while others are not.  Examples of conditions that may occur include ...a transient condition a condition that occurs commonly after a procedure.  However ACS 1904 also states that a post procedural complication is a complication which occurs or persists after the procedure and is not evident at the time of the procedure.  The definition is: a condition of injury which is directly related to a surgical/procedural intervention is the definition.  

Going by this definition this could include transient conditions such as vomiting.

Response:
Regardless of whether or not a condition is transient, ACS 1904 Procedural complications states that procedural complication codes should only be assigned if they meet the following definition: 'A condition or injury which is directly related to a surgical/procedural intervention.'

Based on this definition and the information provided in the query, it does not appear there is documentation to support that the hypotension is directly related to the procedure and so cannot be coded as a procedural complication. Therefore only a code from the I95 Hypotension range should be assigned.


Query Title:
DRG allocation for endometrial thickening

Query Text:
When a patient is admitted with endometrial thickening for investigation based on previous imaging results and nothing is found we have coded endometrial thickening R93.5 Abnormal findings on diagnostic imaging of other abdominal regions, including retroperitoneum (a change in Ninth edition)
Also coded: Hysteroscopy, D&C and GA

Grouping of this admission takes it to 801C. This doesn't seem correct to me. Can you advise if this is correct given the PDx is a gynae symptom following the changes in 9th edition. Previously the code for endometrial thickening was N85.9 which grouped to a gynae DRG following the procedure.

Search details:
9th edition training information
ICD 10 am - 8th and 9th edition
AR DRG manual 7.0

Response:
The updated advice in Ninth Edition to code endometrial thickening to R93.5 Abnormal findings on diagnostic imaging of other abdominal regions, including retroperitoneum is based on a World Health Organization (WHO) update.  AR-DRG Version 7.0 was released prior to this update.  

This code is a Major Diagnostic Category (MDC) 6 code and dilation and currettage (D&C) is a MDC 13 code, hence the allocation to DRG 801C.  The same situation will occur in AR-DRG Version 8.0 as its development was completed before the WHO update release. 

Coders are advised to follow the Ninth Edition Index entry to assign R93.5 for documentation of endometrial thickening regardless of the DRG outcome.

Coders are also advised that the ACCD public submission process can be used to notify them of AR-DRG issues.


Query Title:
Congestive cardiac failure and pleural effusion

Query Text:
Is the retired advice titled Heart failure pubished in Coding Matters Volume 7 Number 3 regarding coding Congestive Cardiac Failure (CCF) and pleural effusion (PE) still current?

Advice provided:  "Acute pulmonary oedema (APO) is a life-threatening manifestation of acute left ventricular failure secondary to sudden onset of pulmonary venous hypertension forcing fluid out of the pulmonary veins and into the pleural cavity (pleural effusion). If it is documented that the patient has APO and CHF, assign only I50.0 Congestive heart failure. 

It is not necessary to code pleural effusion unless specific treatment (eg drainage) is required."

Therefore if a patient has CCF and PE, we wouldn't need to code the PE unless it is treated, which (if the cause was CCF) would only be via drainage.

We cannot find advice elsewhere on this.  ACS only relates to LVF and APO.

Response:
The advice titled Heart failure published in Coding Matters December 2000 was retired in 2013 so is no longer current. VICC advises that a code for pleural effusion can be assigned with congestive cardiac failure if it meets ACS 0002 Additional diagnoses.


Query Title:
Principal diagnosis selection for viral induced wheeze

Query Text:
Viral induced wheeze is a common final diagnosis for emergency short stay observation unit patients and other overnight admissions at our hospital.  These patients are children who are often under the age of three.  Treatment is centred around the wheezing, and generally follows the same protocols as treatment for asthma.  Asthma is usually not formally diagnosed in children under three, as wheezing can be due to small airway calibre rather than asthma.

We would appreciate advice on Principal Diagnosis selection.

Some coders assign R06.2 Wheezing with B34.9 Viral infection unspecified as an additional diagnosis, arguing point 2 of problems and underlying conditions in ACS 0001.

Other coders assign B34.9 only, arguing point 1 of problems and underlying conditions in ACS 0001.

Please advise on the appropriate codes for the diagnosis of "viral induced wheeze".

Search Details:
Royal Children's Hospital Asthma Best Practice Guidelines 
http://www.rch.org.au/uploadedFiles/Main/Content/clinicalguide/BPG-FINAL-26OCT.pdf

Kids Health Info Fact Sheet - Asthma
http://www.rch.org.au/kidsinfo/fact_sheets/Asthma/

Response:
VICC considers that for documentation of viral induced wheeze, the principal diagnosis is the wheeze as it is the condition described.  VICC also suggests the assignment of B97.8 Other viral agents as the cause of diseases classified to other chapters to describe the causative agent.

VICC does not consider it is correct to assign B34.9 Viral infection unspecified as viral infection or viral disease is not actually documented.


Query Text:
Could you advise if the following Index entry for 'Twin' is correct? 
Twin (fetus or newborn) (pregnancy) P01.5 Fetus and newborn affected by multiple pregnancy

Should we be assigning it for all twin deliveries?  

Or should the Index entry  be the same as that for 'Triplet'? Triplet, affecting fetus or newborn P01.5

Response:
ACS 1609 Newborns affected by maternal causes and birth trauma states that codes in categories P00–P04 Fetus and newborn affected by maternal factors and by complications of pregnancy, labour and delivery should only be assigned to indicate that a newborn has been affected by a maternal condition.

P01.5 should not be coded in a twin delivery, unless the criteria outlined in ACS 1609 is met.

VICC recognises that the Index could be improved and suggests you may wish to consider a public submission to ACCD asking for improvements to the Index in this area.


Query Text:
ACS 0112 Infection with drug resistant microorganisms instructs coders to assign Z06.X Resistance to antimicrobial drugs when a clinician documents resistance to an antibiotic.   We understand we cannot code resistance that is solely documented on pathology reports.

However, we are  finding clinicians are not documenting the word resistance in the progress notes but are using the letter R instead, and in the version of abbreviations we can find, this is not an approved abbreviation.  For example it might read:
R vancomycin
R  penicillin
R  amoxicillin
S drug A
S drug B
Is it appropriate to code Z06.* from documentation of R alone?

Also at our hospital, our electronic discharge summary system allows clinicians to copy and paste pathology results from the pathology system so they will often do this with the resistant organisms.  We understand from VICC Query 2966 that we can code resistance if its on the discharge summary but we want to confirm if it is still OK if the only documentation is R rather than the term resistant.

Search Details:
VICC Query #2966 Assignment of drug resistance to microorganisms code from electronic discharge summary
The Australian dictionary of clinical abbreviations acronyms and symbols (2004)

Response:
VICC agrees that in the context of this query, documentation of R in the progress notes is synonymous with the term resistance and therefore Z06.- Resistance to antimicrobial drugs can be assigned when supported by pathology results.


Query Text:
Patient working as a chef in a restaurant (no indication of whether retail or otherwise) preparing food when he cut his hand with a chef's knife.

The place of occurrence - service area - restaurant

Activity code - do you code this to:
-  retail trade  U73.04 - which is about selling food = which is not what he was doing
or
- U73.02 manufacturing (which includes manufacturing of food for income)

Coders involved in the course have disagreed on the correct answer.  I believe it should be manufacturing as the location is already clearly defined in the place of occurrence and from a data perspective it should not be what is recorded in the activity semantic space as it is what they are doing, not where they are doing it.

I would value guidance both on the answer and on the logic behind the correct code to be assigned to assist explaining the 'rules' to students. 

The index does not provide guidance in this case.

Search Details:
Index, Tabular List, Standards - none, Coding Rules - U73.8, Coding Database and Coding Matters.

Response:
As there is no documentation of retail or manufacturing to enable you to follow the Index entries for those terms, and there is no specific Index entry for chef or cooking, VICC advises to assign U73.08 Activity, other specified work for income following Index entry Activity/work/specified NEC.  

VICC notes that activity code U73.08 includes work for income in cafés and restaurants.


Query Text:
Patient admitted with ketoacidosis complication of diabetes due to his insulin pump being broken.

Code:  E14.11 Unspecified diabetes mellitus with ketoacidosis, without coma followed by Z96.4 Presence of endocrine implants
or
Code:  T85.6 Mechanical complication of other specified internal prosthetic devices, implants and grafts,  E14.11 Unspecified diabetes mellitus with ketoacidosis plus Y83.1 Surgical operation with implant of artificial internal device.

After consulting with a number of coders we come up with 50/50 on which solution should be used - please provide guidance and if possible not just an answer but the rationale to assist in explaining this to students.

Response:
As the complication (in this case the ketoacidosis) relates to the breakdown of the insulin pump, in accordance with ACS 1904 Procedural complications, VICC advises that the correct principal diagnosis is T85.6 Mechanical complication of other specified internal prosthetic devices, implants and grafts following Index entry Complications/catheter (device)/mechanical.

VICC considers that the correct external cause code to assign is Y84.8 Other medical procedures following Index entry Complication/infusion/procedure because the insulin pump is an infusion device. See Coding Rules advice titled Insulin pumps updated 1 July 2015 for further information on Insulin pumps.

VICC agrees that a code for diabetes with ketoacidosis should be assigned as an additional diagnosis but notes that the unspecified diabetes code E14.11 Unspecified diabetes mellitus with ketoacidosis, without coma has been assigned and suggests seeking further information on the type of diabetes.


Query Text:
The list below are codes where there are inconsistencies as to what prefix to apply for these codes.  Most often, the confusion is to whether a P or A prefix is used.  I have reviewed the VIC addition to the ACS, but in some cases the rules can be interpreted differently. 
 
If you could provide some clarity that would be great.  
 
Z37 – Outcome of delivery
Z38 – Place of birth
Z50 – since code is now an additional code in Ninth Edition
Z80 - Z84 - family history (including when assigned as Adx after Z12 for screening endoscopies)
Z85 – Z92 – Personal history (including when assigned as Adx follow up endoscopies)
Other Z codes

Response:
VICC cannot provide definitive advice on each of the Z codes listed in the query as the Prefix for some of the Z codes may vary depending on the circumstance in which the code is assigned.  VICC advises to firstly refer to ACS 0048 Condition onset flag and then to Vic 0048 Condition onset flag for supplementary advice which instructs coders to assign prefix P 'Primary condition' when in doubt.

For outcome of delivery (Z37) and place of birth (Z38) ACS 0048 Condition onset flag says that the COF value assigned should always be COF 2, therefore VICC advises to assign the equivalent Victorian prefix P to these codes.  

For rehabilitation (Z50) where the patient is admitted for rehabilitation VICC advises to assign Prefix P, noting that the P prefix can be assigned to multiple codes.

For family history codes (Z80 - Z84) if assigned in accordance with ACS 2111 Screening for specific disorders, VICC advises to assign Prefix P.


Query Text:
Patient admitted with ischaemic heart disease has angiography and angioplasty with stent.

In 8th Edition there was a code also when performed instruction in Block 671 to code angiography.  This instruction is not in 9th Edition.

Does this mean that cardiac anigography should not be coded in this case, or does the absense of a specific instruction to code or not to code leave the decision to the coder?  Seeking a consistent single rule to follow please.

Search Details:
Note: under [671] in 8th edition there is a note:
Code also when performed:
Coronary angiography
This note does not appear in [671] in 9th edition.

There is no documentation in ACS 0940 Ischaemic Heart Disease OR in ACS 0941 Arterial Disease to indicate that angiography should not be coded with angioplasty

In ACS 0042 Procedures normally not coded, point 5, codes in block [668] Coronary angiography are excluded.


CONCLUSION: it appears that angiography NOS 38215-00 [668] (i.e coronary angiography without cardiac catheterisation) is not to be coded with angioplasty.

8th edition
[671]    Transluminal coronary angioplasty with stenting
Transluminal balloon angioplasty
Includes:    balloon dilation of artery
that with drug eluting stent(s)
Code also when performed:
coronary angiography (38215-00, 38218 [668])

9th edition
[671]   Transluminal coronary angioplasty with stenting
Transluminal balloon angioplasty
Includes:    balloon dilation of artery
that with drug eluting stent(s)

Code also when performed:
coronary angioplasty with:
aspiration thrombectomy (90218-00, 90218-01 [669])
embolic protection device (90218-02, 90218-03 [669])

Response:
VICC advises to follow the advice in the FAQ titled Coronary angiography published in Coding Rules on 15 September 2015 and reproduced below:

SUBJECT: Coronary angiography 

Q:
Patients routinely present for coronary angiography/catheterisation and then undergo percutaneous transluminal coronary angioplasty (PTCA) in the same visit. Should  both PTCA and coronary angiogram/catheterisation be coded? When should a code for coronary angiogram be assigned? 

A: 
As per the Coding Rule Catheter based cardiac intervention with angiogram (September 2014), when a catheter is inserted into coronary arteries to evaluate the coronary arteries, it is termed coronary angiogram. When a coronary angiography is performed in addition to a catheter based cardiac intervention i.e. not for access alone, assign 38215-00 Coronary angiography. 

The code also when performed instruction for coronary angiography has been deleted from a number of percutaneous cardiac procedures to avoid confusion with catheter access for percutaneous procedures, which should not be assigned a separate code. If a diagnostic coronary angiography (classified to block [668]) is performed in conjunction with these procedures, then an additional code from block [668] is assigned and an instructional note is unnecessary.


Query Title:
Supplementary codes for chemotherapy patients

Query Text:
We currently copy morphology and neoplasm codes from previous chemotherapy episodes for specificity.  With the introduction of supplementary codes can we also copy them across to other episodes as chemotherapy patients do not have a full assessment for each episode.

Response:
VICC advises that if there is no documentation of the chronic condition in the same day episode, the supplementary codes cannot be copied from one episode to another and ACS 0003 Supplementary codes for chronic conditions does not apply.  This is supported by the following FAQ published by ACCD on 15 September 2015 reproduced below:

SUBJECT: ACS 0003 Supplementary codes for chronic conditions 

Q: 
Should supplementary codes be assigned for all episodes of care, including same day dialysis? 
A:
Supplementary codes should be assigned for all episodes of care where additional diagnoses are routinely assigned. This includes multi-day and same-day episodes of care.  As per the Coding Rule Diabetes and day only admissions (June 2005), where coding is autogenerated (such as for dialysis episodes) and the full record is not available to inform the coding process, it may not be possible for some hospitals to comply with ACS 0003 Supplementary codes for chronic conditions in these episodes.


Query Text:
Is the advice in the retired VICC query #2290 Repair of perforated ulcer still current?

#2290 Repair of perforated ulcer
Publication Date: 2006-07 March Database ICD 10 AM Edition: Fifth edition  Retired Date: 30/6/2013

Response:
VICC considers that the advice in #2290 Repair of perforated ulcer is still applicable and is reproduced below:

Query:
Male patient 32 year of age presented with a perforated duodenal ulcer (not bleeding). The operation report states suture of perforated peptic ulcer, omental patch fixed (operation report attached).  

The current advice at our organisation is to code as repair of site being patched. See Repair, intestine, small NEC 30375-19 [901] . Another possible code would be Suture, ulcer, perforated (duodenal) (gastric) 30375-10 [887].

If both suture of ulcer and omental patch were performed, which is the more appropriate code to use?

Search details:
NCCH query Q43 applies to repair of a bleeding ulcer using an omental patch so is not relevant.

Response:
The VICC advises that if both the suture of the perforated ulcer and the omental patch are performed, that both procedures are coded. The correct codes to assign for each procedure are:
30375-10 [887] Suture of perforated ulcer, for the suture of the ulcer
30375-19 [901] Other repair of small intestine, for the omental patch


Query Text:
Some of our gastroenterologists are performing capsule endoscopy as a day case by inserting a pill capsule that contains a camera during a visit to theatre after they have performed the gastroscopy/colonoscopy.  This is performed  when further investigation of the small bowel is required. 

During the visit to the endscopy suite the camera is directly implanted into the duodenum.  The camera isn't removed, it is naturally expelled in bowel movements.

The reporting and analysis of the results is performed in the Doctors rooms.

Currently we are assigning the code 11820-00 Panendoscopy via camera capsule.

The application of the code influences DRG assignment in version 5.1 and 6x.

Can you confirm that the code should be assigned when the capsule camera is directly implanted during an endoscopy.

Response:
VICC advises that for the case cited, it is correct to assign a code for the insertion of the capsule camera in addition to the gastrosopy/colonoscopy code as the insertion of the capsule camera is a separate procedure and not a procedural component of the gastroscopy/colonoscopy.

VICC notes that the code 11820-00 [1005] Panendoscopy via camera capsule influences the DRG assignment in AR-DRG Versions 5.1 and 6x because of the backward mapping to an 'OR' procedure code when the code was created.  In Version 7.0 and later of AR-DRG where no mapping to another code is required, the code 11820-00 [1005] has no influence on DRG outcome.

Therefore in the case described, the case will group to the 'Other' partition in MDC 06 in AR-DRG Version 7.0 because of the gastroscopy code and the camera capsule code will have no impact.


Query Text:
Can you please clarify the application of ACCD Coding Rule published in March 2014 titled Situational Crisis.  The query says
Where 'situational crisis' is documented, coders should look for documentation within the clinical record or seek clarification from the treating clinician to determine if the patient has a condition classifiable to Chapter 5 Mental and behavioural disorders (F00-F99) for example, an acute stress reaction or an adjustment disorder.

If documentation or clinical advice clarifies that the patient has a mental or behavioural disorder, assign an appropriate code from F00-F99. 

Does there have to be a direct link/relationship between the patient's situational crisis and the patient's chapter 5 mental & behavioral disorder?

For example
1. Patient admitted for situational crisis with past history of depression.  Depression medication altered during admission.  Should the principal diagnosis be R45.89 Other symptoms and signs involving emotional state or F32.90 depression or should both be coded?

2.If a patient is admitted with situational crisis due to relationship issues and is documented as having associated conditions Alcohol dependence (which meets ACS002).  Should the principal diagnosis be situational crisis R45.89 Other symptoms and signs involving emotional state or F10.2 (as this is a condition classifiable to Chapter 5) or should both be coded?

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

Situational crisis is a culturally acceptable, normal reaction to a stressful life event, such as the death of a family member or threatened job loss.

If, however, the symptoms are ongoing, beyond normal, acute stress or are more intense, it becomes a problem of adjustment and the ongoing symptoms are now considered to have developed into a disorder. This may be described as a situational crisis, but the main problem is one of adjustment.

Where 'situational crisis' is documented, coders should look for documentation within the clinical record or seek clarification from the treating clinician to determine if the patient has a condition classifiable to Chapter 5 Mental and behavioural disorders (F00-F99) for example, an acute stress reaction or an adjustment disorder classifiable to category F43 Reaction to severe stress, and adjustment disorders.

If documentation or clinical advice clarifies that the patient has a mental or behavioural disorder, assign an appropriate code from F00-F99.

When clinical advice is unavailable or there is uncertainty regarding whether the patient has an acute stress reaction or adjustment disorder, assign R45.89 Other symptoms and signs involving emotional state.

Improvements to the Alphabetic Index will be considered for a future edition of ICD-10-AM.[end of ACCD response].

VICC interprets the ACCD response to mean that there needs to be a documented relationship between the patient's mental health condition and the situational crisis before a code from F00-F99 can be assigned as principal diagnosis.  Clinical coders should not assume that the patient's mental health condition is the underlying cause of the situational crisis.  

In the absence of supporting documentation or documented clinical clarification R45.89 Other symptoms and signs involving emotional state is assigned as principal diagnosis and an additional code for the patient's mental health condition is assigned if it meets ACS 0002 Additional diagnoses.

Where the documentation supports a relationship between the situational crisis and the mental health condition a code for the condition can be assigned as principal diagnosis and R45.89 Other symptoms and signs involving emotional state is not assigned.


Query Text:
Can the VICC please provide guidance for assigning a procedure code when a code under the lead term or sub-term does not exist and clarification by the clinician is not available.

For example, there is no index classification for drainage of a parapharyngeal abscess.
1. What steps should be followed to assign a procedure code?
2. Can you default to index classification procedure, anatomical site?

Please note there is no index entry for procedure, parapharyngeal.

3. In this case would you assign 9014700 [422] Other procedure on pharynx by following the index classification, procedure pharynx, which is the closest anatomical site?

Search Details:
ICD-10-AM Tabular list, Conventions used in the tabular list of disease, 
page xxi, examples 32 and 33

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

1. ACHI does not contain guidelines for instances when there are no specific index entries listed in the Alphabetic Index. Clinical coders are advised to apply the guidelines in the Guidance in the use of ACHI, and where necessary seek clinical advice in order to clarify the procedure performed. If necessary a public submission may be submitted to update the classification for a future edition.

2. For the scenario cited (drainage of parapharyngeal abscess), clinical advice supports the assignment of either of the following codes (as appropriate) as a best fit:
31409-00 [421] Excision of parapharyngeal lesion by cervical approach
31412-00 [421] Excision of recurrent or persistent parapharyngeal lesion by cervical approach [end of ACCD response].

Given the advice above, VICC advises that when there are no specific Index entries listed in the ACHI index for a specific procedure, coders should in the first instance seek clinical advice to inform their assignment of a ‘best fit’ code. A query to VICC must then be submitted to have the code selection ratified by referral to ACCD, as the ACCD is the authority to provide ‘best fit’ code advice.


Query Text:
We are enquiring in regards to Extra-corporeal Membrane Oxygenation (ECMO) Coding (90225-00) due to its own speciality DRG A40A/ A40B and significant WIES Funding:
 
If we have a patient that is being retrieved from our hospital by the retrieval team and ECMO is initiated prior to transfer (discharge), what would be the answer to the following…..
1.       Can we code this intervention?
2.       Is there a time limit or any parameters from initiation?
 
Our hospital had two episodes with ECMO Retrieval Process involved, with the following documentation in one of our episodes of care - *The Cannulation of the ECMO was undertaken by the Alfred ECMO Specialist Team*

Response:
VICC advises that as the Extra-corporeal membrane oxygenation (ECMO) was initiated prior to separation from your site, a code for the ECMO can be assigned by your site.


Query Text:
Scenario 1: Patient admitted for treatment of chronic active kidney transplant rejection with IV methylprednisolone.

Scenario 2: Patient admitted for biopsy of transplanted kidney for ? rejection with diagnosis of chronic rejection on histology.

According to the new Index entry in Ninth Edition below, we should code these to chronic kidney disease, however this doesn't seem appropriate when the admission is for treatment or investigation of the rejection, not the CKD.

Failure, failed
- transplant T86.9
- - kidney
- - - acute T86.1
- - - chronic (irreversible) - see Disease/kidney/chronic

It seems that this index entry was added due to the Coding Rule below, however it seems like there should be more options in the index.  Can you please confirm that the index entry to code CKD should be followed in these scenarios?

Ref No: TN197 | Published On: 15-Mar-2010 | Status: Current  
Kidney transplant failure/kidney transplant status
Q:
A patient admitted to hospital is noted to have had a previous renal transplant which had failed and the patient was now requiring dialysis. Should kidney transplant failure be assigned or kidney transplant status?
A:
Hyperacute rejections of transplanted kidneys are immediate and acute rejection is highest in the first three months after transplantation.  However, acute rejection can also occur months to years after transplantation. Chronic transplant rejection is irreversible and cannot be treated effectively. When deciding whether to code kidney transplant failure or kidney transplant status the coder should attempt to determine, from the information in the clinical record, whether the failed transplant is chronic and irreversible or in an acute rejection phase. Acute rejections will likely be the focus of the admission with the objective being the treatment of the rejection. For chronic irreversible kidney transplant rejection, the patient is likely to be on maintenance dialysis to treat the CKD stage 5. Therefore, T86.1 Kidney transplant failure and rejection should only be assigned for acute kidney transplant rejections that meet the criteria for code assignment as per ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses. Z94.0 Kidney transplant status should be assigned as per the following advice in ACS 1438 Chronic kidney disease, Kidney replacement therapy which states:
"For patients who have received a kidney transplant and documentation pertaining to this status satisfies criteria for coding under ACS 0002, assign Z94.0 Kidney transplant status together with N18.3 Chronic kidney disease, stage 3 or higher, as indicated by an eGFR level." Therefore, for a patient with a failed kidney transplant who is now requiring dialysis, as per the scenario cited, assign Z94.0 Kidney transplant status in addition to N18.5 Chronic kidney disease, stage 5. If it is impossible to determine whether the transplant rejection is acute or chronic, then the coder should seek clarification from the clinician.
(Coding Matters March 2010 Volume 16, Number 4).

Response:
VICC advises that it is correct to follow the Index entry Failure/transplant/kidney/chronic - see disease/kidney/chronic for the scenarios cited in the query as both scenarios have chronic transplant rejection documented.  Although the code title at T86.1 is Kidney transplant failure and rejection, the Index only allows this code to be assigned for acute kidney transplant rejection.

Therefore only assign CKI stage 3 or higher with the addition of kidney transplant status code as per ACS 1438 Chronic Kidney Disease.

You may wish to write a public submission to ACCD suggesting the Index entries be reviewed.


Query Text:
Should a code from P07.0- Extremely low birth weight or P07.1- Other low birth weight be routinely assigned in the birth episode for all babies weighing less than 2500g at birth or do the actual words low birth weight (in prematurity) or similar need to be documented?

Coding Rule Q2648 Low birth weight and prematurity states that codes for both birth weight and gestational age should be assigned when the documentation is available.  However example 1 in ACS 1605 only states birth weight 1300 and 
P07.12 (Other low birth weight 1250-1499g) has been assigned.

It is possible to get to these codes following Index:
Weight
- 499 grams or less at birth P07.01
- 500-749 grams at birth P07.02
- 750-999 grams at birth P07.03
- 1000-1249 grams at birth P07.11
- 1250-1499 grams at birth P07.12
- 1500-2499 grams at birth P07.13

Search Details:
Coding Rules Q2648 - Low birth weight and prematurity (15 Dec 2012)
ACS 1605

Response:
VICC advises that a code for low birth weight is only routinely assigned for babies who are premature.   This is in accordance with ACS 1618 Low birth weight and gestational age, which says 'a code for low birth weight at normal gestational age should only be assigned on the infant's record when this is documented by the obstetrician/clinician/midwife and meets the criteria of an additional diagnosis'.  

P07.12 Other low birth weight 1250–1499g was assigned in example 1 of ACS 1605 Conditions arising in the perinatal period, because the baby was premature.


Query Title:
Mechanical ventilation in patients with a tracheostomy

Query Text:
Could the committee please clarify application of the changes to ACS 1006 Ventilatory support for patients with a tracheostomy?

The standards states that "where there is documentation of weaning from CVS, such as the use of positive pressure ventilation or oxygen delivery via a tracheostomy collar, include the weaning in the duration of CVS up to a maximum of 24 hours following the cessation of CVS, or the removal of the tracheostomy"

When a patient is then commenced on CVS after a period of 24 hours, our confusion relates to when we stop counting again. If the patient receives 2 hours of CVS (following cessation for >24 hours) and no further evidence of CVS, does the count of CVS for coding and reporting include an additional 24 hours to the 2 hours providing there is evidence of weaning?

Search Details:
ACS 1006 Ventilatory Support
ACCD 9th edition education tutorial

Response:
As per ACS 1006 Ventilatory support under heading Cessation of CVS for patients with a tracheostomy (after any period of weaning) provided there is evidence of weaning, a maximum of 24 hours can be added to the duration of CVS. 

Therefore in the scenario cited, the documented hours of weaning up to a maximum of 24 hours can be added to the two hours of CVS following the cessation of CVS.

Please note that VICC currently has a query with ACCD seeking clarification about the definition of weaning.


Query Title:
ACS 0003 Supplementary codes for chronic conditions

Query Text:
ACS 0003 states that U codes for chronic conditions are only to be assigned where it is evident that the condition is part of the current health status of the patient.  We have taken this to mean that if a condition is incurable it can be assigned a U code. To avoid coders having to make this decision we have put together the following list of conditions that our research indicates cannot be cured (which has been confirmed by a clinician). The conditions listed as can be cured or unclear require the coder to confirm that they are current.

Cannot be cured:
CF, Schizophrenia, Disorders of intellectual development (with the exception of developmental delay), Parkinson's, MS, CP IHD, Chronic heart failure (except by transplant), Emphysema, COPD, Asthma, Bronchiectasis, Crohn's disease, RA, OA, SLE (but can have periods of remission), OP, CKD, Spina bifida, Down's syndrome, Dementia documented as Alzheimer's

Can be cured, therefore you need to find further information that this is a current condition:
Epilepsy, Obesity, Plegias Ulcerative colitis

Unclear, therefore you need to find further information that this is a current condition:
Depression, Dementia not documented as Alzheimer's, HT not documented as essential, Chronic respiratory failure (unlikely to be cured but depends on underlying cause. Possible cure by transplant), Chronic liver failure (unlikely to be cured but possibly by transplant)

This query was sent to ACCD but didn't appear in the FAQs.

1.Do you support this approach?

2.The advice in ACCD Coding Rule TN907 appears contradictory as it says that where it is unclear if the condition is continuing in the patient, follow the guidelines in ACS 0003 Supplementary codes for chronic conditions and do not assign a U code. But in the example given a U code is assigned for hypertension even though there is no evidence that it is a current condition. Should hypertension always be coded when documented?

Where a patient episode is documented with a past medical history of hypertension, IHD and OA, all of these conditions should qualify. However, where it is unclear if the condition is continuing in the patient, follow the guidelines in ACS 0003 Supplementary codes for chronic conditions and do not assign a U code.

3.In the example in Coding Rule TN907 a U code has not been assigned for asthma as it has not occurred since the patient was a teenager. However, the Asthma Foundation website says that asthma is incurable. What evidence do coders need to look for in order to determine that asthma is part of the current health status?

4.Coding Rules also state that not all chronic conditions are managed with ongoing medication and so it is not necessary to review medication charts to inform code assignment.  Some coders are looking up medications to verify whether a chronic condition is current (eg documentation of hypertension in notes and Coversyl listed on medication chart, but not documented as the treatment for HT).  Can we make the link between a drug (whether or not on a medication chart) and a condition to allow assignment of a U code, e.g. U82.3 Hypertension?

Search Details:
ACCD Coding Rules Ref No:TN907, Published 15 Sept 2015

SUBJECT: ACS 0003 Supplementary codes for chronic conditions
Q:
What documentation can be used to assign supplementary codes for chronic conditions (U codes)?

Q:
Do conditions listed under the heading of past history or background/problems qualify?

Q:
Do conditions need to be medicated to prove they are current?

A:
Clinicians may use the heading past history to represent conditions or procedures etc. occurring in the past, including the recent past. Therefore, conditions listed under such headings may be part of the current health status of the patient and should not be excluded based on the heading.  However, conditions listed in previous admissions and correspondence, but not listed in the current episode of care are not to be used (as per Coding Rule Coding from documentation in previous admissions).

Not all chronic conditions are managed with ongoing medication and so it is not necessary to review medication charts to inform code assignment. ACS example 5 highlights asthma as a child with no further documentation as to its relevance for the adult.

Where a patient episode is documented with a past medical history of hypertension, IHD and OA, all of these conditions should qualify. However, where it is unclear if the condition is continuing in the patient, follow the guidelines in ACS 0003 Supplementary codes for chronic conditions and do not assign a U code.

In the example above, a U code would only be assigned for hypertension as childhood asthma has not occurred since a teenager and ischaemic heart disease is only queried.

Response:
VICC cannot support the approach detailed in the query as in order for a supplementary code for chronic conditions to be assigned, the condition must be documented in the episode and the condition must also be indexed under the Lead term Supplementary codes. The decision to assign a code must be based on documentation of the condition rather than a list.   

Errata 3 for Ninth Edition includes an additional sentence to ACS 0003 Supplementary codes for chronic conditions which says 'the U codes represent chronic conditions that may be assumed to be current unless there is documentation that indicates otherwise'. 

Refer also to VICC query #3046 U code for overweight for further information on coding of supplementary codes for chronic conditions.


Query Text:
Coding Rule Q2880 and VICC #2820 state that it is not necessary to assign an additional code for suturing of a wound at the same site as an excisional debridement.

Scenario 1
Discharge summary: Lower lip laceration. OT - Repair lower lip laceration. 
Operation findings: Laceration left angle oral commisure involving skin, mucosa and muscle.
Procedure details: Washout, debridement and exploration. Repair of muscle with 5-0 Monocryl. Repair of skin and mucosa with 6-0 CG.

Should both debridement of skin and repair of lip wound (full thickness) be coded in this scenario as the repair involved a deeper structure than the debridement (even though it's of the same site)?

Scenario 2
Discharge summary: Left lower lip lacerations. Debrided and repaired in theatre. Absorbable sutures.
Operation findings: Lower lip dry mucosa and cutaneous skin laceration
Procedure details: Debrided wound edges. Closure 5.0 vicryl rapide lower lip and cutaneous lower lip.

Is it correct to only code debridement of skin in this scenario as the documentation suggests that the method of repair was suture and the repair/suture and debridement were of the same site?

Scenario 3
Discharge summary: Multiple facial lacerations repaired.
Operation findings: Laceration of nose, cheek and lower lip.
Procedure details: Cleaned and debrided. Cheek and lip repaired with 5.0 vicryl rapide.

As there is no documentation of suture should codes be assigned for repair of wounds of face and lip in addition to debridement of skin in this scenario?

Search Details:
ACS 1203 Debridement
ACS 1217 Repair of wound of skin and subcutaneous tissue
Coding Rule Ref No Q2880 Debridement of skin with suturing (March 2015)
VICC # 2820 Excisional debridement of skin (2013-14 September database)

Response:
VICC considers that a code for the suture in addition to the debridement code is not required, regardless of the depth of the debridement, as the suture is a component of the procedure.  This is in accordance with ACS 0016 General procedure guidelines under section titled 'Procedural components' and ACCD Coding Rules Q2880 titled Debridement of skin with suturing published in March 2015.  Please note that whilst the title of Q2880 includes the term 'skin', the advice applies to excisional debridement of any site.

With respect to scenario one of the query, based on the information provided, VICC suggests that the debridement may be of soft tissue rather than skin.


Query Text:
Are all complications that meet ACS 0001/0002 that occur during a procedure, by definition always to be coded as a 'misadventure'? 

For example if an intraoperative complication such as 'intra-operative hypotension due to a procedure' is documented and requires extra treatment would the external cause code be a Y65.8 (other specified misadventure during surgical or medical care ) or a code from the Y83 range (Surgical operation and other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the produre).

There is some disagreement as to whether ANY complication that occurs during a procedure should be coded as a misadventure because it has occured intraoperatively.

Response:
VICC advises that when a complication occurs during a procedure and meets criteria for coding, the correct external cause code to assign is from range Y60 - Y69 Misadventures to patients during medical and surgical care.  This in accordance with ACS 1904 Procedural complications which says 'A code from block Y60 - Y69 Misadventures to patients during medical and surgical care should be assigned when the complication occurs during a procedure'.  This is also supported by ACCD advice titled Procedural complications (Ref no: TN202 Published on: 15 Dec 2008 Status: Current) reproduced in part below: 

Q: 
The following issues were raised regarding the coding of procedural complications: 
- Coding of CVAs, MI, haemorrhages, hypertension which occur during a procedure (ie intra-operatively) - are these classified to T81.8 Other complications of procedures, not elsewhere classified then the external cause being a misadventure or is the condition really a result of an existing condition and therefore just use the specific chapter code without an external cause code? 
- If the condition doesn't meet the definition for a procedural complication then should the condition be coded in its own right and therefore a T code is not assigned? 
- What codes should be assigned for an intra-operative haemorrhage? - a T code plus a Misadventure external cause code as per ACS 1904 Procedural complications, Definition of a misadventure. 
A: 
If the intraoperative event e.g. haemorrhage, MI, CVA etc meets: 
- the definition of an additional diagnosis as per ACS 0002 Additional diagnoses and 
- the definition for a procedural complication as per ACS 1904, (ie is directly related to the surgical/procedural intervention) 
then for the diagnosis code, apply ACS 1904 and follow the index lookups. This means that the first diagnosis code could come from either the end of chapter codes or the T code section. The next code in the string will indicate the condition/problem ie MI, CVA etc and an external cause code will be assigned from Y60-Y69 Misadventures to patients during surgical and medical care, refer to examples 17 and 18 in ACS 1904.[end of ACCD advice] 

With regard to the last point in the query, please note that a condition which arises during a procedure is not always a complication. The condition would need to meet ACS 0002 Additional diagnoses and the definition of procedural complication in ACS 1904 Procedural complications before it can be coded.


Query Text:
Can you please advise how to correctly code CANVAS? This syndrome has three components of:
- cerebral ataxia (CA)
- peripheral nerve damage (N neuropathy)
- vestibular areflexia (VA)
and has been documented by clinicans as the reason for a couple of our patients' falls.  Do we code out these three conditions separately?

Response:
VICC research concurs with the enquirer in that patients with CANVAS combine cerebellar ataxia (i.e. coordination problems -- the CA), peripheral nerve damage (neuropathy - N), and loss of vestibular function (vestibular areflexia -- the VA). This combination causes major disturbances to balance as each of these systems contributes to balance. 

VICC advises to code out all the manifestations in accordance with ACS 0005 Syndromes which states that when multiple codes represent the syndrome, assign codes for the manifestations that are relevant for the patient.  

Therefore for a patient with a diagnosis of CANVAS VICC advises to assign all of the following codes:
G11.9 Hereditary ataxia, unspecified following Index entry Ataxia, ataxy, ataxic /cerebellar (hereditary)

G62.9 Polyneuropathy, unspecified following Index entry Neuropathy, neuropathic/ peripheral (nerve) 

H81.8 Other disorders of vestibular function following Index entry Disorder/vestibular function/specified NEC as the condition is that of loss of vestibular function. Lead term 'Disorder' was followed in the absence of a subterm 'areflexia' under lead term 'Disease' and in the absence of a lead term 'Areflexia', as per the Conventions used in the Tabular List of Diseases under section 'Other' and 'Unspecified' codes in the ICD-10-AM Disease Tabular List.

Eleventh Edition ACS 0005 Syndromes advises to assign U91 Syndrome, not elsewhere classified, as an additional diagnosis to flag that the manifestations are related to a syndrome.


Query Text:
VICC #2486 Late termination of pregnancy was retired on 1 July 2015 with the introduction of Ninth Edition 
ICD-10-AM/ACHI/ACS.

Can this query please be reviewed to be reinstated.  More so the first part of the query than the last part.

Response:
VICC considers that the advice in #2486 Late termination of pregnancy is still applicable and is reproduced below:

Query:
Can you please advise on what diagnosis codes to assign for the following scenarios, particularly in regards to the abortion codes. 

Admission 1: 
Late termination of pregnancy (31 weeks) for severe IUGR and other abnormalities (cardiac and cerebral). Patient has fetal reduction in this admission, as well as Mifepristone, but no labour or delivery. She is discharged home to return in three days. 

Would we assign the medical abortion code in this admission? If so, is O04.4 Medical abortion, incomplete without complication, appropriate. 

Admission 2: 
The same patient returns three days later for completion of the abortion (so now 31 + 6 days gestation). Prostin is administered but patient is not favourable to ARM. Patient has some uterine tightenings but nothing to suggest labour. Patient is discharged to return the next day. Again, would we assign codes for incomplete medical abortion? 

We are finding this scenario difficult to code. This is because the delivery (abortion) does not occur in the admission. The case is clearly not a failed medical abortion and nor does it seem to be an incomplete abortion but it is rather the process that occurs in a late termination of pregnancy. 

Search Details: 
ACS 1511 Termination of Pregnancy 

Response:
The VICC agrees that for both admissions the appropriate additional code to assign is O04.4 Medical abortion, incomplete, without complication as no aborted products were delivered. Fetal reduction did however take place thus terminating the pregnancy so as per the documentation the index look up for this code would be Termination, pregnancy - see Abortion. 

Please see ACS 1511 Termination of pregnancy for code sequencing. 

Please note that as the patient was told to return in three days for completion of the abortion, VICC considers the patient should have been placed on leave. This is in accordance with the VAED definition of Leave with permission in section 2 of the VAED manual which states 'Leave with permission occurs when an overnight or multi-day patient leaves the hospital temporarily with the approval of the hospital and/or treating medical practitioner, with the intention that the patient will return within seven days to continue the current treatment.'


Query Text:
What is the correct code to assign for documentation of poor feeding?

Can coders assume that poor feeding is synonymous with a feeding problem and follow the Index pathways below to assign R63.3 Feeding difficulties and mismanagement (or P92.- Feeding problems of newborn for newborns)?

Problem
- feeding R63.3
- - newborn P92.9
- - - breast refusal, persistent P92.5
- - - due to
- - - - short frenulum P92.8
- - - - tongue tie P92.8
- - - incoordinate suck P92.8
- - - overfeeding P92.4
- - - slow P92.2
- - - specified NEC P92.8
- - - uncoordinate suck P92.8
- - - underfeeding P92.3

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

Search details:
The only similar advice I could find was this query: 
VICC query #2473 Poor oral intake (2008-09 June Database - retired 30/6/15) 

Query:
What is the correct code to assign for documentation of the following; 

poor oral intake 
decreased oral intake 
po intake (documented with a down arrow) 

all of the above have adequate documentation of treatment and meet ACS 0002 Additional diagnoses. 

We believe this is considered a problem related to feeding, management and difficulties due to a number of reasons related to the patient and hence the correct code to assign is R63.3. Does the VICC agree with this code? 

Response:
The VICC advises that in the absence of documentation of the reason for the poor oral intake, the appropriate code to assign is R63.8 Other symptoms and signs concerning food and fluid intake, which can be reached by following index entry Symptoms specified, involving, food and oral intake.

Response:
VICC agrees that poor feeding is synonymous with a feeding problem and therefore the lead terms 'Problem' or 'Feeding' can be followed in the Index for documentation of poor feeding.


Query Title:
Coding of complications based on routine vs non routine care

Query Text:
We noted the following advice regarding routine care versus non routine care published in HDSS Bulletin, Issue 195 6th May 2015, Item 195.4, please see cited below.

Can you please confirm if this advice should be applied to all complications, not just those that relate to wound ooze (T81.8) and IV catheter complications (T82.5 and T82.8)?

195.4 Routine care versus non routine care 
The March 2015 VICC queries database released on 26 March contains query responses that specifically differentiate routine care versus non routine care.
These queries are:
#2725 Coding of wound ooze in specific examples
VICC referred this query to ACCD who published their response in the December 2014 Coding Rules (titled Wound ooze). VICC has added additional advice to this response to specifically clarify what constitutes routine care and beyond routine care in the management of wound ooze.

#3006 Other complications of intravenous catheters
This query was answered by VICC and clarifies what constitutes routine care and beyond routine care for management of intravenous catheters. This response complements advice published by ACCD in the December 2014 Coding rules titled Q2825 Dislodged and leaking intravenous catheters.

It is important that routine clinical interventions do not result in the coding of complications of care as this has a substantial impact on the monitoring of patient safety and quality outcomes that are increasingly being carried out by the department and the Commonwealth.  Clinical coders are reminded that the coded data has relevance in many areas of the department's business and is not used just to inform the funding models.

The department therefore requires that clinical coders adhere to the instructions provided in these specific queries which relate to codes T82.5, T82.8 and T81.8. The department also requires that coders give due consideration to the principles used in these responses before assigning codes for other types of procedural complications.

The advice in queries #2725 and #3006 is applicable for separations on or after 1 April 2015. The department expects that the advice in Q2825 published by ACCD would have been applied for separations on or after 1 January 2015.

Search Details:
HDSS Bulletin, Issue 195 6th May 2015, Item 195.4
#2725 Coding of wound ooze in specific examples
#3006 Other complications of intravenous catheters

Response:
VICC advises that whilst the instructions in the specific queries detailed in the HDSS Bulletin relates to T81.8, T82.5 and T82.8, the principles used in these responses must always be applied when coding procedural complications.  Some of the principles clinical coders are expected to consider include but are not limited to:
- clinician consultation resulting in a change of patient management
- commencement of antibiotics
- theatre management


Query Text:
A patient presented to our facility for definitive enucleation of a mandibular cyst following initial marsupialisation 12 months prior. However an index entry does not exist for enucleation of a mandibular cyst, jaw cyst etc.

We have therefore been using 30283-00 [403] Excision of cyst of mouth, following the pathway:
Excision:
- cyst
- - mouth (mucocele) (ranula) 30283-00 [403] Excision of cyst of mouth

Could VICC please advise if this is the correct code for this procedure?

Response:
Research undertaken by VICC indicates that mandibular cysts generally arise in the bone.

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


Query Title:
Insertion PEG tube with jejunal extension (PEG-J)

Query Text:
Could you please clarify the correct code(s) to use for Gastroscopy with insertion of PEG tube with jejunal extension (PEG-J). 

The procedure is being done for administration of long term Duodopa for treatment of Parkinson's Disease.

Response:
With this procedure the gastrostomy tube is extended into the jejunum.

VICC therefore considers the correct code to assign is:
30478-05 [892] Percutaneous endoscopic jejunostomy [PEJ] following Index entry Insertion/tube/intestine/small/jejunum — see Insertion/tube/jejunostomy.


Query Text:
What is the correct code to assign for a patient admitted with septic shower? Currently there is no Index entry for Septic shower.  The term Septic leads us to - "see also condition".

According to the internet septic shower is defined as: A septic shower is the sudden systemic influx of pathogens that have colonized in an inserted device triggered by the infusion of fluids into the device causing septic shock in the patient. This is a life threatening condition and requires urgent medical attention.

With the above definition are we able to code sepsis (A40.- and/or A41.-) with R57.2 Septic shock? 

If a patient has a device are we able to assume the sepsis is due to the device and therefore we assign the appropriate T code  with sepsis and septic shock?

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

Septic shower:
• is the sudden systemic influx of colonised pathogens
• most commonly associated with an in situ/implanted device
• often follows infusion of fluids into an in situ/implanted device
• may result in septic shock.

Where septic shower is documented as associated with the presence of a device, assign an appropriate code from T82-T85 by following the Alphabetic Index at Sepsis/due to/device, implant or graft/by type of device.
Assign codes for sepsis and septic shock as per the guidelines in ACS 0110 SIRS, sepsis, severe sepsis and septic shock. Assign external cause and place of occurrence codes, as applicable.
Amendments will be considered for a future edition of ICD-10-AM.
[End of ACCD response]

Further to the ACCD advice,  VICC advises to follow the guidelines in ACS 0110 SIRS, sepsis, severe sepsis and septic shock  to assign a code for sepsis when septic shower is documented. A additional code for septic shock can be assigned only when septic shock is documented in the record. If it is unclear whether the patient has septic shock then a clinician query can be sent for clarification.


Query Title:
Principal diagnosis for bone marrow biopsy

Query Text:
A patient was admitted, as a same day admission to our hospital for a bone marrow biopsy.

Could you please clarify how best to select the Principal Diagnosis for the following bone marrow biopsy results.
We are unable to seek further clinical advice and the reports are the only documentation we have.  The report offers two possible diagnoses and we are uncertain which of the two diagnoses to select as the two diagnoses described result in the 
allocation of two separate diagnosis codes:

MDS (myelodysplastic syndrome) D46.2 & M9983/3
Or
AML (acute myeloid leukaemia) C92.00 & M9861/3

The following report results are included for your review:

Histology conclusion :
Markedly hypocellular with trilineage dysplasia and increased blasts, consistent with the diagnosis of (hypocellular) Myelodysplastic syndrome. WHO subtype: RAEB-2.
Please correlate with cytogenetics and flow cytometry reports. (see below)

Flow cytometry results:
The findings could be consistent with Myelodysplastic Syndrome or Acute Myeloid Leukemia.

Could you please advise:
1. Do we code one of the possible diagnoses, if so which one?
2. Do we code both diagnoses?
3. Or do we return to the clinical indication for the BMAT which was Anaemia with erythroblastic picture?

Response:
Based on the information provided in the query, VICC considers that only a code for the myelodysplastic syndrome should be assigned.  This is because the histology conclusion supports a diagnosis of myelodysplastic syndrome which is further supported by the flow cytometry result and the clinical indication.


Query Title:
Bone graft with open reduction with internal fixation (ORIF)

Query Text:
Can the committee please give advice on the correct bone graft code to assign, when the graft is performed in conjunction with an ORIF.
The lookup is:
Graft 
- bone 48239-00
- - with
- - - internal fixation NEC 48242-00

If you also look up:
Graft
-bone
 - - specified site NEC 48239-00 
- - - with internal fixation NEC 48242-00 

Is it correct to just code the bone graft as the internal fixation is already included in the ORIF procedure or should we use the bone graft with internal fixation code 48242-00 to give more specificity?

Response:
VICC advises that there is no classification advice which precludes the assignment of both the open reduction with internal fixation (ORIF) as well as the bone graft with internal fixation provided the bone graft is of the same site as the internal fixation.  Therefore if the internal fixation relates to the open reduction and the graft, it is appropriate to assign 48242-00 [1569] Bone graft with internal fixation, not elsewhere classified in addition to the ORIF code.

However, if the bone graft was not at the same site as the ORIF, 48242-00 [1569] Bone graft with internal fixation, not elsewhere classified would not be assigned, instead a code for the bone graft without internal fixation would be assigned.


Query Title:
Transcatheter transapical mitral valve replacement via thoracotomy

Query Text:
TWELVE TAMAR (transapical mitral valve replacement using the TWELVE delivery system) is a new procedure being performed at our health service which involves thoracotomy and implantation of a mitral valve replacement bioprosthesis via an incision at the apex of the heart using a catheter.

The attached example includes an operation report where the title of the procedure is a transcatheter mitral valve replacement.  Some transcatheter aortic valve replacements (e.g. TAVR/ TAVI/ Corevalve) can also be performed via hemisternotomy.

Index:  
Implant, implantation
- heart valve, transcatheter -  See Insertion/valve/heart/percutaneous with bioprosthesis.

Index:  
Replacement
- valve
...
- - heart
- - - mitral
- - - - with
- - - - - bioprosthesis 38488-03 [628]
- - - - - - percutaneous 38488-09 [628]

Which Index entry should we follow as this is not only a percutaneous procedure?

Should there be new codes to capture open transcatheter valve replacements?

Response:
VICC considers that because a thoractomy was performed, this is an open procedure even though there was a transcatheter replacement of the valve.

In accordance with the documentation of replacement, VICC advises to follow Index entry Replacement/valve/heart/mitral/with/bioprosthesis, to arrive at 38488-03 [628] Replacement of mitral valve with bioprosthesis and not select subterm percutaneous given that a thoractomy was performed.

You may wish to consider submitting a public submission to ACCD for creation of new codes that combine percutaneous replacement of heart valves with thoractomy.


Query Title:
Fluid overload with current congestive cardiac failure (CCF)

Query Text:
Can the committee please confirm if both CCF and fluid overload codes can be assigned when both conditions are treated during an episode of care?  Retired Coding Matters Volume 7 No 3 under Congestive heart failure advised it is not necessary to code fluid overload in a patient with CHF.

Retired VICC query #2247 refers to the advice above adding 'However if a patient has a history of CCF, it does not mean that they have it now'. Both national and Victorian advice are retired as of 30 June 2013.

Can the committee please advise the correct code assignment for the below scenarios.

Scenario 1
Patient admitted with a principal diagnosis of congestive cardiac failure. The 3rd page of the discharge summary lists fluid overload as a problem initially fluid overloaded on admission diuresed to good effect. IV Frusemide 80 mg TDS initially 20mg oral frusemide on DC. The chest x-ray notes fluid overload and the doctors have written in the notes 
Imp: diastolic heart failure. Doctors later note the patient has refractory angina, CCF. On the day before discharge the doctors note HF relax fluid restriction to 2L, Frusemide to 20mg daily.

Scenario 2
Patient admitted with a principal diagnosis of fluid overload secondary to non-compliance with fluid restriction. There is documentation in the clinical notes of CCF on frusemide then later fluid overload  IV frusemide. Doctors note Imp: infective exac CCF +  fluid intake. Patient is on a 1.5L fluid restriction as well.

Response:
VICC advises that if the documentation supports that both the fluid overload and the congestive cardiac failure independently meet criteria for coding, a code for both conditions can be assigned.  Sequencing of the codes will be in accordance with ACS 0001 Principal diagnosis and ACS 0002 Additional diagnosis.

With respect to scenario 1 VICC considers that only the CCF would be coded because it is the documented principal diagnosis and there is no indication that the fluid overload was treated independently of the CCF.

With respect to scenario 2, VICC considers the fluid overload would be assigned as principal diagnosis as it is the documented principal diagnosis, followed by the code for non-compliance. As the documentation also notes that the patient is on Frusemide for CCF and that the Frusemide was altered, a code for the CCF should be assigned in addition in this case.


Query Text:
We have recently had two PICQ (Fatal) errors because we have coded two different severity degrees for a patient's haemorrhoids. It is clearly documented that the patient's internal haemorrhoids (second degree) were treated with a banding procedure and the fourth degree were treated with a haemorrhoidectomy. We therefore don't see why both degrees should not be coded accordingly.  If we only code the most severe degree the procedure coding will appear a bit odd as there is a procedure related to a diagnosis which has not been coded. Could you please clarify how we should code different degrees of haemorrhoids.

Search Details
Coding Rules (Oct 2013) states that, clinical advice indicates that it is only necessary to assign one code for the most severe haemorrhoid grade.

Response:
As you have noted, in accordance with the Coding Rules advice published in October 2013 titled Haemorrhoids, as part of the Eighth Edition Education Workshop FAQs - Part 1, clinical advice indicates that it is only necessary to assign one code for the most severe haemorrhoid grade.

This advice applies regardless of whether different procedures are performed.  

The PICQ indicator has therefore triggered correctly as it follows the Coding Rules advice.

You may wish to consider submitting a public submission to ACCD requesting an amendment to the coding rule to allow the coding of different haemorrhoid degrees when different procedures are performed.


Query Text:
Re VICC query # 3043.  I question the response to this query.  

I believe the correct code for a groin haematoma at a cardiac or vascular catheterisation site where there is no stent (or other prosthetic device, implant or graft) is T81.0 as the exclusion at this code is only for haemorrhage due to or associated with prosthetic devices, implants and grafts (T82.8, T83.8, T84.8, T85.8-).  Where the catheterisation involves stenting T82.8 is correct.

Response:
This query was originally published in the 2016-17 September VICC queries database release as follows:

As the catheter is a type of vascular device, VICC confirms that the correct code to assign for groin haematoma at catheterisation site is T82.8 Other specified complications of cardiac and vascular prosthetic devices, implants and grafts as per the excludes note at T81.0 Haemorrhage and haematoma complicating a procedure, not elsewhere classified and Index entry Haemorrhage/due to or associated with/device, implant or graft/vascular NEC.  

Assignment of T82.8 is further supported by Coding Rules Q2736 Conventions used in the Tabular List of Diseases, 2nd question titled Postprocedural complications - haemorrhage/haematoma updated 1 July 2015 which says:
"To classify a haemorrhage/haematoma due to or associated with prosthetic implants, devices and grafts assign one of the following codes as appropriate:
T82.8  Other specified complications of cardiac and vascular prosthetic devices, implants and grafts
T83.8  Other complications of genitourinary prosthetic devices, implants and grafts
T84.8  Other complications of internal orthopaedic prosthetic devices, implants and grafts
T85.81 Other complications due to nervous system device, implant and graft
T85.88 Other complications of internal prosthetic device, implant and graft, NEC

There doesn't need to be a cause and effect relationship stated between the haemorrhage/haematoma and the device, implant or graft".

Please note that the provision of this advice is not intended to mean that a groin haematoma at catheterisation site is always coded as a  procedural complication.  Refer to VICC #3081 Coding of complications based on routine vs non routine care published in the 2015-16 December Database for instructions on coding of procedural complications based on routine interventions.

Following publication of March 2017 Coding Rules the original response is superseded by the following advice titled Complications of prosthetic devices, implants and grafts/haematoma following cardiac catheterisation:

Q:
How do you code haematoma following cardiac catheterisation? Is code assignment different if a device (eg stent) has been inserted via cardiac catheterisation?

A:
For post procedural groin haematoma following cardiac catheterisation, assign:
T81.0 Haemorrhage and haematoma complicating a procedure, not elsewhere classified 
Y84.0 Cardiac catheterisation (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

For post procedural groin haematoma following cardiac catheterisation with insertion of cardiac stent, assign:
T82.8 Other specified complications of cardiac and vascular prosthetic devices, implants and grafts 
Y83.1 Surgical operation with implant of artificial internal device
Y92.22 Place of occurrence, health service area

The following should also be noted:
- There is a difference between cardiac catheterisation as operative approach for insertion of a device and as a diagnostic procedure (see also Coding Rule (Q3070): External cause code for complication of percutaneous angioplasty with stenting of coronary arteries)
- Haemorrhage/haematoma is classified similar to complications such as embolism, fibrosis etc, and as per the guidelines in ACS 1904 Procedural complications 
- Assign T82-T85 Complications of prosthetic devices, implants and grafts regardless of whether a cause and effect relationship is stated between the complication and the prosthetic device, implant or graft. However, where documentation specifies that a complication is related to a specific cause, assign codes for complications of the documented cause not the prosthetic device, implant or graft. For example:

- shoulder pain from laparoscopy gas following insertion of Filshie clips;  code the pain as a complication of the laparoscopy, not a complication of the Filshie clips

- bleeding from endotracheal (ET) tube post general anaesthetic for joint replacement; code the bleeding as a complication of the endotracheal tube, not the joint replacement.

(See also Coding Rule (Q2736): Conventions used in the Tabular List of Diseases).

Following publication of September 2018 Coding Rules and in line with Tenth Edition the original response is superseded by the following advice titled Haematoma following cardiac catheterisation:

Q: How do you code haematoma following cardiac catheterisation? Is code assignment different if a device (eg stent) has been inserted via cardiac catheterisation?

A: Cardiac catheterisation may be performed:
- alone, as a diagnostic procedure, where the catheter is inserted into the heart chambers and valves to perform various tests
- with insertion of dye into the coronary arteries to evaluate coronary artery disease (ie coronary angiography)
- with a catheter based intervention, where the cardiac catheterisation serves as a guiding catheter (eg percutaneous coronary angioplasty with stenting).

For post procedural groin haematoma following cardiac catheterisation performed as a diagnostic procedure or with coronary angiography, assign:

T81.0 Haemorrhage and haematoma complicating a procedure, not elsewhere classified
Y84.0 Cardiac catheterisation (as the cause of abnormal reaction, or of later complication, without mention of unintentional events at the time of the procedure)
Y92.24 Health service area, this facility

For post procedural groin haematoma following cardiac catheterisation performed with a catheter based cardiac intervention (eg insertion of cardiac stent), assign:

T82.81 Haemorrhage and haematoma following insertion of cardiac and vascular prosthetic devices, implants and grafts
Y83.1 Surgical operation with implant of artificial internal device
Y92.24 Health service area, this facility

Published 15 September 2018, for implementation 01 October 2018.


Query Title:
Chest pain following touching an electric fence

Query Text:
Principal diagnosis is documented as chest pain following touching an electric fence.  

There were no injuries sustained and no other documentation of injury.  

I have queried with the doctor who is stating that chest pain is the diagnosis.   Am I able to put a non injury code with external cause codes?  Would this create a fatal in PICQ?

Response:
Based on the information provided which states that the principal diagnosis is 'Chest pain following touching an electric fence' VICC advises to assign T75.4 Effect of electric current as the principal diagnosis following Index entry Effect, adverse/ electric current, electricity (shock).  R07.4 Chest pain can be assigned as an additional diagnosis to provide  specificity of the manifestation, followed by the appropriate external cause, place of occurrence and activity codes.

However, if there is evidence in the clinical notes that the chest pain is unrelated to the contact with the electric fence assign R07.4 Chest pain as the principal diagnosis.

In accordance with ACS 2001 External cause code use and sequencing, external cause codes may also be used as additional codes with conditions classified in chapters other than Chapter 19 'Injury, poisoning and certain other consequences of external causes'.   

If it is established that the chest pain is unrelated to contact with the electric fence an external cause code would not be assigned with R07.4 Chest pain.


Query Title:
Gastrostomy and other artificial opening status codes

Query Text:
A common scenario arising in our hospital is where an inpatient with a PEG (inserted in a prior admission) is administered their feeds and/or medications through the PEG.

(a) Does this meet ACS 0002 and is it therefore appropriate to assign Z93.1 Gastrostomy status for these patients?
(b) If Gastrostomy status does not meet ACS 0002 criteria to code in this scenario, under what circumstances could the Gastrostomy status code be assigned?
(c) Can your answers to (a) and (b) above be extrapolated to the assignment of the remaining Artificial Opening Status codes from Z93?

References:
Z93		 Artificial opening status
Excludes:	
artificial openings requiring attention or management (Z43.-)
complications of external stoma (J95.0, K91.4, N99.5)

Z93.1		 Gastrostomy status

Z43		 Attention to artificial openings
Includes:		 
closure
passage of sounds or bougies
reforming
removal of catheter
toilet or cleansing
Excludes:		 
artificial opening status only, without need for care (Z93.-)
fitting and adjustment of prosthetic and other devices (Z44-Z46)
malfunction or other complication of device see Alphabetic Index
Z43.1		 Attention to gastrostomy  
Excludes:		 
malfunction or complication (K91.4)

Q2991 Coding Rules December 2015 states to assign Z43.1 Attention to Gastrostomy if the gastrostomy received attention or management during the episode of care.

Response:
In answer to your questions, VICC advises that:
a) Administration of feeds and/or medication via a PEG tube alone, does not constitute increased clinical care as per ACS 0002 Additional diagnoses and therefore Z93.1 Gastrostomy status would not be assigned 

b) Circumstances in which the gastrostomy status would meet ACS 0002 Additional diagnoses are, for example, if the presence of the PEG tube changed the patient's course of treatment or prevented treatment being administered

c) Yes, the advice can be extrapolated to the assignment of the remaining artificial opening status codes from range Z93 Artificial opening status


Query Text:
ACS 1221 Pressure injury:

Classification
1. Codes from category L89.- Pressure injury capture both the severity and the site of the pressure injury. Assign multiple pressure injury codes as appropriate to identify all pressure injuries, however, do not double code (ie repeat code in the code string for the same site and severity. See also ACS 0025 Double coding) (see Examples 1 & 2).
...
5. Pressure injuries may improve or deteriorate during hospitalisation. If different stages are documented for a pressure injury of the same site, assign a code that reflects the highest stage for that site (see Examples 7 & 8).

Example 1 shows a patient with L & R heel pressure injuries of different stages - 2 codes are assigned.
Example 2 shows a patient with L & R heel pressure injuries of same stage - 1 code is assigned.
Example 7 shows a patient with stage II on coccyx that evolves to stage III - 1 code (stage III as highest) is assigned.
Example 8 shows a patient with stage I/II on sacrum and coccygeal area that heals by discharge - 1 code (stage II as highest) is assigned.

Does 'site' mean the body site, or based on whether it goes the same code?  Based on example 1, bilateral is considered to be separate sites, but what if the pressure injuries are not bilateral?

My query is with a patient admitted with different stage pressure injuries of different anatomical sites that are coded to the same code, e.g. stage 1 pressure injury of right knee and stage 2 pressure injury of right ankle.

Should this be coded with 2 codes:
L89.09		 Pressure injury, stage I, other site of lower extremity (excluding heel and toe)
ankle
foot
knee
malleolus (lateral) (medial)
L89.19		 Pressure injury, stage II, other site of lower extremity (excluding heel and toe)
ankle
foot
knee
malleolus (lateral) (medial)

Or 1 code, as they are of the same 'site' (by code), so code to the highest stage L89.19		 Pressure injury, stage II, other site of lower extremity (excluding heel and toe)
ankle
foot
knee
malleolus (lateral) (medial)

Response:
VICC advises that when the anatomical sites are different within the same fifth character subdivision, provided the stage of the pressure injury (represented by the fourth character of the code) is different, a code for both stages can be assigned.  

Therefore in the case cited where there is a stage 1 pressure injury of right knee and stage 2 pressure injury of right ankle, it is correct to assign both L89.09		 Pressure injury, stage I, other site of lower extremity (excluding heel and toe) and L89.19		 Pressure injury, stage II, other site of lower extremity (excluding heel and toe) because the stage of the pressure injury is different.  Had the stage of the pressure injury been the same, only one code would have been assigned because it is the same code for both.

The intent of ACS 1221 Pressure injury classification point 1 is that the same code is not assigned more than once.

This is supported by example 4.8 of Ninth edition education:
Scenario:
A 78 year old is admitted from home with Stage I pressure ulcers on the buttock and upper leg.  On day three pressure ulcers have progressed to stage II on the buttock and upper leg and a new stage I pressure ulcer has developed on his ankle.

Answer:
L89.15 (2) Pressure injury, stage II, ischium
L89.19 (2) Pressure injury, stage II, other site of lower extremity (excluding heel and toe)
L89.09 (1) Pressure injury, stage I, other site of lower extremity (excluding heel and toe


Query Text:
Shockwave lithoplasty is a new percutaneous intervention being used to treat coronary and peripheral artery disease which utilises lithotripsy to disrupt calcium and normalise vessel wall compliance prior to low pressure balloon dilatation.

Attached is an example of shockwave coronary lithoplasty.

Should this be coded to angioplasty, by site or 'other procedure' on arteries?

Do we need new codes created for these procedures?

Response:
Research undertaken by VICC indicates that shockwave lithoplasty is performed via a balloon dilatation catheter, which supports the information provided in the query.

Therefore VICC considers it is correct to code this procedure as an angioplasty following Index entry Angioplasty/transluminal balloon by site and does not consider that new codes are required for this procedure.


Query Text:
How do I code Seratonin syndrome with no indication of what drugs were involved.

Response:
The Australian Prescriber Volume 26 No 3 indicates that Serotonin syndrome is a toxic state caused mainly by excess serotonin within the central nervous system. It results in a variety of mental, autonomic and neuromuscular changes, which can range in severity from mild to life-threatening. Most cases are self-limiting. Severe serotonin syndrome is nearly always caused by a drug interaction involving two or more 'serotonergic' drugs, at least one of which is usually a selective serotonin reuptake inhibitor or monoamine oxidase inhibitor. Management involves withdrawal of the offending drugs, aggressive supportive care and occasionally serotonin antagonists such as cyproheptadine. Treatment of the condition for which the serotonergic drugs were prescribed should be reviewed.

VICC advises the following possible coding options based on the information available in your clinical notes:
1.  In accordance with ACS 1902 Adverse effects, if the syndrome is caused by an adverse effect of a drug and a symptom(s) is documented, code the symptom(s) followed by the external cause code to indicate the drug or medicinal agent which caused the adverse effect. As the drug(s) is unknown in your case, assign Y57.9 Drug or medicament, unspecified.

If the manifestation of the adverse drug reaction is unspecified, assign code T88.7 Unspecified adverse effect of drug or medicament.  

2.  In accordance with ACS 1901 Poisoning if the syndrome is caused by improper use of a drug, assign a code from range T36–T50 Poisonings by drugs, medicaments and biological substances to identify the drug.  As the drug(s) is unknown in your case, assign T50.9 Other and unspecified drugs, medicaments and biological substances followed by external cause code Y14 Poisoning by and exposure to other and unspecified drugs, medicaments and biological substances, undetermined intent.


Query Title:
Calculating the duration of continuous ventilatory support (CVS) for tracheostomy patients

Query Text:
Could the Committee please provide clarification on the amended section in ICD-10-AM 9th edition ACS 1006 Ventilatory Support regarding the calculation of the duration of CVS for patients with a tracheostomy? 
Specifically:

1.  Does the directive to include the weaning in the duration of CVS up to a maximum of 24 hours following the cessation of CVS or the removal of the tracheostomy only apply to patients who have subsequent / multiple episodes of CVS during the one admission?

2.  For a patient who has a singular episode of CVS via a tracheostomy, when does the duration of CVS end?  Is it still correct to stop the count at the time of the last recording of pressure support?

Example:
Patient admitted for complex head and neck surgery for cancer, including a tracheostomy (surgery time 0800 - 1300).  The patient was transferred to ICU post-operatively and was placed on SIMV for 44 hours, CPAP / PEEP for 22 hours and then oxygen via a high flow cannula for the next three days until transfer to the ward for continued care.  Can the Committee please provide the procedure codes that would be assigned for the CVS hours and the total number of CVS hours in ICU for reporting purposes?

Response:
The directive to include the weaning in the duration of CVS up to a maximum of 24 hours following the cessation of CVS or the removal of the tracheostomy applies to each episode of CVS.  

VICC considers it is correct to stop the count at the time of the last recording of pressure support unless there is documentation of weaning of which you can add up to a maximum of 24 hours but please note that VICC has a query with ACCD seeking clarification of what constitutes weaning.

In terms of the example, if the oxygen via high flow cannula is provided via the tracheostomy it is considered continuation of the CVS and 13882-02 [569] Management of continuous ventilatory support, ≥ 96 hours would be assigned.  

If the oxygen via high flow cannula is not provided via the tracheostomy, the correct code for CVS would be 13882-01[569] Management of continuous ventilatory support, > 24 and < 96 hours.  The administation of the high flow oxygen would be considered non invasive ventilation (NIV) and 92209-01[570] Management of noninvasive ventilatory support, > 24 and < 96 hours would be assigned as an additional code.

This is accordance with ACS 1006 Ventilatory support classification point 1 a. Which says:
'When both CVS and NIV are used for treatment (not weaning – see note d below), code each type separately. Use the appropriate duration extension on each code to indicate how many hours the patient received each type of ventilatory support'.

To calculate the hours reported in the Duration of Mechanical Ventilation Hours in ICU field in the VAED use the same principles as above and also refer to the VAED definition of the data element as well as the article titled Coding and reporting of CVS updated 2015 on the HDSS website.


Query Title:
Anaemia or thrombocytopenia in sameday oncology patients

Query Text:
We are seeking clarification in regards to coding patients with anaemia or thrombocytopenia in same day oncology patients who are admitted for blood products either packed red blood cells or platelets.

Example 1:
Diagnosis: Myelodysplastic syndrome (MDS)
Indication: Thrombocytopenia
Treatment: Platelets

Would you code the MDS or thrombocytopenia as principal diagnosis?

Example 2:
Diagnosis: Metastatic Adenocarcinoma Lung
Indication: Anaemia
Treatment: Packed Red Blood Cells

Would you code the adenocarcinoma of lung or anaemia as principal diagnosis?

Example 3:
Diagnosis: MDS/Follicular Lymphoma
Indication: Thrombocytopenia
Treatment: Platelets and subcutaneous chemotherapy

Would you code the MDS or Thrombocytopenia or Z51.1 pharmacotherapy session for neoplasm as principal diagnosis?

We have referred to VICC query #3045 Anaemia and myelofibrosis.  Do we apply this advice to myelodysplastic syndromes, refractory anaemia, and myeloproliferative disease patients only as anaemia is included in these codes or all cancer patients if the cancer is documented as the final diagnosis?

Reference: VICC query #2708 Criteria for admission versus principal diagnosis.

Response:
VICC notes that the response to #3045 Anaemia and myelofibrosis is specific to myelofibrosis and the logic should not be applied to all cancer patients.

VICC has made the following observations in relation to this query:
1.  The examples provided have the heading Diagnosis, not Principal diagnosis
2.  The indication can be interpreted as the reason for admission
3.  Documentation and forms design varies amongst hospitals
4.  ACS 0001 Principal diagnosis Problems and underlying conditions point 2 provides examples of coding the problem as the principal diagnosis
5.  There needs to be a link between the diagnosis and the treatment in the documentation

Based on the observations above, VICC is unable to provide specific answers to the examples provided.  Clinical coders may need to consult with clinicians to ensure that documentation and forms design supports appropriate application of ACS 0001 Principal diagnosis.


Query Text:
We have discovered this breast quadrants and neoplasm codes diagram and relevant information on several websites that assists in classifying breast neoplasm site codes (http://training.seer.cancer.gov/breast/anatomy/quadrants.html)

We have discussed this diagram with the head of our Breast and Endocrine unit who described the clock positions and quadrants in accordance with the diagram attached.

1. Are we able to use this diagram to assist with code allocation?

2. Can we suggest for ACCD to publish a breast quadrants and neoplasm codes clinical update or something similar to this?

Response:
As the diagram is an internationally recognised anatomical diagram, VICC considers it is a useful reference to assist in determining the site of the neoplasm.  However code assignment must be based on the documentation in the medical record and by following the Index to arrive at the appropriate code.

VICC will forward the suggestion to publish the diagram as a clinical update to ACCD.

This query has been superseded by VICC query #3598 Assignment of cancer site codes based on clock positions or diagrams.


Query Title:
Admissions for high risk neutropenia / neutropenic monitoring

Query Text:
At our hospital there has recently seen an increase in admissions for what is documented on the discharge summary as 'high risk neutropenia'.  We have seen similar admissions at other hospitals documented  'neutropenic monitoring'.

These are cancer patients who have had chemotherapy in a previous admission.  They are admitted three to five days later because doctors consider them at high risk of developing neutropenia.  Some do develop neutropenia during the admission and others do not.  The patients usually do not receive chemotherapy or radiotherapy during their admission for high risk neutropenia-neutropenic monitoring. The admissions are multi-day stays.

What are the appropriate diagnoses for these admissions?  We have considered the following:
(a) Cancer code only
(b) Cancer code plus neutropenia code
(c) Cancer code plus neutropenia code only if the patient develops neutropenia during the admission
(d)		 Neutropenia code plus cancer code
(e) Observation code plus cancer code

Response:
VICC advises that if the patient is not neutropenic on admission, assign as principal diagnosis Z03.8 Observation for other suspected diseases and conditions.  This is in accordance with ACS 0010 General abstraction guidelines which says 'If a threatened/impending condition is documented but did not occur during the episode of care, then the clinical coder should refer to the index to determine if the condition is indexed as impending or threatened under the lead term or subterm. If such an index entry exists, then assign the appropriate code. If such an entry does not exist, then the condition described as impending or threatened should not be coded'.

If the impending condition does occur, in this case the neutropenia develops during the admission, assign as principal diagnosis D70 Agranulocytosis.  This is supported by ACS 0001 Principal diagnosis under heading 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 or following an accident or other incident that ordinarily results in a health problem, and where no supporting evidence for the suspected condition is found and no treatment is currently required. An observation code is not to be used on a record with additional related codes'.

Based on the information provided, in this scenario VICC considers that the cancer does not meet ACS 0002 Additional diagnoses and therefore would not be coded.


Query Text:
We would like to seek clarification on guidance for postictal state and confusion.  This condition is frequently documented with non epileptic or undiagnosed epileptic seizures. For example, seizure with postictal confusion.

Mosby's medical dictionary defines postictal as 'following a seizure' no specification of epileptic.  However the Coding Rules , December 2012 only specifically mentions postictal state/confusion following an epileptic seizure and the pathway has the descriptor 'epileptic. This pathway has not been amended since the release of this advice.
The rule also states:
Where postictal state is documented without further specification, assign G40.90 Epilepsy, unspecified, without mention of intractable epilepsy. This phrase states that postictal state should be coded as epilepsy, even when epilepsy is not documented.  This would have the potential to see many non epileptic patients coded as epileptic.

Clinical advice we have sought states that this state/confusion can arise in seizures in a non epileptic patient such as hypoglycaemic , alcoholic or hyponatraemic seizures  (excluding psychogenic and pseudoseizures).

1. Should epilepsy be automatically coded if the postictal state is documented in these cases?

2. If postictal confusion is documented should F05.8 Other Delirium still be assigned even where there is no documentation of epileptic seizures or epilepsy?

Response:
In response to question one, VICC advises that epilepsy should only be coded for documentation of postictal state in an epileptic patient.  In response to question two, F05.8 Other delirium should be assigned when postictal confusion is documented in an epileptic patient.

VICC advises that the Coding Rules advice noted in the query only applies to postictal state following an epileptic seizure.

For documentation of postictal state, without documentation of epilepsy VICC advises to assign:
R56.8 Other and unspecified convulsions as the default at Lead term Seizure(s)

For documentation of postictal confusion, VICC advises to assign:
R41.0 Disorientation, unspecified as the default at Lead term Confusion; and 
R56.8 Other and unspecified convulsions as the default at Lead term Seizure(s)


Query Text:
Can the committee please provide some guidance around the use of codes of Z72.2 Drug use and Z86.42 Personal history of drug use disorder.

ACS 0503 Drug, alcohol and tobacco use disorders doesn't specifically address the use of these two codes, and we're 
not sure if we should be using them.

We routinely assign Z72.0 for Tobacco use, current, or Z86.43 for Personal history of tobacco use disorder when we are unable to assign an F code for smoking status. Can we apply the same logic for the drug use codes?

We see many times where there is documentation of regular drug use (mainly marijuana, &/or ICE) in our region, and are not sure if we can use Z72.2 or Z86.42 to give a clearer picture of drug use?

We don't readily have the resources to query every admission where drug use is documented, to determine if dependance can be coded, so feel that if we don't assign a Z code at all, we are missing some valuable health information.

Can the committee please provide some advice regarding the use of the two Z codes mentioned.

Response:
As you have noted, ACS 0503 Drug, alcohol and tobacco use disorders does not provide instruction on the assignment of Z72.2 Drug use and Z86.42 Personal history of drug use disorder. Therefore VICC advises that these codes cannot be routinely assigned for documentation of regular drug use but can be assigned if the drug use meets ACS 0002 Additional diagnoses.

VICC considers that documentation such as referral to a detoxification programme or a social worker for management of the patient's drug use or violence due to drug use requiring restraint would meet the criteria in ACS 0002 to allow Z72.2 Drug use and Z86.42 Personal history of drug use disorder to be assigned, unless a more specific code is applicable.


Query Text:
Q1:
When coding pelvic adhesions complicating pregnancy (either to O34.8 or O65.5), would a coder routinely assign an additional code to identify the adhesions?

The 'use additional code' instruction in the obstetrics tabular list is applied to obstetric infection codes to identify sepsis (eg O75.3, O85) and to codes in O99 to identify the specific condition, but there is no such instruction for codes in the other sections of the tabular list, where the specific condition may or may not be an inclusion term.

We note that there was a coding rule in 8th edition December 2014, which advised to add an additional code for adhesions, but this rule was retired when the index was updated for 9th edition.

Q2:
Could VICC please confirm that the correct obstetric chapter code for pelvic adhesions requiring division during caesarean section is O65.5 Labour and delivery affected by abnormality of maternal pelvic organs, and that O34.8 Maternal care for other abnormalities of pelvic organs would only be used if the adhesions were known beforehand, and did not require any care or intervention during delivery.

This appears correct according to ACS 1506, and Coding Rule Q2840, but the 8th edition coding rule directed coders to assign O34.8 for adhesions divided during a caesarean section, and ACS 1506 does only refer to labour rather than labour and/or delivery.

Q3:
The alphabetical index at Pregnancy, complicated by, conditions in, N70-N73, leads to O23.5 Infections of the genital tract in pregnancy.  Are there any circumstances in which this pathway should be followed, or is this an indexing error?  We note that this was the subject of VICC query #2734 in September 2012-13.

Response:
With regard to question 1, in the case of pelvic adhesions complicating pregnancy, VICC advises that in order to translate the medical statement N73.6 Female pelvic peritoneal adhesions is assigned in addition to O34.8 Maternal care for other abnormalities of pelvic organs or O65.5 Labour and delivery affected by abnormality of maternal pelvic organs.  Therefore although ACCD Q2817 titled Pelvic peritoneal adhesions complicating a caesarean delivery has been retired, the logic still applies.

With regard to question 2, VICC agrees with the enquirer's interpretation as per Index entries Pregnancy/complicated by/adhesions (pelvic) (peritoneum) and Pregnancy/complicated by/adhesions (pelvic) (peritoneum)/affecting labour or delivery.

With regard to question 3, clinical coders should first follow the Index entry Pregnancy/complicated by/adhesions (pelvic) (peritoneum) because it is more specific than Index entry Pregnancy/complicated by/conditions in.


Query Title:
Non Hodgkins Follicular Lymphoma stage 4a

Query Text:
There is no index for Non Hodgkins Follicular Lymphoma Stage 4a.  

In this instance the patient had previously been diagnosed and coded to Non Hodgkins follicular lymphoma Stage 2. C82.1, M9691/3.

Now the disease has progressed to stage 4a. Following the pathway:
Lymphoma
-follicular (centroblastic-centrocytic) (nodular) (with or without diffuse areas) (M9690/3) C82.9
- - grade 1 (M9695/3) C82.0
- - grade 2 (M9691/3) C82.1
- - grade 3 NEC (M9698/3) C82.2
- - grade 3a (M9698/3) C82.3
- - grade 3b (M9698/3) C82.4
- - histiocytic (M9698/3) C82.2
- - large cell (cleaved) (noncleaved) (M9698/3) C82.2
- - mixed cell type (M9691/3) C82.1
- - noncleaved (large cell) (M9698/3) C82.2
- - small cleaved cell (M9695/3) C82.0
- - - and large cell (M9691/3) C82.1
- - specified NEC (M9690/3) C82.7

The concern is that there is no stage 4 in this index entry and by assigning the default code, we code to a lower morphology than stage 2, when we are trying to represent a higher stage of the disease.



Please advise how to code Non Hodgkins Follicular Lymphoma Stage 4a.

Response:
VICC advises that there is a difference between the terms 'stage' and 'grade' in the context of cancer.  Stage refers to the extent of spread of a cancer and grade refers to the aggressiveness of the cancer.

In the case of documentation of Non Hodgkins Follicular Lymphoma Stage 4a without documentation of grade, assign the default code at Index entry Lymphoma/follicular (centroblastic-centrocytic) (nodular) (with or without diffuse areas) (M9690/3) C82.9 because there is no subterm for stage in the Index.


Query Title:
Use of abbreviations, symbols and test result values to inform code assignment for abnormal pathology results

Query Text:
Thank you for publishing the updated ACCD Coding Rules advice in VICC query #2819 Documentation of down arrows after a result.  To some it was very helpful, yet for others it created some confusion.  Can the Committee please clarify the following:

"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."

One example given in the ACCD response was:

For example, where (downward arrow) K or a potassium level (eg K2.9) 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

This example provides all the criteria above to assign E87.6 Hypokalaemia.  The clinician does not need to verify hypokalaemia in this example.  Is this correct?  Some coders believe it still requires clinician confirmation.

An example we may find in our records is:
Nursing notes:  K+3.1, paged Dr and Slow K ordered.  Drug chart confirms Slow K was given.  Investigation shows Potassium is *3.1 (3.5 - 5.2) mmol/L.  

If we are unable to have hypokalaemia verified by a clinician, is it still enough to assign E87.6 Hypokalaemia because the example given meets all three criteria as noted above?

Response:
VICC considers that the ACCD advice to clarify the significance of the documented shorthand is in the context of the instruction that test result values, symbols and abbreviations are not to be used in isolation to inform code assignment.

Therefore when there is further documentation in the clinical record that meets the three criteria copied below, a code for the relevant condition can be assigned:
• 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. 

With regard to the example provided, VICC considers that there is sufficient documentation to meet the three criteria enabling E87.6 Hypokalaemia to be assigned.

If the only documentation were a test result of K+ 3.1 and Slow K on the medication chart, VICC does not consider that the three criteria are met and therefore the relationship between the test result and the treatment would need to be clarified with the clinician.


Query Text:
Wound Debridement Ref No: Q3026 Published 15-Mar-2016

Following on from the ACCD Query on Wound debridement, published on 15-Mar-2016, can the Committee please advise which debridement code should be assigned in the following example:

Operation report:
Operative Diagnosis/Indication:
Left 1st webspace laceration (hand) stanley knife

Operation Performed: Debride/Washout Repair 

Findings:
Muscle
Tendons  all intact
NV Bundle

Procedure:
Sedation
Prep/drape/tourniquet
Wound edges debrided
Washout N/Saline ++++
Repaired 4-0VR

J/G/C
Bulky bandage

Plan:
RPAO
Home
Follow-up 1/52

The example shows that soft tissue structures were explored and no injuries noted and wound edges debrided.  Would 90665-00 [1628] Excisional debridement of skin be assigned or 30023-00 Excisional debridement of soft tissue be assigned to reflect that soft tissue structures were explored.  It is difficult to know at what level the debridement occurred.  As per ACCD Query "where documentation in the clinical record, in particular the operation report, states that debridement was of soft tissue, deep tissue or soft tissue structures assign 30023-00 [1566] Excisional debridement of soft tissue by following the index pathway:

Debridement
- soft tissue, excisional NEC 30023-00 [1566]

Would this example support assignment of 30023-00 Excisional debridement of soft tissue?  Please provide the reason for or against.

Response:
ACS 1331 Soft tissue injuries defines soft tissue as muscles, nerves, tendons, fat, blood or lymph vessels, fasciae and tissue around joints (synovial tissue).  In accordance with this definition VICC advises to only assign 30023-00 [1566] Excisional debridement of soft tissue when there is documentation that the soft tissue structures are debrided, not just explored.

Therefore in the example cited, as there is no evidence to indicate that the soft tissue structures were debrided, only that wound edges were debrided, VICC advises to assign 90665-00 [1628] Excisional debridement of skin.


Query Title:
Administration of solution 120 in newborn episode

Query Text:
Solution 120 is a solution of electrolytes with an addition of 5%dextrose.

What is the correct Procedure code(s) to assign when Solution 120 is administered In the newborn episode?.

a. 9619908 - IV administration of pharmacological agent, electrolyte
or
b. 9619908 - IV administration of pharmacological agent, electrolyte
    +
 9619909- IV administration of pharmacological agent, other and unspecified pharmacological agent

Response:
As ACS 1615 Specific diseases and interventions related to the sick neonate under the heading Parenteral fluid therapy specifically lists electrolytes and dextrose, VICC considers that it is appropriate to assign a code for both components of Solution 120.

This advice applies to this specific solution as the components are specified in ACS 1615.  It is not intended that this advice be applied to all infusions.


Query Title:
Presumed sepsis (with documented symptoms) in neonates

Query Text:
Can we still apply the advice in VICC query #2513 (Symptoms of sepsis in neonates)? Query #2513 was retired 30 June 2015 but we cannot see that the retired advice has been incorporated into or altered by another change to the classification.

We understand the coding of risk of sepsis but would like clarification pertaining to presumed/suspected sepsis with initiation of treatment and documented symptoms. Essentially our query is exactly the same as query #2513, we are only seeking clarification because it has been retired.

Response:
This query was orignally published in the 2016-17 September Database as follows:

VICC considers that the advice in #2513 Symptoms of sepsis in neonates is still applicable and is reproduced below:

Query:
Could you please clarify some issues raised by VICC query #2408 Neonatal sepsis/Risk of sepsis? 

1. Could you please identify/elaborate on the symptoms of sepsis that are required before applying ACS 0012 Suspected sepsis? (e.g. are they limited to the manifestations listed in ACS 0110 Septicaemia involving temperature, heart rate etc or can they be symptoms as listed by the doctor such as those in the following cases?) 

2. Could you please advise on how to code the following examples of documentation from discharge summaries? 

Case 1 
Presumed Sepsis - septic work was performed because of desaturation and the infant was commenced on penicillin and Gentamicin which were ceased 6 days later; cultures negative. 

Case 2 
Presumed sepsis - septic work was performed after birth because of tachypnoea and the infant was commenced on penicillin and Gentamicin which were ceased 2 days later; cultures negative. 

3. Can you please clarify why we have been instructed (in VICC #2408) to apply ACS 0012 with the 'clause' that symptoms be present for the coding of presumed sepsis, even though there is no mention of symptoms needing to be present when applying ACS 0012 in general? 

Response
The VICC advises that the symptoms of sepsis are those listed by the clinician (they are not limited to the manifestations listed in ACS 0110 Septicaemia). 

For the examples cited, it is appropriate to code sepsis as per ACS 0012 Suspected conditions. This is because treatment was commenced for a diagnosis of presumed sepsis (with documentation of symptoms). 

The intent of the advice in VICC #2408 is to clarify that ACS 1617 Neonatal Sepsis/Risk of Sepsis is applied when there is clearly no sepsis and no condition (or symptoms). The neonate may be treated with prophylactic antibiotics. If there is documentation of a condition (or symptoms), ACS 1617 does not apply and you therefore follow ACS 0012 Suspected conditions.


Following publication of ACCD Coding Rules on 15 December 2018, the VICC response is superseded by the following advice titled Neonatal sepsis/risk of sepsis:

Q: What code is assigned for suspected neonatal sepsis?

A: ACS 0012 Suspected conditions provides the following guidelines in regard to suspected diseases and conditions in neonates:

Z03.7- Observation and evaluation of newborn for suspected condition not found is assigned following the criteria in ACS 1611 Observation and evaluation of newborn and infants for suspected condition not found and ACS 1617 Neonatal sepsis/risk of sepsis.

ACCD acknowledges that the Note at category Z03.7 Observation and evaluation of newborn for suspected condition not found and the risk of sepsis classification instructions within ACS 1617 Neonatal sepsis/risk of sepsis are ambiguous, as neonates with risk of/suspected sepsis may be symptomatic and have other conditions. However, coders should apply the guidelines in ACS 1617 regardless of whether the neonate has signs or symptoms, or coexisting conditions documented.

Therefore:

• when there is documentation of “suspected neonatal sepsis” but there is conflicting, unclear or no supporting documentation in the body of the clinical record, seek clinician clarification prior to code assignment

• where a diagnosis of ‘neonatal sepsis’ is confirmed, assign a code for sepsis, as per the guidelines ACS 1617 Neonatal sepsis/risk of sepsis

• for classification purposes, a diagnosis of ‘risk of sepsis’ or ‘suspected sepsis’ (ie probable, possible, likely, queried sepsis) are synonymous in neonates. Assign Z03.71 Observation of newborn for suspected infectious condition regardless of whether the neonate has signs or symptoms, or coexisting conditions documented.

Amendments may be considered for a future edition.



VICC notes that this will be a change of practice for Victorian coders.


Query Text:
In many patient episodes, CCF or LVF are treated concurrently with fluid overload.

As fluid overload (E87.7) is documented and treated, and is not a symptom code from R00 - R99 range, should the fluid overload be coded in addition to the CCF or LVF?

Response:
VICC advises that if the documentation supports that both the fluid overload and the left venticular failure/congestive cardiac failure meet criteria for coding, a code for both conditions can be assigned.  Sequencing of the codes will be in accordance with ACS 0001 Principal diagnosis and ACS 0002 Additional diagnoses.

Note that not all symptoms are classified to the R00-R99 range and this is supported by the information at the beginning of Chapter 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified, first sentence of the second paragraph that says 'Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in other chapters of the classification'.

Please also refer to query #3089 Fluid overload with current congestive cardiac failure (CCF) published in the 2015-16 June Database.


Query Text:
Many patients are admitted with 'discogenic back pain' for corrective spinal surgery.

Should discogenic back pain be coded to:

1.  Back pain (to the appropriate level) M54.-, following lead term 'Pain', then sub-term 'back'  

Or,

2. Other specified intervertebral disc displacement M51.2, following lead term 'Disease', then sub-term 'discogenic'

Response:
As the term 'pain' is documented, this is the lead term that should be looked up in the Index.  

Following Index entry Pain/back there is no subterm for 'discogenic' so follow the Index to Pain/back/specified NEC as the pain is specified as discogenic and assign M54.8- Other dorsalgia.


Query Text:
VICC query #2483 Blanket decisions was on retired 30 June 2015, can you please re-instate this advice or provide an updated response?

Response:
VICC considers that the advice in #2483 Blanket decisions is still applicable and is reproduced below:

Query:
Should 'blanket' decisions be accepted, for example when a clinician says 'all my patients have senile cataracts', does that mean this clinician's patients should all be coded as having senile cataracts, even if it is not documented in each patient's record? 

Search Details: 
Can't find anything searching by the word 'blanket' but I thought there had been previous Victorian Coding Committee advice to say 'blanket' decisions were not acceptable. 

Response:
'Blanket' decisions such as letters, lists and statements from clincians are not acceptable for code assignment. Code assignment must be supported by documentation in the medical record and reference to this can be found in: 

1. ACS 0010 Clinical documentation and general abstraction guidelines under section Roles and responsibilities in the documentation and abstraction process which states that 'The listing of clinical concepts (eg diseases and interventions) on the front sheet and/or the discharge summary (or equivalent) for an episode of care is the responsibility of the clinician. These responsibilities include identifying and documenting the principal diagnosis, and listing all additional diagnoses and interventions performed during the episode of care. Each diagnostic statement and intervention must be as informative as possible in order for the clinical coder to classify the clinical concept to the most specific ICD-10-AM or ACHI code.

Before classifying any documented clinical concept, the clinical coder must verify information on the front sheet and/or the discharge summary (or equivalent) by reviewing pertinent documents/data within the body of the current episode of care'.

2. The introduction section of the Australian Coding Standards which states that 'Documentation with the current episode of admitted care is the primary source of information for the classification of inpatient morbidity data. Accurate classification is possible only after access to consistent and complete clinical information. Without good documentation, classification guidelines are difficult, if not impossible, to apply. Classification decisions are not made solely based on information documented in the episode of  admitted care front sheet and/or discharge summary (or equivalent). Similarly, in an electronic health record environment, do not make classification decisions based solely on admission and discharge data. Analysis of the complete (current) episode of admitted care is required to qualify any ambiguous documentation, or to identify specificity for documented diseases/conditions'.


Query Text:
Hot biopsy forceps are used to excise small polyps (up to a size of 5 mm) in the upper and lower gastrointestinal tract using high frequency current.

When a colonoscopy is performed and a biopsy is taken using hot biopsy forceps, can this be coded to 32093-00 Fibreoptic colonoscopy to caecum, with polypectomy, as per the Includes note. Or should these be coded to 32090-01 Fibreoptic colonoscopy to caecum, with biopsy, as 'polypectomy' is not documented.

Response:
VICC advises that regardless of the instrument used, the procedure code assigned will be in accordance with the intervention performed. 
 
Therefore if you have documentation of excision of polyp, or polypectomy, regardless of whether it has been performed using hot biopsy forceps, assign the code for colonoscopy with polypectomy.  If however you have documentation of colonoscopy with biopsy, regardless of the instrument used, assign the code for colonoscopy with biopsy.


Query Text:
Dysphagia is the medical term for the symptom of difficulty in swallowing, but not hurting. Odynophagia is the medical term for painful swallowing.

How should Odynophagia be coded as there is no index for this condition, nor painful swallowing?

Would Problem, swallowing R13 be appropriate, even though this classifies to Dysphagia?

Response:
VICC notes that clinical definitions and the classification are not always aligned and that various issues associated with swallowing are classified together as they do not warrant their own unique code.

For documentation of odynophagia, it is appropriate to follow Index entry Problem/swallowing to assign R13 Dysphagia in the absence of the Lead term 'Odynophagia'.


Query Text:
Could you please clarify whether both polypectomy and biopsy are performed during colonoscopy, are both coded (biopsy is specified as being separate site to polypectomy). 

We have it in our mind that polypectomy overrides the biopsy there is now discussion that if it is clear that these are at different sites, both should be coded. There are no excludes notes in the tabular. I thought there was a (old!) VICC query in relation to this but can't find anything.

Response:
VICC advises that there is no classification advice that provides a hierarchy between polypectomy and biopsy.

Therefore in cases where both polypectomy and biopsy are performed during a colonoscopy, it is appropriate to assign a code for both the polypectomy and the biospy.


Query Text:
VICC query 2069 (retired) stated 'pressure area' could be assigned a code from L89. In 9th edition the preferred term of pressure injury was introduced with the education noting the retention of legacy terms including pressure area as synonymous inclusion terms.

The index entry Pressure/area, skin ulcer - see Injury/pressure includes 'skin ulcer' as an essential modifier.  Therefore, unless skin ulcer is documented the 'see Injury/pressure' cannot be followed and therefore one cannot get to code L89 and the link to ACS 1221.  

All other synonymous terms have an index entry that leads to L89.

The clinical information in the Tabular List at L89 does not include 'Pressure Area', although ACS 1221 does list it as a synonymous term.  

If the only documentation is of a 'pressure area' and there is no skin ulcer, can a code from L89 be assigned, assuming the condition meets ACS 0001 or ACS 0002?

Response:
VICC notes the enquirer's comment regarding the term 'skin ulcer' being an essential modifier at Index entry Pressure/area, skin ulcer and received confirmation from ACCD that the comma in the Index does represent an essential modifier. ACCD have included an amendment in errata 1 for Tenth Edition, for implementation 1 July 2017.

Therefore VICC advises that as 'pressure area' is listed as a synonymous term in ACS 1221 Pressure injury, that the Index entry Injury/pressure can be followed to assign a code from category L89.- Pressure injury for documentation of pressure area.


Query Text:
Is the advice on code assignment for open injury into joint, published in the ICD Coding Newsletter - November 2001 still current?  In summary, the article states, "Where there is an open wound communicating with an injury of the joint capsule, the following codes should be assigned and sequenced in this order:

1. A code for the sprain of the particular joint involved
2. A code for the open wound of the anatomical site

It is suggested that you pencil an entry into your Alphabetic Index for:
Wound, open, communicating with a joint - see Sprain, by site"

The reference in the article to the Tabular List of Diseases is now located on p362 in Ninth edition and states:

"Dislocation, sprain and strain including:
avulsion
laceration of cartilage, joint capsule, ligament"

Response:
Whilst the advice in the article still applies, VICC advises to follow the Index to assign the relevant codes for documentation of open injury into joint.  Like open fractures and open dislocations, two codes are required for open injury into joint.

To assign a code for the open injury of the joint, follow Index entry Laceration/joint, capsule - see Sprain.

A code is also required for the open wound and can be found by looking up lead term Wound, open.

Sequencing of the two codes will be in accordance with ACS 0001 Principal diagnosis.


Query Title:
Pressure injury secondary to thromboembolism deterrent stockings (TEDS)

Query Text:
Ventilated patient - documentation clearly states pressure injury to feet secondary to TEDS.
Should this be coded as:
- ? Complication of medical care
- ? Complication of 'device' or
- ? Contact with....

Response:
VICC advises that pressure injuries should be coded in accordance with ACS 1221 Pressure injury.  

ACS 1221 lists synonymous terms for pressure injury such as plaster ulcer and VICC considers that such external causes are included in the code and not complication or external cause code should be assigned.  VICC also considers the pressure injury concept would also include other assistive and adaptive devices such as nasal prongs and TEDS.  

For the case cited, VICC advises to assign L89.x9 Pressure injury, other site of lower extremity (excluding heel and toe) only.

Refer to ACS 1221 point 6 Mucosal membrane pressure injuries for specific advice on the coding of mucosal membrane pressure injuries.


Query Title:
Supratherapeutic INR and high or up arrow INR

Query Text:
As per ACS 0303, abnormal coagulation profile is also known as:
- unstable INR
- overwarfarinisation
- prolonged bleeding time
- abnormal bleeding time

Does VICC consider 'Supratherapeutic INR' and/or 'High/Up arrow INR' to be synonymous with the terms listed above, and therefore would assign D68.3 Haemorrhagic disorder due to circulating anticoagulants, for these conditions?

If not D68.3, would VICC assign R79.8 Other specified abnormal findings of blood chemistry and Assign Z92.1 Personal history of long term (current) use of anticoagulant as per VICC 3017?

Search details:
ACS 0303 - Abnormal coagulation profile
VICC 3017 - Warfarin therapy
Coding Rule June 2015 - Admission for subtherapeutic INR 
(underwarfarinisation) and bridging therapy for temporary cessation of an 
anticoagulant
VICC 2268 - ACS 0303 Abnormal coagulation profile (Retired June 2013)

Response:
VICC considers that supratheraputic INR and high or up arrow INR are synonymous terms for overwarfarisation and advises to follow ACS 0303 Abnormal coagulation profile due to anticoagulants for guidance in regard to assignment of D68.3 Haemorrhagic disorder due to circulating anticoagulants.


Query Title:
External cause code for cardiopulmonary resuscitation (CPR) by member of the public

Query Text:
Patient admitted post cardiac arrest. CPR administered by member of the public resulting in fractured ribs and flail chest. 

I have used external cause code X58 Exposure to other specified factors as the CPR was not performed by a health worker so I felt I couldn't use the medical procedure. Patient was in VF when the ambulance arrived and received direct current reversion (DCR) but no CPR. 

Is this the correct external cause code?

Response:
VICC advises that cardiopulmonary resuscitation (CPR) is considered a medical procedure regardless of who performs the CPR.  The place of occurence code will identify that the CPR was not performed in a health service area.

VICC therefore advises to assign Y65.8 Other specified misadventures during surgical and medical care following Index entry Unintentional event(s)/specified type NEC as the external cause code in the case cited.


Query Title:
Coding High Flow nasal prongs (HFNP) as NIV

Query Text:
We would like to clarify the coding of High flow nasal prongs (HFNP) as Non-Invasive Ventilation (NIV). The 9th edition changes to the Australian Coding Standards in relation to ACS 1006 Ventilatory Support state 'clinical coders should ensure that NIV is being provided via the device, and not assign a code for NIV based on the device alone.'

The documentation at our health service is usually HFNP patient on High Flow via NP. As we don't have documentation that NIV is being provided by the device we have been asking the clinician to review. 

We are aware of the advice by the NCCC in regards to 'High flow nasal cannula' (retired in June 2013) which 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.

Could VICC please advise how the new sentence in the standard should be interpreted. Is the change of wording in the standard stating we are unable to use the documentation of high flow nasal cannula as this is the device?

If there is documentation of HFNP in the medical record can the index entry HFNC or High flow nasal cannula be followed even though these are types of non-invasive devices? We understand the pathway in the index Therapy/high flow leads us to an NIV code, however would we need high flow therapy documented?

Response:
VICC advises that ACCD Coding Rules Q2953 titled High flow therapy provides advice for this query and is reproduced below:

Q:

What is the correct code to assign for high flow therapy when administered via nasal cannula or tracheostomy?

A: 

High flow therapy (HFT), also known as high flow nasal cannula (HFNC) or high flow nasal prongs (HFNP), is a type of respiratory support introduced as an alternative to noninvasive ventilation (NIV). HFT is more than simple oxygen enrichment or humidification as it involves the administration of ventilatory support, therefore in ACHI HFT is classified as noninvasive ventilatory support. 

High flow therapy devices, unlike conventional oxygen administration or NIV, use a system of heated humidification and large-bore nasal prongs to deliver oxygen at flows of up to 50-60 L/minute. This is usually used in conjunction with an oxygen blender, allowing delivery of precise inspired oxygen concentrations. 

HFT is used on patients ranging in ages from preterm infants to adults who receive flow rates for respiratory support in a variety of conditions, such as: 
• Newborns: used in the management of respiratory distress or apnoea and weaning from invasive forms of respiratory support. HFT is generally administered at 2-7 L/minute for neonate
• Paediatrics: used in conditions such as viral bronchiolitis, bacterial pneumonia and reactive airway disease. HFT is generally administered at 4-12 L/minute for infants and young children
• Adults: used in a variety of clinical care settings for patients with conditions such as type 1 (hypoxic) respiratory failure, pulmonary oedema, chronic obstructive pulmonary disease (COPD) and acute respiratory distress syndrome (ARDS). HFT is generally administered at 20-40 L/minute for adults.

HFT can also be delivered through a tracheostomy with an entrainment device. 

Despite the similar description, high flow oxygen (or humidified oxygen) is not the same as high flow therapy. HFT depends on the device being able to generate a sufficient pressure gradient to improve oxygenation. While the required pressure can be generated through a nasal cannula (prongs), it cannot be produced with a face mask. Therefore, despite the modalities listed for NIV in ACS 1006 Ventilatory support, including mask, high flow oxygen must be delivered through a nasal cannula (prongs) or tracheostomy to be considered as high flow therapy and coded as noninvasive ventilation. 

Clinical coders should assign high flow therapy based on clinical documentation and not on the basis of the delivery flow rates alone. Clinical documentation must be clear that high flow therapy is being provided (ie, high flow oxygen administered via nasal cannula/prongs or tracheostomy). If high flow is documented without being administered via these techniques, clinical coders should verify with the clinician whether it is HFT before classifying as NIV.

When HFT is documented in the clinical record, assign an appropriate code from block [570] Noninvasive ventilatory support following the lead terms: 

HFNC (high flow nasal cannula) (heated) (humidified) — see block [570] 

HFT (high flow therapy) (heated) (humidified) — see block [570]

High flow nasal cannula (HFNC) (heated) (humidified) — see block [570] 

Therapy 
- high flow (heated) (HFT) (humidified) (nasal) — see block [570]

Where high flow therapy is delivered via a tracheostomy, follow the Excludes note at block [570] Noninvasive ventilatory support to assign a code from block [569] Ventilatory support.

Improvements to ACHI will be considered for a future edition. [end of ACCD advice].


Query Title:
Incidental findings/conditions for GP follow-up

Query Text:
Should a condition be assigned as an additional diagnosis when it is a finding during the patient's episode of care and the clinician states for the patient to follow-up with the GP? 

We have been told that this meets the dot point under ACS 0002 Additional diagnoses increased clinical care and/or monitoring.  We find this unclear as the hospital has not increased their clinical care for the patient as they are getting the GP to follow the patient up after discharge from hospital (as most patients see their GP after discharge). They have not changed the way they have managed the patient or said they were going to observe them for a longer period etc.

Can we please have clarification about what would meet additional diagnosis criteria for increased clinical care?

Can you please clarify if conditions referred to GP for follow-up meet additional diagnosis criteria? For a condition to meet the dot point increased clinical care, should the care only be care provided in the current episode or does this extend to writing external referrals?

Response:
In the context of your query in relation to a referral to a GP, VICC considers that there needs to be evidence in the body of the record that the condition required increased clinical care or monitoring during the admitted episode in order for the condition to be coded.

Writing of a referral alone for post-discharge review of a condition/finding does not qualify that finding under ACS 0002 in its own right. However if there was for example, a clinical consultation in the episode of care in addition to the writing of the referral, the clinical consultation would constitute increased clinical care and therefore meet ACS 0002.

VICC notes that ACCD Coding Rule Q2639 titled ACS 0002 Additional diagnoses and newborn conditions (1 of 2) (2 of 2) was updated in September 2015 to reinforce that the advice applies only to newborns.


Query Text:
We would like to seek clarification around the coding of R45.81 Suicidal ideation in conjunction with a mental health disorder. 

We often have patients who are admitted with a mental health disorder and also have suicidal ideation (usually this is the reason they are admitted as their psychiatric condition has exacerbated). We understand there is an excludes note at R45.81 which states it excludes signs and symptoms constituting part of a mental disorder.

Is this a type 1 excludes note, and therefore does not apply in Australia as we undertake multiple condition coding?

If we have documentation of suicidal ideation in conjunction with an underlying mental health disorder, are we able to assign R45.81 Suicidal ideation as an additional diagnosis (if it meets ACS 0002 Additional diagnosis) to complete the clinical picture?

Response:
Although excludes notes have a definition, VICC notes that each excludes note has not been identified as a Type 1 or Type 2 excludes note by the national coding authority.

VICC interprets the Index entry Ideation, suicidal /constituting part of a mental disorder — see condition to mean that where there is a documented relationship between the suicidal ideation and the mental health condition, a code for the mental health condition is assigned and R45.81 Suicidal ideation is not assigned.  Where there is no documented relationship between the mental health condition and the suicidal ideation, codes for both conditions can be assigned.


Query Title:
Induction of labour for Decreased Fetal Movements

Query Text:
Patient is assessed in clinic for decreased fetal movements and is asked to present to hospital the next day for an induction.  Patient then presents the next day for a medical and surgical induction for "Decreased fetal movements".

According to ACS 1537 Decreased Fetal Movements, "Where a 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 Pdx followed by a code from category O80-O84 Delivery".

In reference to VICC Query 2589 "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.

Can the committee please advise whether O80-O84 should be Principal diagnosis or O36.8 Maternal care for other specified fetal problems.

It is interesting to note that there is a specialty standard that instructs the coder to assign O36.8 as Principal diagnosis when a patient is admitted with a diagnosis of decreased FMs. We already have advice in ACS 0001 under the heading"Obstetrics" "Where the patient is admitted for management of an antepartum condition, assign the antepartum condtion as the Pdx..."

Why would there be a specialty standard on Decreased FMs when according to VICC's response in Query 2589, the coder needs to follow the advice in ACS 0001 under heading "Obstetrics"?

Many coders interpret ACS 1537 to mean that regardless of whether the patient is admitted for IOL or LUSCS, if the patient is admitted with a diagnosis of decreased FMs then O36.8 is the Pdx.  Otherwise, why have a specialty standard?  Is it because the Index lacks an entry term for "Maternal care for decreased fetal movements"?  Perhaps ACS 1537 needs to be removed and the Index improved to allow code assignment for decreased FMs undelivered - Z36.8 Other antenatal screening and decreased FMs delivered O36.8 Maternal care for other specified fetal problems.  As for Pdx selection, it depends on ACS 0001.

Search Details
ACS 1537, Index of Diseases, VICC Query 2589

Response:
VICC interprets ACS 1537 Decreased fetal movements to apply to patients who are admitted with decreased fetal movements and subsequently deliver in that episode, as opposed to being admitted for delivery.  

This is supported by the part in ACS 0001 Principal diagnosis under the heading Obstetrics which says 'Where the patient is admitted for management of an antepartum condition, assign the antepartum condition as the principal diagnosis. If the patient delivers during the episode of care, assign a code from O80–O84 Delivery as an additional diagnosis'.

In the case cited, as the patient is admitted for delivery, apply the part in 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...'.

VICC understands that ACS 1537 is on the ACCD's task list to review.


Query Text:
We have multiple patients who present to us for endoscopy who have had a previous ileal pouch created after colectomy for management of their ulcerative colitis, indeterminate colitis or familial adenomatous polyposis. Patients will have their initial follow-up endoscopy after their procedure which can often indicate pouchitis.

The patients with pouchitis (Inflammation of the ileal pouch) then continue to re-present to our hospital for endoscopy to assess and manage this. 

We currently code pouchitis to A09.9 Gastroenteritis and colitis of unspecified origin following Index entry Inflammation/intestine - see Enteritis.

What is the correct code to assign for this condition?

Response:
VICC considers that if there is documentation that supports that the pouchitis is an exacerbation of an underlying chronic incurable condition such as ulcerative colitis, it is appropriate to assign a code for ulcerative colitis as the principal diagnosis. 

In the absence of such documentation, VICC advises to assign pouchitis as the principal diagnosis following the Index entry noted in the query.

Note: This query was originally published in September 2016 and was retired on 30 June 2020. The query has been reinstated as VICC considers the advice is still current for Eleventh Edition ICD-10-AM.


Query Text:
Autism spectrum disorder appears to be a combination of autism and Asperger's syndrome.  How should this be coded?

Response:
VICC advises that in the absence of specific documentation such as Asperger's syndrome, assign F84.0 Childhood autism as per Index entry Disorder/autistic.


Query Title:
Principal diagnosis allocation for laparoscopic gastric band removal

Query Text:
A 37 year old female was admitted for a removal of a laparoscopic band. 

The struggle was to find an appropriate principal diagnosis code for this episode. The current code allocation is the following:
Z090 Follow up examination after surgery for other conditions
Z924 Personal history of major surgery, not elsewhere classified
Z465 Fitting and adjustment of ileostomy and other intestinal appliances
E669 Obesity
E1172 Type 2 diabetes mellitus with features of insulin resistance
K660 Peritoneal adhesions

Response:
VICC advises that in the absence of a documented reason classified elsewhere, (e.g. displacement of gastric band (T85.5)) for the removal of the gastric band, assign Z45.89 Adjustment and management of other implanted devices following Index entry Management/implanted device/specified NEC.


Query Title:
Principal diagnosis for documentation of 'Urosepsis'

Query Text:
The Ninth edition changes instruct coders to assign two codes for documentation of 'Urosepsis', following the lead term 'Urosepsis' - See Sepsis and Infection, urinary.

When 'Urosepsis' is documented as the principal diagnosis on the discharge summary, what should be sequenced first, N39.0 Urinary tract infection, site not specified or A41.- Sepsis?

Applying ACS 0001 Principal diagnosis is not possible as we only have one condition documented 'urosepsis' on the discharge summary, and we've been instructed by the Index to code two conditions, so there is no 'first mentioned diagnosis'.

On a separate note, Urosepsis is linked to ACS 0110 SIRS, sepsis, severe sepsis and septic shock  in the Turbocoder, but there is no reference to Urosepsis in the standard for Ninth edition, but this may be a question for the vendor.

Response:
This query was referred to ACCD who provided the following advice;

The indexing at the lead term Urosepsis in the Alphabetic Index is:
Urosepsis — see Sepsis AND Infection, infected (opportunistic)/urinary (tract) NEC

The See reference in the above indexing:
• directs coders to two lead terms, as two codes are assigned to classify urosepsis
• is not a sequencing instruction.

Apply the guidelines in ACS 0001 Principal diagnosis and ACS 0002 Additional diagnoses to determine whether sepsis or urinary tract infection (UTI) is the principal diagnosis for each individual case, based on the clinical documentation. [End of ACCD response]

Further to the ACCD advice, VICC advises that a principal diagnosis should be selected based on the documentation  within the record. Clarification may also be sought from a treating clinician. 

In the index of the Australian Coding Standards, Urosepsis is referenced to ACS 0110 SIRS, Sepsis, Severe Sepsis and Septic Shock, because Urosepsis contains two clinical terms.  Therefore the reference is directing coders to the standard in order to assign an appropriate code for the sepsis.


Query Text:
ACS 1008 - Chronic Obstructive Pulmonary Disease (COPD) instructs that when there is 'COPD with pneumonia', it is sufficient to assign J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection.

Does this rule apply to all types of pneumonia, e.g. Aspiration pneumonia (J69.0)?

Response:
This query was originally published in the 2016-17 September Database as follows:

VICC interprets the advice in ACS 1008 Chronic obstructive pulmonary disease which says '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' applies to all types of pneumonia.  There is no classification advice that says this part of the standard does not apply to all types of pneumonia.

Therefore VICC considers it is appropriate to assign J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection for documentation of COPD and aspiration pneumonia. [end of original response]

Following publication of ACCD Coding Rules on 15 March 2018, the VICC response is superseded by the following advice titled COPD with aspiration pneumonia/Mendelson's syndrome.

Aspiration pneumonitis and pneumonia are caused by inhaling toxic substances, usually gastric contents, into the lungs (Sethi 2007).

Aspiration pneumonia occurs when oropharyngeal contents, for example bacteria, food, liquids, are aspirated leading to infection of the lungs. It is commonly seen in in stroke or motor neurone disease patients with difficulties in swallowing. In Mendelson's syndrome, aspiration of gastric acid or contents in patients under anaesthesia results in rapid development of inflammation in the lungs causing chemical pneumonitis (Swaminathan 2017).

In ICD-10-AM, the terms ‘pneumonitis’ and ‘pneumonia’ are used interchangeably. Aspiration pneumonia is classified to category J69 Pneumonitis due to solids and liquids.

ACS1008 Chronic obstructive pulmonary disease (COPD) states:

Infective exacerbation of COPD does not require an additional code to reflect the infective description unless the infective condition is a condition in its own right, such as pneumonia (see COPD with pneumonia).

For documentation of COPD with aspiration pneumonia assign:

J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
J69.- Pneumonitis due to solids and liquids
with appropriate external cause codes

Where aspiration pneumonia is documented and there is no indication of what was aspirated, do not assign an external cause code, as it will not provide any additional information (see also Coding Rule: Aspiration pneumonia.)

For documentation of COPD with Mendelson’s syndrome assign:

J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
J95.4 Mendelson's syndrome
W78 Inhalation of gastric contents
Y48.- Anaesthetics and therapeutic gases causing adverse effects in therapeutic use
with appropriate activity and place of occurrence codes

Apply the guidelines in ACS 0001 Principal diagnosis and ACS 0002 Additional diagnoses to determine sequencing of the above codes. 

Amendments will be considered for a future edition.


Query Text:
Could you please confirm what the correct code is for a sphincteroplasty of the biliary tract that is performed with a balloon dilation during ERCP.

Looking in the Index under Sphincteroplasty, Sphincter of Oddi it takes you to 30458-04 [971].  This groups the episode to H02B Major Biliary Tract Procedures W/O Catastrophic CC which doesn't seem appropriate for a same day patient.

Is Index entry Dilation, biliary tract NEC, endoscopic 30494-00 [971] is a more appropriate code?

Response:
VICC reviewed the operation report noting that there is documentation of a sphincteroplasty of the biliary tract. Therefore VICC advises that it is correct to follow Index entry Sphincteroplasty/sphincter of Oddi to assign 30458-04 [971] Repair of sphincter of Oddi.

VICC also advises to assign a code for the ERCP an additional code if the sphincteroplasty is performed endoscopically.

In regard to a more appropriate code, you may wish to submit a public submission to ACCD suggesting the creation of Index entries for open and closed at Lead term Sphincteroplasty/sphincter of Oddi.


Query Title:
Newborn conditions and ACS 0002 Additional Diagnoses

Query Text:
NCCC Q&A, Q2639 titled ACS 0002 Additional Diagnoses and newborn conditions (2 of 2) published  June 2011 states that a code should be assigned for a condition that is referred for an external opinion.

Does this include where follow up ultrasound is organised prior to discharge? For example, is it correct to code clicking hips in a newborn where an outpatient ultrasound (4 weeks post discharge) has been arranged prior to the newborn being discharged (and no other testing or clinical evaluation has been completed for the condition).

Response:
VICC considers that a follow up ultrasound organised prior to discharge is a type of referral for an external opinion for which a code can be assigned for the condition in a newborn.  

It is therefore appropriate to assign a code for clicking hips in a newborn when a follow up ultrasound has been organised, provided there is documentation in the clinical record of clicking hips as the reason for the ultrasound.


Query Text:
Could you please clarify the correct coding of the IV administration of infliximab for the following scenario. 

A patient is admitted for a day episode of care (> four hours) for administration of IV Infliximab to treat the principal diagnosis of Crohns disease. The drug is described on MIMS as a chimeric human-murine IgG1 monoclonal antibody produced in murine hybridoma cells. 

Could you please confirm the correct procedure coding for this scenario? Is it administration of blood product 92064-00, administration of gamma globulin 13706-05 or other and unspecified administration pharmacotherapy IV 96199-09 or other?

Response:
VICC advises that infliximab is an immunosuppressant and is therefore not classified as a blood product.  The correct code to assign for intravenous administration of infliximab is 96199-09 [1920] Intravenous administration of pharmacological agent, other and unspecified pharmacological agent.

The correct Tenth Edition code for intravenous administration of infliximab is 96199-19 [1920] Intravenous administration of pharmacological agent, other and unspecified pharmacological agent.


Query Text:
What is the correct ACHI code to assign for uterine synechiolysis? Currently no Index entry exists for uterus under synechiolysis, only entries for corneovitreal and iris (posterior).  

Synechiolysis of the uterus is required to treat adhesions often resulting from uterine trauma (e.g. Asherman's syndrome).  

Can the committee please confirm that it is appropriate to assign 35633-00 [1262] Division of intrauterine adhesions for documentation of synechiolysis?

Response:
Uterine synechiae are adhesions or scar tissue that form inside the cavity of the uterus and uterine synechiolysis is the division of these adhesions.  Research indicates that uterine synechiolysis is performed hysteroscopically.

In the absence of the subterm 'uterus' under lead term Synechiolysis, VICC agrees it is appropriate follow Index entries Lysis — see also Division and Division/adhesions/intrauterine, hysteroscopic to assign 35633-00 [1262]  Division of intrauterine adhesions, provided there is no documentation that the procedure was not performed hysteroscopically.


Query Text:
We have recently had patients admitted to our hospital for a nasendoscopy to investigate FOSIT (feeling of something in throat). The nasendoscopies were performed and no abnormalities were found to account for the patient's presenting symptom.

In ICD-10-AM a sore throat is classified to J02.9 Acute pharyngitis, unspecified, which is in Chapter 10 Disease of the Respiratory System. In view of this we have coded FOSIT to R09.89 Other specified symptoms and signs involving the respiratory system.

Could VICC please advise if this is the correct code?

Index:
Sore
- throat (acute) (see also Pharyngitis) J02.9

Symptoms specified
- involving 
- - respiratory system NEC R09.89

Response:
VICC agrees that the throat is classified to the Respiratory system in ICD-10-AM.

In the absence of an established condition and the patient has symptoms involving the throat, VICC considers it is appropriate to assign R09.89 Other specified symptoms and signs involving the respiratory system following Index entry Symptoms specified/involving/respiratory system NEC.


Query Title:
Septoplasty vs nasal septum reconstruction

Query Text:
We are seeing in a lot of ENT records the terms 'septoplasty' and 'septal reconstruction' used interchangeably.  On querying this with the ENT registrar, he said that they are essentially the same thing, but some surgeons use 'reconstruction' as the term is quite broad and the MBS item is worth more.

If we have documentation of both septoplasty and septal reconstruction, should we assign both procedure codes, or does one include the other?  It is not clear from the index or the tabular how these codes differ.
41671-02    Septoplasty
41671-03    Septoplasty with submucous resection of nasal septum
41672-00    Reconstruction of nasal septum

On googling this it was apparent that many clinicians use the terms interchangeably.

Response:
VICC reviewed the operation reports submitted with this query and noted that while the MBS numbers listed conflicted, the documentation in the operation reports did not.  VICC advises that the documentation rather than the MBS numbers must be used to support code assignment. 
 
VICC further advises that if documentation in the body of the operation report indicates that both septoplasty and septal reconstruction are performed, both should be coded by following the Index. There is no classification rule that precludes the assignment of both codes.  Where differing documentation exists in different parts of the record, the term supported by the operation report should be used for code assignment rather than the term documented elsewhere in the record.


Query Text:
We have differing opinions on coding skin lesions, where the C44.x code is the same, but the actual site is different, and there are multiple morphology codes.

For example, the following histopathology report:
CONCLUSION:
1.  Left side nose:  Nodular and infiltrative basal cell carcinoma,excised.
2.  Right neck:  Moderately differentiated squamous cell carcinoma,excised.
3.  Right nose:  Active folliculitis, excised.
4.  Left cheek:  Well differentiated squamous cell carcinoma, excised

Should the C codes be assigned as follows?:
C44.3 & M8097/3 (for lesion 1)
C44.4 & M8070/3 (for lesion 2)
C44.3 & M8070/3 (for lesion 4)

OR
as there are two C44.3 codes, do you code that once with only the highest M code - M8097/3,

OR
as there are 2 separate lesions (nose & cheek) both coded to C44.3, use M8070/3 & M8097/3 with C44.3 coded once?

These are quite common occurrences where multiple skin lesions are excised in the one episode, so the committee's comments would be appreciated.

Response:
VICC notes that it is not always possible to represent multiple sites for each morphology completely. 

When two anatomical sites are allocated to one site code, the code can only be assigned once.  Applying this principle to the case cited, C44.3 Skin of other and unspecified parts of face is assigned once.  However more than one morphology code can be assigned to reflect the morphology of each lesion.

VICC notes that ACS 0233 Morphology, and Appendix A:  Morphology of Neoplasms instruct to choose the higher morphology code when a morphological diagnosis contains two qualifying adjectives with different code numbers.  This does not apply when coding two different lesions.

VICC therefore advises to assign the following codes for the case cited:

C44.3 Skin of other and unspecified parts of face (for nose and cheek)
M8070/3 Squamous cell carcinoma NOS
M8097/3 Basal cell carcinoma, nodular
C44.4 Skin of scalp and neck
M8070/3 Squamous cell carcinoma NOS
L73.9 Follicular disorder, unspecified


Query Text:
1.  Does ACCD Coding Rule TN199 titled Use of abbreviations, symbols and test results to inform code assignment for abnormal pathology results only apply to abnormal pathology results or can it be applied to any abnormal test result, for example, a documented low temperature in newborn? The term pathology is included in the heading but the answer talks about test results and the term pathology report is in brackets.

2. If we can apply ACCD Coding Rule TN199, can we refer to our health service's policy on body temperature in newborns to confirm that a documented temperature reading is outside the normal range and apply the above ACCD advice to this?

For example, temp 35.8 placed under heater documented in newborn's progress notes. Can P80.9 Hypothermia of newborn, unspecified be assigned?

Search Details
Ref No: TN199 | Published On: 15-Sep-2009 | Status: Updated | Updated On: 15-Sep-2015
Use of abbreviations, symbols and test result values to inform code assignment for abnormal pathology results

Response:
VICC considers that ACCD Coding Rule TN199 applies to abnormal pathology results only; the advice cannot be applied to other observations that are not pathology tests.  

Consequently the health service's policy on body temperature in newborns cannot be used to confirm that a documented temperature reading is outside the normal range; hypothermia must be documented in the clinical notes as the reason for the intervention.


Query Text:
1. Can you please advise whether I10 Essential (primary) hypertension or R03.0 Elevated blood-pressure reading, without diagnosis of hypertension should be assigned in the following scenario?

Example of documentation in notes:
Increased BP
BP 171 / 85
Plan: Micardis
*history of hypertension documented in external correspondence

Example of documentation in notes:
Increased BP
BP 171 / 85
Plan: Micardis
No history of hypertension

2. Index Elevated/blood pressure defaults to I10 hypertension. Should the default be to R03.0 Elevated blood pressure reading, without a diagnosis of hypertension?

Elevated, elevation
- blood pressure (see also Hypertension) I10
- - reading (incidental) (isolated) (nonspecific), no diagnosis of hypertension R03.0

Response:
VICC considers that, whether or not there is a documented history of hypertension, if there is documentation of elevated blood pressure, the Index entry High — see also Elevated, elevation/blood pressure (see also Hypertension) should be followed, and the default code I10 Essential (primary) hypertension assigned.  

If there is specific documentation that the patient does not have hypertension, follow the subindex entry ‘ - - reading (incidental) (isolated) (nonspecific), no diagnosis of hypertension’ to assign R03.0 Elevated blood-pressure reading, without diagnosis of hypertension. 

VICC notes that these index entries exist in ICD-10. You may submit a public submission to the ACCD if you wish to have this index entry reviewed.


Query Title:
Low pregnancy-associated plasma protein-A (PAPP-A) score

Query Text:
Induction of Labour for Low PAPP A score.

We have been informed that a Low PAPP A score may be an indication of Placental Insufficient/IUGR.

In the absence of  documentation of Placental Insufficiency and/or IUGR, what is the correct code to use to capture low PAPP A?

Response:
VICC research finds that PAPP-A (pregnancy-associated plasma protein-A) is a protein produced by the embryo and placenta, the levels of which rise throughout pregnancy. A blood test conducted on the woman during the first trimester is used to assess risk of a range of chromosomal anomalies, and includes testing for level of PAPP-A. A low PAPP-A result is considered to indicate an increased risk of anomalies and adverse outcomes, including IUGR.

In the absence of documentation of placental insufficiency or IUGR, VICC considers it correct to assign both:
O28.0 Abnormal haematological finding on antenatal screening of mother and R77.8 Other specified abnormalities of plasma proteins following Index entries:
Abnormal/finding/antenatal screening, mother/haematological NEC O28.0

Abnormal/plasma/protein/specified NEC R77.8


Query Title:
Abnormal or non-reassuring CTG in labour and delivery

Query Text:
VICC query #2174 stated that 'if you have documentation of abnormal CTG or non-reassuring CTG only as the reason for intervention with no specific heart rate anomalies documented assign the code O68.8 labour and delivery complicated by other evidence of fetal stress'. This query has since been retired.

Would the committee please review the response and advise if this advice should still be followed? If not, please advise on how to assign a code for these situations, if appropriate.

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

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

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

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


Query Text:
Patient was admitted for insertion of abdominal PleurX catheter for ongoing drainage of malignant ascites.
Patient had an abdominal paracentesis performed and the PleurX catheter inserted in Imaging.  Patient was then discharged with PleurX insitu to manage ongoing drainage of ascites at home.

I coded 30406-00 [983] Abdominal paracentesis and 90376-00 [983] Insertion of peritoneal access device.

Is 90376-00 [983] the correct code to use for insertion abdominal PleurX?

Response:
VICC considers that the PleurX catheter insertion is a component of the paracentesis process and following ACS 0016 General procedure guidelines, only 30406-00 [983] Abdominal paracentesis is required for this procedure.


Query Title:
Procedures for manifestations of cerebral palsy

Query Text:
We are seeking clarification on ACCD Coding Rule Q2969 Injection of Botox for manifestations of cerebral palsy.

We are questioning whether this advice is specific to botox injections or whether it should also be applied to other procedures for cerebral palsy manifestations.

For example: patient with muscle contractures and cerebral palsy is admitted for surgical release of the contractures (no Botox given). Principal diagnosis is documented as contractures on the discharge summary.  The operative diagnosis is also documented as contractures.  The procedure was release of contractures.  We have assigned the contractures as Principal Diagnosis.

However, at a recent audit conducted at our hospital, DRG changes assigning cerebral palsy as Principal Diagnosis were put through for the above scenario.  Coding Rule Q2969 was quoted as supporting evidence for this change.

Can you please clarify whether Q2969 Injection of Botox for manifestations of cerebral palsy applies ONLY in cases where the admission is for Botox, or whether the Coding Rule also applies to other procedures for the manifestations of cerebral palsy?

Response:
In accordance with the sentence in ACCD Coding Rule Q2969 Injection of botulinum toxin (Botox) for manifestations of cerebral palsy ‘…where documentation indicates that the patient has CP and the admission is for injection of botulinum toxin for spasticity (eg focal spasticity, muscle spasticity), assign a code from G80.- Cerebral palsy…’ VICC considers this advice is only applicable to episodes of botox for spasticity. In all other cases apply ACS 0001 Principal diagnosis to correctly assign the principal diagnosis.


Query Title:
Acute renal failure (ARF) with chronic kidney disease (CKD) supplementary code

Query Text:
Please advise when to code active vs supplementary code in the following scenarios:

Scenario A:  A patient is admitted with a diagnosis of Acute Renal Failure. The patient also has a documented history of Chronic Kidney Disease.  The eGFR levels are monitored throughout the admission but there is no further mention of management of the CKD.
Question: Is it reasonable to assume that CKD is being monitored by the fact that the eGFR levels are being monitored, and hence that ACS 0002 applies to the documentation of CKD?"

Scenario B: A type II diabetic patient is admitted with a diagnosis of Acute Renal Failure.  The patient also has a documented history of Chronic Kidney Disease. The patient's eGFR levels are monitored throughout the admission and patient seen by nephrologist but there is no further mention of management of the CKD.
Question: Is it reasonable to assume that CKD is being monitored by the fact that the eGFR levels are being monitored, and hence that ACS 0002 applies to the documentation of CKD?"

Scenario C:  patient has a kidney transplant, and they are admitted for "viral illness due to immunocompromised status", then the transplant status is coded.  The question is - is the CKD coded as a N code or a U code? (given that the CKD was not treated during the admission).

Response:
VICC advises that it cannot be assumed that the taking of eGFR levels is increased monitoring of CKD, however there are other ways that CKD meets criteria for coding in scenarios A and B.  

For scenarios A and B, where acute renal failure is the principal diagnosis and chronic kidney disease (CKD) is also documented, the CKD should be coded to N18.- Chronic kidney disease. As stated in ACS 0001 Principal diagnosis/Acute and chronic conditions, ‘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’. Assignment of supplementary code U87.1 Chronic kidney disease, stage 3-5 is not appropriate.

If the acute renal failure is documented as an additional diagnosis with CKD documented as the underlying condition, follow ACS 0002 Additional Diagnoses/Problems and underlying conditions to assign a code for both conditions. However if the CKD is not documented as the underlying condition, or does not meet ACS 0002 in its own right and is documented as being stage 3 - 5, apply ACS 0003 Supplementary codes for chronic conditionsand assign supplementary code U87.1 Chronic kidney disease, stage 3-5. 

In regard to scenario C, if the underlying cause of the viral illness is the immunocompromised status, the immunocompromised status (D89.8) is assigned as an additional diagnosis as per ACS 0002 Additional diagnoses/Problems and underlying conditions. In this case the transplant status code is not assigned and therefore the appropriate code for the CKD is U87.1 Chronic kidney disease, stage 3-5.

If however the immunocompromised status is stated as being due to the transplant status, then a code for the transplant status is assigned and in accordance with ACS 1438 Chronic kidney disease the transplant status code must be assigned together with N18.3 Chronic kidney disease, stage 3 or higher as indicated by an eGFR level. It would not be appropriate to assign supplementary code U87.1 Chronic kidney disease, stage 3-5 in this circumstance.


Query Title:
Labour and delivery complicated by fetal stress (distress)

Query Text:
Question 1:
When instrumental or surgical intervention has been performed for early, late or variable decelerations should O68.8 Labour and delivery complicated by other evidence of fetal stress be assigned because these decelerations are detected on CTG or should O68.0 Labour and delivery complicated by fetal heart rate anomaly be assigned?  Decelerations is not an Index lead term.  ACS 1546 Fetal Heart Rate Decelerations only instructs the coder to assign a code when it meets the criteria noted in this standard.

Question 2:
When there is documentation in the record of fetal bradycardia written on delivery suite progress notes, followed by documentation of NRCTG by the O&G consultant who decides an emergency LUSCS is required and notes this as the indication for ELUSCS on the operation report, is it appropriate to assign both O68.0 Labour and delivery complicated by fetal heart rate anomaly AND O68.8 Labour and delivery complicated by other evidence of fetal distress?  What if there was also biochemical evidence of fetal distress, could O68.3 Labour and delivery complicated by biochemical evidence of fetal distress also be assigned?

There is retired advice (VICC 2174 Fetal stress/distress, retired 30/6/2010) that states "If you have documentation of 'abnormal CTG' or 'non-reassuring CTG' only as the reason for intervention (with no specific heart rate anomalies documented) assign the code:O68.8 Labour and delivery complicated by other evidence of fetal stress. It also goes on to say "There is no hierarchical system that applies to categories within O68 Labour and delivery complicated by fetal stress [distress].  More than one code can be used if appropriate.

Can the Committee please advise when it is appropriate to assign more than one code in category O68.x?

Response:
ACS 1546 Fetal heart rate decelerations advises that ‘decelerations’, taken to mean decelerations of fetal heart rate (FHR) in this context, are only to be coded where there is either documentation of fetal stress or where instrumental or surgical intervention is undertaken. 

Q1, because intervention has been undertaken for the decelerations, the decelerations may be coded, in accordance with ACS 1546. While ACS 1546 does not advise on specific code assignment, where the intervention was for [FHR] ‘decelerations’ so stated, code O68.0 Labour and delivery complicated by fetal heart rate anomaly is the most appropriate code. 

Q2, codes O68.0 Labour and delivery complicated by fetal heart rate anomaly, O68.3 Labour and delivery complicated by biochemical evidence of fetal stress and O68.8  Labour and delivery complicated by other evidence of fetal stress can all be assigned.  There is no limitation on the number of codes from the O68 range that can be assigned for a given case, but please note that O68.2 Labour and delivery complicated by fetal heart rate anomaly with meconium in amniotic fluid combines the concepts in O68.0 Labour and delivery complicated by fetal heart rate anomaly and O68.1 Labour and delivery complicated by meconium in amniotic fluid, and so these would not be assigned in addition to O68.2.


Query Text:
A 30 day old baby admitted with feeding problems and bulging fontanelle.  An ultrasound of the baby's head is done to rule out hydrocephalus. No abnormality found on ultrasound and baby is sent home. Should the bulging fontanelle be coded in this circumstance, and if so, what code should be used?

Response:
VICC considers that as bulging fontanelles is a clinical sign which has been investigated with no definitive diagnosis being made, a code could be assigned in accordance with ACS 1802 Signs and symptoms.  

VICC considers that the appropriate code to assign in this circumstance is R68.8 Other specified general symptoms and signs following the Index entry Abnormal/clinical findings NEC.


Query Title:
Haematochezia with no causal link with another condition

Query Text:
According to the Merriam-Webster medical dictionary, haematochezia is the passage of blood in the faeces. Haematochezia is often documented in the medical record and currently there is no clear clinical code for this nor is there any current advice to guide code assignment.

As there is no index classification for haematochezia, could VICC please advise the appropriate code assignment for 
Haematochezia?

Response:
VICC advises that in the absence of a specific index entry for Haematochezia, it is appropriate to assign K92.2 Gastrointestinal haemorrhage, unspecified following Index entry Bleeding/gastrointestinal NEC.


Query Title:
Insertion of fetal pillow in emergency caesarean section

Query Text:
Is it necessary to code insertion of fetal pillow during a caesarean and if so which code should be assigned to classify the  procedure?

Background Information:
The fetal pillow is a balloon device which is used to elevate the fetal head where the caesarean is performed late in labour. It is inserted vaginally behind the fetal vertex and inflated using saline fluid with a syringe.  The procedure reduces trauma to both the mother and the baby.
The ICD-10-AM 9th edition code for caesarean section includes:
-forceps to after-coming head
-manual removal of placenta
-suture of uterine lacerations/tears during caesarean section

We have coded: 1652003 [1340] Emergency Lower Segment Caesarean section

We sought advice from the Head of the Obstetrics Unit regarding the use of this procedure.  He advised: Fetal pillow will be used in some emergency caesareans when the woman has been in labour for a long time  and a difficulty in getting the fetal head out of uterus is anticipated. It is not used routinely in all emergency caesareans.

1.		 Can you please confirm if the insertion of the fetal pillow should be coded in addition to the caesarean or is the insertion of the pillow an inherent part of an emergency caesarean and thus not necessary to code?
2.		 If an additional code for the insertion of the fetal pillow is necessary,  is 90477-00 [1343] the most suitable code?

Response:
VICC advises that following ACS 0016 General procedure guidelines, insertion of a fetal pillow in an emergency caesarean section is an ‘inherent part of the diagnostic or therapeutic treatment plan’ and should not be coded. 

Although not performed in every emergency caesarean section it will be utilised if required in certain circumstances in accordance with current clinical practice and is therefore a component of surgery rather than a discrete procedural intervention.


Query Text:
How should we code respiratory desaturation(s) that then requires monitoring and/or intervention such as oxygen therapy? We are seeing it documented more frequently for both children and adults.

Depending on how you look it up and what words you use you can get to different codes, for example:
- Disorder, respiratory function, impaired J96.99
- Decompensation, respiratory J98.8
- Abnormal, breathing R06.8

We do query if this is respiratory failure and the clinicians response is frequently that it isn't.

Response:
VICC advises that documentation of respiratory desaturation, meeting criteria for coding, should be coded to R09.89 Other specified symptoms and signs involving the respiratory system following the Index entry Symptoms specified NEC/involving/respiratory system NEC.


Query Text:
Pressure area to axilla appears to go to L89.99 (NEC) but this descriptor is 'site unknown'. 

This doesn't seem to adequately capture the picture of this pressure injury. Is there another code I can use e.g. Upper extremity?

Response:
VICC advises that the correct code to assign for pressure injury to axilla is L89.90 Pressure injury, unspecified stage, site unspecified. Even though the code title includes ‘site unspecified’ the list of inclusions under the fifth character '0' code includes ‘other site NEC’.


Query Text:
What is the correct sequencing of codes for preparatory care when the condition is known? 

We are starting to have gastroscopies done prior to lap sleeve gastrectomies where there has been previous bariatric surgery perfromed. Obesity and often the complications from past surgery is documented e.g. "complete staple line break down".  "Workup for sleeve gastrectomy" is also in the operative diagnosis. From what I can see from past queries, I have coded the condition first with an additional diagnosis if Z51.4 Preparatory care for subsequent treatment, not elsewhere classified. I am confused at to what is the current directive.


Search Details:
I have found past responses from NCCH and VICC queries back to 2010, some of these are retired and most pertain to renal dialysis prep.  I am unable to find clarification in the current Alphabetical Index or the Tabular list.

Response:
VICC advises that Z51.4 Preparatory care for subsequent treatment, not elsewhere classified is assigned as principal diagnosis when the only documentation is preparatory care and there is no further documentation of the condition. 
 
For the scenarios cited, assign as principal diagnosis a code representing the documented reason for surgery.   Z51.4 Preparatory care can be assigned as an additional diagnosis code if documentation of preparatory care also exists.


Query Title:
Diabetes with pressure sore / area / injury

Query Text:
When there is documentation of a pressure sore/area/injury and the patient has diabetes, can E1-.69 Diabetes mellitus with other specified complication be assigned?

We note that ACS 1221 Pressure Injury states that synonymous terms for pressure injury are pressure ulcer, decubitus ulcer, pressure area, plaster ulcer and bedsore.

Given that the terms pressure sore/area/injury/ulcer are synonymous, is it therefore appropriate to follow the Diabetes with ulcer, skin and assign E1-.69 when there is documentation of a pressure sore/area/injury and the patient has diabetes?

Response:
The following VICC query was originally published in the 2016-17 March VICC queries database release as follows:

As per Rule 3 of ACS 0401 Diabetes Mellitus and intermediate hyperglycaemia, VICC advises that even though the ulcer has been identified as having a different cause, the Diabetes, - with Index entries represent an association rather than a cause and effect relationship between conditions.  

VICC also agrees that the synonymous terms for pressure injury, specifically the term ‘ulcer’ can be used when coding out the diabetes.  Therefore it is appropriate to follow the Index entry Diabetes/with/ulcer to code the diabetes to E1-.69 Diabetes mellitus with other specified complication. [end of response]

The above advice is superseded by the ACCD Coding Rules advice Q3237 Pressure injury with diabetes mellitus published on 15 December 2017 as follows:

Q:
Is a pressure injury classified as a complication of diabetes mellitus?

A:
ACS 1221 Pressure injury states that synonymous terms for pressure injury include pressure ulcer, decubitus ulcer, pressure area, plaster ulcer and bedsore.

ACS 0401 Diabetes mellitus and intermediate hyperglycaemia/General classification rules for DM and IH states:
Rule 3. 
The classification includes conditions (often termed 'complications') which occur commonly with DM or IH. These conditions may or may not have been a direct consequence of the metabolic disturbance and are indexed under Diabetes, with or Hyperglycaemia/intermediate/with. Always refer to these index entries to classify DM or IH (see examples 2-7).

None of the synonyms listed above for pressure injury are listed in the Alphabetic Index under Diabetes, with. Therefore, the guidelines in ACS 0401 for ‘complications’ of diabetes mellitus do not apply to pressure injury in a patient with diabetes mellitus, unless the criteria for diabetic foot are met.

See also ACS 0401 Diabetes mellitus and intermediate hyperglycaemia/6. Diabetic foot.


Query Text:
An obstetric patient at 18 weeks gestation is admitted to a medical ward for treatment of an E. coli UTI.  Admission was 4 days, patient treated with antibiotics and seen only once by an O&G Registrar on last day of admission, to listen to fetal heart rate and arrange follow-up at next antenatal appointment.  At no point is there documentation to state that the pregnancy is complicated by the UTI.

The 3M Encoder and the ICD-10-AM Index both have the following entries/pathways
-Pregnancy, complicated by
- infection
- - urinary tract O23.4

Infection
-urinary tract
- - complicating pregnancy O23.4

O23.4 Unspecified infection of urinary tract in pregnancy.

Given the above circumstances, what is the correct code(s) for this case

(a)		 N39.0, B96.2, Z34.x
or
(b)		 O23.4, B96.2

Response:
VICC advises that in episodes other than the delivery episode the infection must be documented as complicating the pregnancy before the index entry Pregnancy/complicated by can be followed.  This is in accordance with ACCD advice titled ACS 1521 Conditions complicating pregnancy (2 of 2) ACS 1521 and the postpartum period updated 30 June 2013.

Therefore the scenario cited in this query would be coded to:
N39.0  Urinary tract infection, site not specified
B96.2  Escherichia coli [E. Coli] as the cause of diseases classified to other chapters
Z34.x  Supervision of normal pregnancy


Query Text:
Can you please clarify the correct codes to assign for iliac artery stenosis in a patient with diabetes?
We note previous VICC advice 2005 2006/07 December database in which the patient had T2DM, PVD and iliac artery stenosis and the direction was to code E11.51 and I70.8.  This advice has been retired.

We also note VICC advice 2542 2010/11 December database which stated that 'The VICC notes that whilst clinical advice indicates that the iliac artery is a peripheral artery, the classification defines peripheral as extremities and nowhere in the classification is the position of the iliac artery classified as a peripheral site. Therefore for documentation of stenosis of the iliac artery, follow ACS 0941 Arterial disease to determine if it can be coded to atherosclerosis and if so, follow the index entry Atherosclerosis, specified artery NEC I70.'  This advice has also been retired.

1. Although the advice has been retired, is it correct to apply the same logic for coding of iliac artery stenosis and follow the index pathway for Arteriosclerosis, specified artery NEC I70.8?

2. If a patient has documented iliac artery stenosis with diabetes with no other complications (ie no PVD), can you please clarify the correct diabetes code?  Is it correct to assign E1-.9 diabetes mellitus without complication, if the iliac artery is not classified as a peripheral site and it is therefore incorrect to follow the pathway Diabetes, with, angiopathy, peripheral (without gangrene) E1-.51 ?

Search Details:
VICC #2005 2006/07 December database
VICC #2542 2010/11 December database

Response:
VICC advises that whilst clinical advice indicates that the iliac artery is a peripheral artery, the classification defines peripheral as extremities and nowhere in the classification is the position of the iliac artery classified as a peripheral site.  Therefore the correct codes to assign for iliac artery stenosis in a patient with diabetes are:

E1-.9 Diabetes mellitus without complication; and 
I70.8 Atherosclerosis of other arteries

The sequencing of these codes should be based on documentation in the record.


Query Title:
Newborn follow up for breech presentation and delivery

Query Text:
Newborn delivered by breech delivery and with breech presentation in utero.

These infants are usually followed up at 6 weeks of age with a hip ultrasound.

If there no issues with the newborn's hips during the birth episode and the only mention of the Breech position and delivery is indicated by the hip ultrasound at 6 weeks, is it necessary to assign a code to reflect the future ultrasound?

If yes, what is the correct code to assign?

Response:
VICC advises that as no condition or symptom has been documented there is no code to assign. Code assignment is not based on an intention to perform a future investigation.


Query Text:
Is unlooping cord around neck an assisted delivery?

When the cord is manually freed from around the baby's neck before delivery, is this classed as an assisted delivery?
The designated episode was a ventouse delivery so will be coded as such, but conversation between coders queried the relevance of unlooping the cord when there was no other intervention.

Response:
VICC considers unlooping the cord from around the neck constitutes minimal assistance, as encompassed by code O80 Single spontaneous delivery. This is supported by clinician’s advice. It is unnecessary to assign any other code for this action.


Query Text:
Could you please indicate what code should be assigned when a newborn is found to have an absent red eye reflex on examination and is referred to specialist eye services for further investigation?

Response:
VICC considers that as red eye reflex is a clinical sign which has been investigated with no definitive diagnosis being made, a code could be assigned in accordance with ACS 1802 Signs and symptoms.  

VICC considers that the appropriate code to assign in this circumstance is R68.8 Other specified general symptoms and signs following the Index entry Abnormal/clinical findings NEC.


Query Title:
External cause code for motorised wheelbarrow

Query Text:
Can you give advice on an external cause code for fall from motorized wheelbarrow?  The clinical notes indicate the patient was riding his motorised wheelbarrow, reversing and hit a tyre, thrown off wheelbarrow and landed on his chest.

Response:
As the patient was riding the motorised wheelbarrow VICC considers this to be a conveyance. In the absence of further documentation to describe the type of motorised wheelbarrow, VICC advises to default to external cause code V98 Other specified transport accident following the Index entry Accident/transport/specified NEC.

This is supported by the definition in Chapter 20:Transport Accidents (V00-V99) stating 'A transport accident is any accident involving a device designed primarily for, or being used at the time primarily for, conveying persons or goods from one place to another'.


Query Text:
I have a query in regard to coding of incontinence. The standard notes it should be coded only when the incontinence is persistent to admission, present at discharge or persists for at least 7 days.  

Are we able to code incontinence where a patient is admitted who has pre-existing incontinence, is noted on care plan tick sheets as being incontinent throughtout the episode however there is no documentation of this within the progress notes?  I am reluctant to code this from tick sheet evidence only - am I correct in this assumption?

Response:
VICC considers that a ticked box is a form of documentation, and provides evidence of care and conditions when present on documents such as a Care Plan.

However there must be evidence that incontinence meets ACS 0002 Additional Diagnoses and meets the criteria in ACS 1808 Incontinence before it can be coded; completion of a tick box alone would not provide that evidence.


Query Title:
Labile blood sugar levels (BSL) in a diabetic patient

Query Text:
Can labile BSL be coded to unstable diabetes mellitus in a diabetic patient?

Please note ACCD Q&A Labile diabetes Published 15 June 2016, for implementation 01 July 2016.:
SUBJECT:  Labile diabetes
Q:
Can labile diabetes mellitus be assigned to unstable diabetes mellitus?
A:
In the context of diabetes mellitus the term labile is used to describe wide, recurrent fluctuations in blood glucose levels. Synonymous terms include unstable or brittle diabetes. While unstable diabetes may be associated with any form of diabetes 
mellitus, brittle diabetes is associated specifically with E10 Type 1 diabetes mellitus as listed in the Includes note.

Where labile diabetes is documented assign E1-.65 * diabetes mellitus with poor control following the Alphabetic Index:
Diabetes, diabetic
- unstable E1-.65

Updates to ICD-10-AM will be considered for a future edition.

Response:
VICC notes that ACCD Q3028 indicates that, in the context of diabetes mellitus, ‘labile’ is synonymous with terms including ‘unstable’, and directs to the Index look up Diabetes, unstable, in circumstances where labile diabetes mellitus is documented.
VICC also notes VICC 2628 Poorly controlled blood sugar levels (BSL), which reports; ‘several clinicians who are unanimous in their advice that documentation of uncontrolled blood sugar levels in diabetic patients is equal to uncontrolled diabetes in a diabetic patient’.
Accordingly, VICC considers it is appropriate to code unstable diabetes where BSLs are described as ‘labile’ in a diabetic patient.


Query Text:
Which code do you use, Z09.0 Follow-up examination after surgery or Z09.8 Follow up examination after other treatment when a patient has previously had a colonoscopy with polypectomy (ie is a polypectomy considered to be surgery)?

Enquirer notes: ACCD advice Q2671 Z09 Follow-up examination after treatment for conditions other than malignant neoplasms published June 2012 indicates a biopsy does not meet critieria for Z09.0 but doesn't mention polypectomy.

Response:
VICC considers that as a polypectomy requires an excision it is considered surgical treatment. Therefore it is appropriate to assign Z09.0 Follow-up examination after surgery in the case cited.


Query Title:
External causes for motor vehicle accident and assault

Query Text:
Patient admitted post struck by a car and pushed into a fence.  This was documented as both MVA and assault by partner as this was allegedly deliberate. Place of occurrence is unknown, it may have been on a public highway or in a private driveway. We assume we use external cause codes for both assault and motor car accident (? traffic or nontraffic)

Response:
In accordance with the Excludes note in Chapter 20: Transport Accidents (V00-V99) which indicates that assault by crashing of motor vehicle is classified to range Y03.-, VICC advises that where an assault has been carried out with a motor vehicle, only one external cause code is required.

In the case cited, as the place of occurrence is unknown, follow Index entry Assault/crashing of motor vehicle to assign an external cause code from the Y03 range.


Query Text:
How do you code fracture blisters?  These blisters are not part of the original trauma (where they would not be coded as they are a superficial injury as per ACS 1916) but develop after the original trauma.

Fracture blisters are a relatively uncommon complication of fractures in locations of the body, such as the ankle, wrist elbow and foot, where skin adheres tightly to bone with little subcutaneous fat cushioning. The blister that results resembles that of a second degree burn

These blisters significantly alter treatment, making it difficult to splint or cast and often overlying ideal surgical incision sites.

Do you code T798  Other early complications of trauma, plus another code to further specify the trauma following the index, blister. Plus appropriate External cause codes.

Response:
This query was originally published in the 2016-17 June Database as follows:

VICC research indicates that although fracture blisters may take some time to manifest in a patient with a fracture they are still a superficial injury at the site of a more serious injury and are directly related to the fracture. Therefore in accordance with ACS 1916 Superficial injuries VICC advises that an additional code for the blisters should not be assigned.

Following publication of ACCD Coding Rules on 15 September 2018, the VICC response is superseded by the following advice titled Fracture blisters:

Q: What code is assigned for fracture blister?

A: Fracture blisters arise on skin overlying an acute bony fracture, or more rarely, they may occur after bone/joint surgery (eg arthroplasty). Fracture blisters occur on tight, thin skin with minimal soft tissue between the skin and underlying bone (eg ankle, wrist, elbow, foot, distal tibia). Fracture blisters are caused by shearing forces on the skin created by angulation of a bony fracture, post traumatic oedema and/or local tissue hypoxia. Other risk factors for fracture blisters include peripheral vascular disease, hypertension and diabetes mellitus. The presence of fracture blisters may complicate and delay fracture repair, and may result in chronic ulcers or infection, and prolong hospital admission (Cheng 2015; Nall 2018; Uebbing et al 2011; Wheeless 2012).

Clinical advice confirms that fracture blisters following a traumatic fracture are complications of the underlying fracture, not the original trauma that resulted in the bone fracture.

Where a fracture blister occurs following a traumatic fracture and meets the criteria in ACS 0002 Additional diagnoses, assign:

- a code for Blister/by site
- X58 Exposure to other specified factors as the external cause code, to differentiate the external cause of the fracture blister from the external cause of the traumatic fracture.

Where a fracture blister occurs following bone/joint surgery, follow the guidelines in ACS 1904 Procedural complications.

Amendments will be considered for a future edition.  

References:
Cheng, H 2015, Fracture blister, DermNet New Zealand (New Zealand Dermatological Society), viewed 13 December 2017, https://www.dermnetnz.org/topics/fracture-blister

Nall, R 2018 Fracture blister, Healthline, viewed 9 July 2018, https://www.healthline.com/health/fracture-blisters

Uebbing, C, Walsh, m, Miller, J, Abraham, M & Arnold, C 2011, ‘Fracture blisters’, Western Journal of Emergency Medicine, 2011 Feb; 12(1): 131-133, viewed 13 December 2017, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088393/

Wheeless, C 2012, Fracture blisters, Wheeless’ Textbook of Orthopaedics (Presented by Duke Orthopaedics), viewed 13 December 2017, http://www.wheelessonline.com/ortho/fracture_blisters

Published 15 September 2018, 
for implementation 01 October 2018.


Query Text:
A patient presented to our hospital with a submasseteric abscess, which was thought to have been a consequence of a third molar infection.

They were taken to theatre where the third molar was extracted and incision and drainage of the abscess was performed. The drainage was performed via intraoral (buccal) and extraoral  (inferior border of mandible) incisions. The patient remained intubated and was transferred to ICU.

Our research indicates that the submasseteric space (also termed the masseteric space) is a fascial space of the head and neck (sometimes also termed fascial spaces or tissue spaces). It is a potential space in the face over the angle of the jaw, and is paired on each side. It is located between the lateral aspect of the mandible and the medial aspect of the masseter muscle and its investing fascia. The submasseteric space is sometimes involved by the spread of odontogenic infections, such as a pericoronal abscess associated with an impacted mandibular third molar when the apices of the tooth lie very close to or within the space (source:  wikipedia).

Given that the infection was deemed to have been odontogenic in nature, should a submasseteric abscess be coded to K12.2 Cellulitis and abscess of mouth?

Enquirer notes: 
Index:
Abscess
- mouth (floor) K12.2

Response:
VICC research indicates that the submasseteric space is part of the face. 

In the absence of documentation that the abscess is of the fascia, VICC considers it is appropriate to follow Index entry Abscess/face (any part, except ear, eye and nose) to assign L02.0 Cutaneous abscess, furuncle and caruncle of face.

VICC does not consider K12.2 Cellulitis and abscess of the mouth appropriate as although the infection may have begun in the tooth site the abscess is now of the face.


Query Text:
R45.81 has an excludes note that states that this code is not to be used if the signs and symptoms constitute part of a mental disorder.  As suicide prevention has received special funding it is important to be able to capture if someone has suicidal ideation upon presentation or during their episode of care regardless of the presence of a mental illness. Therefore I would like to know if we can commence capturing this vital piece of information?

Response:
Funding not withstanding, VICC advises that R45.81 Suicidal ideation cannot be assigned when there is a documented relationship between the suicidal ideation and the mental health condition. Please refer to VICC Query #3135 Suicidal Ideation published in the September 2016 VICC queries database. 

A health service may collect this data internally provided it is not reported to the VAED. 

You may wish to make a public submission to the ACCD to improve the classification for the future.


Query Title:
Diagnostic and Statistical Manual of Mental Disorders terminology and ICD-10-AM coding

Query Text:
Diagnostic and Statistical Manual of Mental Disorders 5 was introduced in most Victorian mental health services in 2014. There have been some changes in terminology as well as new diagnoses added and some removed from this classification.  One of these changes affecting mental health coders is the way in which substance use is documented.  The terminology now being used by mental health clinical staff is substance use disorder which is split into mild, moderate and severe.  ICD-10-CM (USA) maps these in the following way: mild = harmful use, moderate/severe = dependence.  Victorian Mental Health coders will now not be able to classify substance use (harmful use/dependence) appropriately in ICD-10-AM because it is documented differently.  Are Victorian coders allowed to use the US guide or, if the diagnosis of substance use disorder (mild, moderate or severe) meets the criteria for coding do we need to code to F1*.9 (unspecified mental and behavioural disorder)?

Response:
VICC advises that clinical coders must code in accordance with ICD-10-AM conventions and standards following the documentation in the clinical record. Therefore it is not appropriate to map from the Diagnostic and Statistical Manual of Mental Disorders to ICD-10-AM.

VICC acknowledges that this may lead to the assignment of less specific codes and you may wish to make a public submission to the ACCD to improve the classification for the future.


Query Text:
Our private hospital group which has hospitals in Victoria, NSW and QLD has a query regarding the ACCD Coding Rule Q2667 titled T88.4 Failed or difficult intubation.

ACCD advice outlines there are in principle three markers of a difficult intubation: the anaesthetist intubators (clinical) opinion, the patient, and the procedure. The ACCD advice directs the coder to seek clinical advice as quoted:  Where documentation is unclear, coders should seek clinical advice. The ACCD advice do not specify who can provide this clinical advice. Can only the treating Anaesthetist/ Intubator provide this advice or can other suitably qualified medical staff (such as an ICU Director, Medical Director) provide this clinical advice?

We want to ensure that our coding is consistent across our hospitals. We have a robust clinician query process in place at each of our hospitals and we want to ensure that we are line with Australian Coding Standards and ACCD advice. We also want to ensure that our documentation and coding practices accurately reflect the care that our patients have received.

Response:
VICC considers that the treating anaesthetist is the most appropriate clinician to give clinical advice regarding failed or difficult intubation in the first instance. However, when it is not possible to obtain clinical advice from the treating anaesthetist, VICC considers it is appropriate to seek clinical advice from another anaesthetist.  This is supported by the sentence in the introduction to the Australian Coding Standards which says ‘In order to assign a code associated with a particular clinician's documentation, the documented information must be appropriate to the clinicians discipline.’

When intubation is performed for reasons other than for anaesthesia, for example, intubation in  ICU, it is appropriate to seek clinical advice from a clinician qualified for intubation. 

Please also note that ACCD Coding Rule Q2667 T88.4 Failed or difficult intubation has been retired by the ACCD with the introduction of ACS 1924 Difficult intubation.


Query Text:
Can you please clarify how to code anterior cruciate ligament (ACL) disruption?

Principal diagnosis on discharge summary: ACL reconstruction
Operative diagnosis: Right ACL disruption.
Notes indicate that this is due to an acute twisting injury.
Procedure: Right arthroscopic ACL reconstruction.
Pre- admission MRI report shows partial thickness ACL tear
No diagnosis documented elsewhere.


We note that disruption of knee ligament is indexed as a dislocation but disruption of ligaments of other sites are indexed to sprain?

Disruption
-ligament(s), see also Sprain
--knee
---current injury, see Dislocation/knee
---old (chronic) M23.5-
----laxity M23.8-
---spontaneous NEC M23.6-

Dislocation (articular) T14.3
-knee (tibia, proximal end) (tibiofibular joint) S83.10
--anterior S83.11
--cap S83.0
--congenital Q74.12
--lateral S83.14--
--medial S83.13
--old M23.8-
--pathological M24.36
--posterior S83.12
---femur (distal end) S83.11
--recurrent M24.46
--specified NEC S83.18

Internet search for ACL disruption finds information re ACL tear, ACL injury, ACL sprain but not dislocation.

In the case above, if we coded from the documented diagnosis, we would code dislocation which doesn't seem right as the admission is to treat the ACL not reduce a dislocation. Whereas if the documentation was tear (as noted on MRI but not necessarily confirmed at operation) we would code sprain.

Is the index correct in leading us to dislocation for ACL disruption?

Sprain, strain (joint) (ligament) T14.3
-cruciate, knee (current injury) S83.50
--anterior S83.51
--old (chronic) M23.5-
--posterior S83.52

Rupture, ruptured (see also Injury/by site)
-joint capsule, see Sprain
-ligament (traumatic) (see also Sprain) T14.3
--cruciate (current injury) (knee) S83.50
---anterior S83.53
---old (chronic) M23.5-
---posterior S83.54

Tear
-ligament, see also Sprain
--knee (current injury) NEC S83.6
---cruciate S83.50
----anterior S83.53
----posterior S83.54
---old (chronic) M23.5-

Response:
In the absence of further clarification from a clinician VICC advises that the correct code to assign for anterior cruciate ligament (ACL) disruption is S83.18 Other dislocation of knee following Index entry Disruption/ligament/knee/current injury - see Dislocation/knee/specified NEC

You may wish to make a public submission to the ACCD to improve the classification for the future.


Query Title:
Anaphylactic reaction/shock due to overdose/wrong substance

Query Text:
To assign a code for anaphylactic shock or reaction due to overdose, we 
follow the index entry of:
Shock, anaphylactic
- Drug or medicinal substance
- - overdose or wrong substance given or taken T50.9 Poisoning by other and unspecified drugs, medicaments, and biological substances.

This leaves us with a T50.9 code without mention of the anaphylaxis.In contrast, if assigning a code for anaphylactic shock or reaction due to stings, we follow the index entry of:
Shock, anaphylactic
- Following sting T63.9 Toxic effect of contact with unspecified venomous 
animal.

There is a Use Additional Code note at the beginning of the T63 block instructing to add a code to identify the reaction, such as anaphylaxis T78.2.

Despite the lack of a Use Additional Code note on the T50.9 chapter, should we add the T78.2 Anaphylactic shock, unspecified code when assigning a code for anaphylactic shock or reaction due to overdose to provide further specificity?

Response:
Although there is no ‘use additional code’ note at T50 Poisoning by diuretics and other and unspecified drugs, medicaments and biological substances, ACS 1901 Poisoning states ‘In addition to the code for poisoning, an additional diagnosis code should be assigned to indicate any significant manifestation (eg coma, arrhythmia)'. 

Therefore in the case cited VICC advises it is correct to add T78.2 Anaphylaxis and anaphylactic shock, unspecified as it is a significant manifestation of the overdose.


Query Text:
At the beginning of ACS 2103 Admission for post acute care it clearly states that the definition of post-acute care is for classification purposes.

There is no similar statement at the beginning of ACS 2117 Non-acute care.

Is the definition of non-acute (or maintenance) care in the first sentence of ACS 2117 Non-acute care also intended for classification purposes and independent of the Care Type under which the patient is admitted?

There seems to be some confusion around the interpretation of ACS 2117 in that if a hospital assigns Z75.1- Person awaiting admission to adequate facility elsewhere as the principal diagnosis, then the Care Type must be Maintenance Care but what if the hospital is not approved to report the Care Type for Maintenance care and the documentation in the record supports the assignment of Z75.1- as the Principal diagnosis?

ACS 2104 Rehabilitation clearly states that Z50.9 Care involving use of rehabilitation procedure may be independent of the admitted patient Care Type; however this same statement is not included in ACS 2117.

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

ACS 2117 Non acute care contains both definitional and classification information with regard to nonacute episodes of care.

Definitions are provided in ACS for clinical coder information only; for classification purposes follow the guidelines in the Classification section of an ACS.

The issue of ‘care types’ is outside the scope of ICD-10-AM/ACHI/ACS, and as such, classification guidelines are independent of the admitted episode care type.

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

Further to the ACCD response VICC advises to follow the documentation to assign the appropriate principal diagnosis irrespective of the Care Type of the episode.


Query Text:
Often patients present with Iron Overload for Venesection.  There is currently no essential modifier for 'Iron' under the lead term 'Overload'.

Can you please confirm the correct code to assign for documentation of Iron Overload is E83.1  Disorders of iron metabolism?  Following the lead term:

Disorder
- Metabolism
- - Iron E83.1

Response:
VICC advises that in the absence of a sub term for iron under lead term Overload, to follow the Index entry Disease/iron metabolism or storage to assign E83.1 Disorders of iron metabolism. This is supported by Example 32 in the Conventions used in the Tabular list of diseases which says, ‘the main term Polyp in the index does not include a subterm of 'oesophagus'. To find the correct code assignment, next search the index for Disease/oesophagus/specified, which indicates code K22.8 Other specified diseases of oesophagus’.


Query Title:
Conditions noted to be "on a background of..."

Query Text:
When a clinician is describing a condition, they'll often use language such as "Patient presented with Pneumonia on a background of Lung cancer" and "Patient admitted with Sepsis on a background of COAD"

Without seeking further clarification from the clinician, does VICC consider the phrase "on a background of" (or similar) to be the "underlying cause of the problem" and apply advice in ACS 0001 and/or ACS 0002? Or does VICC consider this to be the patients current/recent history only?

Response:
VICC does not consider the phrase "on a background of" to be synonymous with “underlying cause of the problem”. A number of conditions may co-exist in a patient, but without a documented causal link it cannot be assumed that one is the underlying cause of another.

These conditions must meet ACS 0002 Additional diagnoses or a specialty standard in order for a code to be assigned.

Please also see VICC query #3210 Underlying condition for further information.


Query Title:
Coding when patient complains of a condition or symptom

Query Text:
Often the nurses and or clinicians will document that 'the patient complains of a condition or symptom' and treat the condition.

For example:
a) The patient complains of constipation -> movicol commenced
b) The patient complains of abdominal pain -> buscopan commenced.

If the condition that 'the patient complains of' meets ACS 0002 Additional diagnoses, should this be coded?

Or, does VICC consider that that this type of documentation is ambiguous, and the coder should seek clarification from the clinician prior to code assignment?

Response:
VICC considers that regardless of whether the patient complains of a condition or symptom, if the condition or symptom has been documented in the notes by a treating clinician, that documentation can be considered when determining if a condition meets criteria for coding.

If there is doubt that a link has been established between the condition and subsequent management a code cannot be assigned. 

For the examples cited, if the treatment is nurse initiated and no further documentation regarding the condition is available, the condition does not meet the criteria for significance in Vic 0002 Additional diagnoses and a code cannot be assigned. If there was a treatment plan for the condition documented by a treating clinician then a code for the condition could be assigned.


Query Text:
The answer to VICC query #2996 Assignment of drug resistance to microorganisms code from electronic discharge summary states

'...VICC considers that "on a background of" is not the same as underlying cause....'

1. Is this advice specific to this query only, or is it advice that can be applied to coding in general.

2. Are statements "in context of" and "in a setting of" the same as "on a background of" or do they not indicate any linkage for coding underlying causes.

For example:  "imp:  febrile convulsion in context of URTI".   Does this indicate URTI as an underlying cause?

Response:
VICC advises that the advice given in query #2996 Assignment of drug resistance to microorganisms code from electronic discharge summary  regarding the interpretation of ‘on a background of’ is not specific only to that query and can be applied in other contexts.
VICC does not consider the phrases ‘on a background of’, ‘in context of’,  ‘in a setting of’ or any other similar wording  to indicate a link for coding underlying causes.  
The statement  ‘febrile convulsions in context of URTI’ suggests a relationship between the two conditions which may or may not indicate an underlying cause and should be clarified with a treating clinician. 
If an underlying cause is not clearly documented both the febrile convulsions and URTI must meet ACS 0001 Principal diagnosis, ACS 0002 Additional diagnoses or a specialty standard in order for a code to be assigned.
Please also see VICC query #3207 Conditions noted to be "on a background of…" for further information.


Query Text:
Can the committee please clarify the correct coding of the following common scenarios:

1. Patient admitted for follow up cystoscopy due to past history of TCC of bladder documented on the operation report. Result of the scope is NAD. Histopathology from previous admissions, the past history was low grade papillary urothelial carcinoma. 

Do we use the condition documented in the current admission and code:
Z08.0 Follow-up examination after surgery for malignant neoplasm
Z85.5 Personal history of malignant neoplasm of urinary tract
OR
Use available histology from previous admissions and code:
Z09.0 Follow-up examination after surgery for other conditions
Z86.0 Personal history of other neoplasms

2. Patient admitted for follow up of previous colonic polyps as documented on the operation report. Scope is NAD. Histology from previous admissions, the past history was colonic adenoma. Do we use the condition documented in the current admission and code:

Z09.0 Follow-up examination after surgery for other conditions
Z87.12 Personal history of colonic polyps
OR
Use available histology from previous admissions and code:
Z09.0 Follow-up examination after surgery for other conditions
Z86.0 Personal history of other neoplasms

Response:
VICC advises that when there is no available histology from the current admission assign a code based on the clinical documentation. Clinical Coders cannot assume that histology from a previous admission is the only histology for that patient, or reflects the original cancer diagnosis. 

If the documentation is not clear, a clinician query may be sent to clarify the diagnosis as per ACS 0010 General abstraction guidelines which states ‘In the event that an investigation result varies from the clinical documentation…the case should be referred to the clinician’.

Based on the information provided or the cited scenarios VICC advises to assign the following codes:

Scenario 1
Z08.0 Follow-up examination after surgery for malignant neoplasm
Z85.5 Personal history of malignant neoplasm of urinary tract.

Scenario 2
Z09.0 Follow-up examination after surgery for other conditions
Z87.12 Personal history of colonic polyps


Query Text:
Could the Committee please provide advice on how to code the following scenario:

Patient admitted for excision of skin lesions (lipoma) on their back. Post excision of the skin lesions, when the patient had returned to the ward it was determined that the incorrect lesions were removed from the patient:

Progress notes state the following:

'Explained to patient that wrong procedure initially performed due to patient's position in OT'

As a result of this the patient returned to theatre later that day for excision of the correct skin lesions on their back.

There is no documentation of any adverse effects due to the incorrect lesion being removed except for the patient having to return to theatre for excision of the correct lesion.

We have had discussion amongst our coders and have come up with the following code options to capture that the incorrect procedure was performed and the patient was required to return to theatre:

1. T81.8 Other complications of procedures, not elsewhere classified
Y65.5 Performance of inappropriate operation.
Y92.22 Health service area

OR

2. Z04.3	 Examination and observation following other accident
Y65.5 Performance of inappropriate operation.
Y92.22 Health service area

OR

3. Z04.8 Examination and observation for other specified reasons.

Could the committee please advise the correct diagnosis/diagnoses codes to assign to capture that the incorrect procedure was performed, in addition to the skin lesion/lipoma codes?

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

ACCD does not respond to specific scenarios, however note the following guidelines regarding unintentional events:

The primary reporting mechanism for hospital clinical incidents (including sentinel events) and unplanned returns to theatre is via hospital risk management systems and the patient management system, not through classification data.

ACS 1904 Procedural complications states:

UNINTENTIONAL EVENT(S)

An unintentional event (previously termed misadventure) is defined as injury or harm caused during medical or surgical care. An unintentional event may be identified at the time of the procedure or after completion of the procedure. Examples of unintentional events include:
- foreign body accidentally left during a procedure
- infusion of contaminated medical or biological substances
- mismatched blood used in transfusion
- failure of sterile precautions during surgical and medical care
- inadvertent exposure of patient to radiation
- unintentional cut, puncture, perforation during surgical and medical care.

The conditions listed above must meet the criteria in either ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses in order to assign a code for an unintentional event.

An external cause code from Y60–Y69 or Y70–Y82 is assigned only when there is documentation of:
- an injury during the provision of care OR
- harm that resulted from an unintentional event during the provision of care

Therefore, it is not appropriate to assign procedural complication (and external cause) codes in instances where events have not resulted in injury or harm.

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


Query Title:
Elective LUSCS with Internal Version due to Malpresentation

Query Text:
An obstetric patient was admitted for repeat LUSCS. Baby's position in utero was cephalic.
Following incision into the uterus, the baby's arm protruded through the incision. The arm was not able to be replaced over the head so a decision was made for internal breech version and extraction. Lovsets to shoulders and MSV (Mauriceau-Smellie-Veit) manoeuvre to head with ease.

Given the above intervention, should we also assign a procedure code for Internal Version and/or Breech extraction or does the code for LUSCS cover all interventions within the delivery process?

Response:
VICC research indicates that caesareans can be carried out in different ways depending on the circumstances and internal version and breech extraction is a variation of a standard caesarean. Therefore 16520-01 [1340] Elective lower segment caesarean section is the only code required for this scenario.


Query Title:
Induction of labour due to meconium in liquor

Query Text:
When an obstetric patient is admitted for induction of labour due to meconium in liquor, there is always great difficulty in assigning a code to capture the Meconium in Liquor before labour. Is the correct code in this instance O36.3 Maternal care for signs of fetal hypoxia? 

We have checked Index entries and have arrived at this code via the following pathway

Meconium in liquor-  see Distress Fetal
Distress 
- fetal
-- affecting
--- management of pregnancy (unrelated to labour and delivery) O36.3

Response:
In accordance with Ninth Edition ACS 1547 Meconium in liquor, O36.3 Maternal care for signs of fetal hypoxia should only be assigned when fetal distress is documented or instrumental or surgical intervention is undertaken.
 
As fetal distress is not documented in the scenario cited, assignment of O36.3 will be dependent on the type of induction performed.  If a code cannot be assigned from the available documentation you may consult a treating clinician.

Please note, ACS 1547 Meconium in liquor has been deleted in Tenth Edition. Therefore O36.3 Maternal care for signs of fetal hypoxia can now only be assigned for meconium in liquor before labour if fetal distress is also documented as per the Index entry at lead term Meconium, and it meets ACS 0002 Additional diagnoses.


Query Text:
We have been reviewing the pathway for the procedure of 'replacement of spinal infusion pump' and have noticed quite a significant difference in WIES value if coded different ways. We seek advice on whether coding pathways and cost weights need to be revised to reflect the costs involved in this procedure, rather than advice on correct coding of this procedure.

1.       Operation report states replacement of spinal pump. Pump is removed and a new one inserted.

If we code this following the pathway of "replacement spinal pump" we get 39126-00 [56] Revision of implantable spinal infusion device or pump (includes notes =replacement). DRG I10B = 1.6811 WIES

If we code following the pathway of "insertion spinal pump" we get 39127-00 [39].  If we then code "removal" of pump (ignoring option of 'with replacement') code 39133-02 [40] with DRG A11B = 4.8251 WIES.

We acknowledge that the preposition "with" replacement should be followed for sound coding practice, however, this is such a big difference in WIES yet the same procedure.The cost of the pump device alone is approximately $16,000.  If we were to code as "replacement" reimbursement would only be about half of this cost which we don't understand.

We have been advised that the insertion code takes the episode into the A pre MDC but replacement code does not. Possibly this question needs referral to ACCD to review index entries.
Thank you for your advice

Response:
Notwithstanding AR-DRG and WIES implications VICC advises coders to use the documentation available and follow the Index pathway to assign a code. In the case cited the correct code to assign is 39126-00 [56] Revision of implantable spinal infusion device or pump following Index entry Replacement/pump/infusion/spinal.
You may wish to make a public submission to the ACCD to improve the classification for the future.


Query Text:
We often have documentation of tongue tie in newborns. The medical staff may document their treatment of this as 'snipping' or 'cutting' of the tongue tie.

Could VICC please advise what procedure code(s) should be used in these cases?

Response:
The snipping or cutting is of the fraenulum  in order to treat the tongue tie. 

VICC considers cutting and snipping to be synonomous with clipping and incision, both of which have an Index entry. 

Therefore the correct procedure code to assign for snipping or cutting of tongue tie is 30278-02 [390] Lingual fraenotomy following either Index entry Incision/fraenulum – see Fraenotomy/tongue, or Clipping/fraenulum, fraenum/lingual(tongue).


Query Title:
Suturing of multiple obstetric lacerations

Query Text:
Some maternity patients may experience more than one obstetric laceration post delivery which are sutured. For example we had a patient who had a second degree perineal tear and a labial tear both of which were sutured.

Could VICC please advise if a procedure code should be assigned for each laceration that is sutured?

Response:
In accordance with ACS 0020 Bilateral/Multiple Procedures  VICC considers it is appropriate to assign two procedure codes for the case cited provided the obstetric lacerations are documented as being of different sites.


Query Text:
Could the committee please advise of the diagnosis codes to be assigned for a patient who presents for routine/protocol kidney transplant biopsy where results are normal? These biopsies are performed at specified intervals post transplant to check the functioning of the transplanted kidney.
Suggested codes are:
Z09.0, Z94.0 and N18.*
or
Z48.8, Z94.0 and N18.*
or
N18.*

Response:
VICC considers that the correct diagnosis codes to assign for routine kidney transplant biopsy where there is no indication of rejection is Z09.0 Follow-up examination after surgery for other conditions, Z94.0 Kidney transplant status and the appropriate code for chronic kidney disease. 

Follow the Index entry Examination/following surgery NEC to assign Z09.0 as principal diagnosis. This code should be used when the patient is having a follow-up procedure, as per the excludes notes at Z48.8 Other specified surgical follow-up care and at the Z40 - Z54 block of codes. 

VICC does not consider Z48.8 Other specified surgical follow-up care an appropriate principal diagnosis as no care is being provided following the surgery.
 
VICC also does not consider N18.- Chronic kidney disease an appropriate principal diagnosis as the condition is not being treated during this episode of care. 

For the scenario cited an additional diagnosis code for chronic kidney disease is assigned as per the code also note at Z94.0 Kidney transplant status and ACS 1438 Chronic kidney disease.


Query Text:
Could the committee please advise if a condition meets ACS 0002 Additional diagnoses when the documented plan is not followed through? For example, condition documented as thrush for canestan to be commenced. There is no documentation on the medication chart or discharge script that canestan was prescribed or given. Also no documentation in the nursing notes that it was applied.

Response:
A condition documented with a plan of care, that is not carried out, may meet the criteria of an additional diagnosis based on supporting documentation. 

VICC advises to follow point 1 of ACS 0002 and Vic 0002 Additional diagnoses and code only when treatment is commenced, altered or adjusted, unless it has been refused by the patient or there is a documented contraindication. 

VICC considers that there is insufficient documentation in the example provided to represent clinical significance. Therefore a code would not be assigned in this case as the condition does not meet the criteria in ACS 0002 and VIC 0002 for an additional diagnosis.


Query Title:
Cannabis Hyperemesis Syndrome or hyperemesis - cannabinoid induced

Query Text:
Could the committee please advise how documentation of Cannabis Hyperemesis Syndrome or hyperemesis - cannabinoid induced should be coded?

Response:
VICC advises that the correct codes to assign for Cannabis Hyperemesis Syndrome or hyperemesis – cannabinoid induced are R11 Nausea and vomiting  followed by F12.1 Mental and behavioural disorders due to use of cannabinoids, harmful use. This is because there is a documented relationship between the hyperemesis and the cannabinoid use in accordance with ACS 0503 Drug, alcohol and tobacco use disorders.


Query Text:
The patient with renal AVM was admitted for laser renal AVM under retrograde pyeloscopy (see the attached operation note). What is the correct diagnosis code to assign for renal AVM? 

Renal AVM is not a very rare medical condition. However, there is no specific code for this condition or a procedure code for laser renal AVM. 

I will get an error DRG (801C) and inappropriate funding for the case if I only assign a diagnosis code Q27.3 Peripheral arteriovenous malformation by following the coding pathway and the procedural codes 90370-00 [1046] Other destruction of lesion of kidney with 36652-00 [1040] Retrograde pyeloscopy.

AVM is a congenital lesion with persisting direct connection between its arterial and venous components, and it forms because of failure of the embryonic vascular plexus to fully differentiate and develop a mature capillary bed in the affected area. Considering that it is a kind of congenital malformation, there are two equally appropriate index entries which can both be followed:

Malformation –see also Anomaly 

Anomaly-Kidney-Other specified Q63.89 Other specified congenital malformations of kidney

And

Malformation-arteriovenous, aneurysmatic Q27.3 Peripheral arteriovenous malformation

Can I assign the code Q63.89 Other specified congenital malformations of kidney as principal diagnosis with Q27.3 Peripheral arteriovenous malformation as an additional diagnosis because it can describe the disease more specifically both the manifestation and aetiology? It also resolves the error DRG issue and gets an appropriate DRG allocation.

Response:
This query was referred to the ACCD, who provided the following response:

Arteriovenous malformation (AVM) of the kidney may be either congenital or acquired, and each type has its own different characteristics. Renal arteriovenous malformation commonly refers to the congenital type of malformation, while the acquired type of renal arteriovenous anomalies may be idiopathic, but often occurs by iatrogenic means such as renal biopsy or surgery, degeneration, malignancy, or trauma, and are more correctly termed as renal arteriovenous fistulas (AVFs) (Cura et al. 2010; Wakefield 2016).

For congenital AVM of the kidney, assign Q27.3 Peripheral arteriovenous malformation.

Follow the ICD-10-AM Alphabetic Index:

Malformation (congenital) — see also Anomaly
- arteriovenous, aneurysmatic (congenital) Q27.3

The treatment of AVM can vary greatly. For example, by destruction, embolisation, excision, or nephrectomy.

In the scenario cited, for destruction of AVM of the kidney using laser, assign 90370-01 [1046] Endoscopic destruction procedures on kidney.

Follow the ACHI Alphabetic Index:

Destruction (ablation) (cauterisation) (coagulation) (cryotherapy) (diathermy) (HIFUS) (irreversible electroporation) (laser) (microwave) (radiofrequency) (thermotherapy)
- kidney (percutaneous)
- - endoscopic 90370-01 [1046]

For any DRG implications of the code assignment, please submit a AR-DRG public submission via https://www.accd.net.au/Submissions.aspx

Amendments will be considered for a future edition.

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

Further to ACCD’s response, VICC notes that congenital, acquired or unknown origin of an AVM should be assigned Q27.3 Peripheral arteriovenous malformation as ‘congenital’ is a non-essential modifier in the Index entry mentioned  above.


Query Text:
The introduction to the ACS states that "The clinical record should be the primary source for the coding of inpatient morbidity data. Accurate coding is possible only after access to consistent and complete clinical information. Without good documentation, coding guidelines are difficult, if not impossible, to apply. It is assumed that coding decisions are not made solely based on information provided on the clinical record front sheet and/or the discharge summary (or a copy of same) but that analysis of the entire clinical record is performed before code assignment."

Can you please further clarify the definition of 'entire clinical record' specifically in reference to a multicampus/hospital organisations with a scanned/electronic medical record? For example, our organisation has several hospitals operating with the same Patient Administration System, one unit record number system and a single scanned clinical record.  Users can access episode documentation across the organisation.   From a coding perspective, can documentation from previous admissions at other sites within the same organisation be used to inform code assignment in the admission being coded or should coders limit their review to only the individual campus/hospital's episodes?

Response:
VICC interprets ‘entire clinical record’ to mean the clinical information available to a coder, in order to classify the principal diagnosis, additional diagnoses and procedures for each episode of care.  The clinical information used at the time of initial coding should also be available for retrospective auditing of codes. Clinical documentation which may be available to a coder to view electronically in a regional/multi campus situation, if that is the decision of a hospital, is not any different from paper copies which may have been received and filed.
  
VICC notes the continual changes associated with digitisation of patient medical records, however it  remains the responsibility of each health service to decide what is appropriate to include in a clinical record, in accordance with legal/jurisdiction/local requirements, whether this is a paper or electronic/digital format.  It is also the decision of each health service as to the structure and management of that clinical information. 
  
Coders must ensure that decisions for assignment of codes appropriate to an episode of care are made in accordance with the clinical information related to that episode of care, however that is presented.  This will be done in conjunction with correct use of the Index and Tabular list, and adherence to Australian Coding Standards and ICD-10-AM/ACHI/ACS Coding Rules.


Query Title:
Principal diagnosis selection for documentation of metastatic cancer

Query Text:
We often see documentation of a principal diagnosis of metastatic cancer ie metastatic colon cancer. As per ACS 0239 Metastases, we note that adjective 'metastatic' is used ambiguously, sometimes to mean secondary deposits from a primary lesion elsewhere and sometimes to mean a primary which is metastasising.

1. If we are able to determine the primary and metastatic site(s)of the cancer, can you please provide clarification on how to assign the principal diagnosis for the following scenarios:

a) Principal diagnosis is metastatic colon cancer. Documentation in the progress notes indicate metastatic sites are lung and liver, and the primary site is the colon.  The patient is admitted for systemic chemotherapy and there is no documentation indicating which site is being targeted for treatment

b) Principal diagnosis is metastatic breast cancer. Documentation in the progress notes indicate metastatic sites are bone and brain, and the primary site is the breast.  The primary site was resected 5years previously. The patient is admitted for radiotherapy to bone (spine) and brain.

2. We note ACS 0001 Principal diagnosis states that when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic work up and/or therapy provided, and the Alphabetic Index, Tabular List or the standard does not provide sequencing direction, the clinician should be asked to indicate which diagnosis best meets the principal diagnosis definition. Where we are unable to obtain clarification from the clinician as to which site best meets the principal diagnosis definition, can you please provide some advice as to how to select the principal diagnosis in these scenarios?

Response:
VICC advises to apply ACS 0236 Neoplasm coding and sequencing which states, ‘The sequencing of primary and secondary neoplasm codes are dependent on the treatment performed at each episode of care. Assign the principal diagnosis as per the criteria in ACS 0001 Principal diagnosis'.

Therefore, when the principal diagnosis is documented as 'metastatic….. cancer’, and metastatic sites have been documented, VICC considers it is appropriate to assign either the primary or secondary site as principal diagnosis depending on the focus of care for that particular episode.  

When there is no documentation of the site undergoing treatment or management, assign the primary site as principal diagnosis.

In answer to your scenarios:

a)	 As the treatment is not documented as being directed at one particular site, assign the colon cancer as the principal diagnosis. 

b) From the documentation provided both the bone and brain metastases are receiving treatment, therefore assign the bone metastases as the principal diagnosis as per ACS 0001 Principal diagnosis as this is the first mentioned metastatic site. Please also refer to #3229 Principal diagnosis selection based on first mentioned diagnosis.


Query Title:
Principal diagnosis selection based on first mentioned diagnosis

Query Text:
ACS0001 Principal Diagnosis sections - Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis and two or more diagnoses that equally meet the definition for principal diagnosis both instruct the coder to ask the clinician to indicate which diagnosis best meets the principal diagnosis definition. If no further information is available, code as the principal diagnosis the first mentioned diagnosis

1. Can you please clarify, does the instruction to code the principal diagnosis as the first mentioned diagnosis only apply to principal diagnoses listed on a Discharge Summary?

2. If no discharge summary has been completed and a treating clinician responds to a documentation query, can the coder apply first mentioned condition to the documentation query response?  Often the clinicians will respond with multiple options even if asked to clarify which diagnosis best meets the principal diagnosis definition.

3. If no discharge summary has been completed, no further clinician advice can be obtained and there is documentation within the progress notes of two or more conditions meeting the principal diagnosis definition, can you please provide some advice on how the coder should select which diagnosis should be assigned as principal diagnosis?

Response:
Assigning the principal diagnosis according to the first mentioned diagnosis needs to be supported by the documentation in the rest of the record, and applies to principal diagnosis, regardless of where it is documented. 

If there is no discharge summary, no documentation of a principal diagnosis elsewhere in the record, and it is not possible to get clinical clarification, then the coder must follow all the guidance in ACS 0001 Principal diagnosis to assign a principal diagnosis based on the available documentation.  If this results in two or more conditions meeting the definition, then the ‘first mentioned’ rule should be followed as per the instructions in ACS 0001 Principal diagnosis.


Query Title:
Assignment of codes based on documentation in a patient completed form

Query Text:
ACCD Coding Rule Q3008 Assignment of U codes from patient documentation states that "in the absence of supporting clinical documentation, a 'U' code should not be assigned based on documentation of patient response(s) alone. This includes where the form has been signed by a clinician, which confirms the form has been completed or sighted but does not necessarily corroborate the clinical content."

1. Can you please clarify, does this advice apply to assigning other diagnosis codes based on documentation on patient completed form/s?

2. Documentation of tobacco use and hepatitis status is often found on a patient health history form. Should codes be assigned for these conditions based on patient documentation alone, or do they need to be documented by a clinician elsewhere in the record?

3. Other documentation such as patient weight/height, past history of procedures and diabetes (and associated conditions) are often used as evidence in conjunction with other clinical documentation within the record to generate a clinician query to clarify a condition. For example, a patient may have clinical documentation of T2DM and up BMI in the progress notes.  There may then be documentation of height and weight on the patient health history form.  Is it appropriate to generate a query to clarify if the patient is considered overweight or obese based on the height/weight documented by the patient?
Is it appropriate to query conditions based on the documentation provided in the patient health history forms or does there need to be clinical documentation within the record also?

Response:
The following VICC query was originally published in the 2017-18 September VICC queries database release as follows:

VICC considers the principles in ACCD Coding Rule Q3008 Assignment of U codes from patient documentation should be applied to all conditions documented on a patient completed form. Therefore VICC advises that a condition or status must be documented by a clinician before a code can be assigned. 

Information obtained only from a patient completed form should not be used to generate a documentation query. [end of response].

Note:  The above advice is supplemented by the HIMAA NCCH Conference Questions published in the Code-it! - ACCD Newsletter Vol 5, No 1, December 2017 as follows:

Question 1: 
Can patient completed admission forms be used to assign codes such as smoker status or U codes (U78-U88 Supplementary codes for chronic conditions)?

Coding Rule: Assignment of U codes from patient documentation
Q:
On the patient's preoperative questionnaire, in response to the question "Are you being treated for high blood pressure", the answer is 'Yes' and anti-hypertensive medication is included in the list of current medications. There is no other mention of hypertension in the record (same-day episode). Should a 'U' code for hypertension be assigned when it has not been documented by the clinician?

A:
The Introduction to the Australian Coding Standards states:

“The responsibility for recording accurate diagnoses and procedures, in particular principal diagnosis, lies with the clinician, not the clinical coder.

A joint effort between the clinician and clinical coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures”.

Assignment of codes for diagnoses and procedures assumes that these have been documented by a clinician. This principle applies to the assignment of supplementary codes for chronic conditions.

While it is not expected that clinical coders should follow-up clinicians for assignment of 'U' codes, it is assumed they should be allocated to conditions that have been documented by a clinician.

Therefore, in the absence of supporting clinical documentation, a 'U' code should not be assigned based on documentation of patient response(s) alone. This includes where the form has been signed by a clinician, which confirms the form has been completed or sighted but does not necessarily corroborate the clinical content.

As per the Ninth Edition Education FAQs, it is not necessary to review medication charts to inform code assignment. Medications may be more than one diagnosis, and the presence of a prescribed medication is not an indication of a diagnosis.  ACS 0003 Supplementary codes for chronic conditions (Errata 3 update) also confirms that conditions may be assumed to be current unless there is documentation that indicates otherwise. (Coding Rules, December 2015)

ACCD Response
The above coding rule is explicit in that a 'U' code should not be assigned based on documentation of patient response(s) alone. This includes where the form has been signed by a clinician, which confirms the form has been completed or sighted but does not necessarily validate the clinical content. 
 
Therefore, if conditions indicated by the patient are not validated elsewhere in the clinical record, then they should not be coded.

The above directive does not apply to Z86.43 Personal history of tobacco use disorder and Z72.0 Tobacco use, current. These are status codes with public health significance.  Therefore, a patient completed admission form may be used to assign Z86.43 and Z72.0 in accordance with ACS 0503 Drug, alcohol and tobacco use disorders.


Note: this query has been retired as covered by Coding Rule Q3008 Assignment of U codes from patient documentation.


Query Title:
Admission for airway monitoring following difficult intubation

Query Text:
A patient was transferred to our hospital for airway monitoring following difficult intubation during a procedure at another facility. The patient is described as having a difficult airway: grade III laryngoscopy (direct), grade II (indirect with bougie). The summary documents that the patient was transferred mostly for airway monitoring post-operatively that there was no airway compromise overnight and that supplemental oxygen was not required. The patient was transferred back to the original facility the following day.

Could the committee please provide advice on the principal diagnosis for this scenario?

Is it appropriate to assign a code from the block Z03 Medical observation and evaluation for suspected diseases and conditions?

Response:
When there is clear documentation that the patient was admitted due to the difficult intubation VICC advises to assign T88.42 Difficult intubation as principal diagnosis. 
If there is no causal link to difficult intubation and a symptom is present on admission then the symptom should be assigned as the principal diagnosis. 
When the only documentation is monitoring in case an issue does occur then a code from Z03.- should be assigned.


Query Title:
Incomplete colonoscopy due to poor bowel preparation

Query Text:
How can we capture poor bowel preparation which results in the patient having an unsatisfactory colonoscopy?  This often requires the patient to:
- have a CT colonoscopy and/or stay overnight for further bowel preparation for this radiological procedure.
- be readmitted for bowel preparation and repeat scope at a later date.

This seems to appear regularly where there is no other condition (e.g. tortuous bowel) present.

Response:
VICC advises that no diagnosis code can be assigned for documentation of poor bowel preparation.

If the procedure is interrupted or shortened due to the poor bowel preparation the procedure should be coded to the extent to which it was performed. 

If the procedure was cancelled due to poor bowel preparation, and the admission meets criteria for reporting, then a code from Z53.- Persons encountering health services for specific procedures, not carried out can be assigned.


Query Text:
Inappropriate ICD shocks are occasionally listed as the principal diagnosis in cardiology admissions. We often query to further clarify if this was a case of malfunctioning of the ICD device however clinician response notes that it isn't. Thus we resort to Z45.0 Adjustment and management of cardiac device. There currently is no ACCD/VICC/ACS advice in regards to this matter.

1. Could VICC please advise the appropriate code assignment for inappropriate ICD shocks?

Response:
VICC advises that in the absence of documentation of a complication of the ICD then it is correct to default to code Z45.0 Adjustment and management of cardiac device when a patient is admitted with inappropriate ICD shocks.


Query Text:
VICC query #2966 states "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".

So if the clinician has pasted results into an electronic discharge summary, then they can be used as "documentation in the record" (but would still need to follow Coding Rules advice, e.g. confirming abnormal pathology and meeting ACS 0002 Additional diagnoses, and not coding from radiology results).

However, the ACCD education states that results/shorthand etc must be documented in the progress notes.

Is VICC #2966 still applicable from 1/7/17?

Response:
VICC advises that query #2966 Assignment of drug resistance to microorganisms code from electronic discharge summary has been superseded by the ACCD Coding Rules Q3224 Pathology and other test results reproduced or copied into electronic documents published 15 December 2017 and is reproduced below:

Q: 
Can pathology and other test results reproduced or copied into electronic documents be used for code assignment?
A:
ACS 0010 General abstraction guidelines/Test results states:
…
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.
…
Laboratory, x-ray, pathological and other diagnostic results should be coded where they clearly add specificity to already documented conditions that meet the criteria for a principal diagnosis (see ACS 0001 Principal diagnosis) or an additional diagnosis (see ACS 0002 Additional diagnoses).
The Introduction of the Australian Coding Standards states:
… coding decisions are not made solely based on information provided on clinical record front sheet and/or the discharge summary (or a copy of the same) but that analysis of the entire clinical record is performed before code assignment. …
and 
… When a diagnosis is recorded for which there is no supporting documentation in the body of the clinical record, it may be necessary to consult with the clinician before assigning a code.
The access to or inclusion of test results in an electronic medical record is no different to a printed result within a paper-based record. Therefore, apply the above guidelines where test results are included in an electronic medical record. 
See also ACS 0010 General abstraction guidelines and Coding Rule: Coding from test results and findings on radiological reports.


Query Text:
A patient was admitted for a colonoscopy. A biopsy of the sigmoid colon and rectum was performed and the histology revealed cytomegalovirus colitis.

We have assigned two codes:
- A08.3 Viral intestinal infection, unspecified
- B25.8 Other cytomegalovirus diseases

Can the committee please advise in which order these codes should be sequenced in order to code the diagnosis of CMV colitis?

Response:
The condition is colitis, with a causative agent of cytomegalovirus identified on histology. Therefore follow the lead term Colitis/ - see also Enteritis/viral/specified virus NEC to assign A08.3 Other viral enteritis.

As there is specific information about the causative agent, an additional diagnosis code B25.8 Other cytomegalovirus diseases should be assigned following the lead term Infection, infected/cytomegaloviral/specified NEC.

The code for colitis is sequenced first, followed by the code for CMV. This is supported by example 2 of ACS 0102 HIV/AIDS, where the codes assigned for CMV retinitis are H30.9 Chorioretinal inflammation, unspecified followed by B25.8 Other cytomegaloviral diseases.


Query Text:
Can the committee please advise the correct code to assign for a parasymphysis fracture of the mandible?

Coders at our hospital cannot agree on whether to assign:
S02.66 Fracture of symphysis of body
S02.68 Fracture of mandibular body, other and unspecified parts

The mandibular symphysis is the line or junction in the midline of the mandible where the two lateral halves fused at an early stage of childhood development.

We note that the prefix para  means beside, side by side, to one side of. For this reason some of our coders believe that S02.66 cannot be assigned because the fracture is not of the symphysis, but is next to it. The other coders believe that S02.66 best reflects the diagnosis of parasymphysis fracture of mandible .

Response:
As noted in the query, the prefix ‘para’ means beside, side by side, to one side of. VICC research indicates that a parasymphysis fracture of the mandible is a fracture that is beside the symphysis in the body of the mandible.

VICC advises to assign S02.68 Fracture of mandible body, other and unspecified parts for documentation of parasymphysis fracture of the mandible following Index entry Fracture/mandible/body.


Query Text:
The Visual Infusion Phlebitis (VIP) score is a 'tool' employed at this hospital and will occasionally appear in the nursing notes as (VIP 2. cannula  resited). There is a score level of 1-5 ( Reference Andrew Jackson - Consultant Nurse, Intravenous Therapy & Care The Rotherham NHS Foundation Trust). 

Question is can we code Phlebitis from this indication or is more documentation required?

Response:
VICC research indicates that the Visual Infusion Phlebitis (VIP) score is a tool for monitoring infusion sites that determines the appropriate discontinuation of peripheral intravenous catheters.

As per ACS 0010 Clinical documentation and general abstraction guidelines section titled Findings that provide more specificity about a diagnosis, a diagnostic result can only be coded when it clearly adds specificity to an already documented condition. As a VIP score is a type of diagnostic result, a code cannot be assigned from the VIP score alone.  

Phlebitis needs to be documented and meet ACS 0002 Additional diagnoses in order for a code to be assigned.

Refer also to ACCD Coding Rules Q3204 titled Nicotine dependence tests published on 15 December 2017.


Query Title:
Clinical diagnosis of cyst with other condition on histopathology

Query Text:
Can histopathology findings be used to further specify a clinical diagnosis of 'cyst'?

Previous advice on mass/lump etc does not help as 'cyst' is not mentioned.

There is a note in the Index under Cyst which says 'In general, cysts are not neoplastic and are classified either as specific entities or to the appropriate category for disease of the specified anatomical site. This generalisation does not apply to certain types of cysts which are neoplastic in nature, for example dermoid, or to cysts of certain structures, for example branchial cleft, which are classified as developmental anomalies.The following listing includes some of the most frequently reported sites of cysts as well as qualifiers that indicate the type of cyst. The qualifiers are not usually repeated under the anatomical sites. Since the code assignment for a given site may vary depending upon the type of cyst, the clinical coder should refer to the listings under the specified type of cyst before considering the site.'

Example 1
Diagnosis: Renal cyst
Pathology result: Multilocular cystic renal neoplasm of low malignant potential

Is it correct to follow Index
Cyst
-neoplastic (M8000/1) - see also Neoplasm/uncertain behaviour

Or

Cyst
-kidney (acquired) N28.1


Example 2
Diagnosis: Ovarian cyst
Histopathology: Cystadenoma of ovary

Is cystadenoma further specificity to the cyst or is it a different condition?

If it is a different condition, is it correct to follow Index

Cyst
-neoplastic (M8000/1) - see also Neoplasm/uncertain behaviour
-benign (M8000/0) - see Neoplasm/benign

Or

Cyst
-ovary, ovarian (twisted) NEC N83.2

Response:
As per ACS 0010 General abstraction guidelines, laboratory, x-ray, pathological and other diagnostic results should be coded where they clearly add specificity to already documented conditions that meet the criteria for a principal diagnosis or additional diagnosis. Therefore, histopathology findings can be used to further specify a clinical diagnosis of cyst.  

As stated, the note in the Index under cyst instructs coders to refer to the listings under the specified type of cyst before considering the site.

The notes at the beginning of Appendix A Morphology of neoplasms outline the fifth digit behaviour codes of neoplasms, with inclusion terms.  It states that in the nomenclature given here, the morphology code numbers include the behaviour code appropriate to the histological type of neoplasm; this behaviour code should be changed if the other reported information makes this appropriate.

Follow the instructional note for cyst, considering the type before the site by using the pathology to choose the lead term. Then consider the note at the beginning of Appendix A to ensure that the behaviour and morphology codes assigned are appropriate to the histological type of the neoplasm.

VICC advises to assign the following codes for the examples cited:

Example 1 – diagnosis of renal cyst with pathology result multilocular cystic renal neoplasm of low malignant potential.
Follow Index entry Neoplasm/renal/uncertain behaviour and Cyst, neoplastic (M8000/1) – see also neoplasm/uncertain behaviour to assign D41.0  Neoplasm of uncertain or unknown behaviour of urinary organs, kidney with morphology code M8000/1 Neoplasm, uncertain whether benign or malignant. Low malignant potential is included in the behaviour code /1.

Example 2 – diagnosis of ovarian cyst with pathology result cystadenoma of ovary.
There is no documentation of neoplasm in this example, therefore the lead term is cystadenoma.
Follow Index entry Cystadenoma (M8440/0) – see also Neoplasm/ovary/benign to assign D27 Benign neoplasm of ovary with morphology code M8440/0 Cystadenoma NOS.


Query Title:
Difficult intubation without documentation of grade

Query Text:
Coding Rules Q2667 Dec 2014 - T88.4 Failed or difficult intubation states that T88.42 Difficult intubation should be assigned 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 T88.42 is assigned. Where documentation is unclear, coders should seek clinical advice.

We are aware that the Coding Rules has been made into ACS 1924 in Tenth Edition the wording is slightly different but the intent the same.

We have an example where 'difficult intubation' is clearly documented but the anaesthetist was unable to grade the patient's airway as the patient was unable to open their mouth so conventional laryngoscopy was not possible.

Can a code for difficult intubation be assigned in circumstances where it has been specifically documented but the Cormack-Lehane or Mallampati score is unable to be determined?

Response:
According to ACS 1924 Difficult Intubation there must be documentation of difficult intubation (or difficult airway) and a Cormack-Lehane or Mallampati score of grade 2 or higher in order to assign T88.42 Difficult intubation. 

Without documentation of both of these, including if the score is unable to be determined, you cannot assign T88.42 Difficult intubation.

You may wish to send a public submission to the ACCD to consider amending ACS 1924 to cover situations where the clinician has documented difficult intubation but is unable to document a grade.


Query Title:
Buccal Misoprostol for induction of abortion / termination of pregnancy

Query Text:
Patient admitted at 17/40 and given buccal Misoprostol for induction of abortion / termination of pregnancy.

The index has suppository as an essential modifier.
Induction
- abortion
- - by
- - - dilation
- - - - and
- - - - - curettage (D&C) 35640-00 [1265]
- - - - - - suction 35640-03 [1265]
- - - - - evacuation (D&E) 35643-03 [1265]
- - - intra-amniotic injection (prostaglandin) (saline) 90461-00 [1330]
- - - prostaglandin
- - - - injection 90461-00 [1330]
- - - - suppository (without labour) 90462-00 [1330]
- - - - - with labour 90465-01 [1334]

Can placement of non-vaginal Misoprostol be termed a suppository to allow assignment of above codes?

Or because it was given orally, the Misoprostol shouldn't be coded (even though it has the same effect)?

Should the term 'suppository' be removed from the index?


Internet search says various routes of administration for Misoprostol are:
Oral - pills are swallowed immediately
Buccal - pills are placed between the cheek and gums and swallowed after 30 minutes
Sublingual - pills are placed under the tongue and swallowed after 30 minutes
Vaginal - pills are placed in the vagina fornices (deepest portions of the vagina) and the woman is instructed to lie down for 30 minutes

Response:
This query was originally published in the 2017-18 December database as follows:

As noted in the query, Misoprostol can be administered orally, bucally, sublingually or vaginally. VICC research indicates that a suppository is a solid dosage that is inserted into the rectum, vagina or urethra. Accordingly, Misoprostol administered by a non-vaginal route should not be termed a suppository.

In accordance with ACS 0042 Procedures normally not coded, drug treatment/pharmacotherapy/prescriptions of drugs is not coded. Therefore a code for the administration of oral Misoprostol should not be assigned.

You may wish to make a public submission to the ACCD to remove the term “suppository” from the Index. [end of original response]

Following publication of ACCD Coding Rule on 15 June 2018, the VICC response is superseded by the following advice Q3294 Administration of Misoprostol:

Misoprostol is a prostaglandin E1 synthetic analogue that may be administered to induce abortion/terminate pregnancy. It is usually administered orally (eg buccally) following ingestion of mifespristone. Misoprostol causes softening and opening of the cervix, and uterine contractions (ie it induces labour) (Alfirevic, Aflaifel & Weeks 2014, NPS Medicinewise 2017; The Royal Hospital for Women 2013).

ACS 1511 Termination of pregnancy states:

PROCEDURES FOR TERMINATION OF PREGNANCY

Termination of pregnancy may be performed by:
- extraction (eg dilation and curettage/evacuation (D&C/D&E) or suction curettage). Assign an appropriate code from [1265] Curettage and evacuation of uterus.
- induction of labour. Assign a code from block [1334] Medical or surgical induction of labour regardless of the duration of pregnancy and outcome/
- other methods (eg insertion of prostaglandin suppository). Code specific procedure(s) performed (see ACHI Alphabetic Index).

Therefore, where Misoprostol is administered to induce labour for abortion/termination of pregnancy, assign 90465-01 [1334] Medical induction of labour, prostaglandin by following the Alphabetic Index:

Induction
- labour
- - medical (administration of pharmacological agent)
- - - prostaglandin 90465-01 [1334]

Amendments to ACHI Obstetric interventions are in progress for Eleventh Edition. 

Q3294 Administration of Misoprostol was retired 30 June 2019.


Query Title:
Manual removal of membranes following spontaneous expulsion of placenta

Query Text:
During some deliveries, after the spontaneous delivery of the placenta, there may still be portions of the membranes sitting inside the uterus/vagina. These are removed by hand or by polyp forceps. We can use code O73.1 Retained portions of placenta and membranes, to capture the condition.

The only code for manual removal refers to manual removal of placenta (MROP).

Do we need to use an intervention code to capture the removal of portions of membranes?  If yes, which code should we use?

Response:
VICC considers that from a classification perspective the membranes are part of the placenta. Removal of placenta may be routine care and a code may not be assigned in every case.

If there is documentation of the essential modifier ‘manual’ follow the Index pathway Removal/placenta/by manual(part)(whole) to assign 90482-00 [1345] Manual removal of placenta.

Note that the terms (part) and (whole) are non-essential modifiers.


Query Text:
Can you please clarify the advice in Vic 0002 Additional Diagnoses 2017/2018, 1a) "The treatment plan is commenced for a newly diagnosed condition following clinical consultation and documentation".

Question 1.
Would hypokalaemia be coded in the following scenario?
A potassium level (eg.K 2.9) is documented (by a nurse) as the indication for commencement of medication and the test results verifies the patient's potassium is below the normal range.  There is no documentation of a doctor's consultation, although the doctor has initiated the administration of the medication by documenting Slow K in the medication chart.
Please refer to Coding Rule TN199 Use of abbreviations, symbols and test result values to inform code assignment for abnormal pathology results.

Question 2.
In reference to the "Victorian Additions to the Australian Coding Standards 2017/2018" document, does the term "Clinical consultation" apply to other clinicians such as midwives, nurses and allied health professionals as per the definition of "Clinician" in the ACS, Introduction, How to Use This Document - The term 'Clinician'.

Question 3.
Can you please clarify if we are able to code from clinical consultations (includes diagnosis and treatment plan) documented by ICU Nurses, Wound Management Nurses, Dietitians, Speech Pathologists, Podiatrists or other Allied Health Professionals?

Response:
VICC advises that in question 1 a code for hypokalaemia can be assigned as the hypokalaemia meets the dot points outlined in Vic 0002 Additional diagnoses. By providing K 2.9 as the indication for commencement of medication the nurse has documented a plan of care. As the doctor has initiated the administration of the medication on the medication chart there is evidence of clinical consultation.

In reference to question 2 and 3, Vic 0002 Additional diagnoses uses the same definition as provided in the introduction to the 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.

Therefore, when ICU Nurses, Wound Management Nurses, Dietitians, Speech Pathologists, Podiatrists or other Allied Health Professionals document a condition that is appropriate to their discipline, ACS 0002 Additional diagnoses and Vic 0002 Additional diagnoses should be applied to determine code assignment.

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


Query Text:
Part 1
Our query relates to indexing of diabetes with polycystic ovarian syndrome which is indexed to E13- (two digit level).

This code seems odd when all other codes at this index level are directed to specific diabetic codes. Please confirm the correct code for this index entry.

Code option for consideration was E13.69 Other specified diabetes with other specified complication

Part 2
Where a patient admitted for gynaecological surgery for polycystic ovarian syndrome and has documented Type 2 diabetes

Index logic directs coder to

Diabetes with
 - Polycystic ovarian syndrome E13.-

We are aware of advice in VICC query #3007 Steroid induced Type 2 diabetes and ACCD Coding Rules advice Q2887 E13 Other specified diabetes mellitus published in March 2015.

Question - Should the code for this index option be E1-.xx (?69) to allow for all types of documented diabetes to be assigned?

Response:
In response to part 1, as noted in the query, diabetes with polycystic ovarian syndrome is indexed as Diabetes with/polycystic ovarian syndrome E13.- . As polycystic ovarian syndrome is not a complication of diabetes it is not appropriate to assign E1-.69 Diabetes mellitus with other specified complication.  

VICC advises to follow the ACCD advice Q2887 published in the March 2015 Coding Rules titled E13 Other specified diabetes mellitus and do not assign E13 when documentation confirms diabetes mellitus as type 1 or type 2. This is reiterated in VICC query #3007 Steroid induced type 2 diabetes.

In response to part 2, for the cited example of polycystic ovarian syndrome and documented type 2 diabetes mellitus, follow the Index pathways Syndrome/ovary/polycystic to assign E28.2 Polycystic ovarian syndrome and Diabetes (without complication)/type 2 to assign E11.9 Type 2 diabetes mellitus without complication in the absence of any other condition indexed under diabetes.


Query Title:
Queries regarding Victorian additions to the ACS - VIC 0002

Query Text:
Queries re: Victorian Additions to Coding Standards

1. Could we please have confirmation that the Victorian Additions to the ACS are applicable to Private Victorian Hospitals? The email from VICC states the reason for its creation as 'DRG optimisation under AR-DRG V8.0 has driven this change in Victoria' however most private Victorian hospitals are not funded in DRG V8.0 and this proposed change would then have the potential for funding implications that were not applied to Victorian Public Hospitals when they were funded on earlier DRG versions.

2. Could you please provide clarification regarding Section 3b which states 'The intention to provide increased monitoring of a condition is documented by a treating clinician in the progress notes'? What are coders advised to do if there is documentation of increased monitoring of a condition outside of the progress notes (e.g. care plans, medication charts, operation reports, anaesthetic charts)? Does this mean the condition cannot be coded?  e.g. intraoperative hypertension documented on the operation reports and/or anaesthetic chart with evidence of increased monitoring on these forms.

3. Could you please provide clarification of documentation query initiation? This document states that 'A symptom or condition that does not meet any of the requirements for significance outlined in this standard should not be the subject of a documentation query'. Could you please provide some examples of when a documentation query cannot be sent and give further information around this?

4. The term 'short-term administration' is currently unclear, subject to different interpretations, could you please provide a definition for this term?

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

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

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

2. Increased monitoring is that which is above the standard management for a condition. It must be evident in the current episode of care. The evidence must include that the increased monitoring is in response to an observation that is documented by a treating clinician. This excludes documentation that is simply outlining the management of surgery or a medical condition. 

A treatment plan is a plan of care that can appear in many parts of the medical record but would typically appear in the admission notes, the progress notes or on a care path. Treatment plans should be documented by a treating clinician including a diagnosis with a clear link to the planned treatment, or investigation. Therefore this documentation may appear in several parts of the record but it must be clear that this is more than routine care. Where it is not clear, an assumption cannot be made that it is increased monitoring.

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

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

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

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


Query Title:
Self-induced urethral injury due to traumatic removal of a urinary catheter

Query Text:
An elderly man was admitted to our hospital with haematuria, on a background of Parkinson's disease and dementia. The patient was a resident of a high level care nursing home and normally had a permanent indwelling catheter (IDC). On admission it was determined that the haematuria was due to a urethral injury that was caused by the traumatic removal of the IDC by the patient without first deflating the balloon. The IDC was reinserted and the patient monitored closely for further bleeding or blockage of the IDC. Once the medical staff were happy that the bleeding had stopped the patient was discharged back to his nursing home with instructions for the LMO to follow up the IDC as required.

Can the committee please advise how to code self-induced urethral injury due to traumatic removal of a urinary catheter?

Response:
For the example cited, VICC advises to follow the lead term Injury/urethra/part unspecified to assign S37.30 Injury of urethra, part unspecified.

As it is documented that the patient unintentionally caused the injury, VICC suggests following lead term Injury/specified cause NEC to assign external cause code X58 Exposure to other specified factors. Place of occurrence and activity codes should also be assigned.

VICC also considers Z46.6 Fitting and adjustment of urinary device could be assigned as an additional diagnosis using index entry Fitting/catheter/urinary, to reflect the reinsertion and management of the IDC.


Query Title:
Laparoscopic hernia repair converting to open repair and reverting back to laparoscopic

Query Text:
Patient presents for laparoscopic incisional peri umbilical hernia repair. The operation reports laparoscopy converted to open repair due to adhesions.

Codes used:
Repair of the incisional hernia followed by 90343-01 [1011] Laparoscopic procedure proceeding to open procedure..

Documentation indicates that the procedure was then completed with the return of the laparoscope (mesh placement).

Do we code the laparoscopy as well as the laparoscopy converted to open procedure code?

Response:
In cases when a laparoscopic procedure is converted to open procedure then returns to laparoscopy, the combined procedure code covers both the laparascopic and open approaches.

In the scenario cited, VICC agrees with the enquirer to assign a code for repair of incisional hernia followed by 90343-01 [1011] Endoscopic procedure proceeding to open procedure.  No additional code for the subsequent conversion back to laparoscopy is required.


Query Title:
Coding of intravitreal triamcinolone acetonide injection (IVTA) with cataract extraction

Query Text:
We need some clarity as to whether we should be coding Intravitreal Triamcinolone Acetonide Injection (IVTA) with cataract extraction and insertion of lens (IOL)?  Does the procedure fall into the category of ‘drug treatment’ per point 8 of ACS 0042 Procedures normally not coded and therefore should not be coded?

This discussion has arisen because these procedures are being performed as contracted procedures and the other hospital is coding IVTA and we hadn’t and there is a difference in the DRG. They are being performed when a patient has a cataract extraction and IOL procedure so we have been coding these and not the IVTA.

The code being used for IVTA is 42740-03 [209] Administration of therapeutic agent into posterior chamber or 
42740-02 [185]Administration of therapeutic agent into anterior chamber as per look up Injection/vitreous.  

If the IVTA is coded the DRG changes from a C16Z to C03A. We will attach an operation so you have an example.  The operation report has IVTA documented along with the extraction and IOL. There is no indication for the IVTA documented other than a cataract. We are not sure if the IVTA procedure should be coded as it is not routinely preformed in cataract procedures but we do see at times. It is however, a drug treatment and potentially should not be coded as per ACS 0042.  

As these are contracted procedures, we unfortunately do not have the ability to send a query or seek clinical advice (we do not do any ophthalmology surgery at our site). Our research indicates IVTA is a drug injected into the eyeball. It can be used at the end of cataract surgery for patients with both cataracts and diabetic macular oedema (DME). We never have documentation of DME and realise that if the patient was documented as being admitted specifically for IVTA for treatment of DME then we would be able to code it, but we do not have this.

Response:
VICC does not consider IVTA to be a routine part of cataract extraction and that ACS 0042 Procedures normally not coded does not apply in this scenario. 

Therefore VICC advises that when IVTA is documented as being performed, to follow the Index entry Injection/vitreous to assign the procedure code 42740-03 [209] Administration of therapeutic agent into posterior chamber.


Query Text:
VIC additions to ACS 0002 state that they are in keeping with the stated intent of ACS 0002. The VIC additions to ACS 0002 includes information directly taken from ACS 0002. In particular, the VIC additions has placed emphasis on the word 'significant' in the paragraph which reads ..."but rather the conditions that are significant in terms of treatment required, investigations needed and resources used in each episode of care." 

I would like to express that in the National Standard there is no emphasis placed on this one word (significant). ACS 0002 states that for coding purposes an additional diagnosis is one that affects patient management in terms of commencement/alteration/adjustment of therapeutic treatment (which refers to 'treatment required' in the above paragraph), diagnostic procedures (which refers to 'investigations needed' in the above paragraph) and increased clinical care/monitoring (which refers to 'resources used' in the above paragraph). That is, a condition is significant if it meets 1 of those 3 criteria. This is backed up in an example used in ACS 1521 Conditions and injuries in pregnancy. Example 6 on page 174 of the ACS states "she was treated with calamine lotion for heat rash during the admission" and a code for the heat rash L74.0 (with O code as it was complicating pregnancy) has been assigned.

Could an explanation please be given on how an additional diagnosis can be assigned under ACS 0002 yet is contradicted by the guideline under VIC Additions to ACS 0002? That is, in VIC additions to ACS 0002 application of cream for nappy rash (which is very similar to the above example) is cited as an example where code assignment is NOT justified.

Response:
As stated Vic 0002 Additional diagnoses is in keeping with the stated intent of ACS 0002 Additional diagnoses. Emphasis was placed on the word significant to provide greater clarity to coders in determining which conditions meet the definition of an additional diagnosis. 

TN1248 ‘ACS mutual exclusivity’ applicable from 1 October 2017 reinforces that the general standards for diseases and interventions must be applied before guidelines in specialty ACS are applied. Guidelines in specialty standards must also be applied on a case by case basis.

Therefore, coders should follow these steps when coding additional diagnoses
1. Is it a condition that is always coded, as instructed in a speciality ACS?
2. If not, does the condition meet ACS 0002 Additional diagnoses?  
3. If yes, does the condition meet the criteria for significance in Vic 0002 Additional diagnoses?
4. If yes, is there a specialty ACS which advises the condition should only be coded following specific criteria?
5. If no, assign the code. If yes, does the condition meet this criteria?
6. If yes, assign the code

Examples in the ACS are used to illustrate the concepts of a coding standard only. The purpose of the heat rash example is to illustrate how to code a nonobstetric condition complicating pregnancy. It is not intended to demonstrate how ACS 0002 Additional diagnoses should be applied. In the example provided, if the heat rash/nappy rash requires ongoing treatment in accordance with a documented treatment plan then the condition can be coded.


Query Title:
Diverticular disease and chronic incurable disease

Query Text:
Q1. Is diverticulosis/diverticular disease considered to be a chronic noncurable disease?

Q2. Patients admitted for a colonoscopy for review after having diverticulitis and only diverticular disease is noted. Are these cases coded to diverticulitis or to diverticular disease?

Response:
Diverticulosis occurs when small defects in the muscle of the wall of the large intestine or colon allow small pockets or pouches (diverticula) to form. Diverticulitis is infection or inflammation of these abnormal pouches. Together, these conditions are called diverticular disease. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/diverticulosis-and-diverticulitis

VICC research indicates that diverticulosis is considered to be chronic and incurable, whereas diverticulitis is an acute condition.

Where diverticular disease is documented without documentation of diverticulitis, a code for diverticulosis should be assigned.

Follow the guidelines in ACS 0052 Same day endoscopy – surveillance to assign diagnosis codes according to the documentation available.


Query Title:
Application of Vic 0002 Additional diagnoses

Query Text:
1. Vic 0002 specifies 'nurse initiated administration of medications/drugs are not considered to be significant'.
Could you please explain how this aligns with the ACCD definition of clinician - 'may refer to other clinicians such as midwives, nurses...the documented information must be appropriate to the clinicians discipline' and (whilst recently retired (7th edition) June 2017) VICC advice that 'coders should trust that the clinician has documented appropriately to his or her discipline.' (Query Number 2752 Coding from nursing documentation)?

2. a. Does this encompass specialist nurse initiated administration of medication/drugs? Vic 0002 section 3b states 'The intention to provide increased monitoring of a condition is documented by a treating clinician in the progress notes.'
b. Could you please explain how this aligns with the ACCD introduction 'analysis of the entire clinical record is performed before code assignment'
c. Could you please confirm advice for code assignment in episodes where documentation to provide (or provision of) increased monitoring of a condition is documented within the clinical record however not specifically in the progress notes, i.e. documentation on observation charts, PACU forms, care pathways, discharge summaries/letters etc.?

3. Vic 0002 Documentation queries states 'a symptom or condition that does not meet any of the requirements for significance outlined in this standard should not be the subject of a documentation query'.

Could you please provide further clarification and examples around this statement?

I.e.
If current documentation supports some of the requirements, queries should be written to ensure complete and accurate documentation is obtained before code assigned (in line with ACS Introduction and Standards for Ethical Conduct in Clinical Coding).

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

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

The term ‘nurse initiated administration of medication/drugs’ relates to those conditions for which a decision is made to administer medication/drugs and the condition does not require any further management. The term “nurse” has been used because it is typically a nurse who provides this type of treatment.

2. (a) Nurse-initiated administration of medication/drugs applies to any nurse. VICC has published a feature article titled Application of Vic 0002 Additional diagnoses to provide further clarification around this aspect of the Standard. 
(b) As per the ACCD introduction 'analysis of the entire clinical record is performed before code assignment', a coder must use all available documentation to assist with code assignment. Vic 0002 Additional diagnoses does not change the requirement to use the entire medical record, just as ACS 0002 Additional diagnoses does not. 
(c) As per the feature article, increased monitoring is that which is above the standard management  for a condition.  It must be evident in the current episode of care. The evidence must include that the increased monitoring is in response to an observation that is documented by a treating clinician. This excludes documentation that is simply outlining the management of surgery or a medical condition. 

A treatment plan is a plan of care that can appear in many parts of the medical record but would typically appear in the admission notes, the progress notes or on a care path. Treatment plans should be documented by a treating clinician including a diagnosis with a clear link to the planned treatment, or investigation. Therefore this documentation may appear in several parts of the record but it must be clear that this is more than routine care. Where it is not clear, an assumption cannot be made that it is increased monitoring.

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

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

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


