# Unresolved queries under discussion

Query Title:
Assignment of codes based on documentation in a patient completed form


Query Title:
Pharmacotherapy for neoplasm / neoplasm related condition


Query Title:
ACS 0002 – Documented plan not carried out


Query Title:
HFT via mask when delivery via nasal prongs/cannula is not suitable


Query Title:
Steroid injection to trachea (with microlaryngoscopy)


Query Title:
ORIF of pubic symphysis disruption/dislocation, without fracture


Query Title:
Principal diagnosis - problem and underlying condition vs two interrelated conditions


Query Title:
Partial gastrectomy without anastomosis, reconstruction or diversion


Query Title:
Loose internal fixation device / metalware / prosthesis


Query Title:
High flow therapy in patient with total laryngectomy


Query Title:
COVID-19 Testing: Multiple tests for different reasons (indications) during one inpatient episode


Query Title:
Coding underlying causes for fall(s) resulting in injury


Query Title:
Acute on chronic cholecystitis with cholelithiasis


Query Title:
COVID-19 testing by a mandated authority


Query Title:
Diagnosis coding for transgender procedures


Query Title:
Ureteric calculus as the indication for surgery - calculus passed prior to surgery


Query Title:
Complications of surgical interventions performed for treatment of a neoplasm


Query Title:
R54 Senility code for assessment of mobility impairment


Query Title:
Replacement of low profile gastrostomy device


Query Title:
Principal diagnosis for same-day episodes with more than one type of treatment or for treatment of more than one condition


Query Title:
Surveillance scopes for synchronous cancers


Query Title:
Admissions for high risk neutropenia/Neutropenic monitoring


Query Title:
Hyperglycaemia as Principal Diagnosis without mention of diabetic poor control, with multiple diabetic conditions


Query Title:
Respiratory infections with multiple infectious agents


Query Title:
Portogram and stripping of fibrin sheath from a port catheter


Query Title:
Coding of ventilation with patient’s own ventilation device


Query Title:
Coding allied health assistant intervention


Query Title:
Ethical query generation from calculation of the BMI from anaesthetic report


Query Title:
Are surgical clips a prosthetic device or implant?


Query Title:
Biodegradable Temporizing Membrane (BTM) graft of burn


Query Title:
VICC query 3649 Streptococcus pneumoniae bacteraemia and Coding Rule Q3522 B95-B97 Bacterial, viral and other infectious agents


Query Title:
Tachysystole documentation in obstetric records


# VICC queries

Query Title:
ACS 0940 and Acute Myocardial Infarction

Query Text:
ACS 0940 Ischaemic heart disease, section title Acute Myocardial Infarction (Classification) , pg 153.  The 3rd paragraph of this section states “codes from category I21 should be assigned for an infarction in both the first hospital to which the patient is admitted for treatment and any other acute care facility to which the patient is transferred within 4 weeks (28 days) or less from onset of the infarction”. Coders are interpreting this standard differently.  

Some interpret this to mean if a patient is treated for their AMI, discharged home then re-admitted to another hospital (or the same one) a few days later, the AMI should be coded during the subsequent episode if it is less than 28 days since the AMI first occurred.  Other coders are only assigning an AMI code during a subsequent episode of care if the patient is admitted for an initial episode of care for an AMI and subsequently transferred to another hospital within 28 days of the initial AMI (usually for treatment).  Basically coders are placing emphasis on two different things: 1) The 28 days or,2) The word “transferred”.

Question: If a patient has an AMI, is treated, discharged home (within 5 days), referred to another hospital for PTCA and stent insertion and subsequently admitted to that hospital 10 days after discharge from the first hospital, should the AMI be coded by the hospital performing the PTCA and stent insertion?  If the MI is coded, the episode groups to DRG F10Z Percutaneous Coronary Angioplasty with AMI, WIES = 2.3343.  If the MI is not coded (and coronary artery disease is assigned as the principal diagnosis), the episode groups to DRG F15Z Percutaneous Coronary Angioplasty without AMI with Stent Insertion, WIES 1.871.

Search Details: 
ACS 0940 Ischaemic Heart Disease pg 153

Response:
The NCCH has been consulted with regards to this complex query, and has responded in the following manner:
'Due to the complexity of this issue, the NCCH is withholding a decision on this query in order to seek advice from the Cardiovascular CCCG and CSAC.  A task has been created to investigate this matter further.  

A final decision will be added to the query database when available.'

In light of this, the Committee has decided to provide an interim response that can be followed until the NCCH is in the position to provide a definitive position.  When the NCCH does provide a response to this query, the VICC will ensure to highlight this in the ICD Coding Newsletter to ensure that Victorian coders are aware of this.  In the meantime, Victorian coders should adhere to the following advice.

For patients who have previously had an AMI who are admitted or transferred to your hospital, apply ACS 0001 'Principal Diagnosis' and ACS 0002 'Additional Diagnoses' to determine if the AMI should be coded.
Once you have determined that the AMI requires coding,
· If the patient is admitted (or transferred) to your hospital within 28 days of the AMI, use the code for a current AMI
· If the patient is admitted (or transferred) to your hospital more than 28 days following the AMI, use the code for an 'old' AMI 
Each case will depend on the individual circumstances.

We acknowledge that ACS 0940 'Ischaemic heart disease Acute Myocardial Infarction' refers to 'transferred' patients, however we consider that this should also apply to patients separated from hospital and readmitted.


Query Title:
ACS 1541 Elective and emergency caesarean

Query Text:
We are querying the intent of ACS 1541 Elective and Emergency Caesarean, particularly in relation to the mismatch of an anaesthetist’s definition of either elective or emergency via the use of ASA scores.  If the anaesthetist documents ‘E’ for emergency, coders have no choice but to code emergency (anaesthetic) and are concerned when, on occasion, ‘elective and emergency’ do not match.  For example, a patient with a history of two LUSCSs is booked to have an elective LUSCS on 19 February on the basis of current breech presentation and previous history.  On 13 February she was admitted contracting with bulging membranes and couldn’t get a satisfactory CTG reading so the decision was made for a LUSCS.  ‘Emergency LUSCS’ documented by anaesthetist ASA = 1E and ‘Emergency LUSCS’ documented by obstetrician.  However, ACS 1541 Elective and Emergency Caesarean precludes the use of ‘emergency’ LUSCS and therefore we have to code 
16520-02 [1340] Elective lower segment caesarean section
From a clinical risk management point of view, ACS 1541 makes it impossible to capture elective caesareans that become emergency.  This high-risk group is therefore unable to be easily identified through our morbidity collection.  We want to include emergency caesareans in our medical record screening program but retrieval by the emergency caesarean code doesn’t capture all the cases we feel need to be looked at.  The difference in terminology becomes a problem in comparing statistics, as the Perinatal Data Collection Unit (PDCU) classifies booked caesareans that become emergency as ‘emergency’ whereas ours stay ‘elective’.  Perhaps the time has come to identify these two groups with a fifth digit for ‘emergency caesarean’ and ‘emergency caesarean booked elective’ to align with PDCU etc.

Response:
The Committee believes that the definitions of emergency and elective Caesarean as defined by the PDCU are consistent with the definitions outlined in ACS 1541 Elective and Emergency Caesarean. It would seem that the inquirer has misinterpreted the PDCU definition of ‘elective caesarean -  labour’, and should refer to ‘Births in Victoria 1999-2000’ published by the PDCU, Victoria 2001, for the current definitions.

If an anesthetist is assessing a patient in an emergency situation, the ASA modifier ‘E’ will indicate this.  An anaesthetist is not concerned with whether the patient has a Caesarean planned for a future date. Therefore, it can be entirely appropriate to have ‘inconsistency’ in terms of the ASA ‘emergency’ indicator relating to an ‘elective’ Caesarean procedure code. 

The collection of data for elective caesareans that become emergency caesareans is made difficult by this coding practice; however, both the ACS and the PDCU definitions support this practice.


Query Text:
Scenario 1:Male presented with shortness of breath and subsequent chest pain and was admitted with angina due to fighting fires in the bush.   As there is no mention of his being either employed as a fire fighter or acting as a volunteer, what activity code should be used? Scenario 2:Female admitted with smoke inhalation while fighting fires as a volunteer.  What activity code should be used?

Response:
When selecting an activity code to assign for fire fighting, a problem arises when the exact fire-fighting role of the patient is unknown. The patient may be employed as a firefighter, or be employed elsewhere and released for firefighting duty, or they may be a volunteer fire fighter.

Scenario 1: If it unknown whether or not the patient was employed, or was acting as a volunteer, then assign: 
U73.8 Other specified activity

If the patient was fighting fires in a paid capacity, it would be correct to assign:
Activity U73.9 
-work (for income) U73.09
--fire brigade services U73.08
U73.08 Other specified work for income

Scenario 2: If the patient was working as a volunteer fire fighter, and therefore not being paid for this role, it would be correct to assign:
U73.1 While engaged in other types of work


Query Title:
Diabetic with ARF and high BSLs due to Prednisolone

Query Text:
Type 2 diabetic admitted in acute renal failure (ARF) and high blood sugar levels (BSLs) due to Prednisolone.  Patient stated as ‘not unstable diabetes’.Question 1:There is another specified cause of the ARF, i.e. drug use, therefore, the ARF should not be attributed to diabetes, but the example in ACS 0401 Diabetes, acute renal failure, states to link them anyway.  This seems to go against how we usually code adverse effects, but is the argument that this is different because this involves diabetes (and everything about diabetes is different!).Is the coding of ARF due to drug in ACS 0401 Diabetes correct?Question 2:How do we code high BSLs due to a drug in a diabetic patient?Index – Hyperglycaemia, due to diabetes – see Diabetes, by type.Patient did not have unstable diabetes.Do we use R73 Elevated blood glucose level?

ACS 0401 Diabetes, p 97.
Acute renal failure
Acute renal failure in diabetes (which may be reversible) can be precipitated by illness including those causing dehydration and by the use of concentrated solutions of intravenous radiological contrast media, particularly where the patient has been fluid restricted. This may be more likely to occur when diabetic nephropathy is already present. 

When acute renal failure develops in diabetes under these circumstances, code as follows: 
E1-.29 Diabetes with other specified renal complication
N17.9 Acute renal failure, unspecified
Y57.5 X-ray contrast media causing adverse effects in therapeutic use
Appropriate place of occurrence code (Y92.-)

Response:
The NCCH was asked to clarify the correct approach when coding conditions attributable to causes other than diabetes, with reference to this particular query.  The NCCH provided the following responses to the specific questions raised in this query:
1. ACS 0401 Diabetes mellitus and impaired glucose regulation states that acute renal failure (ARF) in diabetes can be precipitated by illness and by the use of concentrated intravenous solutions.  Therefore, for the scenario cited, it would be appropriate to follow the classification advice given in the ACS.  The ‘in’ (diabetes) is not a cause and effect relationship, but rather a combination of conditions.  A non diabetic person would not be as susceptible to developing ARF in the circumstances described, thus the need to capture the patient's diabetic status.

2. Code high blood sugar levels as directed by the index:
Hyperglycaemia
-with diabetes (mellitus) see Diabetes, by type

Note that the index uses the terms ‘with diabetes’ not ‘due to’.

Therefore, for the case cited, assign the following codes:
E11.29 Type 2 diabetes mellitus with other specified renal complication
N17.9 Acute renal failure, unspecified
Y42.0 Glucocorticoids and synthetic analogues  (Adverse effect in therapeutic use) with appropriate place of occurrence code

The Committee accepts this advice from the NCCH, and acknowledges that this may be a change in coding practice for some coders, as there has been advice published previously in the Victorian Coding Newsletter, November 2000, Diabetes Quiz Answers, which is overruled by this more recent advice.


Query Title:
Place of occurrence for adverse effect of drug

Query Text:
There have been many discussions at our hospital about what place of occurrence (POO) code should be assigned for a patient being admitted with an adverse effect of a prescribed drug.  Could you please advise the correct answer?Example:Patient admitted with severe rash due to antibiotics, prescribed by LMO.The POO code is used to identify the place where the injury or poisoning (external cause) took place, which is usually unknown unless it occurred during an inpatient episode.  However, many coders are arguing that 
Y92.22 Health service area
should be assigned because it was a prescribed drug.  Isn’t it where the poisoning/accident occurred, not where the drugs were dispensed?The references I found were Volume 1, page 503, and Coding Matters Vol 7, No. 4, pg 13.  The coders arguing for ‘Y92.22 Health service area’ seem to think there has been something else published but I can’t find anything.

Response:
VICC advises that the place of occurrence code relates to the external cause, or the agent that caused the problem, not the adverse effect of that agent. In the case of an adverse effect of a prescribed drug, the external cause is the drug, and the place of occurrence code relates to the place that the drug treatment was initiated.

Therefore, an adverse effect from a prescribed drug  can be assumed to be dispensed from a health service area of some description,  therefore place of occurrence is assigned as either Y92.23 Place of occurrence, health service area, not specified as this facility or Y92.24 Place of occurrence, health service area, this facility.


Query Text:
The following advice was given in the November 2000 Coding Newsletter, under the Diabetic Quiz (page 132). It relates to the coding of Diabetes Mellitus with other conditions:'..However, if the condition you are coding has a documented relationship to another cause or condition (for example, traumatic cataract), then do not reference the Diabetes Mellitus with index entry.'Does the committee consider this to be current advice?To illustrate, if a patient with Diabetes Mellitus is admitted with a traumatic shin ulcer which is described as non-healing, is it correct to not reference the ‘Diabetes Mellitus with’ index entry, and code only the ulcer?:
L97 Ulcer of lower limb, not elsewhere classified
If a patient with Diabetes Mellitus is admitted with acute on chronic renal failure secondary to dehydration, following gastroenteritis, is it correct to not reference the ‘Diabetes Mellitus with’ index entry, and code only the following?:
N17.9 Acute renal failure, unspecified
N18.90 Unspecified chronic renal failure
In both the above scenarios, a specific cause for each of the conditions has been documented, ie. trauma has caused the ulcer and dehydration has caused the acute on chronic renal failure.

Response:
The Victorian Coding Committee has received a number of similar queries that relate to the coding of diabetes with conditions attributable to causes other than diabetes. Therefore, the Committee referred the issue to the NCCH for clarification.

For the scenarios cited, the NCCH supports the use of 'Diabetes, with' codes. Diabetes Mellitus would be a contributing factor in each of these conditions. That is, a non-diabetic person would be more likely to recover without complication from a trauma or illness (such as gastroenteritis), whereas a diabetic patient would be at greater risk of developing complications (dehydration and thus renal failure) and their traumatic ulcer may have difficulty healing.
Note that the terminology used is 'Diabetes, with' not 'due to'.

This query will be published on the NCCH query database, and advice on coding diabetes with conditions attributable to causes other than diabetes will be published in a future edition of Coding Matters.


Query Text:
We often admit same day patients for a transoesophageal echocardiogram (TOE) for investigation of a recent CVA.  The purpose is to identify whether there was a cardiac cause for the embolism.  If the TOE shows no irregularities, how should this episode be coded?  We have been assigning as the Principal Diagnosis: 
Z03.5 Observation for other suspected cardiovascular diseases
but would like advice as to whether this is the most appropriate code to assign.  Should we also include as an additional diagnosis:
Z86.7 Personal history of diseases of the circulatory system
If Z03.5 is assigned as Principal Diagnosis, the episode groups to DRG F74Z - Chest Pain, which has a same day WIES of .2254.

Response:
The TOE was performed to investigate the underlying cause of the CVA. As no cause was established in this scenario, the relevant code for the CVA should be assigned as the principal diagnosis.


Query Text:
How do you code excision of a radial head prosthesis? The operation report states ‘right elbow, lateral incision, capsule divided, excision of excessive intracapsular scar tissue and hypertrophic bone, radial head prosthesis excised’.  The title of block 1409 is ‘Other application, insertion or removal procedures on humerus or elbow’ but the only code in the block is:  
90539-00 Implantation of prosthetic device of arm
There is no code in this block for removal of prosthetic device.  What code should be assigned?

Response:
The NCCH advise that the case cited should be classified as:
48406-03 [1426] Ostectomy of radius
as this code best describes the procedure performed from a technical perspective.

The NCCH will consider the introduction of new codes for 'revision/removal of prosthetic device of arm' in a future edition of ICD-10-AM.


Query Text:
Please provide advice on how to code administration of SIR-spheres or SIRTEX (a product that emits radiation to kill cancer cells in the liver).  Microspheres are injected into a patient's liver.  The microspheres are radioactive isotope yttrium-90, which emit ionising beta radiation that destroys cancer cells.The specific procedure we identified was performed in the Radiology department and involved angiography of the liver.  The hepatic artery was cannulated using a micro-catheter and one third of the total dose was infused into the left hepatic artery.  Two thirds of the dose was then infused into the right hepatic artery via a micro-catheter.How should this procedure be coded?  The following codes have been suggested by various sources:
35317-00 [741] Percutaneous peripheral arterial or venous catheterisation with admin of thrombolytic or chemotherapeutic agents by cont infusion or
15600-00 [1789] Stereotactic radiation treatment, single doseor
16003-00 [1795] Administration of a therapeutic dose of Yttrium 90 (and the angiography code)

Response:
Information on this relatively new procedure was sourced on the internet:

http://www.sirtex.com/?p=57
Targeted Radiotherapy with SIR-Spheres
SIR-Spheres® are biocompatible radio-active micro-spheres that contain yttrium-90 and emit beta radiation. SIR-Spheres® are implanted using a syringe  and travel via the blood stream, whereupon the spheres are targeted to the tumours within the liver. The SIR-Spheres® are trapped in the small blood vessels of the tumour. It is not necessary to identify either the number or location of the tumours within the liver, as the SIR-Spheres® will target them regardless of where they are. Once targeted to the tumour, SIR-Spheres® irradiate it by a process known as Selective Internal Radiation Therapy (SIRT), leading to the destruction of the tumour, whilst most of the normal liver tissue remains relatively unaffected. 

Clinical advice received indicated that this procedure is a combination of both radiotherapy and embolisation:

http://www.radiologyinfo.org/content/interventional/catheter-embol.htm
Catheter Embolization
Embolization, a fairly new treatment method, is a way of occluding (closing)—or at least drastically reducing—blood flow to one or more blood vessels that are doing more harm than good. One of a variety of materials, depending on whether vessel occlusion is to be temporary or permanent, is passed through a catheter whose tip lies in or near the vessel to be closed. This approach can be used to control or prevent abnormal bleeding as well as to shut down the vessels that support a growing tumor.

The Committee decided that the following codes should be assigned for this procedure: 
16003-00 [1795] Administration of a therapeutic dose of Yttrium 90
35321-00 [767] Transcatheter embolisation of blood vessel


Query Text:
Patient admitted with left sided weakness in arms and legs, and shuffling gait.  Doctor examination states partial left cerebrovascular accident (CVA).  CT scan showed bleed into right frontal lobe – CVA.Patient had a past history of right lower lobectomy for removal of primary lung tumour.  CT scan states conclusion:  Right frontal lobe mass presumed to be a metastasis from the known lung cancer.Patient discharged to a private hospital for an MRI.What is the principal diagnosis?

Response:
The information provided includes an admission diagnosis and radiology report details only.  There is inadequate information supplied for the Committee to provide a principal diagnosis.  Coders should always seek to obtain a discharge or final diagnosis when this is not present in the patient’s record.  If no further information is able to be obtained then ACS 0001 Principal Diagnosis should be applied and a decision taken by the coder.


Query Text:
We have found the coding standard in regards to patients admitted for retained products of conception a bit confusing (ACS 1544 Complications following abortion and ectopic and molar pregnancy, page 202).Do we treat retained products from a previous episode of abortion differently to other complications of a previous episode of abortion? That is, if a patient is admitted for haemorrhage due to retained products from previous termination, would you use a code from O08 Complications following abortion and ectopic and molar pregnancy or O03 - O06 Spontaneous, medical, other or unspecified abortion (i.e. a complication of a current, incomplete abortion)?Please advise.

Response:
Retained products of conception (including haemorrhage due to retained products of conception) indicate that an abortion is not complete.  In coding terms, this is not considered to be a complication of the abortion, but rather an incomplete procedure.  This should be coded to:
O03 - O06 Spontaneous, medical, other or unspecified abortion

Complications that are not related to retained products of conception should be coded to 
O08 Complications following abortion and ectopic and molar pregnancy

A Coding Feature published in a previous Coding Newsletter (in ICD-9-CM) will be updated by the Committee and republished for ICD-10-AM.  This should assist coders to overcome any confusion.


Query Text:
My query relates to the coding of femoral endarterectomy.The index entry possibilities are:

Endarterectomy- femoral (extended)-- deep 33542-00 [700]
33542-00 [700] Extended endarterectomy of deep femoral artery     
Endarterectomy >= 7cm in length
or
Endarterectomy, extremities 33539-00 [700]
33539-00 [700] Endarterectomy of extremities

I have opted for the extremities option, as the Tabular List entry states 33542-00 Extended endarterectomy of deep femoral artery and the MBS book entry for 33542 states Extended Deep Femoral Endarterectomy where the endarterectomy is at least 7cms long.

Could you please clarify this and organise, if appropriate, for the index to more correctly define the correct code for use in femoral endarterectomies.

Response:
The NCCH confirm that the correct code is:
33542-00 [700] Extended endarterectomy of deep femoral artery 
Endarterectomy => 7cm in length

The term ‘Endarterectomy >=7cm in length’ is noted to be an inclusion term only, and does not preclude the use of the code for an endarterectomy that is less than 7cm. All femoral arteries (including superficial and common) are deep vessels. 

The Committee feels that a more suitable code title would therefore be ‘Endarterectomy of femoral artery’, that is, without both the ’extended’ and the ‘deep’ terms, and will request that this title be amended in an errata to 4th edition.

Note: This query has been retired due to ACHI classification updates.


Query Text:
Baby born at our hospital at 38 weeks gestation.  Birth weight was recorded as 2850 grams.   Admission was complicated by respiratory distress for which the baby received oxygen therapy.  The baby also had conjunctivitis and was treated with gastric gavage.  On the discharge summary only, the registrar has documented low birth weight - 2850 grams.  Our query is related as to whether we would code low birth weight.  The registrar has documented low birth weight, and the baby has been given gastric gavage.  It would appear that it meets the criteria as set out in ACS 1618 Prematurity and low birth weight however, according to ICD-10-AM coding, newborns > 2500 grams are not low birth weight. Can you please clarify the coding of low birth weight?

Response:
If the clinician documents ‘low birth weight’ this can be coded.  ACS 1618 Prematurity and Low Birth Weight is intended to prevent coders from routinely assigning low birth weight codes for babies born under 2500g.  In the case you have described the baby has actually received treatment for low birth weight, therefore this must be coded.

Low birth weight in term babies should be coded to
P05.0 Light for gestational age
This is reached through the index
Low
-Birth weight
--For gestational age P05.0

Codes from 
P07._ Disorders related to short gestation and low birth weight, not elsewhere classified
are intended for use in low birth weight babies who are born prematurely.


Query Text:
Is there a need to code sedation with continuous mechanical ventilation (CMV)? ‘Codefinder’ prompts for a sedation code for CMV patients. I spoke to Judy Finn from 3M who said she thought it was a hospital in Queensland that asked for it to be included. Could I have the committee's feedback regarding this?Thanks.

Response:
If sedation is given for anaesthetic to perform the intubation, then sedation can be assigned.  Be aware that most patients who are intubated and are receiving continuous mechanical ventilation are routinely kept sedated (not for anaesthetic purposes).


Query Text:
We regularly admit patients for attention to their PEG tube, either because the PEG has become blocked and needs to be replaced or because the patient has removed the tube themselves and it needs to be re-inserted or occasionally because the universal adaptor has broken off (usually because the pt was playing with it).  Often our HITH staff manage these episodes and the patient does not attend the hospital, other times the patient is treated in ED. My questions are:
Question 1) If a PEG tube is replaced by HITH staff, what procedure code should be assigned?  The only code available via the index is Replacement - tube - - gastrostomy, percutaneous endoscopic (PEG) 30482-00 [870]
30482-00 [870] Repeat insertion of percutaneous endoscopic gastrostomy [PEG] tube
However, these PEG replacements are not endoscopic procedures, so this code would be inappropriate.

Question 2) If a PEG tube is removed by the patient, and a new tube is inserted by the HITH nurse, what code should be assigned as principal diagnosis?  

Question 3) Occasionally the notes indicate that only the universal adaptor is replaced, rather than the PEG tube.  In this scenario, what code should be assigned as principal diagnosis?  Should a procedure code be assigned and if so, which procedure code?

Search Details: The NCCH database has two queries (831 and 1074) relating to PEG tubes, but the advice given relates to what code to assign as principal diagnosis and in the case of 1074 the advice given is based on ICD-10-AM first edition, so may not be appropriate anymore.

Response:
Answer 1)
This code is correct - the use of the term ‘endoscopic’ in the title of the procedure code refers to the type of device, i.e. Repeat insertion of Percutaneous Endoscopic Gastrostomy (PEG) tube, rather than referring to the approach of the procedure. In other words, it is the replacement of an endoscopic tube, not an endoscopic replacement of a tube.

Answer 2)
Coders should refer to NCCH Query 1074, as this advice is still current.
The correct code to assign as principal diagnosis is
T85.5 Mechanical complication of gastrointestinal prosthetic devices, implants and grafts

K91.8 Other postprocedural disorders of digestive system, not elsewhere classified should be used where there is a complication of the actual stoma.

Answer 3) 
The adaptor associated with a PEG tube fits onto the tube, and can be removed for regular cleaning, without disturbing the actual PEG tube.
The Committee decided to refer this part of your query to the NCCH, for their advice.
The NCCH provided the following responses to specific queries regarding replacement of an adaptor:
a) What code should be assigned as principal diagnosis?  
The case you have described should be coded as a complication.  Assign 'T85.5 Mechanical complication of gastrointestinal prosthetic devices, implants and grafts' along with the appropriate external cause code.
b) Should a procedure code be assigned and if so, which procedure code?
Several models of PEG can be repaired by replacing the feeding/flushing port (universal adaptor). This is a simple procedure that can greatly prolong the life-span of the PEG. It would not be necessary to assign a code for this procedure, as it is simply replacing a component part on the external device.


Query Text:
When a patient (not a neonate) is commenced on feeds via a nasogastric tube, is it correct to assign 
92191-00 [1885] Enteral infusion of nutritional substances

Response:
The advice of the Victorian ICD Coding Committee is that nasogastric feeding should not normally be coded, as it is listed in ACS 0042 Procedures normally not coded, however, Note a. in this standard indicates that it could be coded if it was required for research or other purposes. 
The suggested code is correct:
92191-00 [1885] Enteral infusion of nutritional substances


Query Text:
Post operative diagnosis chronic sinusitis and chronic nasal obstruction with severe nasal septum deviation and bilateral inferior turbinate hypertrophy.Operation performed septoplasty, bilateral partial resection of inferior turbinates, bilateral middle meatal antrostomy with debridement of maxillary sinuses, bilateral anterior posterior ethmoidectomy with debridement of ethmoid sinuses, bilateral sphenoidotomy and uncinectomy. My questions are: 1. Do you code the uncinectomy? 2. Is there a code for this?We have only started to see this term used. The codes for all the procedures are straight forward except this.

Response:
Uncinectomy (aka Infundibulotomy) involves detachment and removal of the anterior, inferior and superior attachments of the uncinate process. It is performed as part of an intranasal ethmoidectomy in order to gain access to the ethmoid infundibulum, expose the frontal recess and allow visualisation of the frontal recess. 
Uncinectomy is a fundamental step in functional endoscopic sinus surgery (FESS).

Therefore, for the case cited, it is unnecessary to code the 'uncinectomy' component of the procedure.

The NCCH will review the indexing of this procedure and ACS 0807 Functional endoscopic sinus surgery (FESS) for a future edition of ICD-10-AM.


Query Text:
A 38-year-old woman with chronic chest wall/epigastric pain was admitted under the Pain Clinic for IV infusion of Lignocaine.  The IV was placed in the wrist. (see 1 page report labelled ‘1st admission’).I am not sure how to code the infusion of Lignocaine.  Index entries under Infusion and Injection don’t seem to cover this scenario.  Also, in a subsequent admission, the notes say she had IV Lignocaine via CADD pump (see 2 pages labelled ‘2nd admission’). Is the following code able to be used, even though this is in a chemotherapy block?
13942-00 [1780] Loading of ambulatory drug delivery device

Response:
When lignocaine is administered as an IV infusion for analgesia, the correct code to assign is:
Injection
-therapeutic agent NEC 92193-00 [1885]
92193-00 [1885] Injection or infusion of other therapeutic or prophylactic substance

When lignocaine is administered via CADD pump, as in the subsequent admission, it is appropriate to use a code from block [1780] Chemotherapy Administration. The codes from this block are not exclusively for administration of cytotoxic drugs.
13942-00 [1780] Loading of ambulatory drug delivery device is correct.


Query Text:
We would like clarification of how to code haematoma of pacemaker site.  According to ACS 0936 Pacemakers, Complications of the pacemaker system (page 150),‘T82.8 Other complications of cardiac and vascular prosthetic devices, implants and grafts includes haematoma of pacemaker pocket or pacemaker eroded through pocket site.’Our difficulty is that when a patient has a haematoma post pacemaker insertion, the documentation usually states ‘haematoma of pacemaker site’ or ‘PPM wound haematoma’ - it is never documented as a haematoma of the pacemaker pocket.  Questions:1. Is this standard trying to say that all haematomas of pacemaker sites should be coded to T82.8 Other complications of cardiac and vascular prosthetic devices, implants and grafts, or should this code only be assigned if the documentation specifically states haematoma of pacemaker pocket?2. If a haematoma of a pacemaker site is documented (and it's not possible to get clarification of whether it is the pacemaker pocket or skin/wound) should we assign 
T82.8 Other complications of cardiac and vascular prosthetic devices, implants and grafts
or
T81.0 Haemorrhage and haematoma complicating a procedure, not elsewhere classified Excludes: haematoma of obstetric wound (O90.2)haemorrhage due to prosthetic devices, implants and grafts (T82.8, T83.8, T84.8, T85.8)
Note: T81.0 does exclude T82.8 but coders don't like using T82.8 because it seems to be a less specific code.I have spoken to a Cardiology Registrar who has said that it's difficult for them to differentiate between a haematoma of the pacemaker pocket and a haematoma of the wound/skin. T81.0 refers to haematoma, whereas T82.8 refers to complication of cardiac and vascular devices, implants and grafts - so what should we be coding - the haematoma (T81.0) or the complication (T82.8)?Search Details: ACS 0936 Pacemakers

Response:
Answer 1)
As you have pointed out, clinicians find it difficult to differentiate between a haematoma of the pacemaker pocket, and a haematoma of the wound. Therefore, a haematoma documented as being of the pacemaker pocket, of the pacemaker site, or stated as being a PPM wound haematoma, should be assigned the same code.

Answer 2)
The correct code to assign is 
Complications (from) (of) 
-pacemaker (cardiac) (electrodes) (pulse generator) T82.9 
--specified NEC T82.8

T82.8 Other complications of cardiac and vascular prosthetic devices, implants and grafts
This advice is supported by the ‘excludes’ note at T81.0 Haemorrhage and haematoma complicating a procedure, not elsewhere classified, which excludes ‘haemorrhage due to prosthetic devices, implants and grafts (T82.8, T83.8, T84.8, T85.8)’.
It would be clearer if this excludes note read as ‘due to, or associated with’.
This would be in line with the index:
Haemorrhage, haemorrhagic
-due to or associated with
--device, implant or graft (see also Complications, by site and type) T85.88
---electronic (electrode) (pulse generator) (stimulator) 
----cardiac T82.8

The Committee acknowledges that some improvements to the index would help to clarify the coding of pacemaker complications, and will make some recommendations to the NCCH.


Query Text:
A patient had their arm amputated in an accident. Amputation- traumatic-- arm S48.9 (Traumatic amputation of shoulder and upper arm level   unspecified)  --- meaning upper limb - see amputation, traumatic, limb, upper Amputation- traumatic-- limb--- upper T11.6 (Traumatic amputation of upper limb, level unspecified) This index entry seems incorrect because it implies that it is leading you to a more specific code when in fact the T code is unspecified.Therefore it would be very rare to use the T code in this circumstance because the S code is more specific. We think this is an index problem - please forward to the NCCH.

Response:
The Coding Committee acknowledges the problem that the inquirer has with the index terminology. In order to clarify this area of coding, the NCCH provided the following explanation: 

ICD-10-AM Tabular List of Diseases Chapter XIX contains code blocks for the 'upper limb' as follows:
 S40-S49 'Injuries to shoulder and upper arm'
 S50-S59 'Injuries to elbow and forearm'
 S60-S69 'Injuries to wrist and hand'
 T08-T14 'Injuries to unspecified part of trunk, limb or body region'.

Using general language, classification users may assume that documentation of 'upper limb' refers to the 'arm', but for classification purposes the term 'arm' refers to the specific anatomical region between the shoulder and upper arm and 'upper limb' is a less specified site.

The index entries for the section cited in ICD-10-AM are consistent with the relevant section of ICD-10 (WHO).

The NCCH make the point that classification users should abstract terms as specifically as possible, and apply them to the Alphabetic Index of Diseases in order to determine the most correct code to use. Reference should always be made to the Tabular List of Diseases to verify the suitability of the code selected.

This notion is confirmed in ACS 1907 Multiple Injuries: 
Injuries should be coded to the individual site/type whenever possible. 

The use of ‘S’ and ‘T’ codes is further clarified in an introductory statement to ‘Injury, Poisoning and Certain Other Consequences of External Causes’ in Volume 1, p 375:
 Note: The chapter uses the S-section for coding different types of injuries related to single body regions and the T-section to cover injuries to multiple or unspecified body regions as well as poisoning and certain other consequences of external causes


Query Text:
If a patient has a panendoscopy and multiple biopsies are taken, do we need to code this multiple times?  

For example:
1. Panendoscopy with six duodenal biopsies.  Is code 30473-01 [1008] Panendoscopy to duodenum with biopsy coded six times?
2. Panendoscopy with biopsies of oesophagus, stomach and duodenum.  Is code  30473-01 [1008] Panendoscopy to duodenum with biopsy coded three times?

Inclusion notes under code 32090-01 [911] Fibreoptic colonoscopy to caecum, with biopsy mention with multiple biopsies; however, code 30473-01 [1008] does not have the same wording for multiple biopsies.

Response:
It is correct to use this code once, even when there are multiple biopsies taken.

We acknowledge the inclusion note under colonoscopy with biopsy, and will make a suggestion to the NCCH that a similar note be included for panendoscopy.


Query Text:
We are having trouble coding unsuccessful endoscopic retrograde cholangiopanreatography (ERCP).  What code do we use in cases where an ERCP is intended, but neither the common bile duct nor the pancreatic duct is cannulated?According to ACS 0019 Procedure not completed or interrupted, “If a surgical procedure was interrupted or not complete for any reason, code to the extent of the procedure”.  Therefore, according to this standard, we should be coding 30473-00 [1005] Panendoscopy to duodenum, because they only reach the duodenum.We received the following information from one of the General Surgeons at our hospital:“The coding for ERCP should be used whenever there is an attempt to cannulate the ampulla to produce a cholangiogram and/or a pancreatogram.  In other words, whether it is successful or not is irrelevant.  The same equipment is required and the same expense incurred.  The duodenoscope is needed and a catheter and often, if cannulation is difficult, a guide-wire and sphincterotome.  Indeed an inability to cannulate the bile duct often results in much more time and expense than straightforward cannulation.  If an ERCP is planned but the ampulla cannot be identified and approached because, for instance, there is duodenal obstruction, then a gastroscopy is all that is being performed and that would be the appropriate code”.Therefore according to the doctor's description of the procedure, we should be coding and funded accordingly to an ERCP 30484-00 [957] Endoscopic retrograde cholangiopancreatography [ERCP], (assuming no other procedures were performed).Could you please clarify?Search Details: ACS 0019 Procedure not completed or interrupted pg35

Response:
It is possible that this type of problem may arise in private hospitals, where the MBS codes used for billing are being linked to ICD-10 coded data. 
From a coding perspective, it is appropriate to follow ACS 0019 Procedure not completed or interrupted and code as far as the procedure went. The correct code to use in this example is 30473-00 [1005] Panendoscopy to duodenum


Query Text:
A patient was admitted with Osteoradionecrosis (ORN) of the mandible following radiotherapy. On the top of the operation report the surgeon describes this type of procedure as a sequestrectomy.  In the body of the operation the surgeon has written debridement of bone.  See attached notes.The patient was a same day patient.The following diagnosis codes were assigned:
K10.2 Inflammatory conditions of the jaw
Y84.2 Radiological procedure and radiotherapy
Y92.22 Health Service Area

Which of the following procedure codes is correct?
90603-01 [1364] Sequestrectomy of the mandible
Groups to 901Z Extensive O.R. Procedure Unrelated to Principal Diagnosis
OR
45605-00 [1699] Partial resection of mandible
Groups to D02B Head and Neck Procedures W/O CC
OR
30023-01 [1566] Excisional debridement of soft tissue involving bone or cartilage
Groups to 901Z Extensive O.R. Procedure Unrelated to Principal Diagnosis
(with code for general anaesthetic)

Response:
The Committee felt that, since ‘sequestrectomy’ was documented on the operation report, that the correct index trail would be:
Sequestrectomy 
-bone NEC 90573-00 [1563] 
--mandible 90603-01 [1364] 

For this procedure, code
90603-01 [1364] Sequestrectomy of mandible

The Committee acknowledges the grouping anomaly, and will notify the Commonwealth.


Query Title:
Perpetrator of assault - external cause code

Query Text:
Male injured hand striking another person during an assault.  Patient was the perpetrator of assault, not the victim.  Therefore is the correct external cause code?
W51 Striking against or bumped into another person 
Or 
Y04 - Assault by bodily force
Is it correct that Y04 – is used for those with injuries inflicted by another person with intent to injure or kill by any means ie the victim not the perpetrator?Search details:ACS 2008 Perpetrator of assault, abuse and neglect.

Response:
In ICD-10-AM 3rd edition, Volume 1, p486:
ASSAULT
(X85–Y09)
Includes: homicide
injuries inflicted by another person with intent to injure or kill, by any means

The following fifth character subdivision is for use with categories X85–Y09:
This subdivision is used to describe the relationship of the victim of assault to the perpetrator.


The inclusion note, and the direction for assigning the fifth character, confirms that the external cause codes are to be used for the victim, not the perpetrator.

The external cause code to use in this example would be found in the index via:
Striking against 
-person(s) W51

W51 Striking against or bumped into by another person


Query Text:
54-year-old female with Type 2 diabetes, with diabetic foot, admitted with cellulitis of the foot, which had progressed further to osteomyelitis of the same site.  An excisional debridement of soft tissue including bone (noted on operation sheet) was performed to treat the infection.  We coded the following for the procedure given that bone was removed as well as skin/soft tissue.
30023-01 [1566] Excisional debridement of soft tissue involving bone or cartilage
Question:Which is the correct principal diagnosis?  See attached coding sheets showing grouping.
E11.73 Type 2 Diabetes with foot ulcer due to multiple causes
with
L03.11 Cellulitis of lower limb
OR
E11.61 Type 2 Diabetes with specified diabetic musculoskeletal and connective tissue complication
with
M86.9- Osteomyelitis, unspecified
 If E11.73 is the principal diagnosis, this groups to DRG 901Z Extensive OR proc Unrelated to PDiag as a result of the combination with the correct procedure.  If applying our “clinical coders creed” we would have coded E11.61 as principal, as we felt that the infection was worse than just skin (because bone was involved), which groups to DRG I27Z Soft Tissue Procedures (but with a poor weight), which could be appropriate given the procedure.Our problem is that, in ACS 0401 Diabetes Mellitus and Impaired Glucose Intolerance, pg 99, with regard to diabetic foot, it is implied but not stated absolutely that the infection should be coded first, because infection is listed under point one.  Because diabetic foot is documented, we know we have to code E11.73 according to pg 100 of the standards, but does it have to be the principal or can E11.61 be the principal?

Response:
According to ACS 0401 Diabetes Mellitus and Impaired Glucose Regulation, page 87:
Only conditions indexed under 'Diabetes, diabetic' can be classified to 'with complication' categories in E10–E14. 
‘Osteomyelitis’ is not indexed under ‘Diabetes’ in the index, and the Committee was unsure of how the inquirer arrived at E11.61 Type 2 diabetes mellitus with specified diabetic musculoskeletal and connective tissue complication. 

It is presumed from the query that ‘diabetic foot’ has been documented in the record, and therefore, the criteria for coding diabetic foot are met. The correct principal diagnosis would be
E11.73 Type 2 diabetes mellitus with foot ulcer due to multiple causes
with additional diagnoses:
L03.11 Cellulitis of lower limb
M86.17 Other acute osteomyelitis, foot

A code for 
Diabetes, diabetic (controlled) (mellitus) E1-.9
-with 
--ulcer E1-.69
E11.69 Type 2 diabetes mellitus with other specified complication should not be sequenced as principal diagnosis, as this is covered by E11.73 Type 2 diabetes mellitus with foot ulcer due to multiple causes.


The Committee notes the grouping to DRG 901Z Extensive OR proc Unrelated to Pdiag, and will notify the Commonwealth of same.


Query Title:
Grouping of excision of retroperitoneal lipoma

Query Text:
49-year-old female patient admitted for surgery for retroperitoneal lipoma and pelvic adhesions.  Underwent removal of retroperitoneal lipoma and division of adhesions under GA.  Post operatively, she was found to have a wound haematoma.  Allied Health encounters in the postoperative period were: pastoral care, dietetics, physiotherapy and social work.  The case was coded as follows: 
D17.7 Benign Lipomatous Neoplasm of other sites
M8850/0 Lipoma NOS
N73.6 Female Pelvic Adhesions
T81.0 Haematoma complicating a procedure
Y83.8 Other Surgical Procedure
Y92.22 Health Service Area
35713-14 [1299] Excision of lesion of pelvic cavity
30378-00 [986] Divisions of abdominal adhesions
92514-29 [1910] GA ASA 29
92518-00 [1912] Morphine PCA
Grouped to DRG 901Z Extensive OR procedure unrelated to Principal Diagnosis..Question:Is this a grouping anomaly? When D17.7 Benign Lipomatous Neoplasm of other sites is replaced with D20.0 Benign neoplasm of soft tissue of retroperitoneum and peritoneum, it groups to G04B Peritoneal Adhesiolysis (age <50 W CC) but D17.7 is a more specific code and also, D20.0 has an exclusion note that directs the coder to use D17.7.Could you please clarify?

Response:
From the diseases index:
Lipoma (M8850/0) — see also Lipoma, site classification
-site classification 
--connective tissue NEC D17.3 
---peritoneum D17.7 
---retroperitoneum D17.7


From the procedures index:
Excision — see also Removal 
-tumour
--retroperitoneal 
---female (open) 35713-14 [1299] 


The Committee acknowledges that this has been coded correctly according to the index. 
The Commonwealth will be notified of this grouping anomaly.


Query Title:
Spinal cord compression secondary to neoplasm

Query Text:
My query is in regard to the coding of spinal cord compression secondary to neoplasm.The example I have is a patient with rectal carcinoma experiencing spinal cord compression secondary to the cancer.I have coded 
C20 Malignant neoplasm of rectum
M8010/3 Carcinoma NOS
G95.2 Cord compression, unspecified
However, 
G99.2* Myelopathy in diseases classified elsewhereAnterior spinal and vertebral artery compression syndromes (M47.0-†)Myelopathy in neoplastic disease (C00–D48†)
seems to be more specific than the G95.2, but this code can only be reached by looking up the word myelopathy in the index.  Question:Can the code G99.2 be used if ‘cord compression secondary to cancer’ is documented, or does ‘myelopathy secondary to the cancer’ have to be documented before this code can be assigned?

Response:
Myelopathy is defined as ‘any functional disturbance and/or pathological change in the spinal cord’ (Dorland’s Pocket Medical Dictionary, 24th edition, 1989).

Even though it is a term that could be applied to many conditions, it is seldom documented. 
Committee members felt that coders should be able to use their clinical knowledge to interpret spinal cord compression as myelopathy, and therefore follow index entry:
Myelopathy (spinal cord) G95.9 
- in (due to) 
- - neoplastic disease NEC (M8000/1) (see also Neoplasm) D48.9† G99.2*

The NCCH agreed with this logic, and suggested that an additional code for the type of myelopathy be included. The idea of further specifying a condition where a code assigned is for ‘diseases classified elsewhere’ is supported by the notion of ‘translating medical statements into codes’, which is the main aim of coding (refer to Guidance in the use of ICD-10-AM To classify clinical concepts into codes page xxiii of the ICD-10-AM Tabular list).

The correct codes to assign in this scenario are:
C20 Malignant neoplasm of rectum
M8010/3 Carcinoma NOS
G99.2* Myelopathy in diseases classified elsewhere
G95.2 Cord compression, unspecified


Query Text:
32-year old female admitted for removal of IUD and insertion of Implanon.  

Question:Is there a procedure code for the insertion of Implanon.  I have used 14203-00 [1906] Direct subdermal hormone implantation
I
s this appropriate?

Search Details: I have searched Coding Matters & Newsletter indexes without luck.  The NCCH queries database had one reference to Implanon, but was referring to the Removal of Implanon.  Code suggested was 92202-00 [1908] Removal of therapeutic device NEC.  I could not find a comparable code for insertion.

Response:
Implanon is a progestogen only contraceptive implant. It consists of a small plastic rod about the size of a matchstick, which is inserted just under the skin on the inside of the upper arm. The rod is very flexible and not likely to be visible. The hormone is released slowly from the device into the bloodstream over 3 years. 

Insertion only takes a couple of minutes. Local anaesthetic is given to numb the skin and the rod is inserted through a small incision. No stitches are required. A pressure bandage is placed on the arm to reduce bruising. When the anaesthetic has worn off there may be some tenderness and bruising for a few days but there should be no restriction in movement. 
Soon after the rod has been inserted, a small layer of tissue forms around the implant which should keep it in place.      (http://www.fpwa-health.org.au/Implanon.htm)

As previously advised in query #1746 Implanted contraceptive which was published in the Victorian ICD Coding Newsletter, February 2002: 
The Committee therefore agreed with the diagnosis and procedure code suggested by the enquirer for the Implanon implant:
Z30.1 Insertion of (intrauterine) contraceptive device
14203-00 [1906] Direct hormone implantation

The inquirer is correct in assigning this procedure code.


Query Text:
Our problem is with the post procedural analgesia codes and a device called the ‘pain management buster’. This device is a percutaneous implantable pain management catheter, which is attached to an external pain management pump.  It is inserted at the end of an operation (usually shoulder operations) and while still in theatre, a bolus dose of Naprosyn is given via the pain buster, this is to cover wound pain.  The operation up to this point has been covered via a G.A. and an interscalene block.  The catheter is removed on the ward about one or two days postoperatively.We are currently using: 
34528-00 [766] Percutaneous insertion of implantable vascular device
but perhaps because of the bolus dose being delivered whilst still in theatre we should be using:
92517-02 [1912] Management of regional block, nerve of upper limb
Question:Which is the correct code?

Response:
Clinical information received confirms that the pain buster is a subcutaneous device used for continuous infusion of local anaesthetic for analgesia. 
The correct index trail to follow would be:
Analgesia 
- postprocedural 
- - infusion (intravenous) 92518-01 [1912] 

92518-01 [1912] Intravenous postprocedural analgesic infusion

[Although ‘intravenous’ appears in the code title, it is a non-essential modifier in the index, and so can be applied. The NCCH will be notified of this index/tabular anomaly.]

As stated in ACS 0031 Anaesthesia, Classification point 5:
92518-00 [1912] Intravenous postprocedural infusion, patient controlled analgesia (PCA) and 92518-01 [1912] Intravenous postprocedural analgesic infusion may be assigned if data on such interventions is required at the local hospital level (use of these codes is not mandatory for national morbidity data reporting). 

Therefore, this code should only be assigned if the data is required at local hospital level.


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

Response:
Clinical information obtained by the Coding Committee regarding rotator cuff repair indicates that bursectomy is an operative approach performed during reconstruction of the shoulder, in order to expose the cuff margins, and is considered to be a routine part of the procedure. 

Therefore, when bursectomy is documented in conjunction with a repair of the rotator cuff/shoulder reconstruction, it is not necessary to include a separate code for the removal of the bursa. This information was verified by the NCCH.

The NCCH will consider the addition of bursectomy to the includes list in code 48960-00 [1405] 'Arthroscopic reconstruction of shoulder' and any other relevant codes for a future edition of ICD-10-AM.

Please refer to #2659 Bursectomy with repair of rotator cuff for Seventh Edition advice.


Query Text:
I am trying to resolve an issue in regards to advice from the NCCH 25/08/1998 (ID #257 on the NCCH coding query database), which instructs coders, when coding Electrophysiological Studies (EPS) with radiofrequency catheter ablation, not to use codes from Block [601] Destruction Procedures On Atrium, as they describe open cardiac ablation procedures...'  Question:If this is the case, then why do both 
38533-00 [601] Ablation of arrhythmia circuit or focus involving one atrial chamber      (1st Edition ICD-10-AM)
and
38290-00 [601] Ablation of arrhythmia circuit or focus involving both atrial chambers      (3rd Edition ICD-10-AM) 
group to DRG F19Z Other Transvascular Percutaneous Cardiac Interventions in their respective versions of the grouper?The advice states that the correct code to use is:
38212-00 [665] Cardiac electrophysiological study > 4 catheters
My understanding, in keeping with the inquirer's, is that the ablation referred to in this code is for diagnostic purposes rather than curative purposes.

Response:
There will be a new code in 4th edition for Electrophysiological Studies (EPS) with radiofrequency catheter ablation.
Until the release of 4th edition, the correct code, as stipulated in NCCH query 257, is 38212 00 [665] Cardiac electrophysiological study > 4 catheters. Radiofrequency ablation is always performed concurrently with an EPS, therefore it cannot be coded using a code from block [601].

The grouping aspect will be investigated with a view to informing the Commonwealth if it is considered to be anomalous.


Query Text:
Patient admitted with pelvic pain and had drainage of a cyst of the pouch of Douglas via laparoscopy.  Following the Index entry: Drainage- cyst-- pouch of Douglas 35572-00 [1280]
35572-00 [1280] Colpotomy (Incision through vagina to access pelvic sites)
Question:This does not appear correct, as a colpotomy was definitely not performed.  Could the committee please advise?

Response:
The index entry
Drainage
- cyst
-- pouch of Douglas 35572-00 [1280]
is incorrect when not performed via colpotomy.

Laparoscopic drainage of cyst of Pouch of Douglas should be classified as:
Drainage
-cyst
--pelvic cavity (open) 30394-00 [987] 

Laparoscopy (diagnostic) (exploratory) 30390-00 [984] 

30394-00 Drainage of intra-abdominal abscess, haematoma or cyst
30390-00 Laparoscopy

The NCCH will amend the classification to improve code selection for this procedure.


Query Text:
Patient admitted with principal diagnosis of Falls FI.  History reveals patient has had several falls in the last month, the last fall resulting in a very painful hip and difficulty ambulating, so patient brought to ED to exclude fracture. X-ray showed no fracture, the ED notes state to admit patient for CT head and other tests to investigate reason for falls.  No cause was identified during the admission for the falls.ACS 1806 Falls states not to use R29.81 Falls in cases of known trauma.Some of our coders are interpreting this to mean if any trauma results from a fall, no matter what the reason for admission, do not use R29.81.  Others feel it means you can use R29.81 with an injury, so long as the injury was not the reason for admission, but investigation of the falls was the reason.Also, what if the patient had physiotherapy during the above admission, should this change the principal diagnosis even though this was clearly not the reason for admission?

Response:
The Victorian ICD Coding Committee notes that ACS 1806 Falls has caused confusion amongst coders.  Therefore the following is the Committee's interpretation of the standard to provide guidance to Victorian coders:

If the reason for admission is falls for investigation and the patient also has minor injuries, assign R29.81 Falls as principal diagnosis.  Assign codes for minor injuries if they meet ACS 0002 Additional Diagnoses.  If the underlying condition for the falls is found, assign the code for the underlying condition as the principal diagnosis.

If the reason for admission is an injury such as a fracture and falls for investigation is also documented, assign the fracture as the principal diagnosis and assign R29.81 Falls as an additional diagnosis if the falls are investigated.

This may be a change of coding practice for some coders.


Query Text:
According to the index, the correct code for an obstetric non-perineal labial tear isLaceration - labia, complicating delivery O70.0 
O70.0 First degree perineal laceration during deliveryPerineal laceration, rupture or tear (involving):• fourchette  } • labia  } • skin  }  during delivery• slight  } • vagina  } • vulva  } 
Question 1:What is the correct procedure code for suturing a non-perineal labial tear?  
90485-00 Other suture of current obstetric laceration without perineal involvement    (n.b.   Suture, -obstetric laceration, current (tear), --vulva   is indexed here)
OR
90481-00 Suture of 1st or 2nd degree tear of perineum
Search Details:Index, tabular, NCCH queries, Vic newsletterQuestion 2:Please also note the following index irregularities:2.1 There are inconsistencies between the entries under Repair, obstetric and Suture, obstetric:
Repair- Suture-
- obstetric laceration, current (tear) 90485-00 [1344] - - 1st degree 90481-00 [1344] - - 2nd degree 90481-00 [1344] - - 3rd degree 16573-00 [1344] - - 4th degree 16573-00 [1344] - - bladder (and urethra) 90480-00 [1344] - - perineum - - - 1st or 2nd degree 90481-00 [1344] - - - 3rd or 4th degree 16573-00 [1344] - - rectum (and sphincter ani) 90480-01 [1344] - - sphincter ani (and rectum) 90480-01 [1344] - - urethra (and bladder) 90480-00 [1344] - - vagina 90479-00 [1344] - - - with perineal laceration — see Suture, obstetric laceration, current, perineum - obstetric laceration, current (tear) 90485-00 [1344] - - 1st degree 90481-00 [1344] - - 2nd degree 90481-00 [1344] - - 3rd degree 16573-00 [1344] - - 4th degree 16573-00 [1344] - - bladder (and urethra) 90480-00 [1344] - - cervix 16571-00 [1344] - - perineum 90481-00 [1344] - - - 1st or 2nd degree 90481-00 [1344] - - - 3rd or 4th degree 16573-00 [1344] - - rectum (and sphincter ani) 90480-01 [1344] - - sphincter ani (and rectum) 90480-01 [1344] - - urethra (and bladder) 90480-00 [1344] - - uterus 90485-00 [1344] - - vagina 90479-00 [1344] - - - with perineal suture — see Suture, obstetric laceration, current, perineum - - vulva 90485-00 [1344]
2.2 There are no ‘obstetric’ options for Repair, rectum, but there is under Suture.There are no ‘obstetric’ options for Repair, sphincter ani or anal sphincter, but there is under Suture, sphincter ani (but not anal sphincter):
Repair- Suture-
- rectum NEC 90313-00 [940] ***(No obstetric options) - rectum 90342-00 [940] - - obstetric laceration, current 90480-01 [1344] 
- sphincter - - anal (direct) (for anal fissure) (for anal incontinence) 32126-00 [940]99***(No obstetric options) - sphincter ani - - obstetric laceration, current 90480-01 [1344] 
2.3 The indexing of repair of obstetric tear of rectum and sphincter ani also needs to be reviewed.  Neither of these entries give the option for ‘with perineal involvement’:
Repair- laceration — see also Suture, by site and Repair, wound- - obstetric, current 90485-00 [1344] - - - rectum (and sphincter ani) 90480-01 [1344] - - - sphincter ani (and rectum) 90480-01 [1344] ***(no entries with an option for ‘with perineal involvement’) 90480-01 Suture of current obstetric laceration of rectum and/or sphincter ani without perineal involvementExcludes: suture of 3rd or 4th degree perineal laceration (16573-00 [1344])
#There are no entries for:Repair, laceration, sphincter ani or anal sphincterRepair, laceration, perineumRepair, perineum2.4 Why does:Suture, obstetric laceration, current (tear), --vulvago to ‘Other suture of current obstetric laceration without perineal involvement’, and not ‘Suture of 1st or 2nd degree tear of perineum’??Could these be reviewed and amended via errata?

Response:
It is important to recognise that the disease classification was developed by the World Health Organization (WHO), whilst the procedure classification was developed by the NCCH (based on the Commonwealth Medicare Benefits Schedule (CMBS), and therefore, there won’t be perfect alignment between the classifications.

Question 1:
What is the correct procedure code for suturing a non-perineal labial tear?  
90485-00 Other suture of current obstetric laceration without perineal involvement    (n.b.   Suture, -obstetric laceration, current (tear), --vulva   is indexed here)
OR
90481-00 Suture of 1st or 2nd degree tear of perineum

It is also noted that there is a fatal PICQ indicator which identifies cases of 1st or 2nd degree tears without 90481-00 Suture of 1st or 2nd degree tear of perineum.  Therefore, cases with 90485-00 Other suture of current obstetric laceration without perineal involvement are identified by this indicator.

Answer 1:
The question relates to the fact that the diagnosis code represents a number of possible obstetric outcomes, whilst the procedure codes are more specific. Coders are therefore advised to follow the index entries and code accordingly.
The Committee has been advised that the fatal PICQ indicator is flagged for amendment in a future version of PICQ, as this code is correct for repair of a non-perineal labial tear.

The NCCH advise that suturing of a (nonperineal) labial tear should be coded as:
90485-00 [1344] 'Other suture of current obstetric laceration without perineal involvement'.


Question 2.1, 2.2 
There are inconsistencies between the entries under Repair, obstetric and Suture, obstetric.
There are no ‘obstetric’ options for Repair, rectum, but there is under Suture.
There are no ‘obstetric’ options for Repair, sphincter ani or anal sphincter, but there is under Suture, sphincter ani (but not anal sphincter).

Answer 2.1, 2.2
 The NCCH acknowledge the differences between the index entries for Repair, obstetric laceration and Suture, obstetric laceration, and confirm that amendments will be made to a future edition of ICD-10-AM, if necessary, after further review.


Question 2.3
The indexing of repair of obstetric tear of rectum and sphincter ani also needs to be reviewed.  Neither of these entries gives the option for ‘with perineal involvement’.

Answer 2.3
The NCCH refer to an excludes note at 90480-01[1344] 'Suture of current obstetric laceration of rectum and/or sphincter ani without perineal involvement', which directs classification users to the correct code to use with perineal involvement, 16573-00 [1344] 'Suture of 3rd or 4th degree tear of perineum'. 
Instruction terms are used throughout the classification to direct users to other sections, in order to prevent duplication of terms and codes. Note that there is an instruction at 'Repair, laceration' to 'see also Suture, by site'. 


Question 2.4
Why does:
Suture, obstetric laceration, current (tear), vulva
go to ‘Other suture of current obstetric laceration without perineal involvement’, and not ‘Suture of 1st or 2nd degree tear of perineum’?

Answer 2.4
 The NCCH directs coders to follow the Alphabetic Index of Procedures and assign a code according to site, dependent upon documentation (for example, Repair/suture of vulva or perineum or degree of tear if specified).


Query Title:
Admission for excision of ganglion, ganglion not found

Query Text:
If a patient is admitted for excision of ganglion but at operation no ganglion, no other abnormality, was identified, do we code just pain in wrist for the diagnosis and incision of skin for the operation?

Operation report details: Presenting Complaint = Excision of ganglion left wrist (over radial pulse)

Details of operation performed = Exploration of presumptive ganglion. Volar aspect of L wrist – no ganglion found or any other abnormality found. Closure.

Response:
The Committee referred to previously published information:
Victorian Coding Newsletter, July 1997
#1164 Admission for excision of lesion, no longer present

Coding Matters, January 1997, (Vol 3 #3 p16)
Questions raised at the national NCC workshops held in May 1996

In the Committee’s opinion, if the patient presented with a symptom, such as pain in wrist, then this should be the principal diagnosis, as directed in ACS 0001 Principal diagnosis:
Codes from the Z03.0–Z03.9 series, medical observation and evaluation for suspected diseases and conditions
If symptoms related to the suspected condition are noted, then the symptom codes should be assigned, not code Z03.-.

However, if no symptoms are documented, assign
Observation (for) Z04.9 
- suspected (undiagnosed) (unproven) 
- - condition NEC Z03.8

With only the information provided in the query, the procedure should be coded as:
Incision 
- soft tissue NEC 90568-02 [1559] 

Z03.8 Observation for other suspected diseases and conditions
90568-02 [1559] Incision of soft tissue, not elsewhere classified Division of soft tissue NOS


Query Text:
A particular vascular surgeon at our hospital has recently been involved in a pilot study using ultrasonic thrombectomy to blocked peripheral arteries. This procedure uses an ultrasound device, made by Omnisonics Medical Technologies, to direct acoustic energy down a wire which fragments material causing blockage in the arteries into tiny pieces that will be absorbed within the body, without damaging the walls of the arteries.Whilst the surgeon documents the procedure as being a 'thrombectomy', it does not seem appropriate to use such a code given that the procedure does not actually involve direct removal of the thrombus, but rather, destruction of it.We discussed also the use of other codes including:
55054-00[1949] Intra-operative ultrasound of other site(Ultrasound in conjunction with surgical procedure using interventional techniques)
Or 
96154-00[1880] Therapeutic ultrasound
And
35200-00[719] Intra-operative arteriography (Note: Only to be assigned when performed during the course of another procedure)
Please advise.   Search Details: www.omnisonics.com

Response:
This was referred to the NCCH for advice.  

Documentation of 'Ultrasonic thrombectomy' should be classified as: 
Thrombectomy
-artery
-- by site 
with an additional code for 55054-00 [1949] 'Intra-operative ultrasound of other site'. 

The NCCH notes also that the Angiogram/angioplasty report describes angiography of the left superficial femoral artery for the case cited. Therefore an appropriate code needs to be assigned for this procedure.

The NCCH will consider the introduction of a new code for ultrasonic thrombectomy for a future edition of ICD-10-AM.


Query Text:
Please would you help me with coding the condition of 'unconscious collapse’?  It is frequently provided as a diagnosis for short stay ED admissions.  The clinical advice received is that it is different to a diagnosis of 'collapse'.  The patient usually has blood tests, head CT and observations but no cause is identified.The index entry for either of these conditions does not include the whole diagnosis of 'unconscious collapse'.  However, there is an ‘excludes’ note on R55 Syncope and collapse for unconsciousness NOS (R40.2).  I am unable to determine if it is a Type 1 or 2 exclusion.  If it is a type 1, which code would be sequenced first?

Response:
As stated in the clinical advice received by the NCCH, unconscious collapse is:
‘a symptomatic diagnosis rather than representing a pathology.  Usually... people would be assigned to a defined cause such as "seizure", "syncope" or "cardiac arrhythmia". I would suspect a strong overlap with "syncope" which is the commonest diagnosis assigned to such cases.’

Therefore, in the first instance, coders should look in the record for evidence of the pathology causing these symptoms.  If no underlying cause can be identified, code assignment must be determined on an individual case basis, dependent upon factors such as:
- patient's level of consciousness on admission
- documentation of loss of consciousness (and duration) associated with collapse
- other significant symptoms/conditions, such as respiratory arrest.

The Committee discussed the concept of collapse with and without loss of consciousness, with the overriding opinion being that it is possible to collapse without losing consciousness. Therefore, in order to translate medical statements into codes, where both unconsciousness and collapse are documented, each should be coded. Sequencing would depend on documentation.


Query Text:
There appear to be two codes for Streptococcus pneumoniae when it is listed as a cause of disease.  The index has an entry Streptococcus - pneumoniae, as cause of disease classified elsewhere - B95.3 Streptococcus pneumoniae as the cause of diseases classified to other chapters.   However ACS 0103 Streptococcal Infection lists this bacterium as the only organism in Streptococcus Group G, which is indexed to B95.42 Streptococcus, Group G.Other index entries which are also applicable, but confusing, are: · Infection -  Pneumococcus (provided as another name for Strep. pneumoniae in ACS 0103)- as cause of disease classified elsewhere - B95.3.· Infection - Streptococcal - no entry for pneumoniae, only Group G. Which code should be assigned?

Response:
The NCCH confirm that ACS 0103 STREPTOCOCCAL INFECTION is not incorrect. It appears that the information contained in this standard has been misinterpreted. The standard discusses 7 types of streptococcal groups:
1. Group A
2. Group B
3. Group C
4. Group D
5. Group G
6. S.pneumoniae
7. Other
Group G and Streptococcus pneumoniae are two separate groups (ie S.pneumoniae is not a type of Group G streptococcus).

The Alphabetic Index of Diseases should be followed carefully in order to assign the correct code for a documentation of streptococcus infections as the cause of diseases classified to other chapters.

The Committee believes that this confusion has arisen as a result of the print layout of the standard. 

The NCCH will reformat the information in ACS 0103 STREPTOCOCCAL INFECTION to promote understanding. The Victorian Coding Committee will request that the NCCH provide additional index entries for Streptococcal pnuemoniae:
Infection, infected (opportunistic) 
- streptococcal NEC A49.1 
- - pneumoniae A49.1
- -- as cause of disease classified elsewhere B95.3


Query Text:
We would like some clarification on the use of the code: 
B96.81 Helicobacter pylori [H. pylori] as the cause of diseases classified to other chapters
ASC 1122 Helicobacter/Campylobacter refers to an association with active chronic gastritis. Does this also include conditions such as oesophagitis, duodenitis and unspecified gastritis?

Response:
Clinical advice suggests that Helicobacter pylori (H.pylori) is usually associated with some inflammatory conditions or ulcers of the gastrointestinal tract, but not all. For example, H.pylori is not usually associated with oesophagitis.

ACS 1122 Helicobacter/Campylobacter lists the conditions most commonly associated with H.pylori.

B96.81 'Helicobacter pylori [H. pylori] as the cause of diseases classified to other chapters' should only be coded when it is found in the presence of the conditions listed in the standard or it is documented in association with another condition. That is, a causal relationship between the organism (H.pylori) and any morbid condition not specifically listed in the standard, should not be assumed by the coder, but must be supported by documentation.


Query Title:
Removal of supra pubic and central venous catheters

Query Text:
I would like to know under which circumstances you would code the removal of supra-pubic catheters (SPCs) and central venous catheters (CVCs)? Should they only be coded if performed by a medical officer, or if removed under an anaesthetic? Or should all removals of such devices be routinely coded?

Response:
The Committee feels that these procedures should not be coded unless performed under anaesthetic (refer ASC 0042 Procedures not normally coded, Note c.), or unless admission was specifically for the removal of the device in question.

This opinion is based on the logic used in ACS 1436 Trial of Void in which the direction is to code the removal of the urinary catheter when admission is specifically for the purpose of ensuring that voiding is functioning, and therefore, the catheter is no longer required. The standard states that:
*These procedures would not normally be coded (see ACS 0042 Procedures normally not coded) but they are relevant in these circumstances and are therefore included.


Query Text:
Please would you advise all Victorian coders on the use of the code Z51.5 Palliative Care?  Eastern Health has recently been advised by DHS that this code can be used for any admission where the palliative care team is involved.  Hence, if a patient is admitted with an acute problem, but after some time is then deemed for palliation and the Palliative care team is involved, add Z51.5 to the string of codes.However, dot point 3 of ACS 0224 Palliative Care is a little confusing.  When it says 'principal clinical management', does it mean on admission?  Some of our coders have interpreted this as meaning on admission, and never assign Z51.5 unless palliative care is the PDX.Or could it be interpreted that if you were to apply ACS 0224 Palliative Care when palliative care was the PDX, then all those criteria must be met and the coding would follow the standard.  However, is there anything to prevent a coder assigning Z51.5 as an additional diagnosis if the palliative care team is involved in a patient's care?It is hard to know which of the above scenarios is correct.  Another problem is the end use of the data. Would a researcher looking for episodes relating completely to 'palliation' assume that if Z51.5 is in the string of codes, then ACS 0224 has been applied?

Response:
The NCCH confirm that Z51.5 Palliative Care can be assigned when the clinical intent has changed during an acute admission.  The condition requiring palliation would not necessarily be the principal diagnosis. 

Coders are reminded that only one of the three dot points defining palliative care in the standard needs to be met to satisfy the criteria for code assignment. It is understood that palliative care can be provided by a non-palliative care specialist, and should be coded as such, if documentation supports that the intent of care is palliation.

This advice supersedes previously published advice in the Victorian ICD Coding Newsletter, Query #1759 Palliative Care.

A coding feature for Palliative Care will be prepared and published in the August Coding Newsletter.


Query Text:
We understand from the description of activity codes in the Tabular List (page 444) that where more than one activity code applies, to use the highest in the tabular list.Therefore, where a professional footballer is injured playing football, the sport code applies rather than working for an income.  However, there are some cases where the activity code is not so easily determined. Could you please clarify the following:Question 1: A motorcyclist is injured on his way to work as a construction worker when he hits a kangaroo on the road.  I don’t think that motorcycling U65.1 Motorcycling would apply, as he was not taking part in sport – instead, should I use the working for income code U73.03 Construction, as he was on his way to paid work?Question 2: A woman sustained injuries when the car she was driving collided with another car, no further details available.  Is this coded to U73.8 Other specified activity as we know that she was driving a car or U73.9 Unspecified activity as we do not know why she was driving?I have checked articles in Coding Matters Volume 5 no. 1 and NCCH queries 106 and 866.I would appreciate your advice.

Response:
Answer 1: Please refer to ICD-10-AM Vol 1, page 450.
ÄU73.0 While working for income
Paid work (manual)(professional)
Transportation (time) to and from such activities
Work for salary, bonus and other types of income

The appropriate activity code for an event occurring during time spent travelling to (or from) work would therefore be coded as working for income.  In this scenario, U73.03 Construction would be correct.

Answer 2: 

When the activity at the time of the event is specified, as it is in this scenario, but is not covered under U73.0- While working for income, U73.1 While engaged in other types of work, or U73.2 While resting, sleeping, eating or engaging in other vital activities, then ‘U73.8 Other specified activity’ should be assigned for the activity code. 

This advice is confirmed in Coding Matters, Vol 5, No 1, p13, Q1 and Q2.


Query Text:
Prior to publication of the current ICD 10 AM Coding Standards and answer to coding query #1821 re: coding of Non STEMI AMI, we had sought coding advice from our clinicians.  We were advised that “Non STEMI” does not equate to ‘subendocardial’ and that as far as coding is concerned, we should code according to site if specified, regardless of a STEMI or Non STEMI prefix.  Subendocardial should only be coded if specified as such.In addition, advice given in ACS 0940 Ischaemic Heart Disease that Non STEMIs were difficult to site was contradicted by frequent references in records to the sites of Non STEMI AMIs (see examples).In an attempt to clarify the above, advice was sought from three different clinicians at different times.  All have confirmed the view that “Non STEMI” does not always equate to ‘subendocardial’, and coding of AMI by site should take precedence if site is specified.Question:Are we able to code Non STEMI AMIs to the site (if specified), rather than to subendocardial?  Please clarify.

Response:
The correct code for NSTEMI is:
I21.4 Acute subendocardial myocardial infarction
in order to capture the depth of the infarct.
In ICD-10-AM Foruth Edition, I21.4 will have an ‘includes’ note for NSTEMI.


Query Text:
I have been advised to refer this DRG anomaly to the Victorian ICD Coding Committee, to see if it could be raised with the group doing the weight calculations for fixing next year's weights.A 49-year-old female patient is admitted for treatment of hyponatraemia and during her admission receives 23 hours of mechanical ventilation.When this case is grouped it is assigned to:
K62C Miscellaneous Metabolic Disorders W/O Catastrophic or Severe CC Age <75
Relative Weight 0.8049, WIES 2.2758.We queried this case with the clinician to find out why ventilation was given, and were told it was due to aspiration pneumonia. When aspiration pneumonia is added, the DRG changes to: 
K62B Miscellaneous Metabolic Disorders W Severe CC or Age>74 W/O Severe CC
However, the Relative Weight is 0.6507 and WIES 2.1216.  LOS = 5 days.Question:Can someone please explain why this patient would be receiving a lower WIES for a better DRG?Search Details:Case has been grouped using the encoder and in-house grouping software (ISOFT).  DRG reference tables have also been referred to, all of which consistently report the same WIES figures.

Response:
This is one example of DRGs and cost weights that don’t appear to be equitable. The cost weights are derived from cost data, which is submitted from hospitals across the state.  The data is analysed and formulated to arrive at future cost weights.  There will be irregularities within this cost weight data that will sometimes produce such anomalies as the one described in this query. The profile of patients in K62B is not necessarily a more complicated profile, as there are other factors affecting the grouping, such as patient age.
The issue of higher cost weights in ‘lower’ DRGs is an issue that will be reviewed by VACCDI.


Query Text:
22-year-old male with a diagnosis of Papillon-LeFevre Syndrome presents for Branemark implants due to tooth loss.I have coded: 
Q89.89 Other specified congenital malformations 
K05.3 Chronic periodontitis
K08.1 Loss of teeth 
The two additional codes were to depict the body region affected by this syndrome.Question:What is an appropriate diagnosis code?Search Details: We've had round table discussions, consulted the Encoder, the manuals, dictionaries, internet, NCCH, past coding newsletters and Coding Matters.

Response:
Papillon-LeFevre Syndrome is defined as:
"Rare, autosomal recessive disorder occurring between the first and fifth years of life. It is characterized by palmoplantar keratoderma with periodontitis followed by the premature shedding of both deciduous and permanent teeth."
(http://www.diseasesdatabase.com/sieve/item1.asp?glngUserChoice=9583)
This syndrome is also known as ‘Juvenile periodontosis with hyperkeratosis’ and ‘Palmoplantar ectodermal dysplasia type 4’.


The Committee decided that, in accordance with ACS 0005 Syndromes, the appropriate codes to assign would be:
K08.1 Loss of teeth
K05.4 Periodontosis Juvenile periodontosis
Q87.xx Other specified congenital malformation syndromes affecting multiple systems
This standard directs coders to apply the principal diagnosis definition rule, and to include Q87.xx for a congenital syndrome.
As juvenile periodontosis is a manifestation of the syndrome, K05.4 Periodontosis would be assigned in preference to K05.3 Chronic periodontitis, as it is a more accurate description of the condition.


Query Title:
Continuous ambulatory drug device (CADD) disconnections

Query Text:
Question 1: We are confused as to how to code continuous ambulatory drug device (CADD) disconnections when that is the only event occurring in the admission.  Currently we code:
Z45.1 Adjustment and management of implantable infusion device or pump
13942-01[1890] Maintenance (alone) of ambulatory drug delivery device
We have spoken to other organisations where it is coded as:
Z45.1 Adjustment and management of implantable infusion device or pump
13942-00[1780] Loading of ambulatory drug delivery device
Which is the correct?Question 2: How would you then code an admission for loading of a CADD with morphine?  We code:
Z45.2 Adjustment and management of vascular access device
plus the condition as a secondary diagnosis, followed by
13492-00 [1780] Loading of ambulatory drug delivery device
We don’t feel that Z45.1 or Z45.2 are appropriate, but are not sure what else to code.

Response:
Answer 1: The initial response from the Committee was to question the validity of the admission, with the suggestion that patients should not be admitted for a CADD disconnection. The inquirer should refer to the VAED 13th Edition User Manual, to review criteria for admission.
Providing the criteria for admission is met, the correct diagnosis code to assign in this scenario would be: 
Z45.2 Adjustment and management of vascular access device

Z45.1 Adjustment and management of implantable infusion device or pump would not be appropriate, as this device is not implantable (i.e. there is no internal port).

For disconnection of a CADD, assign procedure code:
13942-01[1890] Maintenance (alone) of ambulatory drug delivery device

Answer 2: 
For an admission for loading a CADD with morphine, the principal diagnosis will be the condition requiring the morphine treatment.  This advice is consistent with that provided in the NCCH Query Database Q1788 Day patient admission for refilling of pump (August 2003, 3rd edition).

Note:  In circumstances where a same day admission is for loading of a CADD for "chemotherapy", as per ACS 0044 Chemotherapy, the principal diagnosis will be Z51.1 Chemotherapy session for neoplasm or Z51.2 Other chemotherapy.

For loading of a CADD with morphine, assign procedure code:
13942-00 [1780] Loading of ambulatory drug delivery device

Please note that there are significant changes to the classification of drug delivery in the 4th edition of ICD-10-AM.


Query Title:
Coding anaemia from haemoglobin (Hb) result

Query Text:
I wish to clarify if ‘anaemia’ can be coded in the following instances:

1. Patient admitted for chemotherapy for Non-Hodgkin lymphoma (NHL).  Summary specifies ‘Hb was 90, so 2 units of red blood cells given’.   Pathology report for the date in question specifies ‘Hb. 90L’ (L meaning ‘low’), but the word ‘anaemia’ is not mentioned in the actual admission.  Can I code anaemia on the basis of the pathology report specifying that the Hb was low?  Index entry for ‘low haemoglobin’ is D64.9 Anaemia, unspecified.

2.When an Hb reading is specified in the progress notes, eg. Hb 90, and blood transfusion is given.  Again, no reference is made to ‘anaemia’ in the progress notes, but pathology report specifies that Hb is L (ie. Low).

3. Can I code D62 Acute posthaemorrhagic anaemia when Hb is specified as low in pathology reports, having been normal prior to surgery, but only the Hb reading is specified in the progress notes with no mention of the word ‘anaemia’, and transfusion is given.During a coding workshop for 3rd edition revision of ICD-10-AM, I gave similar examples and was told I could code anaemia because the diagnosis had been made by the pathologist on the pathology report (i.e when the pathologist states the reading is “low”) and not by me as the coder, but we would like confirmation of this.

Response:
The following response has been ratified by the NCCH.  

The vital point underlying this issue is documentation.  Coders may be able to recognise a result, which potentially indicates a condition.  Pathology results alone cannot be used as criteria for assigning a code, and the record should be further reviewed for evidence of clinical documentation, which confirms a diagnosis.

Documentation of a condition on a discharge summary can be confirmed by an abnormal result specified in the body of the record.  However, if there is nothing more than a reading or result to indicate a condition, then this should be queried with the clinician and, if appropriate, it should then be documented by the clinician. 

Coders should be aware that arrows might indicate a trend, rather than a high/low reading.

The clinical significance of pathology results should be evidenced by documentation in the medical record.

Please refer to VICC query#1735 (November 2001) for further information.

In the three scenarios in your query, anaemia cannot be coded.


Query Title:
Removal of spinal fixations post fractured vertebra

Query Text:
A patient is admitted for removal of spinal (segmental) fixations, which were inserted on a previous occasion for vertebral fractures.The procedure index leads you toRemoval-fixation device--internal---spinal 90025-01 [1393] Therefore, we have coded as follows:
Z47.0 Follow up care involving removal of fracture plate another internal fixation device
90025-01 [1393] Revision of spinal procedure with removal of spinal fixation
This yields:
DRG I09B Spinal Fusion W/O Catastrophic or Severe Complications
Is this the correct code to use given that they are simply removing screws and not actually revising a previous spinal procedure?Perhaps this code should be used exclusively for removal of spinal fixations post spinal fusion?The alternative is to use
47927-00 [1554] Removal of pin; screw or wire not elsewhere classified
which yields:
DRG I23Z Local Excision and Removal of Internal Fixation Device Excluding Hip and Femur

Response:
The Committee agrees with the procedure code assigned by the hospital:
90025-01 [1393] Revision of spinal procedure with removal of spinal fixation

The index also supports this choice of code, and, even though ‘revision’ in the code title may seem to be misleading, it is a procedure that requires more resources than a simple removal of a pin, screw or wire. 
It is appropriate that this groups to DRG I09B Spinal Fusion W/O Catastrophic or Severe Complications, considering that it is a revision of a spinal fusion with removal of the devices.


Query Text:
Query: Our Orthopaedic surgeons are using a new postoperative pain relief method using a ‘Stryker’ Pain Pump.This consists of a fine catheter being inserted into the operative site (we have used them for ASD repairs), and a suture is used to hold the catheter in place. The catheter is then attached to a pressurised container of local anaesthetic, which is infused into the joint for either 2 or 5 days. It is not patient controlled, the container is pressurised. It is initiated in theatre, but is not a block, and is not intravenous, so we are not sure if we should be coding it. The only code we could come up with was 92513-xx Infiltration of local anaesthetic, as it is infiltration of local anaesthetic, but this code doesn't show it was for postoperative pain relief.Our theatre staff say it will become more common, so do we need to code it somehow?Thanks.

Response:
The ‘Stryker’ Pain Pump is one of a range of subcutaneous devices used for continuous infusion of local anaesthetic for analgesia. 
The correct index trail to follow would be:
Analgesia 
- postprocedural 
- - infusion (intravenous) 92518-01 [1912] 

92518-01 [1912] Intravenous postprocedural analgesic infusion

[Although ‘intravenous’ appears in the code title, it is a non-essential modifier in the index, and so can be applied. The NCCH will be notified of this index/tabular anomaly.]

As stated in ACS 0031 Anaesthesia, Classification point 5:
92518-00 [1912] Intravenous postprocedural infusion, patient controlled analgesia (PCA) and 92518-01 [1912] Intravenous postprocedural analgesic infusion may be assigned if data on such interventions is required at the local hospital level (use of these codes is not mandatory for national morbidity data reporting). 

Therefore, this code should only be assigned if the data is required at local hospital level.


Query Title:
Grouping of excision of paraurethral cyst

Query Text:
When coding excision of paraurethral cyst, I have followed the index entries:Cyst (colloid) (mucous) (retention) (simple) - paraurethral duct N36.8 Excision - cyst — see also Excision, lesion - - paraurethral 35557-00 [1282] 
N36.8 Other specified disorders of urethra
35557-00 [1282] 35557-00 Excision of lesion of vaginaExcision of cyst:• Gartner's duct• para-urethral
This groups to:
902Z Non-Extensive OR procedure unrelated to principal diagnosis
Should we be using a different disease code? Or is this a grouper anomaly? Search Details: Disease Index Volume 2 page 83 column 3Procedure Index Volume 4 page 75 column 1Operation report and pathology results provided.

Response:
As advised by the NCCH in response to a similar query (#1410), 
“The paraurethral glands are located where the female urethra opens into the vestibule of the vulva. DRG 902Z Non-extensive OR procedure unrelated to Principal Diagnosis is allocated due to the difference in the anatomic site to which paraurethral cysts are classified in the ICD-10-AM disease (urethra) and procedure (vagina) classification.”

The Coding Committee will check Version 5 of the grouper, and will notify the Commonwealth if this grouping problem still exists.


Query Title:
ACS 1614 and respiratory distress syndrome

Query Text:
The third year students at LaTrobe University would appreciate clarification about the following issues.  Neither the coding standards nor a search of the NCCH data base and the VICC newsletters has helped.

1.  The following instruction appears in ACS 1614 
The code for respiratory distress syndrome of newborn (P22.0 Respiratory distress syndrome of newborn) should be reserved to classify the condition of:
• hyaline membrane disease, or
• respiratory distress syndrome, or
• surfactant deficiency.

Respiratory distress unspecified
The term 'respiratory distress unspecified' should not be coded as such, as it is considered a symptom not a diagnosis. Further information regarding a definitive diagnosis should be sought from the clinician.
Does this mean that P22.0 cannot be assigned for 'respiratory distress' or does it mean that 'respiratory distress' cannot be coded at all.  Some of us have coded 'respiratory distress' to P22.9

2. When coding premature neonates, should a code be assigned for the prematurity (P07.2- or P07.3-) as well as a code for the birth weight (P07.0- or P07.1-).  The note on the tabular volume at P07 indicates that priority of assignment should be given to gestational age.  We are unsure whether this means that both should be assigned with gestational age sequenced first, or that when you have both pieces of information you should only code the gestational age.

Search details:
ACS 1618 Prematurity and low birth weight
ACS 1614 Respiratory Distress Syndrome/Hyaline Membrane Disease/Surfactant Deficiency

Response:
Answer 1: The phrase 'should not be coded as such' in this standard should be interpreted as 'should not be coded as respiratory distress syndrome'. 
The Committee recommends that coders look for a more specific respiratory symptom than 'respiratory distress', e.g. P28.83 Grunting in newborn, and only use 'P22.9 Respiratory distress of newborn, unspecified' when there is nothing else documented.

Answer 2:  The Committee confirms that a code for both gestational age (sequenced first), and low birth weight should be assigned for premature infants, where applicable.


Query Text:
We are having trouble deciding on the most appropriate codes to use for removal of implanted hormone devices, specifically Implanon & subcutaneous HRT implants.

We have used Z45.8 - Adjustment & Management of other implanted devices, as the principal diagnosis, and 30064-00 [1605] - Removal of foreign body from skin & subcutaneous tissue with incision as procedure code. 

We sought advice from a larger hospital, and they use Z45.9 Adjustment and management of unspecified implanted device, and 90661-00 [1608] Other incision of skin and subcutaneous tissue.

Can you please advise which are the most appropriate codes to use.


Search Details:
In Vol 4, under Removal, implant there are no applicable options. Under Removal, device, the only option is Therapeutic device 92202-00 [1908] - is this what we should be using?

Response:
The correct codes to assign for removal of Implanon (contraceptive device):
Z30.5 Surveillance of (intrauterine) contraceptive device
and
92202-00 [1908] Removal of therapeutic device, NEC

The correct codes to assign for removal of subcutaneous HRT:
Z45.8 Adjustment and management of other implanted devices
and
92202-00  [1908] Removal of therapeutic device, NEC


Query Text:
Could you please clarify when J98.1 Pulmonary collapse should be coded especially when in association with pneumonia/chest infection?

For example, patient presents with symptomatic chest infection. CXR shows small pleural effusion no collapse/consolidation. CTPA shows minimal consolidation/atelectasis. Neither the effusion or atelectasis require treatment in their own right nor are they specifically monitored hence they do not seem clinically significant.

Would it be appropriate to code atelectasis in the above example when it appears clinically significant ie required treatment, physiotherapy or ongoing monitoring/review?

Search Details: 
Similar query 1179 NCCH database

Response:
The previous NCCH query referred to by the inquirer (dated 1999) is superseded by revised ACS 0002 Additional Diagnoses. The inquirer should code according to this standard, which states that
 "additional diagnoses should be interpreted as conditions that affect patient management in terms of requiring any of the following:
•therapeutic treatment 
•diagnostic procedures
•increased nursing care and/or monitoring".

The condition would be coded if it was found to be clinically significant, and met the criteria in ACS 0002 Additional Diagnoses.


Query Title:
Urinary retention secondary to non-postoperative clots

Query Text:
Pt with urinary retention secondary to clots - non-postoperative.

Newsletter article  'Procedural Complications' - Nov 01 Coding Newsletter - Coding Pointers #9 refers to 'clot retention following TURP'.

In our (non-postop) case, I feel I can't assume clot is from bladder.  Would 'N39.88 Other specified disorders of urinary system' as Principal, followed by 'R33 Retention of urine'  be appropriate?  What do you advise?

Response:
The Committee agrees with the inquirer's suggested codes, when there is no further indication of the cause of the bleeding, and a clinician cannot be consulted:

Disorder
-urinary (tract) N39.9 
--specified NEC N39.88

Retention
-urine R33

N39.88 Other specified disorders of urinary system
R33 Retention of urine

In the case where further investigation has occurred, and there is more information regarding the cause of the bleeding, or the treatment of the bleeding, a more specific code should then be assigned.

To determine the sequencing of codes, apply ACS 0001 Principal Diagnosis.


Query Title:
Counting of mechanical ventilation hours

Query Text:
The Coding Feature in ICD Coding Newsletter, August 2002, advises to cease counting of ventilation hours for a tracheostomy patient at the last recording of pressure support. 

Patients in ICU may have further episodes of CPAP through the tracheostomy after the last recording of pressure support. How are these coded and counted? 

ICU advises that these episodes are part of the weaning and are still mechanical ventilation.

Response:
This query highlights the importance of coders being familiar with their particular hospital's ICU charts and typical documentation.
The Coding Committee reviewed your ICU charts.
The modes of pressure support documented are 'SIMV', 'CPAP' and 'T/S'.   SIMV and CPAP are types of pressure support, as evidenced by pressure support readings documented while these modes are applied.
The ICU charts indicate that, in this particular instance, there were no pressure support readings while T/S (tracheostomy shield) was applied, however, as part of weaning, the patient received further pressure support.
In the example you provide, the Committee agrees with the advice you received from your ICU staff.
The Coding Feature in ICD Coding Newsletter, August 2002, supports this advice on pressure support, and provides instruction on counting of ventilation hours.


Query Title:
Coding of transoesophageal echocardiogram (TOE)

Query Text:
I am aware that the Victorian Coding Committee advised coders in Victoria not to code a TOE performed during CABG (VCC #1691 - June 2001 Newsletter) because a TOE is considered a routine part of the CABG (and this was re-inforced at the Education Seminar at Moonee Valley in August - see Case 3).

However, there is a recent query (26/6/03) on the NCCH database about this issue.  The NCCH decision was that "where a TOE is performed during CABG, assign procedure code 55130-00 [1942]"  

In light of this recent decision by the NCCH, please confirm whether Victorian coders should or should not be assigning a code for a TOE when it is performed intra-operatively (at this hospital an intra-op TOE is quite routine).

Search Details:
VICC #1691 - June 2001 Newsletter
NCCH query 1806 - June 2003

Response:
The Committee referred to NCCH Query database Q1806  (June 2003)
Intra-operative transoesophageal echocardiogram (TOE). This more recent advice from the NCCH supersedes the advice provided in Query #1691 ACS 0909 Additional procedures performed in conjunction with CABGs.
Therefore, TOE performed during a CABG procedure should be assigned
55130-00 [1942] 2 dimensional real time transoesophageal ultrasound of heart performed during cardiac surgery.


Query Text:
In NCCH coding query 984 (26/05/1999) it specifies to code Multiple System Atrophy to G90.3 Multiple System Degeneration [Shy-Drager].  

We have found information on the internet that Multiple System Atrophy comprises three manifestations Shy-Drager Syndrome (G90.3), Striatonigral Degeneration (G23.2) and Olivopontocerebellar Atrophy (G23.8 Other specified degenerative diseases of basal ganglia). 

As there are codes for all separate manifestations should we code out all of these three codes when documentation states Multiple System Atrophy.

Search Details: 
http://www.neurologychannel.com/msa/

Response:
The NCCH has addressed Multiple System Atrophy in their changes to ICD-10-AM 4th edition, and have recognised the three manifestations mentioned by the inquirer.
In 4th edition, there will be an 'includes note' for this condition under G90.3 Multi-system degeneration.
Therefore, continue to code Multiple System Atrophy to G90.3.


Query Text:
According to ACS 1204 Plastic Surgery ‘When the reason for surgery …..is documented code this condition as the principal diagnosis even if the procedure performed is of a cosmetic nature’. 

If a diagnosis of “Mammary Hypoplasia” is documented and an augmentation mammoplasty is performed (Surgeon has given a cosmetic CMBS code). I have been coding Mammary Hypoplasia (Q83.8 Other congenital malformations of breast) as the principal diagnosis. 

However I have heard that other coders believe the Z41.1 should be coded. 

Could you please clarify this?

Response:
The Committee agrees with the assignment of 
'Q83.3 Other congenital malformations of breast (Hypoplasia of breast)', as principal diagnosis, in accordance with ACS 1204 Plastic Surgery, as this is the condition requiring surgery. 

If the procedure is documented as being performed for cosmetic reasons, 
'Z41.1 Other plastic surgery for unacceptable cosmetic appearance'
should be assigned as an additional code. 

It should be noted that there are no 'cosmetic' MBS item numbers, although hospitals may have devised numbers to be used internally to denote 'cosmetic' procedures. These numbers may be used to assist with code assignment, but should not be used as a substitute for documentation.


Query Text:
Thankyou for your advice on coding the following basic concepts of diabetes that we seem to keep revisiting especially since being recently audited and acquiring new staff:

Question 1: 
Can diabetes be coded as an associated condition based on one BSL alone? We had discussed and agreed that using monitoring as a basis for meeting additional diagnosis, more than one BSL would be required according to definition and one level is just a baseline observation always done on admission as part of the nursing admission process (along with urinalysis, resps, pulse, BP,filling out paperwork, medications etc). If it can be coded based on one BSL alone how does this meet additional diagnosis?

Question 2:
How do you code diabetes with ESRF?

E1x.23  Diabetes Mellitus with end-stage renal disease
(as the clinical diagnosis is fully described by the code description)

or 

E1x.23  Diabetes Mellitus with end-stage renal disease
N18.0    End-stage renal disease

Question 3:
How do you code diabetes with PVD (without claudication, rest pain, ulcer or gangrene)?

E1x.51  Diabetes Mellitus with peripheral angiopathy, without gangrene

or 

E1x.51 Diabetes Mellitus with peripheral angiopathy, without gangrene
I70.20  Atherosclerosis of arteries of extremities, unspecified

Question 4:
How do you code diabetes with PVD with (non-foot) lower limb ulcer?

E1x.51 Diabetes Mellitus with peripheral angiopathy, without gangrene
I70.23  Atherosclerosis of arteries of extremities with ulceration

or

E1x.69  Diabetes Mellitus with other specified complication
L97        Ulcer of lower limb, not elsewhere classified
E1x.51  Diabetes Mellitus with peripheral angiopathy, without gangrene

or 

E1x.69  Diabetes Mellitus with other specified complication
L97        Ulcer of lower limb, not elsewhere classified
E1x.51  Diabetes Mellitus with peripheral angiopathy, without gangrene
I70.20  Atherosclerosis of arteries of extremities, unspecified

Search Details: 
Dorlands dictionary defines monitoring as "to check constantly on a state or condition as on the vital signs of a patient under anaesthesia and undergoing surgery".

Response:
Question 1
BSLs are not done routinely for every patient admitted to hospital, and are not always done for a patient with diabetes.  If a single BSL reading were taken for a diabetic patient, this would satisfy the requirement for coding diabetes, as specified in ACS 0002 Additional Diagnoses, specifically by requiring 'increased nursing care and/or monitoring'.

This question is answered in the NCCH 3rd Edition Education Program - FAQs - Part 2, in a question related to diabetes.  The NCCH's answer is to code diabetes when it meets the criteria in ACS 0002 Additional Diagnoses. The taking of BSLs is one indication that diabetes mellitus meets criteria of ACS 0002.

Question 2
The correct code to assign for diabetes with ESRF is 
E1-.23 Diabetes Mellitus with end-stage renal disease.

Although this advice is not consistent with that provided in NCCH database Q1349, the NCCH have verified that, for ICD-10-AM 3rd edition, this answer is correct.

Note that in ICD-10-AM Fourth Edition the code title has changed and an additional code to identify end stage renal failure is required.

Question 3
NCCH 3rd Edition Education Program - FAQs - Part 1, in an example related to diabetes, it was stated that an additional code for peripheral angiopathy NOS 'is not required .…as the concept is covered in the code title of E10.51 Type 1 diabetes mellitus with peripheral angiopathy, without gangrene.'

The correct code for diabetes with PVD (without claudication, rest pain, ulcer or gangrene) is E1-.51 Diabetes Mellitus with peripheral angiopathy, without gangrene.  
The addition of I70.20 Atherosclerosis of arteries of extremities, unspecified does not add any information.

Question 4
The correct codes to assign in this scenario depend on the documentation, and the relationship between the conditions.
If the ulcer is related to the PVD, then the correct codes would be:
E1-.51 Diabetes mellitus with peripheral angiopathy, without gangrene
I70.23 Atherosclerosis of arteries of extremities with ulceration

If there is no documented relationship between the ulcer and the PVD, the correct codes would be:
E1-.69 Diabetes mellitus with other specified complication
L97  Ulcer of lower limb, not elsewhere classified
E1-.51 Diabetes mellitus with peripheral angiopathy, without gangrene.


Query Text:
75 year old patient admitted with unsteadiness and dizziness.  Query CVA, so CT head organised and patient had 8 hours of observation in ED.  Also NIDDM, hypertension.  CT head normal, BSL's performed x1 and normal.  Patient noted to be very hypertensive over several  hours, so medications altered.  Sent home for review by GP next day in regard to medications.  PDx:  Hypertension.
 
If the index entry is followed for Diabetes, with hypertension, then this episode would be coded to:
E11.9 Type 2 diabetes mellitus without complication
I10 Essential (primary) hypertension

Is this correct, it seems bizarre to code this with diabetes as PDx?

Response:
The correct codes to assign in this scenario are:
E11.9 Type 2 diabetes mellitus without complication
I10  Essential (primary) hypertension
Hypertension is a significant co morbidity with diabetes.  

This is consistent with previous advice published by the NCCH.  Conditions listed in the index under 'Diabetes, with' should be coded, regardless of other known or contributing causes.

ICD-10-AM Fourth Edition note
In ICD-10-AM Fourth Edition, diabetes with hypertension is indexed to
E1x.72 Diabetes mellitus with features of insulin resistance


Query Text:
The primary malignancy should be coded as a current condition if the episode of care is for:

• diagnosis or treatment of the primary malignancy, in any of the following circumstances:
-  initial diagnosis of the primary malignancy
- treatment of complications of the malignancy (see also ACS 0207 Complications  associated with neoplasms)
- operative intervention to remove the malignancy
- medical care related to the malignancy, including palliative care (see also ACS 0224  Palliative care)
- recurrence of a primary malignancy previously eradicated from the same organ or tissue 

1. When a patient is admitted to hospital with a diagnosis of “vomiting and dehydration due to chemotherapy” received 2 days prior, does the neoplasm for which they are receiving chemotherapy meet the definition of “medical care related to the malignancy” for assignment as an additional diagnosis?

2. Similarly, when a patient is admitted for insertion of a port [for subsequent administration of chemotherapy to treat their neoplasm], or for flushing of their port, does the neoplasm for which they are receiving the port/flush meet the definition of “medical care related to the malignancy”?

The malignancy in these cases does not meet any of the criteria listed under ACS 0002 Additional Diagnoses.

However, there are differing views amongst coders regarding the definition of “medical care related to the malignancy”.  There is a view that if the patient did not have the malignancy, they would not be receiving chemotherapy that caused the vomiting and dehydration and subsequent admission to hospital.  A similar argument is raised in relation to admission for insertion of port or flushing of port.

I would appreciate the Committee’s opinion regarding “medical care related to the malignancy” with a response to the 2 questions above.

Response:
This query relates to the interpretation of the phrase 'medical care related to the malignancy' in ACS 0236 Neoplasm coding and sequencing. 
This standard is not included in the list in ACS 0002 Additional Diagnoses as one in which coders are instructed to code conditions which do not meet the additional diagnoses criteria.
The Committee believes that the use of the term 'current condition' in ACS 0236 refers to the malignancy being coded from Volume 1 Chapter II (a 'C' code), rather than from Volume 1 Chapter XXI (a 'Z' code for 'history of').

Answers 1 & 2:
In both scenarios, the neoplasm should not be coded, as it does not meet the criteria described in ACS 0002 Additional Diagnoses.


Query Text:
The term “primary” is an essential modifier under index entries for osteoarthritis. 
In Volume 1 Tabular List of Diseases, p 251, there is a definition relating to the term “primary”: 
 
ARTHROSIS
(M15–M19)
Note:  In this block the term osteoarthritis is used as a synonym for arthrosis or osteoarthrosis. The term primary has been used with its customary clinical meaning of no underlying or determining condition identified. 

Does the presence of this definition mean that coders can assume “primary” if no other cause is documented? 

There are many examples throughout the Standards where definitional information is provided [e.g. ACS 1430 Chronic Renal Impairment, and many of the obstetric standards which state that even if the criteria is met, such as with PPH, the condition must be documented in order to assign the code for the condition].

It appears that coders receive differing advice regarding the use of “primary” versus “unspecified”.  A search of the NCCH database reveals some old queries [# 321, # 730, # 1209] that support the use of “primary” even though “primary” is not documented.  Coders also report being advised by some NCCH Coder Educators to assign the code for “primary” unless another cause is stated.

I would appreciate the Committee’s opinion regarding correct code assignment when osteoarthritis, not otherwise specified, is documented.

Response:
A similar query (#1804 Osteoarthritis) which was referred by this Committee to the NCCH, is currently before the Update Reference Committee of WHO.  
The Committee acknowledges that there is conflicting opionion on this issue, however, coders should follow advice published on the NCCH database until a response to the previous query (#1804) is received.


Query Text:
How should Radiofrequency ablation (RFA) of bone tumour be coded? See operation report attached. The operation report identifies the tumour as ……..

In index - ablation, lesion - liver is the only code with radiofrequency ablation.

Procedure code suggestion:
'30241-00[1563]  Excision of benign lesion of bone (NEC)'

No choice of codes for "other procedure on bone" or "other destruction of bone".

Maybe NCCH needs to add some new bone codes.

Search details:
NCCH database query 1250 re Liver RFA
Dictionary definitions:
Ablation - an amputation, an excision of any part of the body or a removal of a growth or harmful substance (Mosby's)
Radiofrequency - that portion of the electromagnetic spectrum with frequencies lower than about 10 HZ (Mosby's)

Response:
In the absence of a more specific code for this procedure, the Committee agrees with the inquirer's suggestion:
Excision
-lesion
--bone
---benign NEC
30241-00 [1563] Excision of benign lesion of bone, not elsewhere classified.


Query Text:
I have a query regarding the diagnosis code for cardiac adhesions:
Adhesions, adhesive (postinfective) K66.0
-cardiac I31.0
'I31.0 Chronic adhesive pericarditis'
Accretio cordis
Adherent pericardium
Adhesive mediastinopericarditis

Is this correct indexing and code assignment?

I understand if you can get to a code via the index then you can use that code even if the code title looks inappropriate.

Can you please pass this on the NCCH to clarify what the correct code assignment and title should be for cardiac adhesions?

Search Details: Dictionary definitions from Mosby's
Adhesion - a band of scar tissue that binds together two anatomic surfaces that are normally separate from each other.
Pericarditis - an inflammation of the pericardium associated with trauma, malignant neoplastic disease, infection, uraemia, myocardial infarction, collagen disease or idiopathic causes.

In my opinion these conditions are quite different and therefore should have different codes assigned to them.

Response:
The Committee is satisfied that this condition is correctly indexed.

The classification convention often results in conditions being 'bundled' together.


Query Title:
Threatened premature labour with delivery

Query Text:
30 year old female admitted at 34/40 in Threatened premature labour.  Patient treated with Bricanyl to halt contractions.  Patient stayed in hospital until 38/40 when an elective caesarean section was performed (patient had previous caesarean section at 29/40).

What would the Principal Diagnosis be?

Is there documentation saying that O47.x False labour is not to be used in a delivery episode?

Response:
This was referred to the NCCH for advice.

The criteria for coding 'false labour' is that the patient is not in true labour and has not delivered on that admission.  Therefore it is not appropriate to use a code from O47.x False labour for the case cited.  The NCCH suggests the following diagnosis codes for the case cited: 
O60 Preterm delivery
O09.5 (Duration of pregnancy) 34-36 completed weeks
O34.2 Maternal care due to uterine scar from previous surgery
Z37.x Outcome of delivery

O60 Preterm delivery should be assigned by following the index pathway:

Labour
-early onset (before 37 completed weeks of gestation) O60

Also, ACS 1515 Antepartum condition with delivery advises that an antepartum condition (in this case the premature labour) requiring treatment for more than 7 days before delivery of a baby should be sequenced as the principal diagnosis.

O09.5 (Duration of pregnancy) 34-36 completed weeks is assigned to indicate the duration of pregnancy at admission on the mother's record in accordance with ACS 1518 Duration Of Pregnancy.

The WHO Update Reference Committee agreed to change the title of O60 Preterm delivery to 'Preterm labour'.  The change will be made for ICD-10-AM fifth edition.

The Victorian ICD Coding Committee also note the O60 Preterm delivery can be assigned following index pathway:

Contractions
-preterm without delivery O60


Query Title:
Use of 'Z53 Persons encountering health services for specific procedures, not carried out'

Query Text:
Patient admitted for endoscopic retrograde cholangiopancreatography (ERCP) for bile duct calculus.  The ERCP could not be completed due to inability to cannulate the duct. When a procedure has been abandoned, in addition to coding the extent of the procedure (in line with ACS 0019 Procedure not completed or interrupted ) can you also add:
'Z53.x - Persons encountering health services for specific procedures, not carried out'? 

'ACS 0011 Admission for surgery not performed' does not cover this scenario. The addition of this code would indicate that the actual procedure the patient was in theatre for did not occur.

Codes assigned:
K80.50 Calculus of Bile duct 
Z53.8 Procedure not carried out for other reasons
30473-00 [1005] Gastroscopy
92515-99 Sedation (ASA unknown)

Response:
This query was referred to the NCCH for advice.

The NCCH does not support the assignment of a code from Z53 Persons encountering health services for specific procedures, not carried out for the scenario cited.  Codes from this block should not be assigned for procedures that are performed, but are not completed or are unsuccessful.

The NCCH will consider the creation of a code to capture the concept of procedures 'abandoned' for a future edition of ICD-10-AM.

The Victorian ICD Coding Committee agreed that if a procedure is commenced but not followed through to the expected procedure, to code the extent of the procedure performed as per ACS 0019 Procedure not completed or interrupted.


Query Text:
Premature infant 34 weeks, birth weight 1800gms.
At the recent HIMAA education session there were some coding examples given for neonatal admissions.  There appeared to be inconsistency in the use of a code for prematurity ('P07.2x Extreme immaturity', 'P07.3x Other preterm infants') and then also in the use of a code for the low birth weight.  

'ACS 1618 Prematurity and low birth weight' and NCCH query 1463 seem to indicate that a code for prematurity is needed where gestational age is less than 37 weeks.  The standard and the query also seem to indicate that a code is needed for a birth weight of less than 2500gms. If the infant is premature, either:
'P05.x Slow fetal growth and fetal malnutrition' 
or
'P07.0x Extremely low birth weight' 
or 
'P07.1x Other low birth weight'.

There was mention of the VAED field for infant weight, but this is admission not birth weight.

A statement was made to the effect that only about half the VAED data contained both codes, but I have spoken to three hospitals (Womens, Southern Health, Box Hill Hospital) where coders always assign a code for prematurity and low birth weight, if applicable, following the standard.

Could the committee please advise on the correct use of the codes in the above scenario?

Response:
In the scenario of a premature baby that has a birth weight of < 2500 grams, and is also described as 'low birth weight' or meets the criteria defined in P05 'Slow fetal growth and fetal malnutrition', the following codes should be assigned (assuming these conditions meet ACS 0002 Additional Diagnoses):
P07.2- or P07.3- Premature gestation
P07.0- or P07.1- Low birth weight
P05.- Slow fetal growth

This advice, (verified by the NCCH), supersedes the previous query VICC #1638 Low birth weight (June 2001).

The excludes note at P07 is a type 2 excludes note.  The NCCH confirm that the 'note' in P07 'Disorders related to short gestation and low birth weight, not elsewhere classified' directs classification users to sequence the code for 'gestational age' before the code for 'birth weight', when documentation of both are present in the clinical record.

The Committee feels that 'ACS 1618 Prematurity and low birth weight' - 'Low Birth Weight' would be clearer if it was a single paragraph.
The NCCH have agreed to review this suggestion for a future edition of ICD-10-AM.


Query Text:
NCCH query 883 states that superficialisation of an AVF should be assigned procedure code '34518-00 [765] Correction of stenosis of arteriovenous fistula'.  

Should '35202-00 [763] Reoperation procedures on other vascular sites' be assigned in addition to 34518-00 [765]?  

If not, in what circumstances would 35202-00 [763] be assigned?

Response:
In the example provided, the code description provides sufficient information about the procedure - there is no need for an additional code to indicate 're-operation'.

'35202-00 [703] Access for reoperation of arteries or veins of neck, abdomen or limb' would be used in conjunction with the procedure code, for a re-operation on the same body area, if the procedure code did not indicate that it was a reoperation.

For example, an open thrombectomy, for a previous bypass operation.


Query Text:
We have come across several patients having "biventricular" pacemaker insertions, and are not sure how to code them!

The device is programmed as DDDR, and 2 ventricular leads are inserted - one in the left ventricle, and one in the right ventricle.
We coded insertion of DDD 38281-10 [651], and insertion of electrode into ventricle x 2 38278-01 [648] - but this groups to F17Z Pacemaker replacement.

Any suggestions?

Search Details: 
We checked on the internet site: heartcentreonline.com which gives good details on the biventricular pacemaker procedure - stating 2 leads are inserted - one into each ventricle.
No queries could be found on the NCCH coding query database.

Response:
A biventricular pacemaker is a triple chamber device and has three leads -  two ventricular leads, and one atrial lead. These devices should not be coded as a dual chamber device.  The correct code to use in ICD-10-AM 3rd edition is:
Insertion
-pacemaker 
--cardiac 
---permanent 38281-00 [652] 
'38281-00 Insertion of chamber pacemaker, not elsewhere classified'
Insertion
-electrode(s) lead(s) 
--heart (cardiac) (for) 
---pacemaker 
----permanent 
-----transvenous 
------atrium 38278-00 [648] 
-------and ventricle 38284-00 [648] 

'38284-00 [648] Insertion of permanent dual chamber transvenous electrodes (Insertion of permanent transvenous electrodes into atrium and ventricle)'

Care should be taken when coding replacement  of pacemakers, as the number of leads may vary depending on whether or not some are retained.

Biventricular pacemakers can also have an automatic implantable cardioverter defibrillator (AICD) component. Coders should investigate documentation of the device details to determine the type of device. If there is an ICD component to the pacemaker, then it should be coded as an AICD.

There will be a specific code in ICD-10-AM 4th edition for a biventricular pacemaker.


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

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

I am now confused about which codes should be assigned.  

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

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

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

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

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


Query Title:
Induction of labour due to fractured ankle

Query Text:
A 28 year old female was admitted to our (obstetric) hospital on 02/09/03 due to fall, resulting in a fractured ankle.
The patient was then readmitted on 03/09/03 for an induction of labour due to the fractured ankle (requiring open reduction surgery). By coding the fracture and external cause codes in the delivery admission, it appears as though the fracture occurred in the current admission, which it didn’t. However, since the fracture has been identified as the reason for the induction, it somehow needs to be coded.
According to 'ACS 1521 Conditions complicating pregnancy' the use of 'O99 Other maternal diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium' excludes codes in the S and T chapters, and the 'Z33 Pregnant state, incidental' would be inappropriate, as the delivery occurred in the current admission. The fracture has been coded as an associated condition. 
Could you please advise on the correct coding in this instance.

Response:
The NCCH has provided the following information in response to a similar query from the Committee.

1. The exclusion note at the beginning of Chapter XV Pregnancy, Childbirth and the Puerperium simply indicates that injuries should be classified to another chapter.  It does not say that a code from the obstetric chapter cannot be used with a code from the injury chapter.  In the presented case, it is valid to describe the injuries of the pregnant woman with a code from the injury chapter as well as a code from the obstetric chapter to indicate problems with the pregnancy as a result of the trauma.

2. ACS 1521 Conditions complicating pregnancy indicates that some conditions aggravating, or aggravated by pregnancy would be coded to O98 Maternal infectious and parasitic diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium or O99 Other maternal diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium.  O98 does not apply in the presented case because it relates to infectious and parasitic diseases.  O99 has an ‘excludes’ note for injury in the same way as the exclusion note at the beginning of the obstetric chapter.  In the presented case, the codes from the injury chapter are sufficient to describe the injury and comply with the ‘excludes’ notes described here. 

The coding of injury in a pregnant patient should be guided by the rules of ICD 10 AM, not by a need to describe the clinical service being provided to the patient, that is, obstetric care.  The ‘excludes’ notes at the chapter and O99 should be followed as a priority.  To assign a code from 099, while indicating that the patient is receiving obstetric care, would contravene the exclusion note.

The VICC suggests the following code assignment for this scenario:

O80 Single spontaneous delivery
Z37.x Outcome of delivery
S82.88 Fracture of other parts of lower leg
W19 Unspecified fall
Y92.9 Unspecified place of occurrence
U73.9 Unspecified activity

This advice may change current coding practice.


Query Title:
Video assisted thorascopic surgery (VATS) thymectomy

Query Text:
What is the procedure code for (R) video assisted thorascopic (VATS) thymectomy? I  spoke with the treating doctor, and it seems none of the codes in block 128 fit exactly, since the surgery was via thoracoscopy.  An incision was made in the mediastinum but the doctor says it was not a mediastinoscopic thymectomy.

Response:
This query was referred to the NCCH for advice.

In accordance with ACS 0023 Laparoscopic/Arthroscopic/Endoscopic Surgery, 'if a procedure is performed laparoscopically, arthroscopically or endoscopically, and there is no code provided which encompasses both the endoscopy and the procedure, then both procedures should be coded'.  

Therefore, the Committee suggests the following code assignment:
38446-01 [128] Removal of thymus via sternotomy
38436-00 [559] Thoracoscopy

The NCCH will consider the creation of a code for this procedure for a future edition of ICD 10 AM.


Query Title:
Transoesophageal echocardiogram (TOE) during CABGs

Query Text:
Would you please clarify if we are to code transoesphageal echocardiograms performed during CABGs.  We were advised  in 2001 (query no. 1691) that the Victorian Coding Committee considered TOE’s a routine part of CABGs and not to code.  NCCH data base query no. 1806 directs that TOEs should be coded as they are “commonly performed during CABGs, but are not routine”.   Your advice would be appreciated.

Response:
Recent advice published by the NCCH (Q1806 Intra-operative transoesphageal echocardiogram (TOE)) supersedes the advice provided in the June 2001 ICD Coding Newsletter (Query #1691 ACS 0909 Additional procedures performed in conjunction with CABGs).

Therefore, as these are not routinely performed during all CABGS procedures, TOE performed during a CABG procedure should be assigned
55130-00 [1942] 2 dimensional real time transoesophageal ultrasound of heart performed during cardiac surgery. 

Likewise, Swan Ganz catheterisation should also be coded when performed during CABGS.


Query Title:
Percutaneous removal of inferior vena cava (IVC) filter.

Query Text:
Please advise on the correct codes to assign for removal of an Inferior Vena Cava (IVC) Filter done percutaneously via a Digital subtraction angiography (DSA) of the abdomen.

I have inserted the description of the procedure below.

Under ultrasound and fluoroscopic guidance, the right internal jugular vein was punctured and dilated with a 12 French dilator. The retrieval device was inserted, via which a contrast run was performed, which demonstrated no significant thrombus within the filter. The hook was snared and sheathed within the retrieval device and removed without complication.

I have 2 suggestions:

90222-01 [739] Other procedures on vein
60024-00 [1994] Digital subtraction angiography of abdomen, less than or equal to 3 data acquisition runs

or

92202-00 [1908] Removal of therapeutic device, not elsewhere classified
60024-00 [1994] Digital subtraction angiography of abdomen, less than or equal to 3 data acquisition runs

Response:
This query was referred to the NCCH for advice.

Currently there is no code in ICD-10-AM to classify removal of an IVC filter. The case cited describes a significant procedure performed on the vein in order to retrieve the IVC filter (‘the right internal jugular vein was punctured and dilated’). 

The following combination of codes should be used to classify this procedure:
90222-01 [739] Other procedures on vein
92202-00 [1908] Removal of therapeutic device, not elsewhere classified
60024-00 [1994]  Digital subtraction angiography of abdomen, <= 3 data acquisition runs

The NCCH will consider the addition of new codes, to classify removal of an IVC filter, in a future edition of ICD-10-AM.


Query Title:
Assignment of principal diagnosis as epididymo-orchitis or sepsis

Query Text:
Please advise on the appropriate code assignment for the following scenario:

A patient presents to ED and is diagnosed with:
Epididymo-orchitis
Sepsis

Both terms are documented as such and are documented in this order in the record. Blood cultures and a urine sample are sent and the patient is
treated with IV antibiotics and IV fluids. The patient is subsequently transferred to another hospital after about 5 hours.
Is it correct to assign:
A41.9 Sepsis, unspecified and
N45.9 Orchitis, epididymitis and Epididymo-orchitis without abscess

in this order because the patient has been treated with IV antibiotics ?

OR

Is is correct to assign:
N45.9 Orchitis, epididymitis and epididymo-orchitis without abscess and
A41.9 Sepsis, unspecified

in this order because this is the order in which the clinician has documented the conditions, and it could be assumed that if the sepsis was not documented first it has been deemed less significant than the epididymo-orchitis ?

Response:
In this scenario, the appropriate standard to apply is ACS 0001 Principal diagnosis to determine the principal diagnosis.  ACS 0110 Septicaemia provides guidance for coding of sepsis versus local infection.

The VICC has forwarded the following proposal to the NCCH.

The Victorian ICD Coding Committee would like to suggest that the NCCH incorporate the content of ACS 0108 Sepsis secondary to urinary tract infection/urosepsis into ACS 0110 Septicaemia if the intention is that sepsis should always be the principal diagnosis in these cases.

Then (in light of the redeveloped ACS 0110 Septicaemia), ACS 0108 Sepsis secondary to urinary tract infection/urosepsis would be redundant, as it addresses a unique situation, and can cause confusion, as it has in this scenario.  The Committee suggests that consideration be given to the removal of ACS 0108 Sepsis secondary to urinary tract infection/urosepsis from the standards.

The NCCH has advised that they will consider amendments to ACS 0110 Septicaemia and ACS 0108 Sepsis Secondary to Urinary Tract Infection/Urosepsis for a future edition of ICD 10 AM.


Query Text:
I have been following advice from NCCH on how to code limb weakness when it meets the appropriate criteria. The advice (NCCH Query 1351 Limb weakness) instructs coders to use 'R29.89 Other and unspecified symptoms and signs involving the nervous and musculoskeletal systems', in line with logic previously used in ICD-9-CM. I would like to further specify that the limb weakness I am coding is a deficit of a stroke. Is it still correct to assign code R29.89 or should I use a similar logic as is used for assigning 'G81.9 Hemiplegia' for right or left sided weakness, and code 'G83.1 Monoplegia of lower limb' or 'G83.2 Monoplegia of upper limb'?

Response:
This query was referred to the NCCH who provided the following advice:

The classification of 'limb weakness' to R29.89 'Other and unspecified symptoms and signs involving the nervous and musculoskeletal systems' is in line with the logic previously used in ICD-9-CM.Current clinical advice indicates that weakness (paresis) of the left or right side of the body (hemiparesis) always arises from a neurological injury or pathology whereas weakness in an individual limb (monoplegia) may arise from many sources (neurological, orthopaedic, musculoskeletal). Hence, 'limb weakness' not stated as having a causal link to another specific condition should be classified as R29.89 'Other and unspecified symptoms and signs involving the nervous and musculoskeletal systems'.Where limb weakness (monoplegia) is documented as having a causal link to a neurological condition, it may be classified as G83.- 'Other paralytic syndromes'.In the case cited the following codes should be assigned:G83.- 'Other paralytic syndromes'I69.- 'Sequelae of cerebrovascular disease'The NCCH advises that the following addition will be made to the decision for query 1925:"I69.- 'Sequelae of cerebrovascular disease' should only be assigned when the treatment period is complete but residual deficits are still manifest (and it fulfils the criteria of an additional diagnosis in ACS 0002 ADDITIONAL DIAGNOSES). If documentation indicates that the patient is still receiving continuing treatment for their stroke, the guidelines in ACS 0604 STROKE should be followed in order to determine code selection".Note that this response is in conflict with the index.The NCCH will be addressing this issue for a future edition of ICD-10-AM.


Query Text:
Re: #1908 Nasogastric tube feeding
The following was published in the August 2003 Victorian ICD Coding Newsletter:
#1908 Nasogastric tube feeding
When a patient (not a neonate) is commenced on feeds via a nasogastric tube, is it correct to assign:
92191-00 [1885] Enteral infusion of nutritional substances

The advice of the Victorian ICD Coding Committee is that nasogastric feeding should not normally be coded, as it is listed in ACS 0042 Procedures normally not coded, however, Note a. in this standard indicates that it could be coded if it was required for research or other purposes. The suggested code is correct:
92191-00 [1885] Enteral infusion of nutritional substances

Could you please explain if this decision is because of ACS 0042 point 12 Nasogastric intubation or because it is ‘reflected in the diagnosis’ (as per the opening paragraph)?

Response:
According to ACS 0042 Procedures normally not coded, it is not necessary to code nasogastric intubation.  This is performed for decompression of the intestine or to enable nasogastric feeding, and is coded to 92036 00 [1895] Insertion of nasogastric tube.

This procedure should not be confused with the procedure for nasogastric feeding, which is coded to 92191 00 [1885] Enteral infusion of nutritional substances.

A code for nasogastric feeding should be assigned when performed.

This advice overrides the previously published advice in the August 2003 Victorian ICD Coding Newsletter, #1908 Nasogastric tube feeding.


Query Title:
Motor Neuron Disease (MND) with respiratory failure

Query Text:
At our hospital we treat many Motor Neuron Disease (MND) patients who present with various problems associated with their MND. One such problem is respiratory failure. Where the patient has known MND and presents with respiratory failure secondary to MND (documented this way on the Discharge Summary), it is often difficult to decide whether to sequence the MND or the respiratory failure as the principal diagnosis. It is firstly difficult to determine if this is actually a 'secondary to' or 'due to' relationship. I am erring on the side of a 'due to' relationship, because I believe the respiratory failure is a direct result of the MND and would be somewhat expected and considered normal development of the MND. In this case, using the advice in the November 2002 Coding Newsletter (Underlying Condition as Principal Diagnosis), I should probably apply the underlying condition aspect of the principal diagnosis standard and assign the presenting condition as principal diagnosis. However, I also feel that the respiratory failure is an indicator of the progression of the MND and not actually a condition in its own right when associated with MND. Meaning, in this case, it may be more correct to sequence the MND first and respiratory failure, being the indicator of severity, second.
Can the Committee please advise ?

Response:
This query was referred to the NCCH for advice.

We have presumed from your query that only the respiratory failure has been treated.

If the underlying condition (that is, the motor neuron disease) is known at the time of admission and this condition is not treated, then the principal diagnosis is the respiratory failure.  With the information provided, the codes would be:

J96.9 Respiratory failure, unspecified
G12.2 Motor neuron disease

If the underlying condition is not known at the time of admission, that is, diagnosed during this admission, then the principal diagnosis is the motor neuron disease and the respiratory failure is not coded.  (Per ACS 0001 Principal diagnosis ‘Assignment of the underlying condition as principal diagnosis').

The Committee notes that in this case, the underlying condition is not a respiratory condition and therefore the respiratory failure is a presenting problem.  If the underlying condition were a respiratory condition, the respiratory failure would represent an exacerbation of that condition.

The Committee also notes the existence of the index entry:
Failure
-respiratory
- -centre G93.8
and advised that this may be relevant in this case, however the coder should check with the clinician for advice before assigning this code.


Query Text:
Scenario:
Patient involved in high speed car accident with splenic rupture.  Currently 29 weeks pregnant.  The patient was admitted to our hospital for 24 hours before being transferred to the RWH because of mild hydrocephaly and subdural hematomas of the fetus.  She had been assessed by an obstetrician, and ultrasound was performed and there was CTG monitoring.

In accordance with what has happened in this scenario I have coded both the injuries from the car accident and also a code to reflect that there was a problem with the fetus.

Codes used:
 In coding this case I coded:
· S36.04 rupture of spleen
· External cause codes
· O35.8 maternal care for other (suspected) fetal abnormality or damage

Questions:
1. Is the code that I have used correct for coding the mild hydrocephaly and subdural hematomas?

2. At the front of the pregnancy chapter of the tabular listing there is an exclude note for S00-T98 with the use of an O code.  What would you do in this situation?

Response:
This query was referred to the NCCH for advice.

The correct codes for this scenario are:
S36.04 Massive parenchymal disruption of spleen
Appropriate external cause, place of occurrence and activity codes
O35.8 Maternal care for other (suspected) fetal abnormality and damage

1. The exclusion note at the beginning of Chapter XV Pregnancy, Childbirth and the Puerperium simply indicates that injuries should be classified to another chapter. It does not say that a code from the obstetric chapter cannot be used with a code from the injury chapter.  In the presented case, it is valid to describe the injuries of the pregnant woman with a code from the injury chapter as well as a code from the obstetric chapter to indicate problems with the pregnancy as a result of the trauma.

2. ACS 1521 Conditions Complicating Pregnancy indicates that some conditions aggravating, or aggravated by pregnancy would be coded to O98 Maternal infectious and parasitic diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium or O99 Other maternal diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium.  O98 does not apply in the presented case because it relates to infectious and parasitic diseases.  O99 has an ‘excludes’ note for injury in the same way as the exclusion note at the beginning of the obstetric chapter.  In the presented case, the codes from the injury chapter are sufficient to describe the injury and comply with the ‘excludes’ notes described here.  O35.8 Maternal care for other (suspected) fetal abnormality and damage is correct for describing the care of the mother related to fetal injuries from the accident.

The coding of injury in a pregnant patient should be guided by the rules of ICD 10 AM, not by a need to describe the clinical service being provided to the patient, that is, obstetric care.  The ‘excludes’ notes at the chapter and O99 should be followed as a priority.  To assign a code from O99, while indicating that the patient is receiving obstetric care, would contravene the exclusion note.

This advice may change current coding practice.


Query Title:
Diabetes with peripheral vascular disease (PVD)

Query Text:
Could you please confirm the coding of a patient who has type 2 diabetes, PVD, leg ulcer and cellulitis of the leg.
Do we code:

E11.69 Type 2 diabetes mellitus with other specified complication
L97 Ulcer of lower limb, not elsewhere classified
L03.11 Cellulitis of lower limb
E11.51 Type 2 diabetes mellitus with peripheral angiopathy, without gangrene
I70.23 Atherosclerosis of arteries of extremities with ulceration

OR

E11.51 Type 2 diabetes mellitus with peripheral angiopathy, without gangrene
I70.23 Atherosclerosis of arteries of extremities with ulceration
L03.11  Cellulitis of lower limb

(the patient was admitted with pneumonia and also treated for the above comorbidities)

Search Details: ACS 0401 pg 99

Response:
The correct codes to assign in this scenario depend on whether there is a documented relationship between the conditions.

If the ulcer is documented as related to the PVD, assign:
E1-.51 Diabetes mellitus with peripheral angiopathy, without gangrene
I70.23 Atherosclerosis of arteries of extremities with ulceration
L03.11 Cellulitis of lower limb

If there is no documented relationship between the ulcer and the PVD, assign:
E1-.69 Diabetes mellitus with other specified complication
L97 Ulcer of lower limb, not elsewhere classified
E1-.51 Diabetes mellitus with peripheral angiopathy, without gangrene
L03.11 Cellulitis of lower limb

You will need to make your decision about the relationship between the peripheral vascular disease and the ulcer based on the available documentation, before you can select the appropriate diabetes code.


Query Text:
We would like advice on which procedure codes to assign for removal of a 'reveal' device (an insertable loop recorder that is implantable - it is a patient activated cardiac event monitor placed just under the patient's skin in the chest area). 
 Is 'Z45.0 Adjustment and management of cardiac device' the appropriate Principal diagnosis code to assign?  What procedure codes do you suggest?

Search Details: NCCH query 1224 provides advice on how to code insertion of a reveal device, but not how to code the removal.

Response:
The correct code to assign for the removal of a 'Reveal' device is:
Incision
-skin (subcutaneous tissue) 90661-00 [1608] 

90661-00 [1608] Other incision of skin and subcutaneous tissue

In ICD-10-AM Fourth Edition, there are four new procedure codes for management of cardiac monitoring devices (insertion, revision, removal and monitoring).

Z45.0 Adjustment and management of cardiac device is an appropriate principal diagnosis for this episode. [end of response]

For Ninth edition advice please refer to query #3035 Removal of cardiac event monitor published in the 2015-16 September VICC queries database.


Query Text:
A patient presented with a peri-prosthetic fracture of the right proximal femur following an unspecified fall.  A hemiarthroplasty for the initial fracture of the right femur was performed three weeks previously.

Could the Committee please advise on the correct coding of peri-prosthetic fracture of the right proximal femur occurring after the patient had an unspecified fall.

I have used the codes:
'M96.69 Fracture of bone following insertion of orthopaedic implant, joint prosthesis or bone plate'
'S72.40 Fracture of lower end femur' 
(external codes)
'W19 Unspecified fall'
'Y92.22 Health service area'

If the code M96.69 can not be used in this scenerio could the Committee please advise when the code M96.69 can be used?

Response:
As this fracture was sustained as a result of a fall, it should be assigned a code from the injury chapter.  M96.6 Fracture of bone following insertion of orthopaedic implant, joint prosthesis or bone plate should be reserved for fractures that occur during surgery, or are due to the presence of the device.  In this scenario, refer to the lead term 'Fracture':
S72.8 Fractures of other parts of femur
Z96.64 Presence of hip implant (if meets ACS 0002 Additional diagnoses)
W19 Unspecified fall'
Y92.9 Unspecified place of occurrence
U73.9 Unspecified activity

NCCH query Q1527 advises that 'M96.6 Fracture of bone following insertion of orthopaedic implant, joint prosthesis, or bone plate should be assigned only when a fracture (and no other type of complication) is a result of the insertion or presence of these devices.’

The code M96.6 Fracture of bone following insertion of orthopaedic implant, joint prosthesis, or bone plate is referenced in the index under the lead term 'Complication'.

It was noted that the inquirer described the fracture as being of the proximal femur, however the suggested code was a fracture of the lower end of the femur.  The inquirer should verify the site of the fracture, and code accordingly.  It was also noted that Y92.22 Health service area would not be the correct place of occurrence, as this corresponds to the diagnosis code instead of the external cause code.  Refer to Victorian Coding Newsletter, May 2003 article ‘Place Of Occurrence Codes For External Causes Related To Surgical/Medical Care’.


Query Text:
76 year old male patient, admitted with iron deficiency anaemia.
Patient had a CT Colonography and I am unsure of how this should be coded.

The only appropriate code I can find is '56401-00 [1962] Computerised tomography of abdomen'.

Response:
Clinical research revealed the following information about CT colonography:

http://www.radiologyinfo.org/content/news/nd050703%2D2.htm
CT (computed tomography) colonography is a new type of x-ray exam that applies the well-known CT technique to examining the interior of the colon, or large intestine.  CT itself is a noninvasive type of radiography that uses a rotating beam of x-rays and detectors placed at varying angles to obtain cross-sectional images, or "slices," of a particular part of the body.  Special computerized analysis converts the images into detailed three-dimensional pictures of the inside of the colon.  In this way it is possible to accurately demonstrate a wide range of abnormal changes including tumor masses. Another name for CT colonography is "virtual colonoscopy," meaning that it enables the radiologist to "see" inside the colon without having to insert a viewing instrument—the colonoscope—into the bowel. 

The Victorian ICD Coding Committee agrees with the inquirer's suggested code.


Query Text:
Could you please inform us of how to code radical laparoscopic prostatectomy?  The pathology states that the seminal vesicles and iliac lymph nodes were removed.
Do we code: 
'37209-00 [1167] Radical prostatectomy' (classified as open)
and
'30390-00 [984] Laparoscopy'
?  

Or do we code:
'37203-06 [1166] Other closed prostatectomy'
'30390-00 [984] Laparoscopy'
'90282-02 [811] Radical excision of lymph nodes of other site'
and
'90393-00 [1168] Excision of seminal vesicle'?

Look forward to hearing your reply.

Response:
The procedure should be coded as an open procedure, as a laparoscopy is not a closed procedure in the same way as an endoscopic procedure, where there are no incisions made.

The correct index trail to follow would be:
Prostatectomy
--perineal, retropubic or suprapubic 
---radical (total) 37209-00 [1167] 

It is a deficiency of the index that there is no clear choice for laparoscopic prostatectomy, and the Committee will request that the NCCH review this indexing.

As instructed in ACS 0023 Laparoscopic/arthroscopic/endoscopic surgery, a code for laparoscopy should be assigned in addition to the other procedure codes.

Therefore, the Committee agrees with the first set of codes suggested:
37209-00 [1167] Radical prostatectomy (includes excision of seminal vesicles)
30390-00 [984]  Laparoscopy

The Committee would also assign a code for the excision of iliac lymph nodes ('code also when performed' at 37209-00 [1167]).
90282-02 [1167] Radical excision of lymph nodes of other site

Documentation should be checked for mention of bladder neck reconstruction in conjunction with this procedure, as it may be appropriate to assign: 
37211-00 [1167] Radical prostatectomy with bladder neck reconstruction and pelvic lymphadenectomy
This code encompasses all procedures in this scenario.


Query Text:
We have quite a few patients who are induced for social reasons. The usual procedure is to administer 1mg Prostin per vagina. If the patient does not commence labour within a given amount of time, a second dose of Prostin is given. Most patients proceed to labour and delivery, however, some do not, and are discharged home.
My query concerns the patients who are discharged home undelivered. We have always used 'O26.88 Other specified pregnancy-related conditions' for social induction when we have no other obstetric/medical problem. However, I recently found on the 3M Encoder pathway that following: 
Induction - as admitting diagnosis only
- other normal pregnancy
--with non-obstetric complaint
leads to codes 'Z34.8 Supervision of other normal pregnancy' and 'Z34.9 Supervision of normal pregnancy, unspecified'.

What is the correct code to use when labour is induced for social reasons, without obstetric complications, and the patient is discharged home undelivered?

Response:
This query was referred to the NCCH for advice.

A code from Z34.- Supervision of normal pregnancy is appropriate for documentation of social induction without indication for induction and without delivery.  Ensure that there is no documentation of 'failed induction'. 

However, in accordance with DHS Hospital Admission Policy, this is (generally) a situation where that patient should be placed on [normal] leave, rather than recording a separate admission and separation.  The June 2004 Special Edition Coding Newsletter (page 27) states 'Specifically, where patients are admitted for induction and are subsequently sent home to wait for established labour, they should be put on leave (as you are expecting the patient to return within seven days), rather than be separated with a new admission recorded when they return'.  Thus, the delivery would have occurred within the admission in question.


Query Text:
Scenario 1:
Obstetric patients present following motor vehicle accidents (MVAs), accidents in the home, workplace etc. They are seen by the O&G clinician, and CTG is performed to assess fetal wellbeing.
We code these episodes according to the 'Minor Trauma Coding Guidelines' (ICD Coding Newsletter - June 2001), as well as coding 'O99.8 Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium' as the principal diagnosis.
That is, if a pregnant patient presents for observation, we would assign:
'O99.8 Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium'
'Z04.1 Examination and observation following transport accident'
'V43.xx Car occupant injured in collision with car, pick-up truck or van'
'Y92.40 Roadway'
'U73.8 Other specified activity'

Is this correct?

Scenario 2:
Obstetrics patient presents with abdominal pain/strain following seatbelt injury,  is assessed by obstetrics team, and CTG is performed.
We would assign:
'O99.8 Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium'
'S39.8 Other specified injuries of abdomen, lower back and pelvis'
'V43.xx Car occupant injured in collision with car, pick-up truck or van'
'Y92.40 Roadway'
'U73.8 Other specified activity'
which groups to DRG 'O65B Oth Antenatal W Moderate/No Comp Diag'.

However, some HIMs are now not using O99.8, and using 'Z33 Pregnant state, incidental' as the last code. That is:
'S39.8 Other specified injuries of abdomen, lower back and pelvis'
'V43.xx Car occupant injured in collision with car, pick-up truck or van'
'Y92.40 Roadway'
'U73.8 Other specified activity'
'Z33 Pregnant state, incidental'
which groups to DRG 'X60C Injuries Age < 65'.

Is preceeding the injury code with O99.8 (as principal diagnosis) correct, or is Z33 as last diagnosis the correct option?

Response:
This query was referred to the NCCH for advice.
Z33 Pregnant state, incidental should not be assigned if a patient requires obstetric observation or care (see ACS 1521 Conditions Complicating Pregnancy, Incidental pregnant state).  Both scenario 1 and 2 state observation by obstetric clinicians and specialist obstetric procedures (CTG monitoring), therefore, Z33 Pregnant state, incidental should not be assigned for either of these scenarios.

The NCCH suggests the following codes for the cases cited:
1. Where an accident has occurred, no injuries are sustained but the patient is seen by the O & G clinician and CTG is performed:
Z04.1 Examination and observation following transport accident
Z34.x Supervision of normal pregnancy
With appropriate external cause, place of occurrence, activity and procedure codes.

2. Where injuries have resulted from an accident but there is no indication of a resulting problem with the pregnancy and the patient is seen by the O & G clinician and CTG is performed:
S39.8 Other specified injuries of abdomen, lower back and pelvis
Z34.x Supervision of normal pregnancy
With appropriate external cause, place of occurrence and activity codes followed by relevant procedure codes.

O99 Other maternal diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium has an ‘excludes’ note for injury.  To assign a code from O99, while indicating that the patient is receiving obstetric care, would contravene the exclusion note.  In the second scenario, the codes from the injury chapter are sufficient to describe the injury and comply with the ‘excludes’ note.

In addition, the official WHO updates to ICD 10 for 2003 include complete code ranges for 'Pregnancy, complicated by, conditions in'.  Codes from Chapter XIX Injury, poisoning and certain other consequences of external causes (S00 T98) are not included in these index entries.

This advice may change current coding practice.


Query Title:
Acute exacerbation of chronic obstructive airways disease (COAD)

Query Text:
Exacerbation of chronic obstructive airways disease (COAD) NOS.  Does the word 'acute' have to be documented in order to assign 'J44.1 Chronic obstructive pulmonary disease with acute exacerbation, unspecified' for exacerbation of COAD?
To me, exacerbation indicates an acute increase in severity.
The index does not allow you to get to J44.1 without 'acute' being used.

Response:
The following information was provided by the NCCH:

By definition, 'acute' means short term and 'exacerbation' is an increase in severity.  Therefore, J44.1 Chronic obstructive pulmonary disease with acute exacerbation, unspecified indicates a short term increase in severity of COPD.

J44.1 is indexed only once in ICD 10 AM Fourth Edition as follows:
Disease
- lung
- - obstructive (chronic) J44.9
- - - with
- - - - acute
- - - - - exacerbation NEC J44.1

The logic behind this indexing (an ICD 10 issue) is to specify that J44.1 is the correct code to assign for a short term increase in severity of the COPD, in contrast to a progressive increase in the severity of the 'chronic' disease.

Therefore, documentation of ‘exacerbation of COAD’ should be coded to J44.9 Chronic obstructive pulmonary disease, unspecified and ‘acute exacerbation of COAD’ should be coded to J44.1 Chronic obstructive pulmonary disease with acute exacerbation as per the index entry above.


Query Title:
Chronic obstructive airways disease (COAD) with asthma

Query Text:
I have always coded Chronic obstructive airways disease (COAD) with asthma (or emphysema) to 'J44.8 Other specified chronic obstructive pulmonary disease'.
I think that at one point we were advised (I cannot find any advice to support this) that it should not be coded to 'J44.9 Chronic obstructive pulmonary disease, unspecified' as it is not unspecified, therefore it should go to J44.8 as 'other specified COAD'.
At the beginning of 'J44 Other chronic obstructive pulmonary disease' there is an inclusion note for obstructive asthma, which implies that you should use J44.9.
Is this how we should be coding COAD/asthma, or is it more correct to assign J44.8?  If this is the case, then there needs to be an amendment to the tabular and index.

Response:
The Victorian ICD Coding Committee referred this query to the NCCH who provided the following advice:

J44 Other chronic obstructive pulmonary disease is tabulated and indexed in ICD-10-AM as per ICD-10.

1. The conditions listed at the third character level at J44 Other chronic obstructive pulmonary disease may all be classified to the fourth character level.  

That is, the listed conditions that present with an acute lower respiratory infection should be classified to J44.0 Chronic obstructive pulmonary disease (COPD) with acute lower respiratory infection.  

Those listed conditions that present as an acute exacerbation should be listed as J44.1 Chronic obstructive pulmonary disease with acute exacerbation, unspecified. 

J44.8 Other specified chronic obstructive pulmonary disease classifies the conditions listed at the third character level that do not state infective or acute exacerbation.

J44.9 Chronic obstructive pulmonary disease, unspecified is used to classify COPD without mention of asthma, emphysema or bronchitis/bronchiolitis and/or without mention of infective or acute exacerbation.

2. COPD with asthma not otherwise stated (that is, with no mention of infective or acute exacerbation) should be classified as J44.8 Other specified chronic obstructive pulmonary disease.  The correct index pathways for this code are:
Asthma
- chronic
- - obstructive 
or
Asthma
- obstructive, chronic

COPD with asthma described as an infective or acute exacerbation should be classified to one of the above codes (J44.0, J44.1) as appropriate.  This advice is supported by ACS 1008 Chronic obstructive pulmonary disease and ACS 1002 Asthma that state:  ‘Asthma described as chronic obstructive or asthma documented with COPD should be assigned a code from J44.-‘.  The VICC will forward a recommendation to the NCCH for enhancements to the Index for COPD with asthma.


Query Title:
Indexing of arthroscopic synovectomy of shoulder

Query Text:
Volume 4 – Procedures.  Page 203.
Release
- contracture
-- joint
--- shoulder
---- with synovectomy 48954-00 [1397]

'48954-00 [1397] Arthroscopic synovectomy of shoulder'

This code is for arthroscopic synovectomy of shoulder.  The index entry indicates the synovectomy is with open release of the shoulder.  Is this an error?  Should “with synovectomy” be indented underneath the arthroscopic entry?

Response:
This was identified as an index error and was referred to the NCCH for advice.

The correct pathway should be:
Release
- contracture
- - joint
- - - shoulder 90600-01[1395]
- - - - with synovectomy 48936-00 [1397]
- - - - - arthroscopic 48954-00 [1397]
- - - - arthroscopic 90600-00 [1395]
- - - - - with synovectomy 48954-00 [1397]

This information will be incorporated into a future errata.


Query Title:
Rhabdomyolysis and compartment syndrome, non-traumatic

Query Text:
Rhabdomyolysis and compartment syndrome, non-traumatic.  Are you able to advise if the non-traumatic codes for rhabdomyolysis and compartment syndrome are the most appropriate?
Rhabdomyolysis is the breakdown of muscle fibres which results in myoglobin being released into the blood stream where it is a toxic compound that can lead to kidney damage, muscle necrosis, dehydration and/or shock.  I would have thought that 'M62.5- Muscle wasting and atrophy NEC' would be a more appropriate code than 'M62.8- Other specified disorders of muscle', as it is this, but in a very acute form.  The code M62.5-  does not contain the word 'chronic'.  In its traumatic form, the code is T79.6 'Traumatic ischaemia of muscle', in which case, if the word 'infarction' was not in code 'M62.2- Ischaemic infarction of muscle', this would perhaps be the more appropriate code.

Compartment Syndrome is the build up of pressure within a muscle group to the point where circulation to the area is compromised and the muscle becomes ischaemic.  Once again, if the word 'infarction' was removed from 'M62.2- Ischaemic infarction of muscle', this would appear to be a more appropriate code than M62.8-.  There is also an exclusion note under M62.2- for compartment syndrome (T79.6) (no specification here for traumatic).

If M62.8- is the most appropriate code for the two conditions, should there be an exclusion note on this for the traumatic form of the two conditions?

I look forward to your advice on these two conditions.

Search Details: http://www.nlm.nih.gov/medlineplus/ency/article/000473.htm
http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=287&
topcategory=About%20Orthopaedics

Response:
This query was referred to the NCCH for advice.

Amendments to the classification and indexing of 'non-traumatic compartment syndrome' in ICD-10 have been ratified by the Update Reference Committee of the WHO. The NCCH will make appropriate amendments to the classification and indexing of this condition for ICD 10 AM Fifth Edition.

In the meantime, continue to follow the index entries for compartment syndrome.


Query Text:
When coding a patient's record who underwent insertion of pleural catheter for drainage of pleural effusion, I have noticed that there appears to be an inconsistency in the index regarding drainage of chest and drainage of pleura.
Drainage of chest has index entries for 'open': '38415-00 [549] Incision of pleura', and 'closed': '38409-00 [560] Insertion of intercostal catheter for drainage'. Drainage of pleura is only indexed to 'open' (38415-00 [549] Incision of pleura'). 

Should there be an index entry for 'closed' drainage of pleura, i.e.'38409-00 [560] Insertion of intercostal catheter for drainage'.

Response:
This query was referred to the NCCH for advice.

Closed (endoscopic) drainage of the pleura should be classified as 
38409-00 [560] Insertion of intercostal catheter for drainage.

The NCCH will consider the addition of appropriate entries for this code to the Alphabetic Index of Procedures for a future edition of ICD-10-AM.


Query Title:
Deep vein thromboses (DVTs) of the lower limb

Query Text:
Could you please provide advice on coding deep vein thromboses (DVTs) of the lower limb.

Question 1. Are DVTs of all femoral veins coded to
'I80.1 Phlebitis and thrombophlebitis of femoral vein'
as indicated in the index, or is this code only used for DVTs of deep femoral veins? If so, would 
'I80.0 Phlebitis and thrombophlebitis of superficial vessels of lower extremities'
be the correct code for a DVT of the superficial femoral vein?
'DVT' is usually the documented diagnosis/teminology used, even though the vein may not be deep, and may in fact be superficial.

Question 2. When coding a DVT that involves multiple veins of the lower limb, is it appropriate to provide a code for each type of vein involved (i.e. superficial, femoral, other deep)?  For example, how would you code thrombosis involving the left distal external iliac, common femoral, superficial femoral, deep femoral, popliteal, and posterior tibial veins? 
'I80.0 Phlebitis and thrombophlebitis of superficial vessels of lower extremities'
'I80.1 Phlebitis and thrombophlebitis of femoral vein'
'I80.2 Phlebitis and thrombophlebitis of other deep vessels of lower extremities'
'I80.3 Phlebitis and thrombophlebitis of lower extremities, unspecified'

Response:
Answer 1
All DVTs of the femoral vein should be coded to I80.1 Phlebitis and thrombophlebitis of femoral vein as all femoral veins are deep vessels.

Deep veins are much larger vessels than superficial veins, and lie deep within the muscle compartments, carrying most of the blood out of the leg.  Reference to a 'superficial femoral vein' is a description of its relative position, however, it is still classified as a deep vein.

Answer 2
When coding DVT follow the index according to documentation.  Thrombosis of the lower limb (DVT) documented as deep, should be assigned I80.2 Phlebitis and thrombophlebitis of other deep vessels of lower extremities except for DVT of femoral vein which is assigned I80.1 Pheblitis and thrombophebitis of femoral vein as it has a specific index entry

Index entry:
Thrombosis
- femoral I80.1


Query Title:
Placement of angioseal after angiogram/angioplasty

Query Text:
Our coronary care unit  has started using angioseals after performing an angiogram/angioplasty. It is a collagen sponge with an absorbable polymer anchor that is connected by an absorbable positioning suture. It is placed into the artery to prevent haematoma or haemorrhage, particularly in patients whose artery has been punctured before.

Information from our cardiologist indicates that this is a separate procedure performed after the main procedure, and requires the clinician to regown and glove. The device itself costs approximately $300. Due to the extra use of resources, it seems appropriate to assign a code. 

Embolisation 
-arteriovenous fistula or malformation 
--via surgical peripheral catheterisation 35321-00 [767] 

'35321-00 [767] 35321-00 Transcatheter embolisation of blood vessel
Includes: Administration of an agent or device such as glue, ethanol, plastic or gelatin sponge, balloon or wire coil to occlude artery, vein, arteriovenous fistula or malformation or to arrest haemorrhage'
is a perfect description of the procedure.

However, assigning this code can have a dramatic effect on the grouping. Hence, we decided to send a query so that this anomaly can be notified to the appropriate body.

Example 1. AMI, angiogram performed and angioseal placed.
'I21.4 Acute subendocardial myocardial infarction'
'38218-00 [668] Coronary angiography with left heart catheterisation'
'59900-00 [607] Left ventriculography'
groups to DRG F41B Circ Dis w AMI W Inv Car Pr No C/S CC (weight 1.6162)

I21.4 Acute subendocardial myocardial infarction'
'38218-00 [668] Coronary angiography with left heart catheterisation'
'59900-00 [607] Left ventriculography'
'35321-00 [767] 35321-00 Transcatheter embolisation of blood vessel'
groups to DRG F14C Vasc Prs Exc Maj Rec w/o Pump w/o C/S CC (weight .9795)


Example 2. Carotid occlusion, angioplasty performed and angioseal placed.
'I65.2 Occlusion and stenosis of carotid artery'
'35303-06 [754] Percutaneous transluminal balloon angioplasty'
groups to DRG 901Z Extensive OR procedure Unrelated to Principal Diagnosis (weight 3.2220)

'I65.2 Occlusion and stenosis of carotid artery'
'35303-06 [754] Percutaneous transluminal balloon angioplasty'
'35321-00 [767] 35321-00 Transcatheter embolisation of blood vessel'
groups to DRG B02C Craniotomy w/o CC (weight 3.0514)

By assigning the angioseal code in this instance, it groups to a craniotomy DRG which is definitely incorrect, and not an accurate description of what occurred during the admission.

Please advise:
- Should we be coding this procedure?
- Is 35321-00 [767] the correct code to use?
- If the answer to these questions is yes, our hospital will be financially disadvantaged by the DRG assignment, until such time that the grouping can be fixed. Will this be addressed?

Response:
A code for the placement of an angioseal should not be assigned. This device is used as a mechanical system for sealing the entry wound caused by angioplasty.  At the end of the procedure, the device is positioned under the skin at the site of the puncture, so as to achieve effective haemostasis. (http://www.chfpatients.com/surgery_old.htm#cathseal)

This is not embolisation of a vessel.  Placement of an angioseal is a component of an angioplasty procedure, as the vessel would always be sealed, and, therefore, according to ACS 0016 General procedure guidelines should not be coded.


Query Title:
Diagnosis code for failed vacuum extraction

Query Text:
'O66.5 Failed application of vacuum extractor and forceps, unspecified
           Failed application of ventouse or forceps, with subsequent delivery by forceps or caesarean section respectively'.

Please confirm whether we are to follow 'and' (in code title), or 'or' (in the inclusion term), in this instance.

As there are procedure codes for failed forceps:
'90468-05 [1337] Failed forceps'
and failed vacuum extraction:
'90469-01 Failed vacuum extraction',
discussion amongst our coders has revealed that not many use O66.5 'O66.5 Failed application of vacuum extractor and forceps, unspecified', as they feel that they have covered the scenario with these procedure codes.

Is it essential that O66.5 be coded in addition to the procedure codes?  If so, do we follow the 'and' or the 'or' direction?

Response:
ACS 0033 Conventions Used in the Tabular List of Diseases provides instruction on how to interpret 'and' in code titles:
In disease codes 'And' stands for 'and/or'.  For example, in the rubric A18.0† Tuberculosis of bones and joints, are to be classified cases of 'tuberculosis of bones', 'tuberculosis of joints' and 'tuberculosis of bones and joints.

This convention does not apply to inclusion terms.

A disease code should be assigned for a failed vacuum extraction.  This will be a code to indicate the reason why the procedure failed, or, in the case where the reason is not documented, assign a code for the failed vacuum extraction, by following the index pathway:
Failure
-ventouse (with subsequent caesarean section) NEC O66.5

O66.5 Failed application of vacuum extractor and forceps, unspecified

The fact that there are procedure codes to demonstrate the events of the admission is not reason to omit disease codes.  It is common for disease codes to be assigned when there are also procedure codes to describe the scenario.


Query Text:
When a patient has reopening of sternotomy for control of post-operative haemorrhage, the sternum is not always rewired at the same time but can be done some time later.  When the sternum is rewired during the same operative episode, should it be coded in addition to reopening?
That is,
'38656-01 [562] Reopening of thoracotomy or sternotomy site'
and
'90596-00 [1378] Rewiring of sternum'

Or is the rewiring inherent in the reopening code?
This is not clear in the Procedure Tabular, as there are no notes under these codes to direct us either way.  I can find no reference in the Australian Coding Standards or on the NCCH database of queries.
Your advice would be appreciated.

Response:
In this scenario, the patient's original sternotomy was re-opened, the post-operative haemorrhage controlled, then the sternotomy rewired in the same operative episode, which would be considered closure of the operative incision.

Reference was made to ACS 0016 General procedure guidelines, specifically:
‘Procedure components
Do not code procedures which are individual components of another procedure.

EXAMPLE 2:
•laparotomy as an operative approach
•bone graft during craniofacial reconstruction
•suture of abdominal incision after surgery’

Therefore, a code for the rewiring component of this procedure should not be assigned in this scenario.


Query Title:
High grade prostatic intraepithelial neoplasia (PIN)

Query Text:
Would like confirmation of correct code for 'high grade PIN' (prostatic intraepithelial neoplasia)
 (ICD-10-AM only offers grade I, II or III).


Search Details: Our pathologist says that:
1. High grade PIN does not necessarily equate to grade III PIN;
2. They don't talk in terms of grade I, II or III PIN - rather, high or low grade - and they also don't talk in terms of ca in-situ of prostate.

Phoned Vic Cancer Registry, who advised to code to grade III/in-situ ('D07.5 Carcinoma in situ - prostate'), and that cases of high grade PIN should be notified.

Response:
This was referred to the NCCH for information and advice.

Clinical advice indicates that 'high grade prostatic intraepithelial neoplasia (PIN)' should be classified as D07.5 Carcinoma in situ, prostate.

The NCCH will consider amending the terminology for prostatic intraepithelial neoplasia (PIN) and the relevant indexing for a future edition of ICD-10-AM.


Query Title:
Neoplasm causing obstruction of biliary stent

Query Text:
Is it acceptable to code the cancer as principal diagnosis in the case of patient who came in with blocked biliary stent documented as due to advancement of liver cancer?  The stent was removed and, after a range of investigations, care became palliative only.

If coding 'T85.88 Other complications of internal prosthetic, device, implant and graft, NEC' as principal, the DRG 'X63 Sequelae of Treatment' did not seem to reflect the picture well.  If coding the cancer as principal, the DRG 'H41 ERCP Compx Therapeutic Procedure' seemed to fit much better.

Search Details: ACS 0236 and ACS 0207

Response:
As it was the advancement of the tumour, which caused the stent to be blocked, assign as the principal diagnosis a code for the liver cancer.  

DRG outcome should not determine principal diagnosis assignment; it should be used as a quality check only.


Query Text:
Our problem is regarding the coding of a procedure, Epidurolysis.  The procedure involves a catheter being inserted into the epidural space and
then injecting different drugs usually to break down the formation of adhesions or scar tissue that have formed from a previous spinal injury or
surgery which can cause chronic back pain in patients.

The principal diagnosis in the majority of cases is listed as chronic back pain.  We had been using 39140-00 [32] Epidural injection for lysis of adhesions, but it was suggested at audit, that with the principal diagnosis being 'back pain', and the doctor listing 'Epidurolysis' as the procedure with no mention of adhesions, or scar tissue formation of the spinal canal, that we further investigate the usage of the procedure code 39140-00 [32] as the code for Epidurolysis.  This suggestion was warranted by the fact that there is no way to look it up in the alphabetic procedure list, as by using the 39140-00 [32] we are assuming a diagnosis of adhesions or scar tissue.

Therefore, my question to the committee is:

1)  Can we use the procedure code '39140-00 [32] - Epidural for lysis of adhesions' when a doctor has listed 'Epidurolysis' as the sole procedure
code when the principal diagnosis is back pain or similar?

If no,

2)  Do we use '90018-02 [32] - Epidural, specified therapeutic substance NEC, combined preoperative, intraoperative & postoperative'?

If no, your suggestion as to what code to use would be greatly appreciated.


Search Details: Prior to Audit - this is the path we followed in the alphabetic list:

Injection
- epidural (space)(with catheterisation)
- - for
- - - lysis of adhesions (hyaluronic acid)(hypertonic saline) 39140-00 [32]

Response:
This query was referred to the NCCH for advice.

The NCCH agrees that epidurolysis should be classified as:
39140-00 [32] Epidural injection for lysis of adhesions

The NCCH will consider the addition of 'epidurolysis' and 'Racz procedure' to the Alphabetic Index of Procedures for a future edition of ICD 10 AM.


Query Text:
Currently the code for peripheral angioplasty (without stenting) does not provide a breakdown for the number of times performed.  When multiple
peripheral angioplasties are performed, we are unsure as to how we should apply ACS 0020 Multiple/Bilateral Procedures.   Our understanding is that
when a balloon is inflated multiple times at the site of a single lesion, this would be counted as one angioplasty, but 

1. Should angioplasty be coded as many times as it is performed for multiple sites? And if so,
2. How should multiple sites be counted?  Should it be based on the number of lesions, number of vessels or number of limbs angioplastied or should it
be based on the number of incisions made to catheterise?

Search Details: ACS 0020 Multiple/Bilateral Procedures

Response:
This query was referred to the NCCH for advice.  The NCCH agrees that the number of peripheral vessels angioplastied should be coded.  

The VICC has suggested amendments to the peripheral angioplasty codes.  The NCCH will consider them when making amendments to a future edition of ICD 10 AM.


Query Title:
Diabetes with conditions documented in previous admissions

Query Text:
During a recent Coding Audit we were advised that it is allowable when coding Diabetes Mellitus (DM) to refer back to the documentation in previous admissions and assign any appropriate 'DM related' codes, even if the conditions are not documented in the admission we are coding.

In some circumstances I believe it is correct to refer back to previous admissions, for example when I am trying to gain further specificity of the type of DM because I only have unspecified DM documented in the admission I am coding.

On one hand I believe the practice of looking back for 'DM related' when there is no indication of these conditions in the current admission I am coding is questionable.

My concerns are (these questions don't have to be answered individually):
- Would this apply to conditions such as hypercholesterolaemia and obesity or only conditions which are found under 'Diabetes, with'?
- If it does apply to obesity, can patients lose weight between admissions and therefore not be classified as obese in the most current admission?
- Would it matter if the patient had past documentation of hypercholesterolaemia and obesity but had not yet been diagnosed with DM?
- When documenting past history, conditions can be copied down incorrectly such as PVD can become PUD and vice versa. Only one person would need to do have done this in a previous admission for the Coder to pick up PVD when the patient actually has a past history of PUD?
- Should this only apply where the conditions are documented in more than one past admission?
- Would this create confusion about eradicated conditions if the conditions are documented in past admissions and not in the current admission but there is no evidence that the condition has been eradicated?
- Are there conditions that can be eradicated before a diagnosis of DM is made?
- Do coders have the time to look back through past admissions in such detail?
- If we decide to follow this practice how far do we go back ? What if we don't have access to all volumes of the medical record, eg. there are closed volumes in storage, do we need to retrieve all past volumes to complete this process thoroughly?
- Should hospitals be instructed to educate clinicians about documenting all conditions relating to DM within each admission rather than expecting coders to look back through past admissions?
- What impact does applying this practice have on conditions other than DM?

On the other hand, it does seem incorrect to code DM without complications based on current documentation when there has been documentation of complications, eg. PVD, Retinopathy in the past admissions.

Presuming DM meets the criteria to be coded in the current admission, are coders expected/required to look back through documentation in past admissions for DM related conditions and assign the appropriate codes, even though these conditions are not documented in anyway in the current admission (this includes implying that a condition existed, eg. Past history of eye surgery) ?

Response:
In accordance with ACS 0010 General abstraction guidelines and once it has been established that diabetes meets ACS 0002 Additional diagnoses in the current episode, then it is correct coding practice to review previous episodes in order to identify and assign codes for conditions related to diabetes.


Query Title:
Documentation of American Society of Anesthesiologists (ASA) score

Query Text:
Could you please advise whether it is appropriate to use the American Society of Anesthesiologists (ASA) score documented on the operation nursing form when the ASA score is not documented on the anaesthetic record? This information is obtained from the anaesthetist by the perioperative nursing staff.

Search Details: ACS 0031 states 'this information must be documented on the anaesthetic form before assigning these codes'

Coding Matters Volume 8, number 3 page 13 (similar comment to above)

Response:
The inquirer is correct in referring to ACS 0031 Anaesthesia where it is stated that this information must be documented on the anaesthetic form before assigning these codes.

An ASA score documented on the operation nursing form should not be used for code assignment.


Query Title:
Same day admission for insertion of peritoneal dialysis catheter

Query Text:
If a patient has a same day admission for insertion of a peritoneal dialysis catheter, what code should be assigned as the principal diagnosis?  If the index is followed, it seems that either of 2 codes are appropriate:

Admission
- dialysis
- - catheter
- - - peritoneal
- - - - fitting and adjustment Z45.8
'Z45.8 Adjustment and management of other implanted devices'


Admission
- dialysis
- - peritoneal
- - - preparatory care only (without treatment) Z49.0
'Z49.0 Preparatory care for dialysis'


Admission
- fitting (of)
- - catheter
- - - dialysis
- - - - peritoneal Z45.8
'Z45.8 Adjustment and management of other implanted devices'


What is the difference between admission for fitting of a peritoneal dialysis catheter (Z45.8) and admission for peritoneal dialysis preparatory care (which usually involves fitting of a PD catheter)?

Block Z45 is titled "adjustment and management of implanted device".  Codes from this block are usually assigned for checking and testing of previously
inserted devices.  Therefore it would seem inappropriate to assign a code from this block as principal diagnosis, for an initial insertion.  Maybe the index needs to
be improved?

Selection of principal diagnosis affects DRG assignment.

Principal diagnosis  'Z45.8 Adjustment and management of other implanted devices'                 
Principal Procedure  '13109-00 [1062]  Insertion and fixation of indwelling peritoneal catheter for long term peritoneal dialysis'
DRG 'Z01B ORPs W Diags Oth Contacts W/O Cat/Sev CC'
WIES 0.415 

or

Principal diagnosis  'Z49.0 Preparatory care for dialysis'
Principal Procedure  '13109-00 [1062]  Insertion and fixation of indwelling peritoneal catheter for long term peritoneal dialysis'
DRG 'L02Z Op'tive Insert Periton Catheter-Dialysis'
WIES 0.8513

What code should be assigned as principal diagnosis?

Response:
This query was referred to the NCCH for advice who advised:
 
For the case cited: 'same day admission for insertion of peritoneal dialysis catheter', assign:  Z49.0 Preparatory care for dialysis

The NCCH will consider amendments to the Alphabetic Index of Diseases relating to this topic to correct anomalies.


Query Text:
70 year old male admitted for percutaneous balloon angioplasty with stent insertion. He has type II diabetes, and peripheral vascular disease, and was found to have stenosis of the iliac artery.
I have coded:
'I70.8 Atherosclerosis of other arteries'
'E11.51 Type 2 diabetes mellitus with peripheral angiopathy, without gangrene'

PVD without diabetes would be coded to:
'I70.20 Atherosclerosis of arteries of extremities, unspecified' 
and as these arteries connect to the iliac arteries, it seems that there should be some connection. Atherosclerosis is not indexed under diabetes, and therefore, I have not made a connection.
Is this correct?

Response:
This query was referred to the NCCH. 

1. The iliac artery is one of two large arteries originating from the abdominal aorta. It supplies blood to the pelvis, abdominal wall and legs. Atherosclerosis of the iliac artery should be classified as I70.8 Arteriosclerosis, specified artery NEC. 

2. ACS 0401 DIABETES MELLITUS AND IMPAIRED GLUCOSE REGULATION, Circulatory complications states: "The precise pathogenetic relationship between atherosclerosis affecting larger blood vessels (macrovascular disease) and diabetes or IGR is not clearly established." Follow the index pathway for 'Diabetes, with, angiopathy, peripheral' to assign the appropriate code for peripheral vascular disease with diabetes.

Assign the following codes for the case cited:
E11.51 'Type 2 diabetes mellitus with peripheral angiopathy without gangrene'
I70.8 'Atherosclerosis of other arteries'.

The sequencing of the above codes will depend on which vessel was stented.
--------
This query is superseded by Coding Rule Q2937 titled Iliac artery stenosis with Type 2 diabetes mellitus and peripheral vascular diseasepublished 15 March 2017.


Query Text:
90 year old female admitted for amputation of toe because of septic arthritis. Patient also has type II diabetes, toe ulcer and peripheral vascular disease (PVD). Had toe amputated, and then developed a haematoma and a post-operative wound infection (Staph. Aureus).

The following codes were assigned:

'M00.97 Pyogenic arthritis, unspecified - ankle and foot'
'E11.73 Type 2 diabetes mellitus with foot ulcer due to multiple causes'
'I70.23 Atherosclerosis of arteries of extremities with ulceration'
'T81.0 Haemorrhage and haematoma complicating a procedure, not elsewhere classified'
'T81.41 Wound infection following a procedure'
'B95.6 Staphylococcus aureus as the cause of diseases classified to other chapters'
'Y83.5 Amputation of limb(s)'
'Y92.22 Health service area'
'44358-00 [1533] Amputation of toe including metatarsal bone'
'92508-49 [1909] Neuraxial block, ASA 49
'30223-00 [1606] Incision and drainage of haematoma of skin and subcutaneous tissue'
'95550-03 [1916] Allied health intervention, physiotherapy'

Are these codes correct?

Arthritis is not indexed under 'Diabetes', however, arthropathy is, but according to NCCH database query 1677, I cannot make a connection.

Response:
The inquirer is correct in stating that no connection can be made between septic arthritis and diabetes.  There is no index entry for 'Diabetes with arthritis', and the term  'arthropathy' cannot be referenced as an alternative for 'arthritis'.  This advice is confirmed in Coding Matters (Vol.8, No.2, p10), and in NCCH query database Q1677.  

Peripheral Vascular Disease and toe ulcer are conditions that meet the criteria for assigning a code for diabetic foot (ACS 0401 Diabetes).

Therefore, the Committee agrees with the inquirer's suggested disease codes. 

Without further information, the procedure codes cannot be confirmed.


Query Title:
DRG 902Z with dilatation and curettage (D & C)

Query Text:
A relatively rare procedure was performed - excision of urethral diverticulum, but as it was performed with a dilatation and curettage (D & C) for menorrhagia, it groups to DRG '902Z Non-Extensive OR Proc Unrelated to Pdiag'.
In theory, we could reverse the order and have menorrhagia and D & C first, which groups to DRG 'N10Z Diagnostic Curettage or Hysteroscopy', but documentation by the clinician indicates that the diverticulum would be the principal diagnosis.
As it is a rare diagnosis and procedure, and as 'excision' is overriding a D & C, thought you may like to have a look.

Codes assigned:
'N36.1 Urethral diverticulum'
'N92.0 Excessive and frequent menstruation with regular cycle'
'Z30.1 Insertion of (intrauterine) contraceptive device'
'Z72.0 Tobacco use, current'
'37372-00 [1118] Excision of urethral diverticulum'
'35640-00 [1265] Dilation and curettage of uterus [D&C]'
'35630-00 [1259] Diagnostic hysteroscopy'
'14203-00 [1906] Direct subdermal hormone implantation'
'92514-29 [1910] General anaesthesia, ASA 29'

Response:
Based on the codes provided, the DRG assignment is correct.  Current grouper logic assigns this episode to DRG 902Z Non-Extensive OR Proc Unrelated to Principal Diagnosis as N36.1 Urethral diverticulum as principal diagnosis is in MDC 11 Disease and disorders of the kidney and urinary tract and 35640-00 [1265] Dilation and curettage of uterus is in MDC 13 Disease and disorders of the female reproductive system and 14 Pregnancy, childbirth and the puerperium. 

37372-00 [1118] Excision of urethral diverticulum is not recognised as an operating room procedure by the grouper.


Query Text:
We are having trouble applying 'ACS 0002 Additional diagnoses' in the following two scenarios.

(1)  A 70 year old patient comes in with 'Exacerbation of COPD'.    A geriatrician sees the patient stating that they have 'osteoporosis' and makes a comment recommending 'Osteolin, Caltrate, Vit D' (which was not commenced during this admission).  Does this warrant coding osteoporosis based on the geriatrician's  recommendation?

(2)  An 84 year old patient is treated for 'R knee pain secondary to osteoarthritis'.  In the doctor's initial assessment, she comments that the patient had '[decreased] memory, STM 0/3 (amnesic type)'.  The dementia did not affect the nursing care given during the episode of care, but the treating doctor documented 'dementia' on the discharge summary and 'Refer to memory clinic'.
Can dementia be coded?

Please clarify whether these conditions meet ACS 0002 and can be coded.


Search Details: Conditions for which a treatment decision is made but treatment is not carried out in this episode of care.  Can such conditions be coded?

ACS 0002 Additional diagnoses - Determining whether the condition affected treatment/LOS  even though not treated.

How to determine the above, what meets this criteria (eg. tests performed? specialist seen for condition?)

Response:
Scenario 1
The Victorian ICD Coding Committee supports the coding of osteoporosis in this scenario as the patient has had active evaluation and active decisions have been made.  Please refer to Additional diagnoses queries and responses query 14 Pneumonia and dehydration on the HDSS website for further guidance.

Scenario 2
The dementia has been actively evaluated and an active decision has been made.  Dementia can be coded in this instance.


Query Title:
Angina with history of ischaemic heart disease (IHD)

Query Text:
Patient admitted with and treated for angina. Ischaemic heart disease (IHD) noted on the history sheet. Is the angina the result/ outcome of the IHD, and therefore, IHD need not be coded, or should the IHD be coded as an additional diagnosis?

Response:
The inquirer should refer to ACS 0940 Ischaemic heart disease for definitions of both angina and ischaemic heart disease.  The standard states:
‘Patients documented as having the current conditions of both ischaemic heart disease and angina can have both I25.9 Chronic ischaemic heart disease, unspecified and I20.9 Angina pectoris, unspecified assigned.’

In this scenario, a code for angina should be assigned as the principal diagnosis, and, if the ischaemic heart disease meets the criteria in ACS 0002 Additional diagnoses (for example, investigation and diagnosis of coronary artery disease), a code should also be assigned for this condition.


Query Title:
Neonate with melaena due to ingestion of maternal blood

Query Text:
We had an episode group to DRG '963Z Neonatal Dx inconsistent w weight' which was only picked up after reconciling WIES reports.

Although the description of the DRG indicates discrepancies with diagnosis and weight, is this DRG also assigned on the basis of diagnosis and
baby's age?

In this case the patient was 28 days old on admission, with a diagnosis of  'melaena secondary to ingestion of maternal blood (from breast feeding)' and an admission weight of 3572g.  A code from "P" chapter was assigned.  As the baby was beyond the age for a neonate, yet a neonatal code was assigned, would this be why this episode grouped to 963Z?

Would it be appropriate to assign two codes for this episode?
K92.1 Melaena
P78.2 Neonatal haematemesis and melaena due to swallowed maternal blood

This ensures a funded DRG plus gives a clear indication of the cause of the melaena.

Would appreciate your feedback.

Response:
This episode groups to DRG 963Z Neonatal Diagnosis inconsistent with weight because you have used a principal diagnosis from the ‘Conditions arising in the perinatal period’ chapter, and the admission weight is greater than 2500 grams.

For some episodes, this DRG can be valid.  This problem is acknowledged by the Victorian ICD Coding Committee and is under consideration by VACCDI.

In this instance, it is correct to assign only
K92.1 Malaena.

The logic behind this advice is based on that provided in Coding Matters (Vol 5, No 1, p 16), in which there is a direction to refer to the main index term 'Jaundice' if the infant is greater than 28 days old.


Query Text:
Patient admitted with a displaced fracture of distal fibula and fracture of distal tibia. Volume 1 of ICD-10-AM 3rd edition page 375 lists definitions of types of fractures, this list includes the term 'displaced'.  There is also an index entry for Displacement, acquired traumatic of bone, cartilage, joint, tendon (without fracture)  NEC - see Dislocation.
My query is whether the term in brackets as a non essential modifier should in fact be an essential modifier?
Some of our coders have been following this index entry for displaced fractures and coding a fracture and a dislocation, which I do not believe to be correct, but the index is misleading.
Thank you for considering this matter.

Response:
The correct index entry to follow is Fracture, by site.
The Victorian ICD Coding Committee will request that NCCH remove the index entry for ‘see Dislocation’.


Query Title:
Continuous ventilatory support (CVS) hours following tracheostomy

Query Text:
We often have difficulty calculating the period of mechanical ventilation for people who have a tracheostomy.  The issue surrounds the definition of "weaning".  ACS 1006 Respiratory support states "cessation of CVS for patients with a tracheostomy (after any period of weaning)".  The August 2002  ICD Coding Newsletter has a coding feature about CVS which states "when a patient has a tracheostomy it is harder to determine when ventilation/weaning ceases as the tracheostomy tube is often left in-situ in case the patient needs further ventilatory support.  Therefore to determine when CVS has ceased in a tracheostomy patient, stop the count at the time of the last recording of pressure support".  This is where the dilemma arises.  How do we determine the last recording of pressure support?

Often patients with a tracheostomy alternate between being on pressure support and being off pressure support (eg using a face mask).  Our ICU has advised us that in this situation, the period of time spent on the face mask (between periods of pressure support) is considered weaning.  For example the patient may alternate between CPAP/BiPAP for a few hours and then a few hours using a face mask and then back onto CPAP/BiPAP.  When this occurs we continue to count the time spent on the face mask as hours of mechanical ventilation, considering the time on the face mask to be "weaning".

The difficulty comes when the patient spends long periods of time off pressure support and then returns to pressure support.  A recent example we came across was:

Patient had tracheostomy inserted on 11/2/04.  Returned to ICU.  Alternated between periods on pressure support and short periods off pressure support until 6.00am on March 3.  At this time, the patient went off pressure support and remained off pressure support until 21.00 on March 5, at which time pressure support was re-commenced (no reason for re-commencement documented).  In total, this patient spent approx 63 hours off pressure support, and then re-commenced pressure support for 10 hours.  At the end of the 10 hours, the patient went off pressure support for the last time.  Our question is, when calculating the total hours of MV in ICU do we include or exclude the 63 hours the patient spent off pressure support?

If we follow the guidelines above, we would include the 63 hours when calculating the total hours of MV.  Is this correct?  If it is correct, is there a time limit to how long a patient with a tracheostomy can spend off pressure support (in between periods of pressure support) before it is considered not to be weaning?

Search Details: August 2002 ICD Coding Newsletter

ACS 1006 Respiratory support, pg 165

Response:
If at the time the patient was taken off MV, there was an intention to recommence, the 63 hours should be included in the count of MV.  There is no time limit for the weaning period.  Coders should refer to ICU staff for clarification of documentation issues and determine if there was an intention to wean.  If however the weaning period was over, then the hours are not counted. The inquirer is advised to look for documentation to determine whether the patient had ceased CVS or was in the process of weaning.


Query Text:
Should a procedure code for bladder washout be assigned when it is performed in the emergency department or on the ward (without any type anaesthesia)?

For example, patient attends emergency department, diagnosed with haematuria and clot retention.  Indwelling catheter (IDC) inserted and bladder washout performed for clot retention.

Index
Lavage
- bladder (diagnostic) 11921-00 [1862]
- - for removal of blood clot(s) (closed) (endoscopic) 36842-00 [1092]
- - therapeutic, endoscopically controlled (hydrodilation) 36827-00 [1108]

Tabular List
Block [1092], code 36842-00  Endoscopic lavage of blood clots from bladder.

In the index, the term 'endoscopic' is a non-essential modifier, yet in the tabular list it's in the title, which is a little off-putting as the procedure was not performed endoscopically.

But the issue is, should this procedure be coded?  It is NOT included in ACS 0042 Procedures normally not coded.

If coded without the procedure code:

Haematuria           R31
Clot retention       N39.88

DRG = L65B           Kidney + urinary tract signs and symptoms without catastrophic or severe CC (medical DRG)(V4.2)
WIES = .4986

If coded with the procedure code:

Haematuria           R31
Clot retention       N39.88
Bladder washout                     36842-00 [1092]

DRG = L06B          Minor bladder procedures without catastrophic or severe CC (surgical DRG)(V4.2)
WIES = .7034

The assignment of this procedure code does have an impact on DRG assignment.  Should it be coded if it is not performed in theatre?

Response:
The Victorian ICD Coding Committee received the following updated response from the NCCH:

A term appearing in a code title does not have to be an essential modifier in the index.  This is the case with the indexing for 'lavage of bladder for removal of blood clot'.  Within the classification there are some defaults and therefore some of the terms appearing in code titles will appear as nonessential modifiers in the index.  This logic needs to be understood by coders when assigning codes.  In the case cited the 'endoscopic' code is the default for bladder washout for removal of a blood clot.  Although 'endoscopic' is a nonessential modifier in the index and a term in the code title in the tabular, this does not preclude clinical coders from assigning the code.

Following further discussion, the NCCH advises that a code should not be assigned for 'lavage of blood clots from bladder via IDC or supra pubic catheter'.  However, if a code is required at a local level or the procedure is performed using anaesthesia, assign:
36842-00 [1092] Endoscopic lavage of blood clots from bladder

The NCCH will consider adding this procedure to ACS 0042 Procedures Normally Not Coded.

This advice overrides advice previously published in the ICD Coding Newsletter Third quarter 2004 05.

The VICC will refer this to the Commonwealth with a view to making this a non-OR procedure.


Query Text:
33 year old male had autologous chondrocyte grafting in a hemiarthroplasty of knee for Osteochrondritis Dissecans.  The most suitable code we could find was 49503-02 [1520] Chondroplasty of knee.  In Block 1520 there is chondral graft with arthroscopy of knee, but in this instance, there is no arthroscopy.

Response:
In this scenario, the correct codes for autologous chondrocyte grafting are:
49503-02 [1520]  Chondroplasty of knee
14203-01 [1906]  Direct living tissue implantation

A similar query #1654 was published in the June 2001 ICD Coding Newsletter.


Query Text:
I am seeking some advice regarding the coding of sequelae of the adverse effects of drugs.   My query is how to code a sequelae of the adverse effects of drugs.
 
Patient:
admitted with Pdx of Viral Illness
also has ESRF secondary to analgesic nephropathy
CAPD 3 years
 receives PD whilst inpatient
 
As there is no indication that the nephropathy resulted from an improper use of drugs I decided to code this as an adverse effect.
 
Coding Option 1:

Principal diagnosis: Viral Illness 
N18.0 End Stage Renal Failure
N14.0 Analgesic nephropathy (coding instruction “use additional external cause code…to identify toxic agent)
Y45.8 Other analgesics and antipyretics
Y92.22  Health Service Area
 
However, this pt had the analgesic nephropathy more than three years prior to this admission.  I considered that the codes from coding option 1 indicated that the nephropathy was recent or current.  I then considered coding the ESRF as a sequelae of the analgesic nephropathy
 
Coding Option 2:
 
N18.0 End Stage Renal Failure
T96  Sequelae of poisoning by drug, medicaments and biological substances
Y86 Sequelae of other accidents
Y92.22  Health Service Area
 
However, I am not comfortable with T96 as there is no indication of poisoning. ACS 1901 also states that “Poisoning involves improper use.”  There is no indication in this record of improper use.
 
If it is not appropriate to code this as a sequelae in this instance, I would appreciate the committee’s advice and some examples as to how to code the sequelae of the adverse effects of drugs.

Response:
The end stage renal failure is not a sequelae of the adverse effect of drugs, it is secondary to the analgesic nephropathy which the patient still has.  A sequelae is a current condition that was caused by a previously occurring condition (or injury, poisoning, toxic effect or other external cause).  Sequelae applies when the underlying cause is no longer present (ACS 0008 Sequelae).

Therefore the correct codes to assign in this scenario are:
B34.9 Viral infection, unspecified
N18.0 End-stage renal disease
N14.0 Analgesic nephropathy 
Y45.8 Other analgesics and antipyretics
Y92.23  Place of occurrence, health service area, not specified as this facility


Query Text:
For patients admitted with diabetic foot, where one of the conditions is decubitus ulcer, can you please tell me if it is warranted to assign the L89 Decubitus Ulcer code as an additional diagnosis code after the E1-.73 Diabetes with foot ulcer due to multiple causes? 

Decubitus Ulcer is a clinical indicator and therefore collection of this data is often generated through diagnosis reports, however if we are not to assign L89 after E1-.73 as it is included in the code title, we are unable to capture the fact that these are decubitus ulcers. This is not an issue when the patient simply has diabetes and a decubitus ulcer as it is necessary to assign the ulcer code as an additional diagnosis code when using E1-.69

Response:
According to ACS 0033 Conventions used in the tabular list of disease, the main aim in coding is 'To translate medical statements into code'.  Therefore, decubitus ulcer can be assigned as an additional diagnosis code as this adds further specificity about the type of ulcer.

Fourth edition note
The codes for decubitus ulcer have changed in fourth edition (see below).
L89 Decubitus [pressure] ulcer
L89.0 Stage I
Decubitus [pressure] ulcer limited to erythema only
Note:  The ulcer appears as a defined area of persistent redness (erythema) in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues, without skin loss.
L89.1 Stage II
Decubitus [pressure] ulcer with:
• abrasion
• blister
• partial thickness skin loss involving epidermis and/or dermis
• skin loss NOS
L89.2 Stage III
Decubitus [pressure] ulcer with full thickness skin loss involving damage or necrosis of subcutaneous tissue extending to underlying fascia
L89.3 Stage IV
Decubitus [pressure] ulcer with necrosis of muscle, bone or supporting structures (ie tendon or joint capsule)
L89.9 Decubitus [pressure] ulcer, unspecified
Decubitus [pressure] ulcer without mention of stage


Query Title:
ACS 0401 Diabetes mellitus and impaired glucose regulation 4th Edition

Query Text:
In 4th edition of ICD-10-AM 'diabetes with multiple microvascular complications' (page 101 ACS 0401) does not contain the errata from the previous edition in the classification box. Is this to be amended via upcoming errata or are the categories to remain as stated?

If the categories are to remain as stated am I correct in understanding that a patient with a diabetic cataract (E1-.36) and acute renal failure (E1-.29) would not be classifiable to multiple microvascular complications but a patient with diabetes, a cataract and acute renal failure (E1-.39, H26.9, E1-.29) would?

Response:
This query was referred to NCCH who advised:

1. The code categories in ACS 0401 Diabetes Mellitus And Impaired Glucose Regulation, 'Diabetes with multiple microvascular complications, Classification' section were reviewed by clinicians for ICD-10-AM Fourth Edition.  'E1-.36' has been excluded.  Therefore, the code categories are correct as they currently appear in ICD-10-AM 4th Edition.

2. Your assumption regarding the scenarios described is correct. 'E1.-.39' and 'E1-.49' had to be included in the code ranges to capture eradicated conditions.  This will result in what appears to be inconsistencies.  However, the NCCH supports these current classification guidelines.


Query Text:
92 years old male patient was admitted with multiple medical problems. He complained of shoulder pain and shoulder X-ray showed gross atrophy or tearing of rotator cuff, some degenerative changes were present at gleno-humeral joint. Orthopaedic surgeon recommended Hydrodilatation of shoulder.  This was performed in X-ray Department and report reads as follows: 
" 11.4mgs of Celestone Chronodose in 2% Xylocaine was administered to the left shoulder and hydrodilatation undertaken with 25cc of contrast and saline. There is extensive opacification of the subacromial bursa consistent with complete tearing of the rotator cuff. The humeral head approximates the acromion".

I am not sure how to code Hydrodilatation of shoulder as there are no queries re this on NCCH site or coding matters and there is  no entry in procedure index for hydrodilatation of shoulder.

Search details:
From internet web site mia.net.au:  
Hydrodilatation is a useful technique which is being increasingly performed in patients with refractory adhesive capsulitis. This is also called distension arthrography or Brisement procedure. This procedure is performed by experienced radiologist and consists of fluoroscopic guidance of the needle via an anterior approach into the shoulder joint space. The intra-articular postion of the needle is confirmed by performing a mini arthrogram using radiographic contrast medium.  This is followed by intra-articular injection of Marcain and steroid such as Depo-Medrol or Celestone.
Approximately 60-80mls of saline is then injected slowly into the joint. This fluid distends the joint capsule and may also cause capsule disruption.
This procedure does improve the patient's symptoms and increases the patient's range of shoulder movement.

Response:
This query was referred to the NCCH for advice.

Please assign the following codes for documentation of 'hydrodilatation of the shoulder':
ICD-10-AM Third Edition:
50124-01 [1552] 'Injection into joint or other synovial cavity, not elsewhere classified'
59751-00 [1985] 'Arthrography'

ICD-10-AM Fourth Edition:
50124-01 [1552] 'Administration of agent into joint or other synovial cavity, not elsewhere classified'
59751-00 [1985] 'Arthrography'

It is not necessary to assign a separate code for the specific agent that is administered, in either edition of ICD-10-AM.

The excludes note following extension -09 in [1920] 'Pharmacotherapy' applies to the whole block (ie all of the codes in block [1920]).


Query Title:
Musculoskeletal injury to thoracic spine

Query Text:
The codes for non-specific injuries to the back are very non-specific. I am trying to code a musculoskeletal injury to the thoracic spine, there
was no fracture or lacerations, therefore I would be looking for an other specified injury of thoracic back, but the only code I have come up with is
T09.8 Other specified injuries of trunk, level unspecified. This code is really not suitable as the level of the injury is specified. Do you have any other suggestions? Should other specified/unspecified injuries to trunk codes be reviewed to include more specificity?

Response:
Musculoskeletal injury to the thoracic spine should be coded to:
S29.8 Other specified injuries of thorax.

The correct index look up is
Injury
-Thorax, thoracic  
--Specified type NEC S29.8


Query Text:
I have two questions from two records which I coded on the same day for which I would need clarification please.

1. A baby admitted at birth, who had several problems, and received a transfusion of Albumex. MIMS lists Albumex as a 'plasma volume expander'. I followed the index entry in Vol 4 - Transfusion, blood, expander 92063-00 [1893]  However, ACS 1615 (Specific interventions for the Sick Neonate) states to code this when performed for the neonate to 92062-00 Transfusion of other serum. Please advise which would be the correct code,
the fact that the index and the standards are different is very confusing.

2.  An adult admitted with multiple problems and receives a transfusion of Albumex.  Does the fact that Albumex contains human albumin (together with other substances used to treat hypovolaemic shock) classify it as a blood product? ACS 0302 Blood Transfusions states 'Blood transfusions and
infusions of blood products should be coded whenever performed'.  I am unsure whether I need to follow ACS 0302 and assign a code for Albumex
infusions in patients other than neonates.

Search Details: ACS 0302, ACS 1615, MIMS

Response:
This query was referred to NCCH who advised:

1. MIMS often classifies drugs according to their therapeutic purpose (indication) whilst ICD-10-AM usually classifies drugs according to class.  Although the purpose of transfusing Albumex may be to expand the blood volume (it is often used in the treatment of shock due to blood loss), it is a natural plasma component, prepared from pooled human plasma.

Transfusion of Albumex (or any albumin product) should be classified as per transfusion of plasma, 92062-00 [1893] Transfusion of other serum.  This is consistent with the advice in ACS 1615 Specific Interventions For The Sick Neonate.

2. Blood expander is classified as a type of blood product in ICD-10-AM; therefore 'transfusion of blood expander' should be classified according to the guidelines in ACS 0302 Blood Transfusions.

Transfusion of all blood products classifiable to block [1893] Transfusion of blood and gamma globulin (including extracts, synthetic/manufactured substances) should be assigned according to the guidelines in ACS 0302 Blood Transfusions.


Query Text:
Fracture distal radius and ulnar shaft.   X-ray reports, progress notes and operation report give no further information.  Codes obtained depend upon whether you follow the index for “distal” or for “shaft” i.e. fracture radius, with ulna, lower ends (distal) S52.6fracture radius, with ulna, shafts S52.4.

1. What is the correct code for this diagnostic statement.  Does “distal” or “shaft” take precedence?

2. The procedure notes say “the grossly deformed distal radius and ulna were manipulated gently”.  How should this be coded?   Should codes be:  47363-00 [1427] and 47363-01 [1428]  ie. code according to the “distal” sites of radius and ulna, or  47390-00 [1431] reduction of fracture of shaft of radius and ulna?

Response:
Neither distal nor shaft takes precedence.  The Victorian ICD Coding Committee is unable to provide a definitive response to this type of query.  Coders are advised to seek further information where possible.  If no further advice or information is available make a logical decision based on the relevant documentation.


Query Text:
Excision of gouty tophi - numerous sites over two separate episodes of care (February and May 2004).  Joint sites such as elbow, PIP toe, MIP toe etc.  Surgeon gave MBS number 30068 'Removal of foreign body in muscle tendon or deep tissue'.  This leads to DRG I27Z Soft tissue procedure.  We feel this is not an appropriate code and checking the index, suggested 90574-00 [1561] 'Excision of lesion of joint, not elsewhere classified'.  Being a new code, the surgeon can't access on MBS.  We feel this is a far more clinically suitable code, however the DRG attained is I23Z Local excision and removal of internal fixation device, excluding hip and femur, which may or may not be appropriate.

Could the committee suggest anything more appropriate?

Response:
The Victorian ICD Coding Committee agreed that code
90574-00 [1561] Excision of lesion of joint, not elsewhere classified
is the most appropriate for this procedure.

This is not a new code, rather it is a code created by the NCCH for ICD-10-AM.  The NCCH created codes (beginning with 9) to represent concepts that are not found in the MBS.


Query Text:
We have had some patients admitted with brain tumours (both primary and mets) having these lesions resected using posterior fossa craniotomy for excision approach.
The problem is the skull base surgery codes are all very specific.  Block [17] 'Skull base surgery for lesion', and none of the codes specify posterior fossa approach.
We cannot use a code from block [15] 'Removal of intracranial lesion' because this block excludes that by skull base surgery.
We believe that a code from block [17] would be most appropriate.
Our head of neurosurgery confirms that this is skull base surgery and that none of the codes from block [17] are appropriate. 
ACS 0612 'Skull base surgery' states that the posterior fossa is included in the skull base.

Response:
This query was referred to the NCCH who advised:

Thank you for the documentation supplied with this query.  The case cited describes ‘Posterior fossa craniotomy with excision of right cerebellar metastasis’.

As the 'posterior fossa craniotomy' cannot be classified to any of the specific codes in block [17] Skull base surgery for lesion, the NCCH suggests coding the case cited to 'Excision, lesion, cerebellum' 39709- 02 [15] Removal of lesion of cerebellum.


Query Text:
I wish to clarify if administration of surfactant to premature babies should be coded, and if so, what code should be used in 4th edition?  

Search Details: I have searched the NCCH query database and note that I have seen query 444.  The advise is to assign 92048-00 [1849] 'Other lavage of bronchus and trachea', however this query dates back to 1998 and this code no longer exists.  When looking up lavage of trachea, via intubation in the index, it directs the coder to use 22007-01 [568]'Management of endotracheal tube, single lumen'.  This code does not seem appropriate to use for this procedure.  I have also looked at block 1889, but there does not seem to be an appropriate code to use here either.
Surfactant can be given as prophylactic treatment for babies at a high risk of developing RDS or as therapeutic treatment of babies that have been clinically confirmed as having RDS.  Survanta is administered via a gavage tube cut so that the tip lies 1cm above the end of the endotracheal tube.

Response:
The NCCH supports the Victorian ICD Coding Committee’s assertion that 'administration of surfactant' should not be coded, as it is routine treatment for premature babies.

NCCH Query Q444 will be updated to incorporate this current decision.

The NCCH will consider the addition of this information to the relevant Australian Coding Standards for a future edition of ICD-10-AM.


Query Title:
Premature rupture of membranes followed by LUSCS

Query Text:
Re: O42.0 Premature rupture of membranes, onset of labour within 24 hours

When a patient is scheduled for an elective CS and her membranes rupture prior to the booked procedure, the patient goes on to have the CS.
The premature rupture of membranes must be coded, but this code description does not meet this scenario as the patient did not do into labour.
Can we please have the code description changed to reflect that this this may be used in the case of a CS?

That is:
O42.0 Premature rupture of membranes, onset of labour within 24 hours (or CS)

Response:
This query was referred to NCCH who advised:

For the case cited, 'premature rupture of membranes, delivery by caesarean section without any commencement of labour', assign:
O42.9 Premature rupture of membranes, unspecified

The advice in ACS 1531 Premature Rupture Of Membranes regarding discharge/transfer of patients following premature rupture of membranes is not applicable to the above scenario or NCCH query Q975.  The NCCH supports the decision for query Q975.


Query Text:
Patient admitted from a nursing home with a diagnosis of pneumonia, hospital acquired. Codes assigned J18.9 Pneumonia, Y95 Nosocomial condition.
Is it correct to follow the information contained in ACS 0111 - Bacteraemia, which instructs coders to add an exteral cause code Y95 (Nosocomial condition) for hospital acquired bacteraemia, for other scenarios?
The index entry for Y95 - Nosocomial condition, is found by looking up Factors, supplemental.  If I had not known about the entry in ACS 0111 I do not think I would ever have been able to find it in either the Index or Tabular, as I had to know the title of the block in the Tabular before I could find the Index entry, a backwards approach to coding! Would it be possible to have improved Index entries for this code?

Response:
This query was referred to the NCCH who advised:

The use of Y95 Nosocomial condition was discussed previously at the Classification Update Forum on Adverse Events.  Members of the forum did not support widespread use of this code as the term 'nosocomial' means 'pertaining to or originating in a hospital' and is therefore too vague to provide much detail on the circumstances of the adverse event.

The NCCH advocates the use of Y95 Nosocomial condition only when 'hospital acquired' is documented and no other reason for the infection/complication/adverse event can be determined.

The Victorian ICD Coding Committee has provided the NCCH with some suggested index enhancements for this condition.  The NCCH has advised that these will be considered for a future edition of ICD-10-AM.

The application of Y95 as explained above can also be applied to infections, complications and adverse events.


Query Text:
In relation to standard 2103 paragraph 3  'If the aftercare follows medical (versus sugical) treatment of a condition, assign the code for the condition as an additional diagnosis'.

Could you please explain in what circumstances you would apply this standard when in relation to medical care.

Response:
The Victorian ICD Coding Committee sought advice from the NCCH when preparing this response.

The NCCH advises that ACS 2103 Admission for convalescence/aftercare paragraph 3 will be altered in a future edition of ICD-10-AM to read, ‘If the convalescence follows medical (versus surgical) treatment of a condition, assign the code for the condition as an additional diagnosis’.

This advice can be applied immediately; therefore for episodes where this paragraph of ACS 2103 Admission for convalescence/aftercare applies, the principal diagnosis would be Z54.x Convalescence.


Query Title:
Decompression laminectomy with nerve decompression

Query Text:
Dx: Lumbar stenosis OP:Decompression laminectomy (one level)with nerve decompression

Problem: 2 different interpretations of the 'with'; convention.

INTERPRETATION 1

Laminectomy
- with 
--rhyizolysis 40330-01[54]

AND THEN

Laminectomy
-with
--decompression of spinal cord --see laminectomy,decompressive
-decompressive
--lumbar spinal canal
---1 level 90024-00[48]nb in tabular it says code also when performed spinal rhizolysis

Therefore 2codes
90024-00[48]& 40330-01[54]

INTERPRETATION 2
Laminectomy with rhizolysis code ONLY because it is under 'with'; and therefore takes precedence over the alphabetical  decompressive entry

Please advise as to what codes should be used.

Response:
Where both decompression of spinal cord and nerve root are performed, a code is applied for both procedures.  As coding attempts to translate medical statements into code, it is sometimes necessary to code one concept twice in order to show all procedures.  It is acceptable to represent the laminectomy twice in two separate codes in order to represent all procedures performed if this is the only option available.

From the operation report, the Victorian ICD Coding Committee was able to determine that two codes, one for decompression of the spinal cord and one for decompression of the nerve roots, are appropriate in this case. 

90024-00 [48] Decompression of lumbar spinal canal, 1 level
40330-01 [54] Spinal rhizolysis with laminectomy

There is a 'Code also rhizolysis' note at Block 48 Decompression of lumbar spinal canal.

Note: This query has been retired due to edition updates to the ACHI Alphabetic Index.


Query Text:
In regard to the changes to ACS 0401 p 103 'eradicated conditions in diabetes', there is a new note about an eradicated ulcer and how this is to be coded.  This information is additional to that given in the 3rd edition FAQs which only covered PVD and did not mention ulcers.

If the patient has diabetic foot (of which the ulcer is a part) and the foot is amputated or reconstructive vascular surgery allows the ulcer to heal, should we still code the patient as having diabetic foot (as per NCCH query #1746) or does the new advice on eradicated ulcers change this?

Search Details: ACS 0401 (4th edition)
3rd Edition FAQs
NCCH query #1746

Response:
TThe Victorian ICD Coding Committee sought advice from the NCCH when preparing this response.

New advice regarding eradicated conditions supersedes the advice in NCCH Q1746.  

Coding of these cases would depend on the condition at admission.

1. If the patient is admitted for diabetic foot for amputation, then code the diabetic foot.

2. If the patient has had a previous amputation for diabetic foot, then code E1-.51 and Z89.x unless other criteria for diabetic foot are met (presuming that PVD was the underlying cause of the ulcer).

The NCCH has advised that ‘the query database is an historical document; therefore queries are never deleted from the database.  The advice in query 1746 is relevant for ICD-10-AM Third Edition.  A note has been added to the decision for query 1746 to alert coders that the advice was superseded in ICD-10-AM Fourth Edition’.


Query Title:
Carotid sinus hypersensitivity with permanent pacemaker insertion

Query Text:
A patient admitted with recurrent syncope due to carotid sinus hypersensitivity undergoes insertion of permanent pacemaker.  I have coded G90.0 'Idiopathic peripheral autonomic neuropathy' with codes for the pacemaker insertion but this groups to DRG 901Z 'Extensive OR Procedure Unrelated to Principal Diagnosis'.  Should it be more appropriately grouped to a pacemaker DRG?

Response:
This is a grouper anomaly.  Patients with this condition are often treated with a permanent pacemaker insertion.  You have coded this correctly.

The Victorian ICD Coding Committee has referred this issue to the Commonwealth for investigation.


Query Text:
Our query relates to the use of the instructional notes in the tabular list of Diseases, (Volume 1) of ICD-10-AM.

This issue was raised during discussion regarding the assignment of additional codes ‘to identify the specific condition’ when assigning codes from O98 Maternal infectious and parasitic diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium, and O99 Other maternal disease classifiable elsewhere but complicating pregnancy, childbirth and the puerperium. Our discussion centred around whether an additional code should be assigned if that code was a non specific code.  For example, the addition D64.9 Anaemia, unspecified does not add further specificity to O99.0 Anaemia complicating pregnancy, childbirth and the puerperium.

It became apparent that there were significant inconsistencies in the way in which these instructional notes are generally applied.   

The following examples illustrate our concerns:

Example one:
The instructional  note:  Use additional code (B95–B97) to identify infectious agent appears under several codes in the tabular.  In practice our coders apply this convention only when the infectious agent is known.  They do not assign B96.88 Other and unspecified bacterial agents as the cause of diseases classified to other chapters when they do not know the infectious agent.

Example two:
The instructional note: Use additional external cause code (Chapter XX) to identify cause. Appears at J69.0 Pneumonitis due to food and vomit. In this instance our coders are applying the convention routinely and assigning W84 Unspecified threat to breathing as an additional code.  This is the default code supplied by the index to external causes when you look up aspiration and is not adding specificity about the pneumonitis (although data users would not know this).

There are numerous instructional notes instructing the coder to ‘add additional code to identify…’.  

Some of these are easily identified as instructions that are applied only when certain conditions exist (identify all manifestation of HIV), (identify presence of hypertension).  Others however imply that a code should be added even if no specific information is available (‘add additional external cause code to identify the drug’ appears at L27.0 generalised skin eruption due to drugs and medicaments)

The following list provides some examples of the variety of instructional notes that appear in Volume one.

‘Add additional code to identify…’
· the underlying disease
· infectious agent (B95-B97)
· infectious agent (B95-B97) if desired  (at J32)
· bacterial agent (B95-B96) (at M00.8, M65.0)
· the drug (external cause code)
· the cause (external cause code)
· if drug-induced or chemical-induced
· underlying condition or associated genetic syndrome
· external agent
· toxic agent
· presence of hypertension
· all manifestations of HIV infection
· any administered anticoagulant
· the type of thyrotoxicosis
· Use additional code to identify previous physical illness (at F48.0)
· Associated physical disorder (at F54)
· Associated conditions, such as autism, other developmental disorders etc (at F70-F79)
· If applicable, to identify mental retardation (at F84.1)
· any associated failure to thrive or growth retardation (at F94.1)
· the cause of any coexisting constipation
· cause, if known (at O21.8)
· obstetric cause of death
· Indicate resultant condition in fetus or newborn (if known) (at P02.3)
· associated malformations of nose
· External cause code for detail regarding alcohol level
· Indicate open wound with complication of foreign body, infection and delayed healing/treatment
· Open wound code to identify an open/compound fracture….
· Open wound code to identify an open dislocation….
· Dislocation with cervical vertebral fractures….
· Identify any cervical spinal cord injury
· Describe fractures associated with cervical dislocations….
· If mention of ventilator dependence
· Use additional external cause code to identify devices involved and details of circumstances (at T80-T88)

In addition to the instructional notes in the tabular, several standards either repeat the instructional note or direct coders to follow instructional notes.

ACS 0002 – Additional diagnoses:
Multiple Coding
As explained in ACS 0027 Multiple Coding, there are situations which require the assignment of additional codes which may themselves not meet the above criteria of an additional diagnosis.  The ICD-10-AM coding conventions referred to in that standard must be followed. For example, when using a code from category I60–I69 Cerebrovascular diseases, hypertension will also be coded if present as there is an instruction at this category to "Use additional code to identify presence of hypertension".

ACS 0027 – Multiple coding
2. Instructional terms
There are situations, other than in the dagger and asterisk system, that permit two ICD-10-AM codes to be used to describe fully a person's condition. Instructional terms such as 'Code also…', 'Use additional code for any…', 'Note…', identify many of these situations.
'Code also underlying disease' – Assign the codes for both the manifestation and underlying cause with the underlying cause being sequenced first. 

'Use additional code to identify manifestation, as…' – Assign also the code that identifies the manifestation, such as, but not limited to, the examples listed. 

Apply multiple coding instructions as directed in either the Alphabetic Index or the Tabular List.

ACS 1915 – Spinal (cord) injury
For open/compound fractures of the vertebral column, use additional open wound code (see also ACS 1917 Open wounds). Where several vertebrae are stated as compound, only apply one open wound code.

ACS 1521 Conditions complicating pregnancy:
To code other conditions complicating pregnancy (or being aggravated by the pregnancy or that are the main reason for obstetric care), a code from O98 Maternal infectious and parasitic diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium or O99 Other maternal diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium is assigned together with an additional code from the other chapters of ICD-10-AM to identify the specific condition.

Our question is:  Should the instructional notes be followed in every case, or should the coder make a decision regarding whether or not the additional code adds further information and only assign an additional code when this is the case.

Response:
This query was referred to NCCH who advised:

Coders should decide on an individual case basis if the assignment of an additional code is necessary to translate the medical statement into code.

See ACS 0027 Multiple Coding.


Query Text:
Could the committee please answer the following questions on the following case.  3 month old infant admitted for repair of bilateral undescended testes, one noted to be intra-abdominal and one inguinal.

Question 1.  We assigned the code Q53.29, following the index Undescended, testis,  bilateral and then assigned the fifth digit of .9 as there does not appear to be a combination code.  An alternative would be to assign two codes, one for unilateral, intra-abdominal and one for unilateral, inguinal.  Which code/s is correct?

Question 2.  It would not appear to be correct to assign Q53.xx Ectopic testis with the 5th digits for canalicular, inguinal or intra-abdominal, as these are the sites the testis normally progresses through in the descending process. Also it would not appear to be correct to assign Q53.1,2 or 9x Undescended testis with the 5th digit of 9 (Other specified site) as the movement of the testis is from the intra-abdominal cavity down through the inguinal canal to the scrotum, and all the other sites are normal positions of the descending testis.

Question 3.  Should there be a 5th digit for multiple sites?

Response:
Answer 1:
In this case it is appropriate to assign two separate codes to accurately describe the position of each of the undescended testes:
Q53.13 Undescended testicle, unilateral, intra-abdominal
Q53.12 Undescended testicle, unilateral, inguinal

Answer 2:
This will be forwarded to the NCCH for advice.

Answer 3:
A fifth character subdivision for multiple sites would not be appropriate, as this would not reflect the specific information provided in the record.


Query Text:
We wish to determine when to use the code Intraoperative computerised tomography Computerised tomography in conjunction with surgical procedure using interventional techniques 57341-00 [1966]

For example, a patient with low back pain, admitted for diagnostic dorsal root ganglion block.  Injection of anaesthetic at L3 under CT guidance.  At the NCCH 4th edition workshop this was an exercise scenario for the Pain Management topic.  The answers included dorsal root ganglion block; 18274-02 [63] and the Intraoperative computerised tomography 57341-00 [1966]

What is considered surgical procedure using interventional techniques?  Does this include procedures without incision?  Does this include injection of nerves paravertebral?  We assumed surgical procedure required an incision.

Search Details: ICD Coding Newsletter February 2004 page 5
Coding Feature - Back to basics - selected coding conventions;

NCCH 4th edition workshop Handout page 22  
Exercises Pain Management (2)

Response:
The Victorian ICD Coding Committee sought advice from the NCCH when preparing this response.  Their advice is reproduced below.

 The NCCH agrees with the VICC interpretation for usage of intraoperative procedure codes.
 
 'Intraoperative' procedures can include procedures performed without incision.  ACS 0016  General Procedure Guidelines discusses the difficulty of distinguishing between surgical and  non-surgical procedures.  'Intraoperative' procedure codes, including the following, should be  assigned when performed in conjunction with any significant procedure, including traditional non- surgical procedures.

 Assign codes in block [1949] Intraoperative ultrasound where an ultrasound has been  performed with another procedure.

 Assign codes in block [719] Intraoperative arteriography where an arteriogram has been  performed with another procedure.

 Assign 35200-01 [739] Intraoperative venography where a venogram has been performed  with another procedure.

 The above advice excludes where these procedures are performed for diagnostic purposes.

 The NCCH is considering amending the terminology in intraoperative procedure codes for  standardisation for a future edition of ACHI.

Specifically addressing the questions in your query.  A surgical procedure does not require an incision.  Injection of paravertebral nerves would be considered to be a surgical procedure for the purposes of this query.

Assign intraoperative codes where a radiological procedure has been performed in conjunction with another procedure.  For example:
CT guided biopsy of lung
38412-00 [550] Percutaneous needle biopsy of lung
57341-00 [1966] Intraoperative computerised tomography
as opposed to
CT of brain under sedation
56001-00[1952] Computerised tomography of brain


Query Text:
I would like to bring your attention to Example 2 in ACS 2113.

Patient admitted for followup of gastric ulcer (treated with medication) - the example directs coders to assign Z09.8 Follow-up examination after other treatment for other conditions
 
I would suggest that in light of a code name change in 4th Edition a more appropriate code would be

Z09.2 Follow-up examination after pharmacotherapy for other conditions

Search Details: ACS 0044 Chemotherapy

Pharmacotherapy is the treatment of a condition by means of drugs/s.

Response:
The Victorian ICD Coding Committee referred this query to the NCCH for information and advice.

The NCCH agrees with the suggestion to amend example 2 in ACS 2113 Follow-Up Examinations For Specific Disorders. 

The NCCH will amend the example for a future edition of the ACS.


Query Text:
In relation to the coding of GEM cases. Patients transferred for aftercare following a procedure who are admitted as a GEM care type.  Do you code the condition or aftercare code as the principal diagnosis?? 
Thank you

Response:
These episodes should be coded according to the documentation and ACS 0001 Principal Diagnosis.

If the patient is transferred for aftercare, apply ACS 2103 Admission for Convalescence/Aftercare.

If the patient is admitted for evaluation and management, apply ACS 2108 Assessment.

With the exception of rehabilitation, care type should not influence code assignment.  Victorian requirements specify that patients admitted under a rehabilitation care type must be coded with a rehabilitation principal diagnosis.


Query Title:
Conditions arising in the perinatal period

Query Text:
Would the committee please advise on the correct coding/use of ACS in the following scenarios.  My difficulty arises with the definitions contained in the ACS, Chapter 16 'Certain conditions originating in the perinatal period'.  ACS 1605 gives the definition of the perinatal period 'Commencing at 20 completed weeks and ends at 28 completed days after birth'.  ACS 1607 gives a definition for the neonatal period, as defined in Australia, which is similar to the perinatal period, in that it ends at 28 completed days after birth.

Infants who are still technically 'premature', who are over 28 days of age, as in the examples below, would seem to be excluded from the definitions within this chapter.  Also ACS 1615 Specific Interventions for the Sick Neonate states 'These standards will provide a valuable body of data which will assist in improving AR-DRG classification of neonatal conditions'.  All the scenarios listed below group to 'neonatal' DRG's, should the criteria listed in ACS 1615 apply in these cases, as they are not classified as neonates. Also some conditions are not 'arising in the perinatal period', therefore should they be coded to P codes or not?

 
1.  Infant transferred to our hospital at 30 days of age for ongoing care of prematurity.  Admission weight 1789 gms. (ex 27 week prem. birth weight 700 gms.,  so now technically only 32 weeks).  Infant documented as developing jaundice of prematurity, treated with phototherapy for 11 hours overnight.  Codes assigned P07.22, P07.02, P59.0, 90677-00 [1611]. (Following ACS 1618)   


2.  Infant transferred to our hospital at 63 days of age for ongoing care of prematurity, required one gavage feed only, then quickly progressed to bottle feeds.  Admission weight 2081 gms. (Ex 26 week prem twin 1, birth weight 880 gms. so now technically 35 weeks gestation)  Codes assigned P07.22, P07.03, 96202-07 [1920]. (Following ACS 1615)  

3.  Infant transferred to our hospital for ongoing care at 38 days of age from interstate, admission weight 1230 gms. (Ex 26 week prem. triplet 3, birth weight 706 gms. so now technically 31 weeks gestation).  Problem list on discharge 1.  Anaemia of prematurity - required top up transfusion  2.  Apnoea of prematurity  3.  Hyponatraemia - treated with IV infusion of electrolytes  4.  Oral candidiasis.  Codes assigned P07.22, P07.02, P61.2, P28.41, E87.1, B37.0, 13706-02 [1893], 96199-08 [1920]

Response:
The VICC referred this query to the NCCH who provided the following advice:
The NCCH agrees with the VICC that the codes for neonates still apply to babies >28 days for babies who are still in the birth episode/continuous from birth.

For patients who have been discharged (home) and then readmitted, neonatal codes may be assigned, if documentation indicates that their condition originated in the perinatal period.  This is supported by advice in ACS 1605 Definition of conditions 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 (16) regardless of the patient's age’.

The NCCH will consider amendments to the standards in Chapter 16 Certain conditions originating in the perinatal period of the ACS to clarify the above advice.


Query Text:
A patient with a known allergy to peanuts presented with anaphylaxis after eating food in a restaurant which he did not know contained peanuts.

Search Details: Previous advice in Coding Matters vol.4 no.1 in July 1997 and NCCH query #732 on 22.12.1998 both advised to code this to T78.0 Anaphylactic shock due to adverse food reaction and Y57.9 Other and unspecified drugs and medicaments, unspecified (causing adverse effects in therapeutic use).

Is this direction still current as Y57.9 appears to be an inappropriate code to use?  It would be difficult to extract information on anaphylactic reactions to foods as opposed to medicinal substances while this code is being used for these cases.  If this advice is still current and there is no better code we would suggest adding a new code in future editions for these cases which are reasonably common and are becoming moreso.

Response:
This query was referred to the NCCH who provided the following advice:
The NCCH has investigated this issue in depth on a number of occasions.  The ICD-10-AM External Causes of Injury Index entry for 'Anaphylactic shock, anaphylaxis' classified to Y57.9 Drug or medicament, unspecified is consistent with ICD-10.  There is no specific index entry or external cause code for anaphylactic shock 'due to food ingestion'.

X58 Exposure to other specified factors or X59 Exposure to unspecified factor have previously been suggested as an alternative to Y57.9.  As neither X58 nor X59 offer any more specificity in relation to the type of foodstuff consumed, the NCCH does not support the assignment of these codes as a long term option.

The NCCH is unable to alter the above classification without approval from WHO Update Reference Committee (URC).  A proposal was presented to WHO URC (by the Nordic Centre) in 2004 but following discussion with members of that committee was subsequently withdrawn for further research prior to resubmission.  The NCCH will investigate the progress of this proposal, specifically in relation to the possibility of an expanded external cause code to indicate the type of food.

In the meantime, where anaphylactic shock due to ingestion of food is documented, assign the following codes:
T78.0 Anaphylactic shock due to adverse food reaction
Y57.9 Drug or medicament, unspecified
with appropriate place of occurrence code.

The VICC has requested that NCCH give consideration to an index entry for anaphylactic shock due to food ingestion for sixth edition.


Query Text:
I am seeking confirmation about coding a patient who was admitted in false labour before 37 weeks gestation.

The patient was observed overnight and the next day was discharged home.  She had pains and tightening, but VE showed a closed cervix.  I have coded the record:
    O470 False labour before 37 weeks, and
    O095 34-36 completed weeks of gestation, and grouped to O64A

Can you please confirm this is correct in light of latest HDSS Bulletin and coding changes.

Response:
The Victorian ICD Coding Committee sought advice from the NCCH when preparing this response.

The enquirer’s coding is correct.  ACS 1550 'Discharge/transfer in labour' is applied when the patient is in true labour.

There has been some confusion about the application of this ACS, mainly due to the inclusion of information about false labour.  The VICC has prepared a submission to the NCCH requesting that ACS 1550 be reworded to remove any confusion around this issue.

The information in the June 2004 Victorian ICD Coding Newsletter referred to women who’s labour is induced, rather than those presenting in false labour.  This information is reproduced here.  ‘Specifically, where patients are admitted for induction and are subsequently sent home to wait for established labour, they should be put on leave (as you are expecting the patient to return within seven days), rather than be separated with a new admission recorded when they return.’


Query Title:
Open reduction and internal fixation (ORIF) of fractured ribs

Query Text:
A 70 year old man was involved in a traumatic blunting injury to his chest.  His injuries included several rib fractures on his left side.  An ORIF was performed to repair these fractures.

I was hoping to obtain some advice as to what code/s to assign for this procedure as a specific code for ORIF of rib fractures does not exist.  For the meantime I have assigned 
47921-00[1554] Insertion of internal fixation device, not elsewhere classified
Reinsertion of internal fixation device
Revision of internal fixation device
Includes: insertion of:
• pin
• plate
• wire
Excludes: that with reduction of fracture or dislocation – omit code

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

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

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


Query Text:
74 year old male admitted for endoscopic procedure for gastro-oesophageal reflux.
New procedure to hospital with injection of 'enteryx' (a co-polymer) into lower oesophageal tissue, this is supposed to bulk up the tissue
to help against reflux. Item number used by doctor - 30490 -

Unsure on choice of codes for procedure
1. K21.9      - oesophageal reflux
   30490-00   - endoscopic insertion of oesophageal prosthesis
   DRG G41A

2. K21.9
   30476-00   - Endoscopic administration of agent into non-bleeding lesion of oesophagus
   DRG G41A

3. K21.9
   90301-00   - Other procedures on oesophagus
   30473-00   - gastroscopy
   DRG G03C

Response:
The Victorian ICD Coding Committee sought advice from the NCCH when preparing this response.

The VICC noted that Enteryx is considered a prosthesis in Schedule 5 ' Benefits Payable in Respect of Surgically Implanted Prostheses, Human Tissue Items and other Medical Devices', and the NCCH supports the assignment of:
30490-00 [853] Endoscopic insertion of oesophageal prosthesis.


Query Text:
Appreciate confirmation of correct coding - have been using Z51.81 Apheresis and 13755-00 [1892] Donor haemapheresis, with particular reference to old advice 1 & 2 in 'Search Details' below.

Search Details: 
1. NCCH ICD-10-AM Commandments Vol 7, No 4, Mar 2001 - Apheresis.
2. NCCH queries database #1375, Donor haemapheresis, 21/12/2000.

Response:
This was referred to the NCCH who provided the following advice:

The NCCH agrees that apheresis for procurement of any blood component should be assigned Z51.81 Apheresis.  This is consistent with the advice in query Q1375 (21/12/2000).

The NCCH will consider changes to the table in ACS 0030 Organ procurement and transplantation for a future edition of the Australian Coding Standards.


Query Text:
Our hospital has recently begun performing sacral modulation for faecal incontinence and we are unsure how to code this.  This procedure is done in
two phases.  The first phase involves having electrodes implanted in the sacral nerves in a day surgery procedure which are later connected to an
external pulse generator. The second phase involves the implantation of a pacemaker about the size of a cigarette lighter, in the upper back or lower abdomen.  The patient contols the pacemaker with an activator, thus enabling bowel control.

We feel that the appropriate codes for this procedure are:
Phase 1:
39130-00 Percutaneous insertion of epidural electrodes
Percutaneous:
• burying } 
• replacement} 
• revision} of epidural electrodes
• threading} 
• tunneling } 
Includes: trial of dorsal column stimulator
Excludes: that with subcutaneous implantation of spinal neurostimulator device (39130-01 [43])


Phase 2:
39134-00 Subcutaneous implantation of spinal neurostimulator device/receiver
Replacement of subcutaneous spinal neurostimulator device
Revision of subcutaneous spinal neurostimulator device
Subcutaneous implantation of:
• spinal pulse generator
• spinal radiofrequency (emitting) device/receiver
Excludes: that with insertion of epidural electrodes (39130-01, 39139-01 [43])

With a diagnosis code of R15 Faecal Incontinence, this groups to a 901Z.
However, there is a code for Insertion of anal electrode at 32206-00 [929] which may be more appropriate.

Response:
This query was referred the NCCH who provided the following advice:
The NCCH supports the codes selected by the enquirer for the case cited.  However, clinical advice states that phase 1 (implantation of electrodes into sacral nerves) may be performed as an 'open' procedure.  If documentation indicates that phase one is an open procedure, assign:
39139-00 [43] Insertion epidural electrodes by laminectomy

MBS contains item numbers that may be more appropriate for this procedure.  NCCH will consider adding them to a future edition of ACHI.

The NCCH and clinical advice support the assignment of K59.2 'Neurogenic bowel, not elsewhere classified' for documentation of 'neuropathic faecal incontinence'.


There is an index error at Insertion, electrode, anal, directing coders to assign: 32206 00 [929] Insertion of gracilis neosphincter pacemaker.  This code is actually in Block [940].  The NCCH is aware of this and has amended it in fifth edition.


Query Text:
Does the criteria in ACS 1550 Discharge/Transfer in labour, apply to admission or discharge gestation?
Patient admitted at 36 + 6 weeks gestation in labour.  Due to lack of beds in post natal ward and nursery patient transferred to another hospital the
next day for further care  (now 37 weeks gestation).
If the criteria are for gestation on discharge then a code from Z34 'Supervision of normal pregnancy' would be assigned.

However, if the criteria are for admission gestation then the correct code to assign would be O60 'Preterm delivery'.
ACS 1518 Duration of pregnancy, refers to duration of pregnancy on admission. This standard would also have to be followed when assigning O60
Preterm delivery, and it seems inappropriate to assign one code based on duration of pregnancy on discharge (Preterm labour) and the corresponding code based on duration of pregnancy on admission (Duration of pregnancy).

Response:
The Victorian ICD Coding Committee sought advice from the NCCH when preparing this response.

For the case cited, follow the index pathway(s):
Contractions
- preterm without delivery O60
or
Labour
- early onset (before 37 completed weeks of gestation) O60
or
Pregnancy
- complicated by
- - onset of contractions before 37 weeks of gestation

Assign the following codes: 
O60 Preterm delivery
O09.5 34-36 completed weeks

Gestation at the onset of labour, as opposed to gestation at admission is used for determining appropriate code assignment.

O60 Preterm delivery is assigned when the onset of delivery (that is, the commencement of labour/contractions) is before 37 completed weeks of gestation, as in the case cited.

The absence of a code from Z37 Outcome of delivery in the code string indicates that the patient did not deliver during this episode of care.

Note that in Fifth Edition the title of this code will be Preterm labour with three new codes denoting without delivery, with preterm delivery and with term delivery.


Query Text:
Could the committee please advise on the coding and application of the ACS's in the following case.
We had a 28 year old patient admitted with a diagnosis of obesity, for gastric stapling.  The patient is an IDDM diagnosed at age 6.  There were
no other complications recorded, particularly no diabetic manifestations. Codes assigned:  E10.9 'Type 1 diabetes mellitus without complication', E66.9 'Obesity, unspecified', Gastric reduction code and G.A.

I have applied ACS 0401 'Diabetes Mellitus and Impaired Glucose Regulation', pg 88 Classification which states 'When
unqualified obesity (E66.x) .....is documented with Type 1 diabetes mellitus, assign the appropriate diabetes code with these conditions as
additional diagnoses'.  This was also in the standards for 3rd edition, but in a different place and not so specifically written.  This would be a
change of coding practice to code in the above way, and I am unsure if this is the intent of this particular part of the standard.

Response:
This query was referred to the NCCH for advice.

The NCCH agrees with the interpretation of this section of ACS 0401 Diabetes mellitus and impaired glucose regulation.  When unqualified 'obesity' (E66.-) or hypertension (I10) is documented with Type I diabetes mellitus, assign the appropriate diabetes code with these conditions as additional diagnoses.


Query Text:
I believe ACS 1506 'Malpresentation, disproporation and abnormality of maternal pelvic organs' Page 202 'Presentations regarded as abnormal' lists 'persistent occipito-posterior position' as being the same as 'face
to pubes'.  However, in the Alphabetical index of diseases these are listed separately and have different codes assigned.  Is the Index entry
incorrect, or the ACS, I have always believed them to be the same condition but cannot understand why the Index entries are now different?

Response:
This query was referred to the NCCH for advice.

The NCCH acknowledges the error in the Alphabetic Index of Diseases.  The correct codes and pathways should be as follows:

Malpresentation
-face
--to pubes O32.3
-persistent occipitoposterior (position) O32.3

Presentation
-face
--to pubes O32.3
-persistent occipitoposterior (position) O32.3

The NCCH will amend the error in a future edition of ICD-10-AM.

To ensure that face to pubes presentation is coded accurately, apply this advice from the NCCH immediately rather than wait for this to be amended in a future edition of ICD-10-AM.


Query Text:
Patient with elective admission for Nissen Fundoplication.  Patient has CF with GORD.  

The operation report states Diagnosis as: CF, severe reflux oesophagitis.
Operation:  Laparoscopic Nissen Fundoplication.


This patient also has bronchiectasis with pseudomonas treated during this admission.

If the GORD is sequenced as PDx this case will group to G03B Stom, Oesophal, Duodenal Pr No Mal +C/S CC, with WIES of 4.4602.

If CF with other manifestations (E84.8)is sequenced as PDx, this case will group to 901Z Ext OR Proc unrel to PDX.

Our question is, can CF with Intestinal manifestations (E84.1) be sequenced as PDx?  If this is done, the case will group to G03B Stom, Oesophal, Duodenal Pr No Mal +C/S CC.

If Standard 0402 Cystic Fibrosis is followed, E84.8 should be PDx.
We thought it might be better to treat CF a bit like diabetes, and if the reason for admission is to treat one particular manifestation, that the CF code for that be sequenced as PDx, and then the multiple code be sequenced further down in the string.  This would then allow this to group to the gastrointestinal DRG.

Search Details: Stnd 0402 Cystic Fibrosis

Tabular Entries E84.8 and E84.1

Response:
The Victorian ICD Coding Committee referred this query to the NCCH who provided the following advice:

For the case cited, assign:
E84.1 Cystic fibrosis with intestinal manifestations
K21.0 Gastro-oesophageal reflux disease with oesophagitis

Thank you for your suggestions for reviewing the coding of cystic fibrosis.  The NCCH will consider amendments for a future edition.  In the interim, advice for your specific concerns is as follows:

Q. Does intestinal include gastrointestinal? 
A. The NCCH will present a submission to the WHO Update Reference Committee to determine whether 'gastrointestinal' manifestations of cystic fibrosis should be classified to E84.1 Cystic fibrosis with intestinal manifestations.  In the interim, the NCCH supports the classification of 'gastrointestinal' manifestations as per 'intestinal' manifestations of cystic fibrosis.  For classification purposes this is the best fit available in E84 Cystic fibrosis.

Q. Should consequences of manifestations always be coded or only if they meet ACS 0002 Additional diagnoses? 
A. ACS 0402 Cystic Fibrosis advises that; ‘Cystic fibrosis should be coded with the appropriate code from E84 Cystic fibrosis followed by a code for any specified manifestation’.  That is, whenever cystic fibrosis is coded for an episode of care, all specified manifestations should also be coded. 
Q. Clarify note in ACS 0402 Cystic Fibrosis that .8 is used for cases with combined manifestations.
A. The NCCH supports the guidelines in ACS 0402 Cystic Fibrosis; E84.8 Cystic fibrosis with other manifestations should be assigned for cases with combined manifestations.

Q. Should these be coded out?
A. As per the advice in ACS 0402 Cystic Fibrosis, a code for any specified manifestation should follow a code from E84 Cystic fibrosis.  This advice is further supported by ACS 0027 Multiple Coding that advises multiple codes may need to be assigned to reflect the various components of a disease and to ensure that the entire medical concept is captured.

Q. Once cystic fibrosis needs to be coded, should all manifestations be coded whether they meet criteria for coding or not?
A. As per the advice above, whenever cystic fibrosis is coded for an episode of care, all specified manifestations should also be coded.

The VICC interpretation of the response is that you can code the specific manifestation (in this case .1) followed by other manifestations (.8) if the specific manifestation (in this case .1) is the reason for the admission.

CF patients are living longer and developing new manifestations of the disease that didn't occur previously when patients had a shorter life expectancy.  This is an example where the classification is not managing to keep up with clinical practice.

The VICC will develop a public submission seeking review of the manifestations of cystic fibrosis for the ACS.


Query Text:
This query has arisen from the PICQ fatal error message sent by the DHS.  The error states '101393 Harmful use of alcohol code with specific related disorder code'.  While trying to correct this error we are finding that there is a conflict in the ACS.

The ACS 0503 DRUG, ALCOHOL AND TOBACCO USE DISORDERS 3rd/4th edition states 'Note from the above definition that the fourth character of '1' cannot be assigned if a specific drug/ alcohol related disorder is present, specifically, dependence syndrome or a psychotic disorder'.

The General classification rules (2nd dot point) also state 'When more than one of 'acute toxication', 'dependence' or 'harmful use' are documented, assign the appropriate codes for those descriptions.

Which one of these rules do we apply?  Do we delete F10.1 Mental and behavioural disorders due to use of alcohol, harmful use if a specific drug alcohol related disorder is present or do we assign the appropriate codes for those descriptions?

Search Details: ACS 0503 DRUG, ALCOHOL AND TOBACCO USE DISORDERS
PICQ fatal error message sent by the DHS. 101393 Harmful use of alcohol code with specific related disorder code.

Response:
Acute intoxication can be used with any of the codes from that section (eg .1, .2 or .3) whereas Codes for 'Harmful Use' of a specific drug/alcohol (.1) can only be used with 'Acute intoxication' (.0) for the same drug/alcohol.


Query Text:
In a previous admission patient with breast carcinoma had Patey mastectomy with clear excision lines.  Represents six months later with a lump under the mastectomy scar which was removed.  Histopathology revealed no evidence of breast tissue.  'Fat necrosis…a right chest wall lump…a soft, predominantly fatty tissue mass 60x40x27mm'.
Volume 2 index
Necrosis, necrotic (ischaemic) (see also Gangrene)  
-fat (generalised) M79.8-
--breast (aseptic) N64.1 
--postprocedural M96.8 

Can you please advise correct diagnosis code?

We feel that 
90575-00 [1566] 'Excision of soft tissue, nec' is the most appropriate procedure code.  Please advise.

Response:
This query was originally published in the 2004-5 March Database as follows:

There is no documentation that the fat necrosis is due to the procedure; therefore this cannot be coded as post-procedural per ACS 1904 Procedural complications.

Follow the index entry:
Necrosis, necrotic
-fat M79.8-

M79.88 Other specified soft tissue disorders, other site

Do not use 'breast' as there is no breast tissue in the sample.

Based on the information you have provided, the procedure code selected is acceptable.


Following review by the committee for currency the response has been updated as follows:

There is no documentation that the fat necrosis is due to the procedure; therefore this cannot be coded as post-procedural per ACS 1904 Procedural complications.

Follow the Index entry:
Necrosis, necrotic
-fat M79.8-

M79.88 Other specified soft tissue disorders, other site

Do not use 'breast' as there is no breast tissue in the sample.

For the scenario sited, VICC advises the correct procedure code to assign is 31350-00 [1566] Excision of lesion of soft tissue, not elsewhere classified following Index entry Excision/lesion(s)/soft tissue NEC.


Query Text:
The alphabetic index appears inadequate for coding herpes simplex conjunctivitis. Using the index for Herpes, conjunctivitis leads to
B02.3 Zoster ocular disease
Zoster:
• blepharitis† (H03.1*)
• conjunctivitis† (H13.1*)
• iridocyclitis† (H22.0*)
• iritis† (H22.0*)
• keratitis† (H19.2*)
• keratoconjunctivitis† (H19.2*)
• scleritis† (H19.0*)

There is no additional entry for herpes simplex conjunctivitis.  Also look up under herpes simplex there is no index entry for conjunctivitis.  Yet in the Tabular list, code H13.1* Conjunctivitis in infectious and parasitic diseases classified elsewhere, includes Conjunctivitis (due to) herpesviral [herpes simplex] (B00.5†).

Response:
This was referred to the NCCH who provided the following advice:

For documentation of 'herpes simplex conjunctivitis' assign:
B00.5 Herpesviral ocular disease
H13.1* Conjunctivitis in infectious and parasitic diseases classified elsewhere by following the index pathway:
Conjunctivitis
-herpes (simplex) (virus) B00.5† H13.1*

The NCCH will consider amendments to ICD-10-AM Alphabetic Index under the lead term ' Herpes, herpetic' to clarify code selection for this condition.

The code selection for the index pathway:
Herpes, herpetic
-simplex
--eye B00.5† H58.8*
B00.5 Herpesviral ocular disease
H58.8*Other specified disorders of eye and adnexa in diseases classified elsewhere is correct and supported by ICD-10 WHO Alphabetic Index:
Herpes, herpetic
-eye
--simplex B00.5† H58.8*

Note however, that where a specific eye condition is documented with herpes simplex (for example conjunctivitis, iritis, keratitis etc), a code for this condition should be assigned as the asterisk code in preference to H58.8.

The Victorian ICD Coding Committee suggests that coders refer to the specific condition in the index when coding eye complications of herpes.


Query Text:
Elderly male admitted with infective exacerbation of COAD.
Infections being a chronic problem and were extensively investigated Cultures identified 3 organisms.  In particular a heavy growth of
'CORYNEBACTERIUM PSEUDODIPTHERITICUM'

ICD10 index under Infection there is an entry for 'corynebacterium diphtheriae' - see diphtheria (A36.x)

The patient does not have diphtheria (confirmed with doctor)

Should I code to A36 or take note of the ?key word 'pseudo' and code to other bacterial organism A48.8 other specified bacterial organism.

Search Details: Spoke to communicable disease section of DHS - they were not sure what to do - suggested I code it to diptheria and send them a 
copy of the microbiology report.

Response:
To follow an index entry you must find the exact description of the organism.  In this case there is no index entry for Corynebacterium pseudodiphtheriticum.  Therefore in the absence of an exact description of the organism in the alphabetic index, you should follow the index entry:
Infection
-bacterial NEC  
--agent NEC 
---as cause of disease classified elsewhere B96.88 

Your codes will be:
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory    tract infection
B96.88 Other and unspecified bacterial agents as the cause of diseases classified to other chapters

Refer to the Coding Newsletter article compiled by Irene Kearsey titled 'Bring out your dead! Has the Black Death returned?’ published in the August 2002 Coding Newsletter for further information.


Query Text:
Pt admitted with distal oesophageal ca for Ivor-Lewis Oesophagectomy.  Abdominal incision made and proximal stomach was resected and oesophagus mobilised, feeding jejunostomy inserted.  Thoracotomy done, lung collapsed, oesophagus mobilised to the hiatus. Stomach was pulled up and anastomosed to the oesophagus.  Drain tubes etc inserted and pt closed up. (This is a brief  version of the op report).  pathology listed 5 cm of oesophagus and the proximal stomach received.

There appears to be a problem with the indexing of Ivor-Lewis Procedures.  If you look up Procedure, - Ivor Lewis, you are directed to 'see Oesophagectomy and Gastrectomy, total'.

Oesophagectomy in the index, then is listed by the site of mobilisation being abdominal, thoracic, transthoracic and cervical.  One of the surgeons who performed the above operation looked at the index and stated that it did not make sense and that there is no difference between thoracic and transthoracic.  In the MBS schedule there is no mention of 'transthoracic' mobilisation. Could there be a review of the indexing and tabular of 'oesophagectomy'?  

When asking the surgeon about a code for the above Ivor Lewis Procedure that he performed, he was at a loss as to which code in the tabular best fitted the surgery that he performed.  He chose a code that he thought was the 'closest' to what he had done 30535-00 [860]

In addition to the oesphagectomy component of the procedure we are also directed to see 'gastrectomy, total' yet all the procedures that I have coded have usually only involved a partial gastrectomy of the proximal stomach.  On checking the coding of others, they are following the direction in the books and coding it to a total gastrectomy, could this be reviewed in the procedure index?

Response:
This query was referred to the NCCH who provided the following advice:

Many procedures in ACHI are identified by eponyms, such as Ivor Lewis procedure.  When eponyms are listed in the Alphabetic Index, the index usually gives a short description of the procedure or the site of the operation.  In the example of Ivor Lewis procedure, the description listed in the index is 'oesophagectomy' and 'gastrectomy, total'.  Coders must, however, confirm what procedures were actually performed for each case by referring to the operation report.  In the case cited, a partial gastrectomy was performed instead of a total gastrectomy, therefore code assignment should reflect this.

The NCCH will consider amendments to the indexing of Ivor Lewis procedure for a future edition.

In the meantime, based on the information provided and in the absence of a default code for oesophagectomy, the VICC recommends that you code the case cited as follows:
30536-00 [860] Oesophagectomy by abdominal and transthoracic mobilisation, with cervical oesophagogastric anastomosis
30518-02 [875] Partial proximal gastrectomy with oesophagogastric anastomosis


Query Text:
24 year old female with total ostectomy of 8th rib for a ?maligant tumour.  Histopathology (report attached) indicates 'giant cell reparative granuloma with early aneurysmal bone cyst formation, rib, benign.
Aneurysmal bone cyst of the rib is coded to M85.58 Aneurysmal bone cyst.

The index look up for granuloma is:
Granuloma L92.9 
-bone M86.8- 
-
-
-giant cell (central) (jaw) (reparative) K10.1 

M86.8 is Other osteomyelitis
while
K10.1 is Giant cell granuloma, central of jaw

Can you please advise the most accurate code to assign?  I would like to suggest that this be forwarded to the NCCH for a possible amendment to the classification.

Response:
The Victorian ICD Coding Committee recommends coding both the bone granuloma and the aneurysmal bone cyst.  Codes to assign are:

M86.88 Other osteomyelitis, other site
M85.58 Aneurysmal bone cyst, other site

This is will be referred to the NCCH for review of the indexing of giant cell granuloma.


Query Text:
Does ca = cancer or carcinoma? Unfortunately both have different M codes and so would be coded differently.

In the index under cancer there is a note that says "The term 'cancer' when modified by an adjective or adjectival phrase indicating a morphological type, should be coded in the same manner as 'carcinoma' with that adjective or phrase.  Thus, 'squamous cell cancer' should be coded in the same manner as 'squamous cell carcinom',  which appears in the list under 'carcinoma'."

Our hospital would like to be consistent between coders. So when ca is written and no descriptive word as detailed above, we all know whether to code as cancer or carcinoma.

Response:
The following advice was published in Coding Matters Volume 12 Number 3 December 2005:

The NCCH was asked to clarify whether the abbreviation ‘Ca’ should be interpreted as ‘cancer’ or ‘carcinoma’.  The NCCH was also asked which morphology code to assign when the abbreviation ‘Ca’ is used in the absence of any other defining documentation in a medical record.

Clinicians, cancer registries and various medical dictionaries have all indicated that ‘Ca’ can be used interchangeably to mean ‘cancer’ or ‘carcinoma’.  On further review of the use of this abbreviation,
WHO ICD-10 indicates that the term ‘cancer’ when modified by an adjective or adjectival phrase indicating a morphological type should be coded in the same manner as ‘carcinoma’ with that adjective or phrase.  Thus, ‘squamous cell cancer’ should be coded in the same manner as ‘squamous cell carcinoma’, which appears in the list under ‘Carcinoma’ (ICD-10-AM Fourth Edition Alphabetical Index of Diseases).

If the term ‘cancer’ is preceded by a term other than a morphological descriptor, assign the morphology code M8000/3 Neoplasm, malignant.  Therefore, if prostate Ca is documented without any available histology report or clinical clarification, assign M8000/3 Neoplasm, malignant.

Inconsistencies in classification examples in the Australian Coding Standards (ACS) will be amended for ACS Fifth Edition.

This advice overrides advice previously published in the ICD Coding Newsletter Third quarter 2004 05.


Query Text:
Often we have the diagnosis of impingement shoulder documented as the reason for a subacromial decompression.
Unfortunately in the index there is no entry for impingement shoulder.
The only appropriate code contains the word "syndrome" (M75.4).  Is impingment shoulder syndrome the same as just impingement shoulder?

Dictionary definitions:

Impingement - no definition
Impingement syndrome - a progressive condition of shoulder pain and dysfunction, usually caused by repetitive placement of the arm in overhead positions.

Response:
VICC members consider M75.4 Impingement syndrome of shoulder to be the correct code to assign for this case.  Impingement describes a symptom of the underlying condition of the shoulder.  

The VICC has referred this to the NCCH requesting indexing of this condition under 'Impingement, shoulder'.


Query Text:
There appears to be errors in the Index which were identified by our coders in a recent education session.
Flexion, deformity joint, hip congenital Q65.8
Deformity, flexion (joint), hip, congenital Q65.9
Also the default appears incorrect for:
Flexion, deformity joint, M21.29
Deformity, flexion (joint), M21.2x

Response:
The Victorian ICD Coding Committee forwarded this query to the NCCH for advice who provided the following response:

Thank you for bringing this issue to the attention of NCCH.  The NCCH will consider amending the highlighted areas in the Alphabetic Index of Diseases.


Query Text:
I have 2 related questions.
1. At one of the 4th edition education sessions it was stated by the NCCH presenter that ACS 1221 (Pressure Ulcer) could be applied to documentation of 'pressure area'.  'Ulcer' or 'sore' did not have to be documented.
However, this is not clearly stated in the ACS, and I am unsure whether to follow this advice.  Under 'definition' in ACS 1221 it mentions 'a pressure ulcer is an inflammation, sore or ulcer', but does not mention 'area'.
I have a patient with documentation on the care plan/action record of 'pressure area outer aspect R heel - duoderm prn' and another patient with the documentation of 'sacral pressure area'. Can I code L89.x from this type  of documentation? I have another patient with 'pressure area' documented by nursing staff on the progress notes, and this is qualified on the wound chart as 'pressure area stage 11.  Do coders have to have qualification of 'pressure area' to code it?
2. I believe that sometimes 'pressure area' is used to mean a 'pressure sore' even if there is no actual ulcer or skin break, as in L89.01 Decubitus Ulcer stage 1.  However, 'pressure area' also appears to be used for cases where a patient needs turning or to use a pillow under their limb because there is a pressure area but once pressure has been relieved, the condition is no longer present.  
How are coders to differentiate between these terminologies.

Response:
This query was referred to the NCCH who provided the following advice:
The original proposal for changes to the pressure ulcer section of ICD-10-AM was the result of a public submission received in February 2002 from a Clinical Nurse Consultant requesting an expansion of L89 to provide more specificity.

Further information was received to support this request from a CCCA member and a representative from QIEP Pressure Ulcer Management Project Team QLD Health Department regarding the classification stages.  Information was also obtained from the Australian Wound Management Association to further clarify the various stages of a pressure ulcer.  Subsequent to this the changes were made to the classification.

The turning of patients to reduce pressure on various areas of the body (that is, pressure care) is a preventative measure and constitutes normal nursing care.  However, when these areas become ‘a defined area of persistent redness’ and require further treatment for example, application of duoderm and therefore meet the criteria of ACS 0002 Additional diagnoses, L89.0 Decubitus [pressure] ulcer, Stage 1, may be assigned.

The NCCH acknowledges that the term ‘decubitus’ is not relevant in current clinical practice.  ICD 10 AM is based on ICD 10 and under contractual agreement with WHO changes cannot be made to code titles at the third character level.  This issue was explained during Fourth Edition education workshops.

In answer to specific concerns cited:
· If ‘pressure area’ is documented and not further qualified, and it meets ACS 0002 Additional diagnoses a code from L89.x Decubitus [pressure] ulcer may be assigned.
· A pillow under a limb is routine, preventative nursing care to relieve limb pressure and therefore does not meet ACS 0002 Additional diagnoses.
· Stage 1 defines the level of severity of a ‘skin ulcer’ and at this level it is ‘limited to erythema only’ as per the definitions supplied in the original proposal, therefore the indexing is correct.  

Please note, the term ‘ulcer’ within this classification does not infer that there is a breakdown of skin surface.


Query Text:
Dementia with psychotic symptoms
> 
> Psychosis, psychotic
> -due to or associated with
> --presenile dementia F03
> --senile dementia F03
> 
> There is no Index entry for Psychosis due to or associated with dementia.  We have been advised by North Western Mental Health to code this to F03.  Since presenile and senile are old terms no longer used in our hospital, is it possible to modify the Index to include dementia with psychosis and delete senile and presenile?

Response:
VICC members consider that psychosis/psychotic symptoms with dementia should not be coded separately from the dementia.  Look up 'dementia' for code assignment.  The VICC has forwarded the following suggested index amendments to the NCCH.
 
Can the NCCH please consider reviewing the index entry for:

Psychosis, psychotic F29
- due to or associated with 
- - presenile dementia F03 
- - senile dementia F03

VICC members suggest the removal of the references to 'presenile' and 'senile', or alternatively amend the index (if considered clinically correct) to read:

Psychosis, psychotic F29
- due to or associated with dementia
- - see dementia


Query Title:
Postural Orthostatic Tachycardia Syndrome (POTS)

Query Text:
22 year old female admitted with a diagnosis of Postural Orthostatic Tachycardia Syndrome (POTS).

There is no index entry for this syndrome.

Following ACS 0005 Syndromes we are instructed to code out the symptoms.

We have assigned:
I47.1 SVT
G98 Other nervous system disorders
R55 Syncope

Is this the best way to code this patient?

Also, would it be possible to refer this to the NCCH seeking a code and index entry for this syndrome?

Research  www.potsplace.com/pots_an_overview.htm

Postural orthostatic tachycardia syndrome is defined by excessive heart rate increments upon upright posture. A person with POTS will experience heart rates that increase 30 beats or more per minute upon standing and/or increase to 120 beats or more per minute upon standing (Grubb, 2000). These exaggerated heart rate increases usually occur within 10 minutes of rising.

While the hallmark of this disorder is an excessive heart rate increment upon standing, patients often exhibit numerous symptoms of autonomic nervous system dysfunction. It is the autonomic nervous system (ANS) that regulates the needed adjustments in vascular tone, heart rate and blood pressure upon standing. The ANS is also responsible for regulating a multitude of other organs and functions throughout the body. Some of these functions include temperature, pupil dilation and constriction, salivation and the digestive tract. A patient experiencing ANS dysfunction may experience abnormalities in the many organs and functions the ANS regulates.

Patients can be affected by different varieties of POTS. The distinct varieties may have numerous causes. Patients with the hyperadrenergic variety are affected by excessive sympathetic activity that is not turned off appropriately by the baroreflex (Grubb, 2000). These patients often have high serum catecholamine levels, decreased norepinephrine clearance, and resistance to the norepinephrine releasing effect of tyramine. They also experience more migraines, cold and sweaty extremities and have an excessive response to isoproterenol. 

Those said to have partial dysautonomia have a system trying to compensate for a lack of venous constriction through excessive catecholamine output (Grubb. 2000). 

Some physicians also believe there is a brain stem dysregulation form of POTS that may lead to total autonomic failure (Grubb, 2000). 

Regardless of variety, POTS patients generally fit into one of four categories upon becoming ill: constitutional, post-viral, postpartum and those whose symptoms became noticeable after their body was exposed to a severe stressor (Grubb, 2000). 

Constitutional patients have been sick all their lives. Post-viral patients developed POTS after an illness believed to be viral in nature. Postpartum patients developed POTS after giving birth. Most of the remaining patients developed POTS after being exposed to bodily stressors, such as surgery, trauma or chemotherapy.  

Regardless of category, POTS is a chronic illness that can be debilitating at times. POTS patients use about three times more energy to stand than a healthy person (Grubb, 2002). It is as if these patients are running in place all the time. Research shows that POTS patients' quality of life is similar to those with congestive heart failure and chronic obstructive pulmonary disease (Benrud-Larson, Dewar, Sandroni, Rummans, Haythornthwaite & Low, 2002) Most patients will have to make some lifestyle adjustments to cope with this disorder. 

It was once estimated that nearly 500,000 Americans had some form of orthostatic intolerance, which made standing up a challenge (Robertson, 1999). However, with research advances and growing physician education the number of patients found to have POTS symptoms is steadily rising. 

POTS patients tend to be between the ages of 15 and 50 (Grubb & McMann, 2001, p. 65). Women are 5 times more likely to develop POTS than men (Grubb & McMann, 2001, p. 65). POTS does run in some families. The onset can be sudden or gradual. The quantity and severity of symptoms varies from day to day. 

POTS symptoms are sometimes correctable if an underlying cause is discovered. Researchers are attempting to identify and treat the mechanisms and causes of POTS. Research shows that most patients will eventually be able to stand up with fewer symptoms (Low, 2000). Most POTS patients can look forward to experiencing improvement with proper treatment.

Response:
The Victorian ICD Coding Committee referred your query for a new ICD-10-AM code to the NCCH.

The NCCH agrees that postural orthostatic tachycardia syndrome should be classified by following the guidelines in ACS 0005 Syndromes.


Query Text:
Need to code 'antegrade' cerebral perfusion with deep hypothermia circulatory arrest.

The title for procedure code 38577-00 (642) describes 'retrograde' perfusion.  However, the index entry for same lists 'retrograde' as a non-essential modifier.

Would it be acceptable in the meantime to use this code for 'antegrade' cerebral perfusion?

Search Details: Vol 4 index entry:  Perfusion, cerebral (retrograde), during hypothermic arrest.

Vol 3 tabular entry:  Retrograde cerebral perfusion during hypothermic arrest.

Response:
It would be appropriate to use:

38577-00 [642] Retrograde cerebral perfusion during hypothermic arrest for antegrade cerebral perfusion with deep hypothermia circulatory arrest.

However you should consider ACS 0909 Coronary artery bypass grafts (CABGs), in particular 'Additional procedures performed in conjunction with CABGs’ to determine whether antegrade cerebral perfusion with deep hypothermia circulatory arrest should actually be coded.  This standard instructs that hypothermia is a routine part of the CABGs procedure and is not coded when CABGs are performed.

The VICC will notify the NCCH about the discrepancy between the tabular list and the index with regard to modifiers.


Query Text:
I am wishing to highlight a problem with the grouper where a patient who is pregnant, admitted for a surgical procedure or other diagnosis unrelated to the pregnancy and receives obstetric care and observation.  These cases group to an antenatal DRG due ACS 1521 Conditions complicating Pregnancy indicating we code an O94-O99 Other obstetric conditions as the Principal diagnosis.

A specific example is a pregnant woman admitted for laparotomy and removal of R ovarian Cyst.  We have coded O99.8 D27 M8441/0 35713-04 [1244].  The DRG is O65B Other antenatal with moderate/ No comp diagnoses, 0.4494 WIES.  If we delete O99.8 and code D27 M8441/0 as the principal diagnosis, the DRG is N07Z Other Uterine & Adnexa Procedures for Non-Malignancy, 1.3217 WIES.  Therefore we are currently receiving insufficient funding for the procedure.

Should the ACS 1521 be reviewed in requiring O94-O99 code for all obstetric observation or care admissions? Or should the grouper be adjusted and group to the procedure, not the Principal diagnosis?

Response:
The VICC interpretation of ACS 1521 Conditions complicating pregnancy is to:
1. Assign Z33 Pregnant state, incidental when there is NO obstetric care;
2. Assign Z34.x Supervision of normal pregnancy when there IS obstetric care but the condition has NOT complicated the pregnancy, aggravated the pregnancy nor the pregnancy is the reason for care;
3. Assign Oxx Obstetrics conditions when there IS obstetric care AND the condition has complicated the pregnancy, aggravated the pregnancy or the pregnancy is the reason for care

This interpretation was confirmed by the NCCH who provided the following information:
1. ACS 1521 states: If a patient is admitted for a condition that:
· is not pregnancy-related
· neither complicates the pregnancy nor is aggravated by the pregnancy AND requires no obstetric observation or care, assign Z33 Pregnant state, incidental as an additional diagnosis (with the code for the condition being treated assigned as principal diagnosis).
The key point, as has been correctly pointed out, is ‘requires no obstetric observation or care’.
2. Z34 Supervision of normal pregnancy should be assigned by following the following index entries:
Antenatal
- care
Pregnancy
- supervision
- - normal
Prenatal
- care
The terms 'care' and 'supervision' imply that obstetric observation or care has been required during the episode.  'Normal pregnancy' in the code title implies that the patient is not being treated for any condition that has complicated or aggravated the pregnancy.
3. Any condition that is complicating pregnancy or is complicated by the pregnancy must have a code from Chapter 15 Pregnancy, Childbirth and the Puerperium:
· Codes from blocks O20-O29 are specific codes for common conditions that are known to complicated pregnancy.
· To code other conditions complicating pregnancy (or being aggravated by the pregnancy or that are the main reason for obstetric care), a code from O98 or O99 is assigned together with an additional code from another chapter to identify the specific condition.
The NCCH will consider amending ACS 1521 to clarify the information contained in the standard.

The VICC advises that the options for groupings cited in the query are correct.  Note that 35713 04 [1244] Ovarian cystectomy, unilateral is not a valid OR procedure in MDC 14 Pregnancy, childbirth and the puerperium.


Query Title:
Division of adhesions, uterovesical pouch

Query Text:
Laparoscopic division of adhesions of the uterovesical pouch and left and right ovarian fossa.

I have coded
90369-00 [1127] Exploration of perivesical tissue once
30393-00 [986] Laparoscopic division of abdominal adhesions twice

Can you please confirm if this is correct?

Response:
The Victorian ICD Coding Committee suggests coding division of adhesions only once.  This is based on ACS 0020 Multiple/Bilateral procedures Exceptions (b) which notes 'Procedures which are inherently bilateral or have a code provided in ICD-10-AM that denotes the multiple or bilateral aspect in the code title or inclusion terms, should only have one code assigned per operative episode'.

The code title for 30393-00 [986] Laparoscopic division of abdominal adhesions indicates division of adhesions (plural), and therefore this code is required only once to reflect the division of adhesions in the left and right ovarian fossa.

If 90369-00 [1127] Exploration of perivesical tissue is the correct code for division of adhesions of uterovesical pouch, one code is required for this procedure as well.  As we don’t have your operation report, we are unable to confirm the validity of the code


Query Text:
Re: # 1910 Infusion of Lignocaine
Query involves the procedure code for a patient with pain to left chest, arm and back up to level of her left  breast.  The patient has small cell lung carcinoma with extensive left hilar, mediastinal and pleural tumour with infiltration of the T2 vertebral body,  left T1-2  and T2-3 nerve root foramen.  There is compression of the left side of the cord at these levels. The patient was treated with a subcutaneous lignocaine infusion via a Grasby pump.  I obtained clinical advice from the Pain Clinic who stated the treatment was systemic and not targeting any specific nerve.
When using 3rd Edition we were instructed to use code 92193-00 [1885] for Lignocaine infusion for pain management.  In 4th edition this block no longer exists and Block 1920 excludes pain management.  Therefore because we have no specific nerve, we coded it to 90022-00 [63] Adminstration of anaesthetic agent around other peripheral nerve.  
Can you instruct us on the correct code for Subcutaneous/ IV infusion of Lignocaine for pain management?
Are we to code all Pain Management  procedures to Blocks specified at the Excludes note at Block 1920?

Response:
Within the current structure of ACHI, there is no specific code for subcutaneous infusion of lignocaine via a Grasby pump for pain management, nor intravenous infusion of lignocaine.  The NCCH advises that the most appropriate codes for these interventions, considering that they are for systemic rather than localised treatment, are:

subcutaneous infusion of lignocaine:
96200-09 [1920] Subcutaneous administration of pharmacological agent, other and unspecified pharmacological agent

intravenous infusion of lignocaine: 
96199-09 [1920] Intravenous administration of pharmacological agent, other and unspecified pharmacological agent


Query Text:
How to code:   SACROILIAC JOINT BLOCKS
This is a pain management procedure performed for Back Pain  (diagnosis given).
As it was a pain management procedure the code 18274-03 [63] Administration of anaesthetic agent around paravertebral sacral nerve was proposed.  
However, the Pain Clinic medical officer said that this was not the procedure performed but injection was directly into the joint.  Therefore code chosen was 50124-01 [1552] Administration of agent into joint or other synovial cavity, not elsewhere classified. 
1. Can you confirm this code or advise another code.
2. Pain management is excluded from Block 1920 and we are sent to Blocks [31] to [32] and [60] to [66]. Can we use codes from other parts of the Tabular List, as we have done with this procedure,  for pain management.

Response:
The NCCH confirms that the correct code for sacroiliac joint block for pain relief is:
50124-01[1552] Administration of agent into joint or other synovial cavity, not elsewhere classified


Query Text:
How to code: Trigger Point Intramuscular Injections with Local Anaesthetic and Steroids 
Diagnosis:  Chronic Neck and L Shoulder/Arm Pain
Operative Detail:  1: 4 mixture of Celestone / 2% Xylocaine injected into Trigger Points of left trapezius,  left pectoralis,  left forearm extensors
Codes considered:
96197-03,  96197-09 [1920]  Intramuscular adminstration of pharmacological agent –steroid, other
However Block [1920] excludes pain management 90022-00 [63]  Administration of anaesthetic agent around other peripheral nerve
Targeted nerves not specified
90560-00 [1552]  Injection, muscle NEC

Response:
It is not appropriate to assign a code from block [1920] Pharmacotherapy for the procedure of trigger point intramuscular injections, as codes from this block are intended for systemic, rather than localised, effect. The correct code to assign in this case is 90560-00 [1552] Administration of agent into soft tissue, not elsewhere classified 

The NCCH acknowledges that the code ranges provided at the excludes note in block [1920] Pharmacotherapy are too specific and that codes from other chapters in the classification may be appropriate for localised pain management procedures. This note will be reviewed as part of an overall revision of pain management interventions for a future edition of ACHI.

The VICC accepts the NCCH responses to these queries and notes that codes in block 1920 Pharmacotherapy are intended for systemic, not localised, effect.


Query Text:
Many patients receive their pharmacotherapy intravenously via Port access (Port-A-Cath). From a clinical treatment perspective, this procedure is virtually identical to patients receiving IV pharmacotherapy via a peripheral or centrally inserted catheter (e.g. Hickmans, PICC) – the difference being that the IV is connected to the Port, rather than an external catheter.  Pharmacotherapy via Port access takes just as long as that via a peripheral or central catheter, as the patient remains in hospital until the IV protocol is completed.  This is unlike loading of a Port, which takes only a matter of minutes.

In 3rd edition ICD-10-AM, the choices for Chemotherapy were:

Chemotherapy 90768-00 [1780] 
-intravenous (> 1 hour) 13915-00 [1780] 
--> 1 and < 6 hours 13918-00 [1780] 
--> 6 hours 13921-00 [1780]  

or 

Loading (of) 
-device 
--drug delivery (infusion pump) 
---external (ambulatory) (CADD) (Infusor) 13942-00 [1780] 
---implantable (reservoir) 13939-00 [1780]  


Intravenous chemotherapy via Port access would have been coded to 13915-00 [1780], as the only way to get to code 13939-00 was to look-up “Loading” in the index, and these patients were not having their Port loaded.

However, with the introduction of 4th edition, the excludes notes at 96199-xx and 96204-xx, excludes administration of a pharmacological agent via an implantable infusion device or pump (a Port being an implantable infusion device), and directs the coder to 13939-00 [1921].
96204-00 Administration of pharmacological agent via external vascular catheter, antineoplastic agent
Administration of pharmacological agent via:
• Broviac } 
• central venous} 
• Cook } catheter
• Groshong } 
• Hickman } 
• Permacath
• PerQCath
• PICC
Excludes:administration of pharmacological agent via:
• ambulatory drug delivery device (13942-00 [1921])
• implantable infusion device or pump  (13939-00 [1921])
• peripheral catheter (96199 [1920])
surgical catheterisation with administration of pharmacological agent  (see block [741]) 


Code 13939-00 is titled Loading of implantable infusion device or pump

13939-00 Loading of implantable infusion device or pump
Refilling of implantable infusion device or pump
Includes:maintenance such as:
• flushing
• injection of isotope to test pump
• withdrawing sample of fluid for culture 

Patients receiving IV pharmacotherapy via Port access are NOT having their implantable infusion device loaded/refilled, however the excludes note is directing coders to this code.

Procedure code 13939-00 is derived from MBS item 13939 - IMPLANTED PUMP OR RESERVOIR, loading of, with a cytotoxic agent or agents, not being a service associated with a service to which item 13915, 13918, 13921, 13924, 13927, 13930, 13933, 13936 or 13945 applies.

MBS item 13939 is listed on the Commonwealth Type C list (procedures not normally requiring hospital treatment).  

Intravenous chemotherapy MBS items are listed on the Commonwealth Type B list (procedures normally requiring hospital treatment that does not include part of an overnight stay).  Procedure codes 96199-00 and 96204-00 are mapped to 13915-00, which was derived from MBS item 13915 (Type B procedure).

I would like to propose that consideration be given to altering the procedure classification to reflect the clinical practice of IV pharmacotherapy via Port access.

The alternatives are:

1.Classify IV pharmacotherapy via Port access to 96204-xx.  This would require amendments to:

The index (change in bold):
Pharmacotherapy 96206 [1920] 
-enteral 96202 [1920] 
-intra-arterial 96196 [1920] 
-intracavitary 96201 [1920] 
-intramuscular 96197 [1920] 
-intrathecal 96198 [1920] 
-intravenous 96199 [1920] 
-oral 96203 [1920] 
-specified NEC 96205 [1920] 
-subcutaneous 96200 [1920] 
-via external vascular catheter 96204 [1920]  
-via port access 96204 [1920]


The tabular list (96204-00 and 96199-00 as examples)
96204-00Administration of pharmacological agent via external vascular catheter, antineoplastic agent
Administration of pharmacological agent via:
• Broviac } 
• central venous} 
• Cook } catheter
• Groshong} 
• Hickman } 
• Permacath
• PerQCath
• PICC
* Port Access

Excludes:administration of pharmacological agent via:
• peripheral catheter (96199 [1920])
loading/refilling of 
• ambulatory drug delivery device (13942-00 [1921])
• implantable infusion device or pump  (13939-00 [1921])
surgical catheterisation with administration of pharmacological agent  (see block [741]) 

96199-00 Intravenous administration of pharmacological agent, antineoplastic agent
Administration of pharmacological agent via peripheral catheter
Excludes:administration of pharmacological agent via:
• external vascular catheter (96204 [1920])
• Port access (96204 [1920])
loading/refilling of
• ambulatory drug delivery device (13942-00 [1921])
• implantable infusion device or pump (13939-00 [1921])
surgical catheterisation with administration of pharmacological agent (see block [741]) 

I do not believe ACS 0045 requires any change, as the relevant section relates to LOADING of drug delivery devices – these patients are not having their drug delivery device loaded.
Loading of a drug delivery device
When the procedure involves loading of medication into a drug delivery device (external or implantable infusion pump) alone (ie the drug delivery device has been connected or inserted in a previous episode of care) assign the appropriate code from block [1921] Loading of drug delivery device:

13939-00 [1921] Loading of implantable infusion device or pump 
13942-00 [1921] Loading of ambulatory drug delivery device 



2.Create a new code for IV Pharmacotherapy via Port access if there is a need to classify IV pharmacotherapy via Port access separately to IV pharmacotherapy via external (central) venous catheter.

Response:
The Victorian ICD Coding Committee referred this query to the NCCH who provided the following response:

The NCCH agrees that IV chemotherapy via portacath is not the same as loading of the device.  

Where IV chemotherapy is performed via portacath, assign:

96204-00 [1920] Administration of pharmacological agent via external vascular catheter, antineoplastic agent.

The NCCH is aware that the above advice is in conflict with the term 'external' in the code title of 96204-xx, but considers this the best code available to classify the procedure performed.  The NCCH will consider amending this area of ACHI for a future edition.  A Coding Matters article will be published in the interim to clarify these classification issues.


Query Text:
Patient admitted for colonoscopy but anaesthetist noted 'iv access impossible secondary to IV drug use'.  Sedation anaesthesia given via percutaneous CVC inserted.  The cvc was then removed in the post-op suite.  

Here are the codes we have used
K92.2 Gastrointestinal haemorrhage, unspecified
F10.2 Mental and behavioural disorders due to use of alcohol, dependence syndrome
T98.2 Sequelae of certain early complications of trauma
Y87.0 Sequelae of intentional self harm
Y92.9 Place of occurrence at or in unspecified place
Z72.2 Drug use
Z22.52 Carrier of viral hepatitis C
Z72.0 Tobacco use, current

32090-00 [905] Fibreoptic colonscopy to caecum
13815-01 [738] Percutaneous central vein catheterisation
34530-04 [738] Removal of venous catheter

Can you please advise if there is a T code to indicate that due to the lack of IV access, the treatment plan was changed.  This had occurred in a previous episode for this patient too.
A code similar to T88.4 Failed or difficult intubation (ie T88.x Failed or difficult cannulation) would be ideal.  Can the Coding Committee please consider submitting a request for such a code to the NCCH?

Failing this, what do you suggest?

Response:
Although failed IV access has changed the treatment protocol for this patient, this is not a condition and there is no code for 'difficulty with IV access'.

If documentation of a condition of vein as the reason for the failed IV access is recorded, you can code this.  Based on the information you have provided, there is no condition to be coded.

Additionally, the removal of the CVC does not need to be coded.  Per VICC #1937 Removal of supra pubic and central venous catheters printed in the Victorian ICD Coding Newsletter February 2004 (reprinted at the end of this response).

92515-xx [1910] Sedation should also be assigned.

The VICC is unable to comment on the remainder of the coding due to lack of information.

VICC #1937 Removal of supra-pubic and central venous catheters (reproduced)

I would like to know under which circumstances you would code the removal of supra pubic catheters (SPCs) and central venous catheters (CVCs)? Should they only be coded if performed by a medical officer, or if removed under an anaesthetic? Or should all removals of such devices be routinely coded? 

The Committee feels that these procedures should not be coded unless performed under anaesthetic (refer ASC 0042 Procedures not normally coded, Note c.), or unless admission was specifically for the removal of the device in question.  This opinion is based on the logic used in ACS 1436 Trial of void in which the direction is to code the removal of the urinary catheter when admission is specifically for the purpose of ensuring that voiding is functioning, and therefore, the catheter is no longer required.  The standard states that: These procedures would not normally be coded (see ACS 0042 Procedures normally not coded) but they are relevant in these circumstances and are therefore included.


Query Title:
Misoprostol insertion for cervical dilation

Query Text:
What procedure codes are correct in the following scenario?

Patient was known to have a tighly closed cervix and was given misoprostol pv prior to D&C/hysteroscopy for recurrent endometritis.  There doesn't appear to be any way to code the misoprostol except when to cause an induction of labour.

The operation report also reveals that the cervix was dilated to 6 Hagar and the to 8 Hagar but required a suture through the anterior cervix for traction.  Is there anyway of indicating a procedure code for the cervix in this case (apart from 16511-00 [1274] Insertion of cervical suture - as this seems to be for cervical incompetence)?

Response:
There is no need to code either the insertion of misoprostol or the cervical suture, as these are procedural components of the dilatation and curettage (per ACS 0016 General Procedure Guidelines - Procedural components').


Query Text:
13 year old female patient admited with Lemierre's syndrome and gram negative anaerobes.  Research from Paediatric infectious diseases journal indicates thrombophlebitis of the internal jugular vein and Fusobacterium necrophorum, which constitutes part of the syndrome.  The patient had both of these conditions.  Can you please advise on the correct coding of this syndrome?  In the interim we have coded
I80.8 Other thrombophlebitis
A41.4 Sepsis due to anaerobes.

We have attached a copy of the research material and micro results for your review.

Response:
Based on the information provided, the correct codes are:

I80.8 Phlebitis and thrombophlebitis of other sites
B96.88 Other and unspecified bacterial agents as the cause of diseases classified to other chapters

Sepsis must be documented before A41.4 Sepsis due to anaerobes can be coded.

Apply ACS 0001 Principal diagnosis to determine the principal diagnosis.


Query Text:
Patient admitted with Chronic headaches.  Has a history of aneurysm of cavernous right ICA.

The patient undergoes a Balloon Test Occlusion.  This involves a balloon being inflated in the artery to see if the patient is suitable for an occlusion of the aneurysm.

We have coded this to:
 90222-00 Other procedure on arteries
 60009-00 DSA of Head and Neck=10 DAR
 60078-00 DSS Arteriography/Venography 3 vessels

This will group to B04A Extracranial Vascular Pr+ CSCC

Are these the best codes to assign?

We also considered code 90007-00 [28] Other diagnostic procedures on skull, brain or cerebral meninges.

Thanks for your advice.

Response:
The Victorian ICD Coding Committee agrees that a balloon test occlusion would be coded as a transcatheter embolisation of a blood vessel with addition of angiogram codes as appropriate.

Coding Matters, Volume 6 Number 2 advised:

Transcatheter embolisation of blood vessels is performed to therapeutically block or occlude blood vessels.  This may be performed to arrest a haemorrhage, treat vascular anomalies such as arteriovenous malformations (AVM) or fistulas or to block blood supply to a tumour.  Embolisation can also be performed as a precursor to surgery, such as excision of tumour or clipping of AVM, as embolisation reduces the risk of haemorrhage or infarct. 

The technique involves the delivery of an agent or device through a small catheter and is generally performed in X-Ray departments or catheter laboratories.  Many agents or devices can be used to occlude blood vessels:
· Sponges—gelatin (Gelfoam) or plastic (polyvinyl alcohol)
· Balloons
· Ethanol
· Glue
· Silastic pellets

Assign the following codes:
35321-00 [767] Transcatheter embolisation of blood vessel
and a code for the intraoperative arteriogram.


Query Text:
Patient is given IV Methylprednisolone as an inpatient, and develops hyperglycaemia as an adverse effect.  When looking up an adverse effect in
therapeutic use, the books direct you to use Y56.0 Local antifungal, anti-infective and anti-inflammatory drugs.

This code is not correct as the methyprednisolone was not used topically, but given as an IV.

We feel that Y42.0 Glucocorticoids and synthetic analogues would be more appropriate.  If you start the pathway with steroid you will get to this
code.

Are we correct in using Y42.0?

Response:
The correct code to assign is Y56.0 Local antifungal, anti-infective and anti-inflammatory drugs

ICD-10-AM classifies drugs according to class not therapeutic purposes.  This is supported by NCCH Q80 (10/08/1998).


Query Text:
SLE
We have recently conducted an audit on patients with SLE. The index entry under ‘Lupus, erythematosus, systemic, with …’ contain only entries for ‘with lung involvement’ or ‘renal tubulo-interstitial disease’.  However, there are many other parts of the body affected by lupus, and many of these conditions are dagger/asterisk combinations which are indexed under the specific condition, such as ‘Pericarditis, in SLE - M32.1+, I32.8*, but not indexed under Lupus.  Others include:
F02.8* Dementia
G05.8* Encephalitis
G63.5* Polyneuropathy
G73.7* Myopathy
I32.8* Pericarditis
I39.x* Libman-Sacks disease
I68.2* Cerebral arteritis
J99.1* Respiratory disorders
N08.5* Nephritis
N16.4* Renal tubulo-interstitial disorders

And also if you look up 'Systemic, lupus, erythematosus' the code M32.9 is given, and there are no further options for any of the dagger/ asterisk combinations.

Checking some medical sites on the internet gave the following information: symptoms of lupus include arthritis, skin rashes, hair loss, sun sensitivity, fatigue.  Body systems affected by lupus include kidneys, lungs, central nervous system, blood vessels, blood, and heart.

The documentation on 3 of our patients is as follows:
Patient 1: Well 17 year old admitted as an overnight patient for IV cyclophosphamide for SLE.  Medical history: SLE diagnosed 1998, cerebral lupus 1998, epilepsy and lupus nephritis – WHO class 4-5 interstitial fibrosis.
Patient 2: 12 year old admitted with SLE for steroid injections into arthritis in the elbow and wrist both arms.  SLE – initially diagnosed in 02.03 when patient presented with pneumonia, pericarditis and pleural effusion, now presents with joint symptoms for treatment.
Patient 3:  15 year old with SLE for IV cyclophosphamide.  Medical history: SLE diagnosed 1994.  Complicated by nephritis, osteoporosis, vasculitic rash.

I have two questions, firstly should all conditions documented as having a relationship to SLE be coded because they are dagger/asterisk combinations, even if past history?  And secondly, what does ‘lung involvement’ under the ‘Lupus’ entry include?

Response:
This query was referred to the NCCH who provided the following advice:
Clinical advice indicates that patients documented with a history of severe manifestations of SLE would have advanced SLE.  However, many complications do resolve and become inactive. Therefore, NCCH suggests that only current conditions should be classified when documented with SLE (if they meet the criteria in ACS 0002 Additional diagnoses). 

In answer to question two, 'Lung involvement' indexed under 'Lupus, erythematosus, systemic' is classified to J99.1* Respiratory disorders in other diffuse connective tissue disorders.  This code includes any respiratory disorder classifiable to Chapter 10 Diseases of the respiratory system.

Therefore the VICC advises that if a condition is chronic and irreversible such as lung fibrosis it would be coded as a dagger/asterisk combination.  Conditions such as pneumonia or pericarditis that are resolved prior to the episode of care would not be coded.

The VICC has asked the NCCH to give consideration to including the asterisk conditions listed in the query in the index under SLE.


Query Text:
Recently over coding discussions with one of our senior surgeons he pointed out in the case to hand that the patient was not what he would call in a “metastatic state”. Following coding protocol and supported by  the encoder prompts this patient was assigned both primary and metastatic codes, as in the initial phase of diagnosis shows lymph node involvement of which some were positive to metastases; as is the case quite often with breast cancer patients also.
 The surgeon intimated that  for a patient to be termed “with metastases or in a metastatic state” this would mean an area metastasised away from the primary area, travel to another part, different area of the body affected  eg secondaries of liver or bone. He considered regional lymph node involvement in the area of the primary not to fall into the criteria for labelling a patient with metastases.
He has indicated with earnest some feedback from the coding authorities in relation to the above scenario mentioned. 
This has raised with us that there may be a definition for coding purposes and may be one in the clinical context and setting for treating patients.

We would very much appreciate your comments and discussions on the above.

Response:
It is acknowledged that there are some differences between coding and clinical interpretation of a condition.  Coders should code according to the classification system, therefore if the patient has breast cancer with documented lymph node involvement, this should be coded as metastatic to lymph nodes.


Query Text:
For the first time we have had cord blood collected at delivery for potential use of stem cells. This is only documented on the mother's record. Is 13750-04 (1892) Apheresis of stem cells applicable in this case as there is no re-transfusion - it is for potential future use should the need arise.  Collection of the blood was carried out by hospital staff, transportation to appropriate facility for storage was the responsibility of the patient and her partner.

Response:
The NCCH advised in query 1640 (NCCH database) that cord blood collection is not coded.  This is not apheresis.

The response to query 1640 is reproduced here for your information:

Cord blood is usually collected after the baby is born but before the placenta is delivered. A four to eight inch area of the umbilical cord is cleaned with antiseptic solution and a blood bag needle is inserted into the umbilical vein.  The blood flows into the bag by gravity until it stops, after which the collection is complete. 

As neither the mother nor baby is admitted specifically for this procedure, the NCCH does not advocate the coding of cord blood procurement.  The classification advice in ACS 0301 Stem cell procurement and transplantation applies to procurement of stem cells via apheresis and bone marrow.


Query Text:
Patient had abnormal limb movements, due to a particular drug.
Following the index - Abnormal - movement, it takes me to a G code - disorder; being a non-essential modifier.  However, the correct code seems to be an R code.  Should disorder be an essential modifier?

Response:
The VICC referred this query to the NCCH suggesting that NCCH alter the default to R25.8 Other and unspecified abnormal involuntary movements.  The NCCH provided the following response:
NCCH agrees that 'abnormal limb movement', not specified as a disorder, should be classified as:
R25.8 Other and unspecified abnormal involuntary movements

The indexing of 'Abnormal, movement' is consistent with ICD-10.  NCCH will submit a proposal to WHO URC to amend the index.
The VICC received the following updated advice from the NCCH:
After further review, NCCH supports the assignment of G25.9 Extrapyramidal and movement disorder, unspecified for the case cited in the query (abnormal limb movement, due to a drug). 

Follow the index pathways:
Abnormal
- movement (disorder) (see also Disorder, movement) G25.9

Disorder
- movement G25.9
- - treatment-induced G25.9

This advice supersedes advice published in the Third Quarter 2005-06 ICD Coding Newsletter.


Query Text:
Our midwifery patients often have cord around neck 'YES' circled. Should we code cord entanglement if there are no problems caused by the cord entanglement, as the descriptor says 'labour and delivery complicated by....' or only if there is some documentation of foetal distress, problems caused, etc. by the entanglement? Thanks

Response:
Documentation of 'cord around neck' should be coded as: 

O69.2 Labour and delivery complicated by other cord entanglement

Refer to NCCH # 255 Cord around neck, without compression for the definitive answer to this question.

VICC #1800 Perinatal recording in record and eBOP published in the August 2002 ICD Coding Newsletter also provides information regarding documentation of perinatal conditions.


Query Title:
Male sling procedure for stress incontinence

Query Text:
75 Year old male with stress incontinence (post radical prostatectomy)
admitted for 'Invance sling  - male sling procedure'

Operation record states - Removal of old ACT balloons and insertion of Invance sling after insertion of 6 bone screws.

I have coded from block 1109 - Procedures for male stress incontinence code 37044-00 Retropubic procedure for stress incontinence, male.  Or should I code the revision procedure.
I have also coded the removal of the artificial urinary sphincters 

Search Details: Have searched the NCCH data base with no luck

Response:
From the documentation provided, the Victorian ICD Coding Committee does not consider this to be a revision procedure but rather a new procedure for the same condition.  Therefore the committee recommends assigning the following codes:

37390-02 [1113] Removal of artificial urinary sphincter for the removal of the ACT balloons 
37044-00 [1109] Retropubic procedures for stress incontinence, male for the insertion of the Invance sling.


Query Text:
77 year old man admitted as a day case for removal of lesion from shin area of leg, Histology showed -

Fat necrosis, fibrosis, chronic inflammation and a 'cholesterol embolus'.  it also states - difficult to tell with certainty whether or not the cholesterol embolus is the cause of the other findings.

I am unsure how to code the cholesterol embolus.
Suggested codes L98.8 other specified disorders of skin and subcutaneous tissue, plus a code from lipidaemia block ? E78.8 other disorder of lipoprotein metabolism.

Search Details: ICD V2 - there is an entry for a Fat Embolism - I do not think this is appropriate.

Response:
Cholesterol embolism is defined as an embolism of lipid debris from an ulcerated atheromatous deposit, generally from a large artery to small arterial branches; it is usually small and rarely causes infarction.  (Better Health Channel On-line Dictionary)

Embolus is defined as a plug composed of a detached thrombus or vegetation, mass of bacteria or other foreign body occluding a vessel.  (Stedman's Medical Dictionary)

Without documentation of the specific vessel involved, the correct code to assign in this scenario is:

Embolism (septic) I74.9 
- lower extremity I80.3

I80.3 Phlebitis and thrombophlebitis of lower extremity, unspecified


Query Text:
Young boy fractures radius and has GAMP.

Is readmitted 2 weeks later because on check x-ray the fracture is found to be malligned (still healing), so for re GAMP

Can this be coded as malunion, or because it is still in healing process would the current injury code be reused? (although this wouldn't really
reflect what has happened) or can a sequaelae of fracture  code be used - although I guess not as it is still the current condition representing?

Response:
This should be coded to a current fracture, as the bones have not united.

If a fracture has united crookedly, this would be coded to malunion.


Query Text:
I have a general problem with procedure codes for those to do with the perineum, both indexing inadequacies & code title, etc problems. All procedures appear in the gynaecological section but can be performed on males as well.
My problem this time is a male patient who had an biopsy of a perineal recurrence of Ca Rectum - there is no look up in the index for any such procedures for the perineum, and as previously mentioned, the word perineum appears in the Block titles (vulva & perineum) but NOT in the actual code titles, except for incision which is both indexed & included on the code title 90446-00 [1290].
Whilst for females, most procedures are covered under vulva, there is a sex edit (6) excluding the use of these codes for males.
For the case mentioned above, I have used biopsy, skin (subcutaneous tissue) - 30071-00 [1618].
Could you please review the use of codes for perineal procedures & advise me of the correct codes to use for perineal procedures for males?
Thanks

Search Details: Check NCCH Query Database, medical dictionary entry for perineum (includes males)

Response:
This query was referred to the NCCH who provided the following advice:
The NCCH agrees with the code suggested for biopsy of male perineum:
30071-00 [1618] Biopsy of skin and subcutaneous tissue


Query Title:
Systemic Inflammatory Response Syndrome (SIRS)

Query Text:
I would like clarification regarding the instruction in this standard that relates to the coding of SIRS. I have copied the relevant section of the standard here.

"SIRS should be coded as follows:
•SIRS due to infection is coded according to the appropriate index entry at Sepsis.
•SIRS due to trauma is coded according to the type of trauma.
•SIRS due to clinical insult other than infection is coded to the type of insult (eg pancreatitis, ischaemia)."

The first bullet point indicates that SIRS due to infection should be coded as sepsis.  The third bullet point indicates that SIRS due to clinical insult other than infection should be coded to the clinical insult.  It provides the example of pancreatitis, which in my mind, is an infection.  

Does the first bullet point actually mean SIRS due to infection with a microbe? Or maybe SIRS due to systemic infection (presumably with no discrete infection identified)?

At the beginning of the standard definitions are provided for SIRS and sepsis that are almost the same. 

As the use of the term SIRS becomes more widespread coders will be assigning codes for the underlying infection (pancreatitis, cholecystitis, urinary tract infection, etc) as principal diagnosis in cases where the principal diagnosis would perhaps be more correct as sepsis.  There will also be an effect on the DRG assignment in these cases. 

Could coding committee please discuss this issue and provide some clarification regarding the meaning of this aspect of the standard?


Search Details: NCCH database - queries 1610, 1719, 1943

Response:
This was referred to the NCCH who provided the following advice:
"In answer to the points raised by the query:
• Pancreatitis is not always caused by an infection
• The definitions in ACS 0110 SEPTICAEMIA for SIRS and sepsis are different:
“SIRS – the systemic inflammatory response to a variety of severe clinical insults.”
“Sepsis – the systemic response to infection…as a result of infection.”

• ACS 0110 does not give sequencing advice. It provides guidelines on how to code these conditions. Sequencing should be decided by following the guidelines in ACS 0001 PRINCIPAL DIAGNOSIS.
• SIRS due to chest infection and SIRS due to pneumonia – both of these scenarios should be coded as sepsis. NCCH agrees that pneumonia is an infection (either viral or bacterial).
• SIRS due to pyelonephritis – would not be coded as sepsis unless the pyelonephritis is due to infection.
• SIRS due to peritonitis – code assignment would be dependent upon whether or not there is an underlying infection.

WHO ICD-10 has recently created four character codes for systemic inflammatory response syndrome. The new codes will be included in ICD-10-AM Sixth Edition. Education will be provided by NCCH to advise coders on the correct application of the new codes".


Query Text:
We are having difficulty applying ACS 0044 'Chemotherapy' for patients with neoplasms who are admitted to our same day oncology ward.  In particular we are having difficulty determining what a ‘neoplasm related condition’ is.  How should the following scenarios be coded?

1.  Patient is admitted as a same day episode to our day oncology ward with dehydration and receives intravenous electrolytes.  Patient has previously been diagnosed with breast cancer.  Is the PD Z51.1 or E86?  What is the correct procedure code to assign 96199-00 or 96199-08?


2.  Patient admitted as a same day episode to our day oncology ward for IV erythrypoietin (a hormone that increases red blood cell production) to treat anaemia.  Pt has previously been diagnosed with a neoplasm.  Is the PD Z51.1 or neoplasm code followed by D63.0?  What is the correct procedure code to assign 96199-00 or 96199-09?


3.  If a patient who has a neoplasm is admitted to our day chemotherapy unit for electrolytes to treat nausea and vomiting, we don’t know whether the nausea and vomiting are neoplasm related conditions or not.  If the documentation does not support or rule that a condition is a “neoplasm related condition”, how should the episode be coded?   Do we assume the condition is a neoplasm related condition or assume that it’s not a neoplasm related condition?

Response:
A condition should not be assumed to be a neoplasm related condition unless documented as such or classified as such by coding convention, index entry or ACS.  

The NCCH provided the following advice:
NCCH suggests that a condition should not be assumed to be a neoplasm related condition unless documented or classified as such.

Assign the following codes for the scenarios cited:
1. E86 Volume depletion (for the dehydration, as the principal diagnosis) 
A code for the breast cancer (if the breast cancer is a comorbidity that has an affect on the episode of care as per ACS 0002 Additional Diagnoses) see also ACS 0236 Neoplasm Coding And Sequencing
96199-08 [1920] Intravenous administration of pharmacological agent, electrolyte (as the principal treatment in same-day episodes of care)

2. The dagger (aetiology)/asterisk (manifestation) multiple code assignment for anaemia in neoplastic conditions indicates that the anaemia is a neoplasm related condition.
Z51.1 Pharmacotherapy session for neoplasm
A neoplasm code (dagger) 
D63.0* Anaemia in neoplastic disease
96199-00 [1920] Intravenous administration of pharmacological agent, antineoplastic agent (as the principal treatment in same-day episodes of care)

3. R11 Nausea and vomiting
A neoplasm code (if the neoplasm is a comorbidity that has an affect on the episode of care as per ACS 0002 Additional Diagnoses) see also ACS 0236 Neoplasm Coding And Sequencing
96199-08 [1920] Intravenous administration of pharmacological agent, electrolyte (as the principal treatment in same-day episodes of care).


Query Text:
Question 1
In coding intervertebral lumbar disc displacement and sciatica, we are able to code the dagger and asterisk combination of M51.1 and G55.1.
However if you have lumbar canal stenosis with sciatica, you are not able to use this code combination,:
Stenosis,-spinal, -- with nerve root compression M48.0- and G55.3*

The tabular code descriptions of G55.1 and G55.3 are the same, but include a different range of dagger codes.  If nerve root compression must be documented to use the extra code, why is this not the same for intervertebral disc displacement, or is the anomaly with the indexing of the spinal canal stenosis?

Question 2
When could you use G55.3 with M45-M46 and M53-M54 as I can find nothing in the index that allows you to use this combination?

Response:
The VICC sought advice from NCCH when preparing this response:

Answer 1:
The VICC agrees that there is no index entry that allows you to use this combination for documentation of spinal stenosis with sciatica.  As stated, there are other entries that index sciatica to nerve root and plexus compressions.  

However, it is not possible to cover every documentation combination in the index.  Coders can and should use clinical knowledge to find synonymous terms when the term documented in the record is not found in the index, to try to fully cover the diagnoses.  Clinical literature refers to sciatica as neuropathy of sciatic nerve and lumbar radiculopathy, one of the causes is stated to be nerve compression.  Using this knowledge the correct code assignment in this case, of lumbar canal stenosis with sciatica, would be: 
Stenosis
-spinal
-- with nerve root compression M48.0- and G55.3*

Similar advice was provided in VICC #1922 Spinal cord compression secondary to neoplasm.

Answer 2:
The NCCH is seeking advice on this issue from WHO URC.


Query Text:
58 year old female admitted with a recurrent genital prolapse and a mid vaginal constriction, undergoes a laparoscopic sacrocolpopexy and a vaginoplasty to improve the vaginal capacity.

Could the committee please advise on the correct coding of the procedure 'vaginoplasty' which is performed for conditions such as vaginal stenosis/constriction, narrowed introitus, tightening of the vaginal muscles etc.  It is often done at the same time as a repair of prolapse and other urogynaecology procedures on postmenopausal women.

Following the index, the only codes available for vaginoplasty are:
Vaginoplasty 
-for 
--ambiguous genitalia 
---with clitoroplasty 37848-00 [1298] 
--congenital adrenal hyperplasia 37851-00 [1298] 
--mixed gonadal dysgenesis 37851-00 [1298] 
[Extracted from NCCH ICD-10-AM, July 2004, V.]

We do not believe that these codes are appropriate for the above cases.  Currently we use code 35567-00 [1286] Other repair of vagina.

Can you please advise on the appropriate code to assign.  Thank-you

Response:
This query was referred to the NCCH who provided the following advice:
A task has been created to review this request.  Please note that NCCH agreed with the code suggested by the enquirer and supported by VICC 35567-00 [1286] Other repair of vagina.  

The MBS item number relevant to this procedure (35567) is being deleted from MBS.  NCCH will propose an appropriate replacement and index it as the default.


Query Text:
With reference to the feature on Drug Administration in Coding Matters Vol 11 No 2, Sept 2004, I am seeking clarification of advice given re multiple drugs given at the same administration.
Advice given was to assign only one code, using the extension that indicates the main intent of the pharmacotherapy.
Does this mean that if there were two conditions being treated we should assign two codes? 
 A possible scenario would be a patient admitted for chemotherapy who also suffered from knee inflammation unrelated to his neoplasm.  He was treated with chemotherapy for his neoplasm and antibiotics for the inflammation.  Both were administered intravenously during a same day admission.  Since the intent was to treat both conditions, I would code 96199-00 and 96199-02 [1920].

Response:
The NCCH has been consulted with regards to this query, and has responded in the following manner:

"Follow the advice given in the second point in the 10-AM Commandment Vol 11, Number 2, Sept 2004, article entitled Drug Administration:
"When a patient receives multiple drugs at the same administration (via the same route of administration) the following guidelines should be used to determine which code extension to be assigned from block [1920] Pharmacotherapy:...

2. Assign the extension that indicates the main intent of the pharmacotherapy.  For example: If a patient is admitted for pharmacotherapy for treatment of a neoplasm and is given a cytotoxic drug together with an antihypercalcaemic, such as Zometa (for hypercalcaemia), at the same administration, assign extension -00 Antineoplastic agent, as the main intent of the pharmacotherapy is for treatment of the neoplasm."

Additionally the guideline in ACS 0042 Procedures normally not coded, point 5, Drug Treatment states:
"Drug treatment should not be coded unless the substance is given as the principal treatment in same-day episodes of care…"

Q2149 will be amended to reflect this advice."


Query Text:
A new procedure is being conducted at our hospital called a Virtual Colonoscopy (VC).  VC use x-rays and computers to produce and display two and three dimensional images of the large intestine, small intestine and rectum.  The procedure is used to diagnose colon and bowel disease, including polyps, diverticulosis and cancer.  VC can be performed with computerised tomography (CT colonography with IV contrast) or with magnetic resonance imaging (MRI) and is performed in the Radiology department of our hospital.  In consultation with a clinician at the hospital, he advised me that VC's will begin to replace colonoscopies in some patients.

Is it suitable enough to use the CT abdomen with contrast code (56407-00 [1962]) or does a new code need to be developed to adequately describe this procedure.

Search Details: *  NCCH queries
*  Clinical input
*  Victorian Coding Newsletter and Coding Matters
*  Internet search

Response:
Based on the information provided, Virtual Colonoscopy should be coded to CT or MRI; whichever is performed.  A new code is not required because the CT or MRI is the procedure actually being performed.


Query Text:
If a pt has a postprocedural intra-abdominal or sub-phrenic abscess, these are currently included in T81.41 wound infection.
These are quite significant infections, should they be moved to K91.8 as they are specifically of the gastrointestinal system?

Response:
The correct code to assign in this scenario is T81.41 Wound infection following a procedure.  This is supported by ACS 1904 Procedural complications and also by the index entries.  Although the code title is 'wound infection' the code does include intra-abdominal and subphrenic abscesses as per the ‘includes’ note.

An additional code K65.0 Acute peritonitis can be added to fully describe the medical statement. 

It is important for coders to remember that ICD-10-AM is a statistical classification so there is not a specific code title for every condition and to follow the index entries and assign a code accordingly.

To have the classification changed, a public submission to the NCCH would be required.


Query Text:
Three questions relating to one case:

1)  Patient admitted for a pancreatectomy and pathology states islet cell tumour of pancreas, which pathologist and surgeon have stated is of uncertain behaviour. In the index the look up Islet cell tumour, pancreas - D13.7 M8150/0, forces you to code it to benign.
However, if you look up:
Tumour
- islet cell (M8150/1)D37.7
-- benign (M8150/0) D13.6
-- malignant (M8150/3)
--- pancreas C25.4
--- specified site NEC - see neoplasm, malignant
-- pancreas D13.7
-- specified site NEC - see neoplasm, benign
-- unspecified site D13.7
This index entry does not make sense.  To code the tumour to the correct morphology of uncertain behaviour, I have to ignore the entries for pancreas.  Could this section of the index please be investigated and amended?

2) In grouping this case if I follow the index and code the tumour to benign (D13.7), I get a 901Z "Extensive OR procedure Unrelated to Principal Diagnosis" DRG.  This appears to be an anomaly in the grouping as malignant, uncertain behaviour and benign (specified but not of the pancreas)which codes to the pancreas (D13.6), rather than the endocrine pancreas (D13.7), all group correctly. Could this anomaly be addressed?

3) The procedure performed in this instance is a distal pancreatetomy with splenectomy.  There is a specific code for distal pancreatectomy which you would then assume to add the code for splenectomy.  The index however, has a 'with' entry for splenectomy which takes you to a code for pancreatectomy with splenectomy.  I would assume that in this instance a total pancreatectomy would be performed, but the index does not specify this. I am forced to code pancreatectomy with splenectomy in this case.  Could you please advise on the correct coding for distal pancreatectomy with splenectomy?

Response:
This query was referred to the NCCH who provided the following advice:
"ICD-10-AM Tabular List, Appendix A Morphology of Neoplasms states: ‘behaviour code should be changed if...reported information makes this appropriate’ and ACS 0233 Morphology point 3 reinforces this: ‘Note that... behaviour code can change depending on the behaviour description of the neoplasm in the clinical record.’

For documentation of 'islet cell tumour of pancreas, of uncertain behaviour', in order to capture the correct topography, assign:
D37.7 (Neoplasm of uncertain or unknown behaviour) Other digestive organs
M8150/1 Islet cell tumour NOS, by following the index pathway:

Neoplasm
- pancreas
- - islet cells (uncertain or unknown behaviour)

The NCCH will consider a review of the indexing of Islet cell tumour, pancreas and Tumour, islet cell benign for a future edition of ICD-10-AM.

The correct code to assign for 'pancreatectomy with splenectomy' (regardless of whether the pancreatectomy is described as distal) is 30593-01 [978] Pancreatectomy with splenectomy."

The VICC notes that the grouper allocates D13.7 Endocrine pancreas to MDC 10 Endocrine, nutritional and metabolic diseases and disorders which is appropriate, however DRG 901Z is assigned because 30593-01 [978] Pancreatectomy with splenectomy is not recognised in MDC 10.  The VICC will refer this to the Commonwealth.


Query Text:
According to ACS 0104 Viral Hepatitis, if a patient is documented as being Hep C +ve, the pt has to be symptomatic for us to be able to assign a code for Chronic Hepatitis C.    In a case I coded recently the patient had had their Hep C investigated extensively 2 years prior but was lost to follow-up.  At the time her Hep C was symptomatic (lethargy, jaundice, generally unwell) and her LFTs were grossly abnormal.  In the current episode she is still noted to be Hep C +ve, but no other information about her HCV was given.

Are we able to use previous documentation to support the fact that the pt has a symptomatic past and code them as chronic HCV?  If a previous episode has been documented  as chronic HCV (ie finding on a liver biopsy) can we code all subsequent episodes as chronic HCV (the standard does not appear to allow this)?  Or can a person go from having chronic HCV back to being a carrier?

What constitutes a symptom of HCV? Are abnormal LFT's alone an indicator that a pt is more than a carrier?

Could we please have some clarification and guidance with the application of this standard?

Response:
Based on current clinical information obtained by the Victorian ICD Coding Committee it is considered possible that, with treatment, a person may go from having chronic HCV back to being a carrier, therefore previous documentation cannot be used to determine if a patient is symptomatic.

Abnormal LFTs attributable to HCV are enough to distinguish chronic hepatitis from carrier, but this should be supported by documentation in the medical record.


Query Text:
53yo lady admitted to Oncology Day Stay unit with aspergillus post bone marrow transplant for CLL for IV antibiotics. On clarifying with nursing staff, they have said that the aspergillus is a lung infection and she is more likely to get it because she is immuno-suppressed because of her post transplant status for CLL.

Do we code:
1)  Z51.1, C91.10, M9823/3, 96199-00 [1920] as per ICD10AM 4th edition training (pharmacotherapy); or,

2)  B44.9, C91.10, M9823/3, 96199-02 [1920] as per example 2 (clarification of the use of extension -00 in block [1920] Pharmacotherapy, E Books, ICD-10-AM commandments, Volume 11, Number 2, September 2004.

Response:
This query was referred to the NCCH who provided the following advice:
ACS 0236 Neoplasm coding and sequencing states: assign the primary malignancy as a current condition if the episode of care is for treatment of another nonmalignant condition, when the malignancy is a comorbidity that has an effect on the episode of care as per ACS 0002 Additional diagnosis.

For the scenario cited, the specialist nursing care provided in the Oncology Day Stay Unit indicates that the CLL should be coded for this case.

Therefore, for the scenario cited, assign:
B44.x Aspergillosis
C91.10 Chronic lymphocytic leukaemia, without mention of remission
M9823/3 B-cell chronic lymphocytic leukaemia/small lymphocytic lymphoma
96199-02 [1920] Intravenous administration of pharmacological agent, anti-infective agent

Note:  As the antibiotics are for treatment of a condition (aspergillus) that is the result of chemotherapy treatment (not a neoplasm or neoplasm-related condition):
· Z51.1 Pharmacotherapy session for neoplasm is not assigned
· -02 anti-infective agent is assigned with the pharmacotherapy code, not -00 antineoplastic agent.

The VICC advises that coding decisions should not be based on where the patient's treatment is provided.

In this scenario, it may be appropriate to assign D89.8 Other specified disorders involving the immune mechanism, not elsewhere classified to describe the patient's immunosuppressed status.  It may also be appropriate to assign Z94.8 Other transplanted organ and tissue status and D84.9 Immunodeficiency, unspecified if these are documented in the notes and meet ACS 0002 Additional diagnoses.

Note that aspergillus is a fungal infection and there are specific codes for pulmonary aspergillus.


Query Text:
A 43 year old female patient was admitted to hospital for D&C and Hysteroscopy for Post Menopausal Bleeding.  On admission she was found to have right middle lobe pneumonia and therefore the procedure was cancelled.  The patient then subsquently remained an inpatient for 6 days with the pneumonia which was treated via IV antibiotics.  According to ACS 0011 Admission for Surgery not Performed, the reason for admission, in this case the Post Menopausal Bleed, should be coded as the principal diagnosis with Z53.0 and J18.1 as associated diagnoses.  The ACS 0011 states If a patient has been admitted to hospital for surgery which for some reason has not been performed and the patient is discharged, code as follows:
However, our query relates to the fact that the patient remained in hospital for 6 days due to the pneumonia and was treated for this condition and not the post menopausal bleed.  Hence the patient was not discharged on the same day as admission.  The standard does not direct coders how to code in these circumstances.

In this case should the principal diagnosis be the post menopausal bleed with the pneumonia and cancellation as associated, 
N95.0
Z53.0
J18.91

or

should the pneumonia be coded as a principal diagnosis with the postmenapausal bleed and cancellation as associated.
J18.9
N92.0
Z53.0 

Search Details: We have discussed with collegues and searched the NCCH queries database and read query 2056, however we would still like to submit this query for further clarification.

Response:
The Victorian ICD Coding Committee recognises that ACS 0011 Admission for surgery not performed does not address coding of patients who are admitted for a procedure that is cancelled and then the patient remains in hospital overnight for treatment of a different condition.  While acknowledging that this is problematic, the VICC advises the enquirer to follow the ACS 0011.  

ACS 0001 Principal Diagnosis ‘Original treatment plan not carried out’ advises to sequence as the principal diagnosis the condition which after study occasioned the admission to the hospital even though treatment may not have been carried out due to unforseen circumstances (see also ACS 0011 Admission for surgery not performed and Coding Matters Volume 12, Number 2, September 2005).

In this case code:
N95.0 Postmenopausal bleeding
Z53.0 Procedure not carried out because of contraindication
J18.9 Pneumonia

Please note that middle lobe pneumonia is not lobar pneumonia (per ACS 1004 Pneumonia).


Query Text:
Could you please clarify the use of these two procedure codes when coding intravenous administration of gamma globulin:  13706-05 (1893) and 96199-05 (1920).  Thank you.



Search Details: Std 0214; VCC Newsletter, Feb 03, query #1863; NCCH queries database, #2025 (8/10/04)

Response:
ACS 0214 Intragam provides advice on code assignment based on route of administration.

If injection is documented, assign a code from block [1920] Pharmacotherapy, with extension 05 Gamma globulin.

If IV access, infusion or transfusion is documented assign:

13706-05 [1893] Transfusion of gamma globulin

Please note that ACS 0214 Intragam overrides the index entry for IV administration of gamma globulin.


Query Text:
Patient admitted for breast reconstruction (operation report provided).

Can you please advise:
1. Should the excision of cartilage be coded?
2. Prolene mesh used in the abdominoplasty repair of donor site - should this be coded?  If so, what is the correct code?

Response:
Excision of cartilage should not be coded as it is the operative approach.  This logic is supported by advice published in ICD Coding newsletter February 2004, VICC #1909 Coding of uncinectomy.

Nor is it necessary to code the prolene mesh separately from the abdominoplasty, as it is the method of repair.

Assign 30403-05 [1000] Repair of abdominal wall following procurement of myocutaneous flap only.


Query Text:
Can removal of impacted/wisdom teeth be assumed to be surgical or must the surgeon state surgical removal.  This is a problem for us because if surgical is not written on the operation report than we are unable to use the correct code if the index trail is followed.

Response:
Removal of impacted wisdom teeth is not necessarily surgical, therefore surgical needs to be documented before the procedure code is assigned.  If coders are unable to obtain further documentation from surgeons, apply ACS 0038 Procedures Distinguished on the Basis of Size, Time or Number of Lesions and code to the least invasive, in this case, non-surgical.


Query Text:
I would be interested to know which code other orthopaedic coders are allocating this diagnosis. This condition is an allergic reaction to the metal components of the prosthesis. We are using T84.5 because of the inflammatory reaction. 

Is this correct?

Response:
T84.5 Infection and inflammatory reaction due to internal joint prosthesis is assigned only if inflammation is documented in the clinical notes.

Therefore for the episode cited, the correct codes to assign are:

T84.8 Other complications of internal orthopaedic prosthetic devices, implants and grafts
Y83.1 Surgical operation with implant of artificial internal device
Y92.22 Place of occurrence, health service area


Query Text:
We have a number of patients admitted for insertion of an electrostimulation device into the para-urethral area known as Miniaturo electrode. This procedure is performed for severe interstitial cystitis.

Currently we can find no code suitable for this procedure in ICD 10 AM. The surgeon is not assigning any MBS code currently for this procedure. It is performed in conjunction with a cystoscopy, biopsy and some diathermy.

This procedure is performed in two stages, first placement of the electrode and second stage the implantation of the generator subcutaneously in the lower abdominal region.

Please find further information at the included sites.

http://www.iicpn-foundation.org/InterstitialCystitis.htm
http://www.ingentaconnect.com/content/bsc/bju/2004/00000094/00000001/art00025

There is no code available for the placement of the electrode (1st stage), however it may be possible to assign 
90012-00[67] Implantation of peripheral neurostimulator for the placement of generator. This results in DRG 901Z in V5 and 4.2 of the grouper if no other procedures are performed.

Please confirm the correct codes to be used for both stages of this procedure?

Search Details: NCCH query database - NIL
Look up Insertion , electrode, - NIL for peripheral, urethra, bladder

Response:
The VICC sought advice from the NCCH when preparing this response.

NCCH sought advice from a hospital where this procedure was performed as part of an international study. The hospital's code assignment for the procedure was determined following consultation with clinical/nursing staff involved with the study.

The MiniatURO device is inserted in a two step procedure.  The procedure for both steps is almost identical.  The first step is only temporary (the device is inserted and trialed for one day) and is performed using local anaesthetic.

The second step is more permanent, with the device being embedded in the pelvic floor muscles and performed using general anaesthetic.

Cystoscopy is performed with both steps.

The NCCH supports the following codes for each of the steps involved in insertion of the Miniaturo™:
90359-00 [1091] Implantation of electronic bladder stimulator
36812-00 [1089] Cystoscopy
a code for the anaesthesia, as appropriate.


Query Text:
We have noticed a discrepancy in the index when coding gastroenteritis due to food poisoning.  Food poisoning is not specified as bacterial in the documentation.

Index:
Gastroenteritis
- due to 
- - food poisoning A05.9
(3M Code Finder also assigns K52.9)

Index:
Poisoning
- food T62.9
- - bacterial A05.9
Code gastroenteritis as a manifestation

We are unsure which is the correct way to code this.

Do we code:

A05.9 Bacterial foodborne intoxication, unspecified
K52.9 Noninfective gastroenterits and colitis, unspecified
(is K52.9 required as well?)

or

T62.9 Toxic effect of noxious substance eaten as food unspecified
K52.9 Noninfective gastroenteritis and colitis, unspecified
X49 Accidental poisoning by and exposure to other and unspecified chemicals and noxious substances
Y92.9 Place of occurence at or in unspecified place
U73.2 Injury or poisoning occuring while resting, sleeping, eating or engaging in other vital activities.

Search Details: Have searched NCCH queries and ICD Coding Newsletters but unable to find advice.

Response:
Clinical information obtained by the Victorian ICD Coding Committee suggests that food poisoning can cause conditions other than gastroenteritis.  Also, viruses, bacteria, parasites or toxic agents such as wild mushrooms can cause food poisoning.  Coders should look up the lead term depending on documentation in the clinical notes and apply excludes notes accordingly.  The Committee does not believe there is a discrepancy in the index.

Therefore, if only food poisoning is documented assign code T62.9 Noxious substance eaten as food, unspecified.  If gastroenteritis due to food poisoning is documented assign code A05.9 Bacterial food-borne intoxication, unspecified.

K52.9 Noninfective gastroenteritis and colitis, unspecified is not required as an additional code as it is not adding any further information.


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

Search Details: 
Searched NCCH query database and Victorian ICD Coding Newsletter, but unable to find any further advice.

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

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

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

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

Please refer to #2657 Perimenopausal bleeding for Seventh Edition advice.


Query Text:
A 55 year old female presented for a Bronchoscopy to investigate haemoptysis and an abnormality found on CT. The results, as reported on a computer generated Bronchoscopy report, are:

No Endobronchial lesion seen. Purulent discharge from lingular lobe noted. No cause for haemoptypsis found.

Washings were taken and the pathology report states:

CULTURE:
Org 1.Aspergillus fumigatus                        Scanty growth

There is no further information in the admission notes regarding this diagnosis, follow up plans or treatment. The episode is a same day episode.

I am querying the assignment of a code for the Aspergillus Fumigatus culture. I have already assigned R04.2 as my Principal Diagnosis code.

Would it be correct to assign: 

B44.1 Other pulmonary aspergillosis  

in accordance with ACS 0046 because the result of the washing is a finding which has not been linked to the symptoms ? Or, Does the culture result first require interpretation by the treating clinician as per ACS 0010, and documentation of the infection in the clinical notes as per the Coding Organisms Coding feature, in which case no code would be assigned for the Aspergillus fumigatus ?

I'm not sure if a culture result should be considered differently to a histological finding.

This query was raised as a result of B44.1 being a Notifiable code in PRS2.

Search Details: Index 

Infection, infected (opportunistic) B99 
- Aspergillus (flavus) (fumigatus) (terreus) (see also Aspergillosis) B44.9 

Aspergillosis, aspergilloma B44.9 
- pulmonary NEC B44.1 

Tabular 

B44 Aspergillosis
Includes: aspergilloma
B44.0  Invasive pulmonary aspergillosis
B44.1  Other pulmonary aspergillosis
B44.2  Tonsillar aspergillosis
B44.7  Disseminated aspergillosis
Generalised aspergillosis
B44.8   Other forms of aspergillosis
B44.9   Aspergillosis, unspecified

ACS 0010, 0045

Victorian Coding Newsletter

Coding Feature, Coding Organisms, Feb 2002

Response:
As pointed out in your query, B44.1 Other pulmonary aspergillosis cannot be coded without clinical interpretation.

Microbiology findings need clinical interpretation regardless of the length of stay of the patient as per ACS 0010 General Abstraction guidelines.

ACS 0046 Diagnosis Selection for Same-Day Endoscopy does not provide justification for the coding of B44.1.

Therefore for the case cited assign the following diagnosis codes:

 R04.2 Haemoptypsis
 R91  Abnormal findings on diagnostic imaging of lung


Query Text:
My query relates to the Neoplasm standard 0236 coding and sequencing.  Dot point number 1 states that you should use the neoplasm code as principal when coding a complication of the cancer.  However, it does not tell you what to do if the complication is a complication of treatment given for the cancer.  

Coding query number 1958 in example (1) suggests that you cannot use the cancer as a principal and you should not use it as an additional diagnosis (unless it meets criteria of ACS 0002 Additional Diagnosis).  Why does the standard not clearly state that complications of treatment (vomiting or diarrhoea following chemotherapy for instance) are excluded?

Is this coding query #1958 still valid?  Is there something that I have missed which clearly sets out what to do with a complication of treatment for malignancy?

Response:
The VICC notes that dot point one in ACS 0236 Neoplasm coding and sequencing relates to the assignment of current condition not principal diagnosis.

This query was referred to the NCCH who provided the following advice:
ACS 0236 Neoplasm coding and sequencing states: assign the primary malignancy as a current condition if the episode of care is for treatment of another nonmalignant condition, when the malignancy is a comorbidity that has an affect on the episode of care as per ACS 0002 Additional diagnosis.

The VICC therefore advises to only assign a code for the neoplasm where there is documentation that the neoplasm is impacting on the episode of care.

VICC query #1958 published in the February 2004 ICD Coding newsletter is still current except for those cases covered by NCCH query Q1982 (18/10/2004).


Query Title:
Coding and grouping of compound fracture of great toe

Query Text:
Patient admitted with compound fracture great toe & nail bed injury.  Treatment repair nail bed and debridement of wound,(fracture untreated).

Episode groups to DRG I30Z - Hand procedure.  

If  code S91.2 - open wound toe with damage to nail is assigned as principal, it groups to DRG X04B - Other Procedures for Injuries to Lower Limb age <60 W/O CC, which seems to be a more correct DRG.  However I understand from ACS 1918 p254. that it is not necessary to code two open wound codes for the same injury site, so using the S91.2 code would be incorrect.

Can you please make comment with regard to the coding and DRG assignment.  Also should we include a code for the nail bed injury (not as principal diagnosis)in addition to the open wound with fracture code to specify the injury to nail or is this over coding?

Search Details: ICD-10-AM Vol 5. ACS 1918 p.254

Response:
This query was referred to the NCCH who provided the following advice:
"The NCCH advises that the correct code assignment for the scenario cited is: 
S92.4 Fracture of great toe (as the principal diagnosis)
S91.81 Open wound (of any part of ankle and foot) communicating with a fracture
S91.2 Open wound of toe(s) with damage to nail

The assignment of both S91.81 and S91.2 is considered necessary to adequately describe the open wound in this case.

The NCCH also agrees that the includes note at S91 Open wound of ankle and foot which reads 'Includes: open wound communicating with a fracture and dislocation’ and 'open wound of ankle and foot NOS' is misleading and will be reviewed for a future edition of ICD-10-AM."

The VICC notes that in AR-DRG V5.1, 46486-00 [1636] Primary repair of nail or nail bed has been added to TAB I20-3.  Therefore when this procedure code is assigned for repair of nail or nail bed of toe, it will group to DRG I20Z Other foot procedures.


Query Text:
This query relates to advice given in NCCH Q2078 [3/12/04] Old Myocardial Infarction and History of IHD.  The original query related to the correct coding for a patient admitted with a cardiac condition where the clinician has documented a past history of MI or history of CABG, without documenting its relevance to the current episode of care.

NCCH advised "That by applying the 'Clinical Coders Creed' it would be appropriate to assign a code for 'old MI' or 'History of CABG' where this is documented in the clinical records of a patient admitted for treatment of a cardiac condition".

This advice is contrary to advice provided in NCCH Q1386 [5/2/01], namely that old MI can be coded if 'The treating clinician has documented that the old AMI is significant for the current episode of care'.

It is also contrary to advice provided in NCCH Q1711 [1/9/02]  'The intent of ACS 0940 (Ischaemic Heart Disease) is not for clinical coders to make assumptions as to whether there is a causal relationship between the old MI and the IHD, this information is rarely documented and clinical coders should not make this judgement'.

ACS 0940 also provides advice when old AMI can be coded.

I feel also that the application of the Clinical Coders Creed to this scenario exceeds the intention of the creed.  The issue of ischaemic heart disease is complex and varied, with each case being different from the next.  Without the necessary clinical documentation, as clinical coders it is not possible for us to know for which patient/episode the old MI or history of CABG is relevant.

To code history of MI or CABG because it is a 'cardiac condition' rather than because it is 'directly relevant to the current episode of care' (ACS 2112 Personal History) or meets ACS 0002, would seem to not be in keeping with correct coding practice.

Could you please advise and comment.

Search Details:
NCCH #2078
NCCH #1386
NCCH #1711
ACS 0940
ACS 2112
Clinical Coders Creed

Response:
This query was referred to the NCCH who provided the following advice:
NCCH has received clinical advice that supports the following:
When a patient is admitted for a cardiac condition, it is appropriate to assign a code for 'old MI' or 'history of CABGs' if this is documented in the patient's history.  It would almost always be clinically relevant and affect the treatment of the cardiac condition for the current episode of care.  A subsequent advice note has been added to NCCH queries 1386 & 1711.

The VICC note that this logic should not be applied in non-cardiac scenarios and that the VICC is working on a revision of ACS 0002 Additional diagnoses with the NCCH.


Query Title:
Metabolic acidosis with diabetes mellitus

Query Text:
30 year old patient with a PDx on discharge summary of  metabolic acidosis.  Patient is also an IDDM, with a history of a flu like illness for the past week, and noted to be dehydrated on admission. Patient stated BSL readings had been good.   LOS 4 days.   

Following the Index Diabetes, acidosis, lactic - lactic is an essential modifier and there is no default or entry for metabolic or any of the other types of acidosis apart from ketoacidosis.  

1. There is an excludes note under E87.2 Acidosis - Excludes: diabetic acidosis (E10- E14 with common 4th character .1).  It would seem as though the classification is telling coders to code all types of acidosis to 'lactic acidosis' when in a diabetic patient.  However the Index entry under Diabetes does not give this impression.  Please could the committee confirm that the correct code/s would be E10.13 'Type 1 diabetes mellitus with lactic acidosis, without coma' for the diagnosis of metabolic acidosis in a diabetic patient.

2. Respiratory, lactic, and metabolic acidosis, ketoacidosis and acidosis NEC are all indexed to E87.2.  
Should coders code all the above conditions in a diabetic patient to E1x.1x 'Diabetes with lactic acidosis' (except of course ketoacidosis which has an index entry under diabetes)? 


Search Details: ACS 0401 Diabetes, NCCH database, Coding Matters, VICC newsletter

Response:
Metabolic acidosis is not the same as ketoacidosis and lactic acidosis.  As metabolic acidosis is not linked to Diabetes in the index, follow the index entry:

Acidosis (lactic) (respiratory) E87.2 
- metabolic NEC E87.2

Assign code E87.2 Acidosis.


Query Text:
Patient has a past history of FAP of the colon and presents for a sameday colonoscopy/gastroscopy.  The results on histology show benign polyps of the stomach.  After consulting the gastroenterology team it was confirmed that FAP, although most commonly found in the colon, can also be found in the stomach.

Question 1:
Should the morphology code assigned, be based on the histology results (benign polyps) or should a morphology code for FAP be assigned?

Question 2:
If FAP of the stomach is diagnosed, should D12.6 be assigned as per ACS 0246 or should D13.1 be used?

Search Details: 
ACS 0246 Familial adenomatous polyposis
FAP Website:  http://www.geneclinics.org/profiles/fap/details.html

Response:
The Victorian ICD Coding Committee has identified that FAP is not always reported as a histological change.  Therefore if FAP is documented in the clinical notes, even though the histology report states benign polyp, the morphology for FAP should be assigned for this episode.  A condition can be coded from clinical documentation in the absence of histological evidence.

If FAP of the stomach is diagnosed, D13.1 Benign neoplasm of stomach should be assigned.


Query Title:
Coding of cancer with insertion/removal infusaport

Query Text:
NCCH Query database number 1982 (18/10/04) states:

“Question:
Patient with breast cancer admitted for insertion/removal of infusaport.
At our state coding committee, a query was received regarding a patient with breast cancer admitted for insertion/removal of infusaport, asking what the principal diagnosis should be.  Committee members agreed that Z45.2 'Adjustment and management of vascular access device' should be the PD.  Then followed much discussion about whether the breast cancer met the definition of additional diagnosis and should be coded. Many wanted to code the cancer to indicate the reason why the patient had a VAD.  We would appreciate your advice on this.

Answer:
The NCCH agrees with the assignment of Z45.2 'Adjustment and management of vascular access device' as the principal diagnosis for the case cited.

ACS 0236 NEOPLASM CODING AND SEQUENCING states: "The primary malignancy should be coded as a current condition if the episode of care is for: medical care related to the malignancy". This guideline overrides the advice in ACS 0002 ADDITIONAL DIAGNOSES. 

Also, as Z45.2 'Adjustment and management of vascular access device' describes an admission for a procedure, it is necessary to provide an additional diagnosis code to 'complete the picture'.

Therefore, the NCCH supports the assignment of codes for the 'breast cancer' for this case.”

I have some questions about this response:

1.  Why is admission for infusaport insertion or removal considered to be ‘medical care related to the malignancy’?  

2.  If it is ‘necessary to provide an additional diagnosis code to complete the picture’ for admissions for VADs, would this advice (to also code the condition) apply to admissions for other VAD insertions/removals, e.g. CVC for dialysis?

VICC #1943, May 2004, for disconnection of CADD does not mention coding the condition as an additional diagnosis.

We are confused whether to now routinely assign a cancer or other condition code having now read the NCCH response.

Response:
Answer 1
The Victorian ICD Coding Committee agrees with the response in NCCH Q1982 (18/10/04) to assign a code for the neoplasm as an additional diagnosis because the infusaport insertion or removal is facilitating the medical care of the malignancy as per ACS 0236 Neoplasm coding and sequencing.
 
The Committee notes that Z45.1 Adjustment and management of implantable infusion device or pump is the appropriate code to assign as principal diagnosis in the scenario discussed in NCCH Q1982.

Answer 2:
The advice in NCCH Q1982 applies only to patients described in that scenario.  For patients with non-neoplastic conditions admitted for VAD, the non-neoplastic condition should meet ACS 0002 Additional diagnoses before it is assigned.

VICC #1943 Continuous Ambulatory Drug Device (CADD) disconnections does not mention coding the condition as an additional diagnosis because the query related to the assignment of the principal diagnosis.


Query Title:
Post operative care versus convalescence

Query Text:
Was hoping for a much clearer definition of post op. care versus convalescence, in view of the huge difference in DRG weight (post op care = .71 versus convalescence 2.14). As we are a regional country hospital we have quite a number of patients transfered back following complex operations at other hospitals. It is difficult to differentiate from the standards definitions the difference between someone who is receiving 'active treatment' versus 'convalescence', and the example gives no detail either as to what could be considered active treatment versus convalescence.( It also seems odd that convalescence gives a higher weight than active care, although I realise this is outside of your scope).

Response:
Based on the information provided there does not appear to be documentation of convalescence or aftercare, therefore ACS 2103 Admission for convalescence/aftercare may not apply.  The correct principal diagnosis in the first example is the burns as the patient received ongoing treatment for this condition.  In the second example, based on the limited information provided, the committee cannot provide a definitive code. 

It is important to note that ACS 2103 Admission for convalescence/aftercare does not apply to all transfers and this standard should only be applied when there is documentation of 'postoperative care' or 'convalescence'.  The Victorian ICD Coding Committee suggests that these types of cases be referred back to the treating clinician for clarification of principal diagnosis whenever possible. 

Please note the following paragraph from Coding Matters Volume 10 Number 3 December 2003 (article titled ACS 2103 Admission for convalescence/aftercare):

The NCCH has received a number of queries concerning the application of ACS 2103 Admission for convalescence/aftercare.  The intent of this standard is to provide guidance for clinical coders when specific documentation is written in the clinical record regarding ‘convalescence’ and ‘postoperative convalescence’ when the patient may still be receiving treatment.  It was not intended for this ACS to be applied to all cases where patients are transferred between hospitals.  The term ‘transfer’ does not imply that all subsequent episodes of care are ‘aftercare’.

Classification
Clinical coders should make the most appropriate decision regarding code assignment by:
· applying the clinical coders creed by assessing each case individually
· referring to clinical documentation
· using appropriate coding standards

Cost weights are driven by historical clinical costing and coded data and are reviewed annually.  Code assignment should not be determined by reference to cost weights.


Query Text:
A patient has been admitted for investigation of ?Cushings syndrome.  She initially underwent an oral Dexamethasone Suppression Test, which, for technical reasons, was not completely successful, so was converted to an IV Dexamethasone Suppression test.  

Dexamethasone, a synthetic glucocortoid hormone, often fails to suppress the function of the hypothalamus, pituitary and adrenal glands in patients with Cushings syndrome and so forms the basis for the suppression test.  [www.cushings-help.com/dex_tests.htm]

The test involves daily urine collection in conjunction with IV dexamethasone administered over a number of days.

My question is how to code the suppression test.  At this stage I have used the following codes:
92204-00 [1866] Non-invasive diagnostic tests, measures or investigations, NEC
96199-03 [1920] IV administration of pharmacological agent, steroid

I have not included a code to identify the oral administration of dexamethasone, given that oral administration of any drug is rarely coded.


Search Details: books, various web sites, NCCH queries, ICD coding newsletter, Coding matters

Response:
The Victorian ICD Coding Committee agrees with the procedure codes assigned by the enquirer for a patient specifically admitted for IV Dexamethasone Suppression Test.


Query Text:
We have recently had a 67 year old man admitted with ? bite from brown snake. He was exhibiting similar symptoms to a snake bite and antivenom was given. This gentleman subsequently passed away and his blood culture results came back after his death showing gram -ve Bacilli and negative on snake bite venom tests. Thus his cause of death has been determined as Gram -ve Sepsis.

Should this case be coded as toxic effect of contact with snake venom (T63.0) considering the antivenom was administered or should it not considering the snake bite has been ruled out?

Response:
As the condition occasioning admission after study was determined to be gram negative sepsis in this scenario, the gram negative sepsis should be assigned as the principal diagnosis.

T63.0 Toxic effect of contact with snake venom would not be coded as it was excluded on the snakebite venom test result.

A procedure code for administration of antidote from Block [1920] Pharmacotherapy should be assigned.


Query Text:
Patient admitted to have ICD implantation.  The type used was a Biotronic Cardiac Airbag, which is listed by our cath lab as a combined VVI (single chamber) pacemaker/ICD.  The documentation in the record supported this, however there was only one lead inserted into the R Ventricle.  On checking with the cath lab this device does only have one electrode which provides both functions.

Could the committee please provide guidance as to which code should be used for the electrode, the choice would appear to be either 38278-01 [648] Insertion of permanent transvenous electrode into ventricle (for pacemaker) or 38521-03 [653] Insertion of defibrillation electrodes …., or should we use both codes, even though only one electrode was used.

With any of the above choices for electrodes the coding does not actually represent what was done.

The grouping does not appear to be effected, as once a defibrillator is coded, the DRG assigned is F01 regardless of whether defibrillator electrodes are coded or not, or a pacemaker is inserted.

Response:
This query was referred to the NCCH who provided the following advice:
"If a patient has a combined AICD/Biventricular device inserted, coders need to assign separate codes for the insertion of the AICD and the pacemaker. This device combines the functions of both in a single unit and would normally require only three transvenous electrodes.

Coders need to check the operation report for the number of electrodes inserted and code accordingly. Where there is a combined device inserted but there is no specific information regarding the placement of the leads, the electrodes will be coded to the pacemaker leads as these leads will be inserted into both ventricles and the atrium (Biventricular pacemaker) and have dual action to pace as well as defibrillate.

There is no appropriate place in Chapter 8 'Procedures on Cardiovascular System' of ACHI to place codes for combined devices. A choice had to be made by NCCH to classify combined devices with either AICDs or pacemakers. As pacemaker codes are more specific than AICD codes in ACHI, the decision was made to classify the combined devices to pacemakers. This was proposed and agreed to by the Coding Standards Advisory Committee for ACHI Fourth Edition. However, following ACHI Fourth Edition production, changes were made due to DRG/funding implications (not classification reasons) that require both AICD and pacemakers to be coded for combined devices."

The VICC notes the NCCH response and advises that the 'code also' coding convention at both the AICD insertion and pacemaker insertion, means that when only one electrode is inserted that performs both functions a code is assigned for each electrode function.  It is acknowledged that this results in the assignment of two codes.  If there is no information on the function of leads, default to pacemaker electrodes.


Query Text:
Male, aged 83 with diagnosis:  renal failure, likely obstructive nephropathy secondary to prostate adenocarcinoma; urinary retention and haematuria  on presentation, R) stent in situ.  Indwelling catheter inserted on admission, voiding well on discharge (no catheter).  The prostate cancer was diagnosed in1995.  Patient  also NIDDM on insulin.  See Disease Index: 
Diabetes 
-with
--failure 
---renal
 ----acute 
----chronic
 ----end-stage.

There is no option for renal failure NOS, therefore I coded the episode as follows: N19,  N13.8, R33, R31, C61, M8140/3, Z96.0, E11.9, Z92.22.  This coding was challenged in an audit and discussed at a round- table coding exercise.  The following questions were asked: 
There was no documented history of previous renal failure in the medical record, so I could have used my Coders Creed and assumed acute renal failure and coded to E11.29, N17.9.  Renal Impairment defaults to chronic, does this also apply to renal failure and therefore coded to E11.23, N18.91.

I disagreed with these suggestions, believing that I should follow the index, especially in regard to Diabetes coding.  What is the opinion of the Victorian Coding Committee?

Response:
This query was referred to the NCCH who provided the following advice:
Coders should, where possible, confirm with the treating clinician whether the renal failure is acute or chronic. When documentation is insufficient and further clinical advice cannot be obtained, assign:
E1-.23 *Diabetes mellitus with advanced renal disease
N18.90 Unspecified chronic renal failure


Query Text:
Patient admitted with ca bladder that has extended into urethra (pt has already had a cystectomy & ileal conduit), complete urethrectomy was performed.

This is grouping to L62A which is a medical DRG.  The procedure for complete urethrectomy 37330-01 [1118] is not listed in the definitions manual at all. 

Could you advise if the grouping is correct or if this procedure needs to be considered for the next version of the grouper?

Response:
The enquirer is correct in that 37330-01 [1118] Complete urethrectomy is not recognised by the grouper as an operating room procedure, hence the episode is grouping to a medical DRG.

The DHS will forward this grouping anomaly to the Commonwealth.


Query Text:
Should accidental punctures & lacerations during procedures be coded when no action is taken? 

Search Details: 
We have checked NCCH query database, ICD coding newsletter & Coding Matters but have come up with no information regarding this subject.

Response:
This query was referred to the NCCH who provided the following advice:
"ACS 1904 PROCEDURAL COMPLICATIONS is currently being reviewed for a future edition of ACS as part of a public submission.  The issue of whether misadventures should be coded if they don't meet the criteria for an additional diagnosis will be clarified as a result of this process,  following consultation with the Australian Commission on Safety & Quality in Health Care.

Given this will potentially be a change in practice for many coders the NCCH advises that in the interim the current guidelines in ACS 1904 PROCEDURAL COMPLICATIONS and ACS 0002 ADDITIONAL DIAGNOSES should be followed".

In view of the NCCH response, the VICC cannot provide a definitive response and therefore advises coders to apply ACS 0002 Additional diagnoses and (then) ACS 1904 Procedural complications.


Query Text:
Could the Index be modified to include an entry for "Postoperative anaemia D62"?

Could we also have an ACS for this, as the only reference we have is found in the ICD Coding Newsletter, November 2001, #1730 p32.
The answer to the query states "Acute posthaemorrhagic anaemia can only be allocated if postoperative anaemia is documented by the clinician..."

The Index has an entry for:
Anaemia
-posthaemorrhagic (chronic) D50.0
 --acute D62

We would like an entry for
Anaemia
-postoperative  D62

Response:
This query was referred to the NCCH who provided the following advice:
"The NCCH advises that it is incorrect to index 'post-operative anaemia' to D62 Acute posthaemorrhagic anaemia, as there may be  multiple causes of anaemia in surgical patients."

In view of the NCCH response, the VICC advises that there must be documentation in the clinical notes linking the anaemia to acute blood loss or haemorrhage in order to assign D62 Acute posthaemorrhagic anaemia.  Therefore this advice overrides advice regarding postoperative anaemia provided in the Procedural Complications Coding feature and #1730 published in the November 2001 ICD Coding Newsletter.


Query Title:
Vaginal vault prolapse and cystocele after hysterectomy

Query Text:
A  recent coding workshop instructed us to code cystocele after hysterectomy to N99.3.   I am aware of the exclusion notes at the start of block N81.  However I have it on (informal) clinical advice that "vaginal vault prolapse" and "cystocele" (and for that matter all other female genital prolapses such as enterocele or rectocele) are in fact separate conditions, even though they are often found in the company of each other.  Vaginal vault prolapse is more common in women post hysterectomy.

The way the exclusion note reads does not indicate to me that all female genital prolapses (post hysterectomy) should be coded to N99.3, just prolapse of the vaginal vault.  The description for N99.3 is "Prolapse of vaginal vault after hysterectomy".

Vaginal vault prolapse occurs when the upper portion of the vagina (dome or apex) loses its normal shape and sags or bulges down into the vaginal canal or outside of the vagina. It occurs in 0.1% to 18.2% of women following either a vaginal or abdominal hysterectomy  It may occur alone or along with a cystocele rectocele or enterocele. Vaginal vault prolapse is usually caused by weakness of the pelvic and vaginal support structures.

Cystocele is the name for a hernia-like disorder in women that occurs when the wall between the bladder and the vagina weakens, causing the bladder to drop or sag into the vagina.

Please advise on the correct code selection for cystocoele, rectcoele and enterocoele post hysterectomy.

Response:
The correct codes to assign are:
N81.1 Cystocele 
N81.6 Rectocele
N81.5 Vaginal enterocele

N99.3 Prolapse of vaginal vault after hysterectomy should only be assigned when there is documentation of vaginal vault prolapse after hysterectomy.

The Victorian ICD Coding Committee has forwarded a suggestion to NCCH to consider revising the index entries for N99.3.


Query Text:
A patient was admitted with 'infective exacerbation of airways disease secondary to pulmonary involvement from Wegener's granulomatosis.' I looked this up in the index under 'granulomatosis' and was led to code M31.3 (Wegener's granulomatosis). When trying to code the lung involvement I noticed that there is nothing in the Tabular List Of Diseases under code M31.3 to indicate that a dagger/ asterisk combination exists for with lung involvement (J99.1). The dagger/ asterisk combination for 'with lung involvement' is indexed correctly under 'Wegener's' and 'syndrome, Wegener's,' however we feel that code M31.3 in the Tabular List needs to have a reference to also code J99.1 (respiratory disorders in other diffuse connective tissue disorders) in cases of lung involvement.

Response:
This query was referred to the NCCH who has advised the suggestion will be considered for a future edition of ICD-10-AM.


Query Text:
We have a trauma patient admitted with a dislocated sternoclavicular joint following  a fall from a building. The patient is taken to theatre for an open reduction of the dislocation.

There are no codes for reductions of sternal dislocations.  Should we be coding to:  Reduction of FRACTURE of sternum, or reduction DISLOCATION Clavicle or are there any other suggestions. 

Thanks for your assistance.

Response:
The correct procedure code to assign is:
47006-00 [1402] Open reduction of dislocation of clavicle.

It is noted that this results in the episode grouping to 901Z Ungroupable.  The Victorian ICD Coding Committee has forwarded a request to the NCCH for the creation of two new procedure codes for:
· Reduction, dislocation, clavicle, sterno-clavicular; and
· Reduction, dislocation, clavicle, acromio-clavicular.


Query Title:
Waterskiing accident external cause code

Query Text:
Please advise which code to use for a waterskiing accident. We assume V94.7 would be correct, with W02.2 exclusion note 'excludes into water'. Just wondering when you would use W02.2 in this case?

Response:
The Victorian ICD Coding Committee acknowledges the difficulties associated with coding waterskiing accidents.  There are changes being made to these codes for ICD-10-AM Fifth Edition, which may resolve these issues when coding water skiing accidents in the future.  Until then, it is correct to assign either:

W02.2 Fall involving water ski
or
V94.7 Other and unspecified water transport accidents involving water skis.


Query Title:
Driver of transport vehicle activity code

Query Text:
We are currently auditing our external cause codes - With activitiy codes, do you use U73.8 for a driver of a transport vehicle NOS because you know the activity he was doing was 'driving' or would you use U73.9 because you don't know what activity he was involved in whilst driving (ie. leisure, working, hobby, etc.) and the cause code already specifies that he was driving a vehicle, etc. ??

Thanks for your advice.

Response:
Coding Matters Vol 11 no. 2 Activity codes provides the following information:

For the code range, V01 - V99 Transport accidents, where the activity at the time of the accident is not specified as sport, leisure or working for an income, assign U73.9 Unspecified activity.


Query Text:
A full term baby of a mother on methadone was sent to Special Care Nursery for NASS scoring as per our hospital protocol, where all babies born to a chemically dependent mother are admitted to SCN for seven days monitoring.  Some babies have severe symptoms which warrant the code P96.1 Neonatal withdrawal symptoms from maternal use of drugs of addiction.  In this instance, the baby suffered no effects from the drugs and is only monitored.  The principal diagnosis used was P04.4 Fetus and newborn affected by maternal use of drugs of addiction.  

ACS 1609 specifies that a code from P00-P04 will never be a newborns principal diagnosis code.  Is it possible to code the Z03.79 Observation for other suspected newborn condition as the principal diagnosis (the effect) and the P04.4 to specify what the baby was being observed for (the cause).

Could the committee please advise on the correct coding in these cases.

Response:
It is not correct to assign P04.4 Fetus and newborn affected by maternal use of drugs of addiction as the baby was not affected by the maternal condition.  Rather, the baby was monitored for a suspected condition that was not found.  Coders should apply ACS 1609 Newborns affected by maternal causes and birth trauma.

Therefore in this scenario the correct codes to assign are:
Z03.79 Observation for other suspected newborn condition
Z38.0 Singleton, born in hospital


Query Text:
Please advise on the correct morphology code for Hidroacanthoma simplex of vulva as stated on pathology as benign.  Have found:
Acanthoma M8070/3
Hidrocystoma M8404/0
Hidradenoma M8400/0
Hidraadenocarcinoma M8402/3

Hidro/Hidra has M84--/- code.  Perhaps M8470/0 is appropriate for hidroacanthoma benign lesion?

Response:
This query was referred to the NCCH who provided the following advice:
"Clinical advice confirms that Hidroacanthoma simplex (HAS) is a rare benign tumour, sometimes described as the intraepidermal counterpart of an eccrine poroma.

The correct morphology code for Hidroacanthoma simplex is therefore, M8409/0 Eccrine poroma. 

Indexing of this term will be considered for a future edition of ICD-10-AM."


Query Text:
My query concerns the use of code 92507-xx Epidural in labour and delivery procedure.  All patients who have perineal lacerations are given local anaesthesia prior to suturing.  If a patient is given an epidural in labour and has perineal lacerations which are sutured under a local anaesthesia but still under epidural - should the epidural be coded to 92506-xx or 92507-xx?  There is no mention that the epidural has been topped up prior to suturing the perineum.

The epidural is only removed prior to the patient being transferred from delivery suite to the postnatal ward in all cases of vaginal deliveries.

This query also relates to a NVD which proceeds to either vacuum extraction or forceps delivery where the epidural was administered for analgesia during the course of labour, however, there is no mention of the epidural being topped up for the vacuum or forceps delivery.

We would only use 92507-xx if the intent of the epidural was used as an anaesthetic rather than an analgesis in the above cases.  Is this correct?
The only indication of the epidural being topped up is when the labour proceeds to a caesarean in which case we would code the epidural to 92507-xx

Please advise which code is to be used as there is no standard in the obstetric chapter re use of this code nor an example of when the code should be used.

Response:
ACS 0031 Anaesthesia states that 92507-XX [1333] Neuraxial block during labour and delivery procedure may also be assigned where, following a vaginal delivery, the same neuraxial block is continued for postpartum procedures such as removal of retained placenta and/or repair of obstetrical trauma.

The 'note' under 92507-XX [1333] Neuraxial block during labour and delivery procedure in the tabular list of procedures states:  
This code is to be assigned for those patients who have a neuraxial block for pain relief in labour and the neuraxial block is continued for anaesthesia during delivery procedure.

Therefore the correct code to assign in these scenarios is 
92507-XX [1333] Neuraxial block during labour and delivery procedure.  

This code can be assigned in accordance with point 3 ACS 0031 Anaesthesia.


Query Text:
A significant number of antenatal patients present to hospital with postcoital bleeding at various stages of pregnancy.  The bleeding is from vaginal tissue and not from the placenta.  The only code regarding haemorrhage from the obstetric chapter comes from O46 Antepartum haemorrhage.

We have used O99.8 and N93.0 to code Postcoital bleeding in pregnancy.  Is this correct?

Response:
As per ACS 1521 Conditions complicating pregnancy and Coding Matters Volume 11, Number 4, if the postcoital bleeding is complicating the pregnancy and the patient receives obstetric observation, the correct codes to assign are:
099.8 Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium
N93.0 Postcoital and contact bleeding

If the postcoital bleeding is not complicating the pregnancy, but the patient receives obstetric observation, the correct codes to assign are:
N93.0 Postcoital and contact bleeding
Z34.x Supervision of normal pregnancy

If the postcoital bleeding is not complicating the pregnancy, and the patient does not receive obstetric observation, the correct codes to assign are:
N93.0 Postcoital and contact bleeding
Z33 Pregnant state, incidental


Query Text:
Is this coded only in the delivery episode or in all antenatal admissions?  Do we need to code GBS positive status in pregnancy in cases of elective/emergency LUSCS given that there is no vaginal delivery and antibiotics are not given?

Please advise as ACS 1549 does not state otherwise.

Response:
ACS 1549 Streptococcal Group B Infection/Carrier in Pregnancy applies to 'obstetric patients with Strep B' regardless of whether the episode is for a vaginal delivery or LUSCS.

GBS positive status should be coded whenever it is documented in all obstetric admissions including antenatal and postnatal, regardless of whether the patient received antibiotics.


Query Text:
ACS 1550 states that the cervix does not actually change in false labour whereas it does dilate and soften during true labour.

Patients often present with mild contractions, 50% cervical effacement and cervix is 1 or 2 cm dilated.  The patients are seen and sent home to await a more established labour.  Our clinicans have informed us that unless there 100% effacement and at least 3 cms of cervical dilation, the patient is not in labour and that this should be coded as false labour.  This information contradicts ACS 1550.  

Please advise as interpretation of the standard and our clinical advice is contradictory.

If a patient presents with a show, no contractions and no changes of the cervix, is this false labour?  If this is not false labour, what code should be used for this antenatal admission?

Response:
ACS 1550 Discharge/transfer in labour overrides clinical advice.   

It is important to note that this standard applies when there is documentation of labour and the patient is transferred or discharged home.  

If labour is documented as false labour, then this should be coded to O47.x False labour.  

If not documented as false labour, the correct code to assign is Z34.x Supervision of normal pregnancy.

Coders should assign codes based on the documentation in the record and the advice in ACS 1550 Discharge/Transfer in labour


Query Text:
When babies are newly born their body temperature is a little lower than normal and the babies are wrapped in blankets and or placed under heaters until the temperature is >=36.6.  The body temperature normally stabilises with the first few hours after birth.

Although there is no documentation of hypothermia, can this be coded as hypothermia of newborn?

Response:
Hypothermia of newborn must be documented before a code for the condition can be assigned.


Query Text:
When coding insertion/removal of infusaport,  we have instructed our coders to use Z45.1 Adjustment and management of implantable infusion device or pump as the principal diagnosis with 34527-01 [766] Insertion of implantable vascular infusion pump
for insertion and 34530-03 [766] Removal of implantable vascular infusion device or pump for removal. 

After searching the NCCH database we noticed that in query Q1982 it stated Z45.2 Adjustment and management of vascular access device should be assigned as the principal and the neoplasm codes as additional diagnoses.  

Please see the index logic for why we have assigned Z45.1:

Admission (for)
-  Fitting (of)
--  Catheter
---  Vascular Z45.2
----  with implantable infusion device or pump Z45.1

Can you please confirm what is the correct code for the principal diagnosis and if we do code the neoplams codes?   If we do code the neoplasms should we follow the same principle when coding insertion/removal pain management for example.

Search Details:
NCCH query Q1982
NCCH ICD-10-AM, July 2004, 6: ICD-10-AM Commandment.
ACS 0045 Drug Delivery Devices
NCCH Coding Query Q2026

Response:
This query was referred to the NCCH who provided the following advice:
"The NCCH acknowledges that the concepts relating to vascular access devices and implantable infusion devices/pumps are not well defined in ICD-10-AM/ACHI/ACS.

ACS 0045 DRUG DELIVERY DEVICES defines an infusaport as a central venous catheter which is
'• tunnelled under the skin and connected to a reservoir [port] or implantable pump. 
= Implantable vascular access
[implantable vascular access device]
[implantable vascular infusion device or pump]
Examples: Infusa-Port, Port-A-Cath'

Given the above advice the correct principal diagnosis code for insertion/removal of an infusaport for a patient undergoing chemotherapy is Z45.1 Adjustment and management of implantable infusion device or pump.

The advice previously given in Q1982 will be amended. The procedure codes for drug delivery devices are being reviewed for a future edition of ICD-10-AM/ACHI/ACS.

Some ICD-10-AM Z codes are legitimate principal diagnoses, however, with regards to coding the neoplasm as an additional diagnosis please refer to ACS 0236 NEOPLASM CODING AND SEQUENCING and ACS 0002 ADDITIONAL DIAGNOSES."

The VICC notes that the advice in NCCH Q1982 applies only to patients described in that scenario.  For patients with non-neoplastic conditions, the non-neoplastic condition should meet ACS 0002 Additional diagnoses before a code is assigned for the condition.


