# VICC queries

Query Text:
Our plastic surgeons perform an open capsulotomy to relieve the pain associated with capsular contraction and breast prostheses, whereby the capsule is cut and the prosthesis (might be) implanted in a deeper location.

There is no apparent index entry for 'capsulotomy - breast'.

Could you please provide advice on the correct diagnosis and procedure codes to accurately capture this type of episdoe

Response:
1. Assuming the the documentation links the pain to the prosthetic device then our advice is to code T85.88 'Other complications of internal prosthetic, device, implant and graft, NEC;
Following the index entry 

Pain (s) R52.9
-due to device, implant or graft (see also Complications, by site and type) T85.88 

2. When the prosthesis is implanted to a deeper location without documentation of excision of fibrous capsule the correct codes to assign would be removal of breast prosthesis 45548-00[1758] 'Removal of breast prosthesis' and insertion of breast prosthesis, 45524-00 [1753] 'Augmentation mammoplasty, unilateral'.  Capsulotomy is not coded as it is the operative approach.  If only capsulotomy is performed then code to 'Incision and drainage of breast' 31551-00 [1742].


Query Text:
Please advise on the correct code assignment for patients admitted for allergy challenges for these two scenarios.

1) Patient admitted for a suspected peanut allergy. The patient is given a smear of peanut butter in the inside of the mouth and observed. Patient does not show any signs of reaction.  Is it correct to assign Z03.6 as principal diagnosis?

2) Patient admitted for a suspected peanut allergy. The patient is given a smear of peanut butter in the inside of the mouth and observed. Patient has a positive reaction & develops hives. Patient is given Zyrtec, observed & sent home.  Is the correct coding:
P)Z03.6 Observation for suspected toxic effect from ingested substance
c)L50.0 Allergic urticaria
c)Y57.9 Drug or medicament, unspecified
c)Y92.22 Health service area
OR
P) L50.0 Observation for suspected toxic effect from ingested substance
P) Y57.9 Drug or medicament, unspecified
P) Y92.22 Health service area

Is Z03.6 appropriate as principal diagnosis in this case to distinguish these patients admitted for a 'challenge' but who then have a positive reaction?  Or because the patient has had a positive reaction to the challenge, do we assume the condition is now not 'suspected' and assign the T code as principal diagnosis?

By coding the T code as principal diagnosis and hence prefixed with P it is identifying these patients as being admitted with a current adverse effect or anaphylactic reaction when in fact they have been admitted completely well but react to the challenge situation. 

Search Details: 
NCCH query Q1534

Response:
The VICC advises that in accordance with ACS 0001 Principal diagnosis section 'Codes from the Z03.0-Z03.9 series, medical observation and evaluation for suspected diseases and conditions' codes from category Z03 are assigned as principal diagnoses for admissions to evaluate the patient's condition where no supporting evidence for the suspected condition is found. If symptoms related to the suspected condition are noted, then the symptom codes should be assigned, not code Z03.- 

Therefore, in response to the enquirer's question 1, the correct principal diagnosis code to assign is Z03.6 Observation for suspected toxic effect from ingested substance because the patient did not show signs of a reaction to the food.  With regard to question 2, the correct principal diagnosis is L50.0 Allergic urticaria because the patient developed hives as a reaction to the food.  T78.- 'Adverse effects, not elsewhere classified' would not be assigned as the principal diagnosis in this case because the specific reaction of hives has been documented.


Query Title:
Admitted for a non weight bearing period

Query Text:
Could you please clarify how to code patients who are admitted for a non weight bearing period. That is, patient has had their operation (some where else) and is now admitted for 6 weeks of non weight bearing.

Response:
From the limited information provided please code according to ACS 2103 Admission For Convalescence/Aftercare.


Query Text:
Neonates admitted to our hospital soon after birth for treatment of a condition other than sepsis always have documentation of 'suspected' sepsis or 'presumed' sepsis and are treated with IV antibiotics for at least 48 hours. After 48 hours, if the blood cultures are negative, the IV antibiotics are stopped. 

Can you please advise on the correct coding for sepsis in this situation? These patients are not documented as 'risk of sepsis' so we believe they do not fall under the instructions of ACS 1617 Neontal Sepsis/Risk of sepsis - do you agree? They are treated for the suspected sepsis with IV antibiotics, so should we follow ACS 0012 Suspected Conditions and code P36.x for the sepsis? On quering with a consultant, he said that if the culture is negative, the child does not have sepsis regardless of the length of time spent on IV antibiotics, therefore we are somewhat reserved about assigning P36.x for every neonate with suspected sepsis. We are unsure of the exact intention of ACS 0012 - is it only for suspected prinicpal diagnosis coding or for any suspected condition during an inpatient stay?

Response:
The VICC sought advice from NCCH with regard to this query who provided the following response:
"The NCCH advises that 'suspected sepsis' and 'presumed sepsis' should be considered as indicative of 'risk of sepsis' in cases where the neonate clearly does not have sepsis and is being treated with prophylactic antibiotics. In these instances code assignment should be based on the guidelines in ACS 1617 Neonatal sepsis/risk of sepsis."

To clarify, the VICC advises that if there is documentation of presumed or suspected sepsis and there are no symptoms, apply ACS 1617 Neonatal Sepsis/Risk of sepsis .  If there are symptoms of sepsis, apply ACS 0012 Suspected conditions.

VICC considers that ACS 0012 Suspected conditions can be applied to any suspected diagnosis, not just principal diagnosis.  See VICC #2307 ACS 0012 Suspected conditions for further information.


Query Title:
Cataract Extraction with Anterior Capsular Tear

Query Text:
We have been reviewing cataract extraction cases where there has been an anterior capsule tear and no vitrectomy and are unsure whether to code this as a complication.  Two cases are described below and I have attached the operation reports (faxed) to this query for you.
Case 1 
Noted on the operation report: Consultant took over case: Anterior Capsule tear noted at 2 o'clock does not extend post.

Case2 
Noted on operation report: Tear in anterior capsule noted, no vitreous loss.  Consultant took over case.  No vitreous to wound.

Should these anterior capsule tears be coded as a complication using codes:
T81.2
Y60.0
Y92.22

Or should no complicaton codes be used as no extra procedure was performed?

Complication codes in the index:

Complication
-Postprocedural
--accidental puncture or laceration
as per ACS 1904 Procedural complications

Response:
The VICC advises that the tear should be coded because the consultant took over the case which is considered increased clinical care therefore meeting ACS 0002 Additional diagnosis criteria.  The correct codes to assign are:
T81.2 Accidental puncture and laceration during a procedure, not elsewhere classified
S05.8 Other injuries of eye and orbit
Y60.0 Unintentional cut, puncture, perforation or haemorrhage during surgical and medical care, During surgical operation
Y92.22 Health service area

Coding Matters Volume 15 No.1 article titled Dropped lens/nucleus provides further information on capsular tears.


Query Text:
I have recently come across a diagnosis of Vascular Steal Syndrome.   

In nephrology, vascular access steal syndrome, also known less precisely as steal syndrome, refers to vascular insufficiency resulting from a poorly constructed arteriovenous fistula (Cimino fistula, or synthetic vascular graft-AV fistula).

I have after much discussion assigned T82.5 Mechanical complication of other cardiac and vascular devices and implants

Response:
VICC research indicates that vascular steal syndrome is not always due to poorly constructed AV fistula.  There needs to be documentation of a complication of the fistula for T85.2 Mechanical complication of other cardiac and vascular devices and implants to be assigned.  Without documentation of a complication of the fistula such as poorly constructed AV fistula, the correct code to assign for vascular steal syndrome in a patient with an AV fistula is I97.8 Other postprocedural disorders of circulatory system, not elsewhere classified.


Query Text:
Can you please provide advice on coding conditions in neonates who are not in their current birth episode?

Our query is should we continue to assign P codes for conditions as the baby's admission started in the neonatal period or because they are actually >28 days when the condition developed do we assign codes from outside Chapter 16? 

That is, are we expected to check date of birth and the date the condition arose to make the decision if the baby is >28 days to then decide on correct code assignment?

For example, baby is transferred to Hospital B for ongoing neonatal care from Hospital A which was their birth episode. Their length of stay in Hospital B is 92 days, and at day 64 they are treated with IV antibiotics for a UTI.  Do we assign:

P39.3 Neonatal urinary tract infection & 96199-02 [1920] Intravenous administration of pharmacological agent, anti-infective agent
or
N39.0 Urinary tract infection, site not specified and do not code the IV antibiotics?

VICC #2042 Conditions arising in the perinatal period indicates that codes for neonates still apply to babies >28 days who are still in their birth episode/continuous from birth.  Is a transfer from the birth hospital to another hospital for ongoing care considered continuous from birth?

Advice given at recent NCCH workshops is contrary to this, and they indicated we would need to establish at what age during the admission the condition arose and assign codes accordingly. This would be a significant impact on current coding practice and we would appreciate clarification of this.

Examples and information in ACS 1605 Conditions originating in the perinatal period Sixth Edition do not cover our scenario, but rather conditions documented as originating in the perinatal period.

Search Details: 
ACS 1605 Conditions originating in the perinatal period 
VICC #2042 Conditions arising in the perinatal period

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

"The NCCH agrees that a baby in the birth episode who is transferred to another hospital for ongoing care should be considered to be still in the birth episode of care by the receiving hospital and P codes assigned as appropriate.

If the baby is discharged and then readmitted for a condition that is documented as having originated in the initial birth episode then the appropriate P code for the condition should still be assigned. However, if the condition arises after discharge from the initial birth episode and the baby is > 28 days old a P code should not be assigned for the condition as it did not arise in the perinatal period i.e. the period commencing at 20 completed weeks of gestation and ending 28 completed days after birth.

In the scenario cited assign:

P39.3 Neonatal urinary tract infection (with 96199-02 Intravenous administration of pharmacological agent, anti-infective agent if antibiotics are given for > 24 hours as per ACS 1615 Specific interventions for the sick neonate.)

See also Coding Matters, Vol 15 No 1, 10-AM Commandments ACS 1618 Low Birth Weight and 
Gestational Age - The use of Z51.88 'Other specified medical care and Coding Matters Vol 15, No 2, FAQs Part , Perinatal.

The examples in ACS 1605 Conditions originating in the perinatal period will be reviewed for a future edition of the ACS."


Query Title:
Complications of surgical and medical care, not elsewhere classified (T80–T88)

Query Text:
Can you please provide coding advice on the following patients:

1. Patient presents with cellulitis of the hand secondary to reusing the same needle to monitor his BSLs for the past month for his newly diagnosed Type 2 diabetes.

2. Patients presents with DKA secondary to insulin pump malfunction

1. When using the following index entry for patient one:
Infection
- due to or resulting from
- - infusion, injection or transfusion NEC T80.2

It takes you to code ‘T80.2 Infections following infusion, transfusion and therapeutic injection’ that has the excludes note ; ‘Excludes: the listed conditions when specified as; due to prosthetic devices, implants and grafts (T82.6 – T82.7, T835 – T83.6, T84.5 - T84.7, T85.7).  The needle is not implanted but it is a device.

The infection is due to the device itself not the infusion procedure, therefore should the same logic be applied as in 1904 'Infected intravenous (IV) site' and code 'T82.7 Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts’ be assigned?

2. When using the following index entry for patient two:
Complication
- infusion (procedure) NEC T80.9
-- blood - see complications, by site and type
-- catheter T82.9
--- infection or inflammation T82.7
--- mechanical T82.5
--- specified T82.8
-- infection T80.2
-- pump - see complications, infusions, catheter

It leads you to use 'T82.5 Mechanical complication of other cardiac and vascular devices and implants’, however an insulin pump is not a cardiac or vascular device/implant. 

The index at Breakdown, device graft or implant, specified NEC leads to 'T85.6', but the code description is '...of other specified internal prosthetic devices, implants and grafts'. 

T80 codes seem to be for the infusion itself not the device. T81 does not include anything that is due to a device and it has an excludes note for when the complication is due to prosthetic devices, implants and grafts.

Can you please advise which is the most appropriate code to use for these patients.

Response:
In response to scenario one, VICC considers that there is no documentation to support the cellulitis being a complication of care.  Therefore the correct principal diagnosis is cellulitis.  As per ACS 2001 External cause code use and sequencing which says that an external cause code can be assigned with conditions classified in any other chapter, if the documentation clearly says that the cellulitis is due to the needle, an external cause code can be assigned as an additional code.  VICC considers the appropriate external cause to assign is W27 Contact with nonpowered hand tool following index entry 'Contact, with, needle'.

In response to scenario two, in accordance with ACS 1904 Procedural complications, VICC considers the DKA is directly related to an intervention (the pump malfunction).  Therefore it is appropriate to follow the complication of care pathway in the index to assign a T code as the principal diagnosis.  VICC considers the appropriate code to assign is T82.5 Mechanical complication of other cardiac and vascular devices and implants, following lead term malfunction, catheter, infusion NEC.


Query Text:
Please advise on prefixes for codes that are coded only because of a 'code also rule'.  In particular:

1.  Duration of pregnancy.  I have previously been told that these are always prefixed with an 'A'.  Is this correct?  If so, why?

2.  Bacterial codes (eg E Coli,  or Helicobacter).  Are they coded with an 'A'or a 'P' or 'C', depending on when they arose.  My query assumes the disease they are associated with (eg UTI or gastric ulcer) is treated.

Response:
VICC advises that O09 Duration of pregnancy should be prefixed with an A in accordance with the Victorian Additions to the ACS Vic 0048 Condition onset flag, third dot point under A - Associated Condition, which says "Diagnosis codes should be flagged with an A prefix if they are conditions that are coded because of 'use additional code...' or similar instructions in ICD-10-AM, or because of a specialty standard (examples are listed in ACS 0002 Additional Diagnoses) directing the coder to assign additional code(s) if these conditions were present on admission, but do not meet the definition of a primary condition."

Organism codes take the same prefix as the condition they relate to, see Vic 0048 example 15 "A wound infection following surgery during the current episode of care will have all codes related to the wound infection (complication code, organism code if applicable, external cause, and place of occurrence) flagged with a C prefix."

The Victorian Additions to the Australian Coding Standards document is available from the HDSS website at: http://www.health.vic.gov.au/hdss/icdcoding/vicadditions/index.htm

VICC will review the document for the next version effective 1 July 2011.


Query Title:
HIV related EBV positive Hodgkins Lymphoma

Query Text:
A patient newly diagnosed with Hodgkins Lymphoma who is also HIV positive has documentation of 'Likely HIV related EBV positive Hodgkins Lymphoma'. 

I am unsure of which B code to use. Should it be B20 Human immunodeficiency virus [HIV] disease resulting in infectious and parasitic diseases or B21 Human immunodeficiency virus [HIV] disease resulting in malignant neoplasms?

Response:
VICC acknowledges that whilst ACS 0102 HIV/AIDS under heading Sequencing and selection of codes says that if the patient has multiple manifestations classifiable to two or more categories within B20–B24, only the HIV code related to the principal diagnosis need be assigned for the episode.  However the standard goes on to say that assignment of more than one code from block B20–B24 is acceptable for those hospitals which may require this level of detail.  

Therefore VICC considers that it is appropriate to assign both B20 Human immunodeficiency virus [HIV] disease resulting in infectious and parasitic diseases and B21 Human immunodeficiency virus [HIV] disease resulting in malignant neoplasms for documentation of HIV related EBV positive Hodgkins Lymphoma in the case cited.


Query Text:
I would appreciate your assistance in confirming the recommended procedure code for diaphragmatic pacing.

We have a patient with a brainstem chordoma, consequent chronic respiratory failure and a permanent tracheostomy.  They are on mechanical ventilation by night and diaphragmatic pacing by day. Therefore they cannot breathe unassisted and require constant monitoring.

According to the web search listed below, in diaphragmatic pacing the patient's breathing is assisted by setting the respiratory rate using electrical stimulation (pacing) of the phrenic nerve (electrodes are surgically implanted into the diaphragm, which is innervated by the phrenic nerve).  Wires from the electrodes in the diaphragm run to and from a control box worn outside the body.

Diaphragmatic pacing doesn't appear to strictly fit either of the following definitions of Continuous Ventilatory Support or Non Invasive Ventilation in ACS 1006 Ventilatory Support:

1. CVS or invasive ventilation refers to the application of ventilation via an invasive artificial airway. For the purpose of this standard, invasive artificial airway is that provided via an endotracheal tube (ETT) or a tracheostomy tube.

2. Noninvasive ventilation refers to all modalities that assist ventilation without the use of an ETT or tracheostomy. For the purpose of this standard, noninvasive devices include: face mask, mouthpiece, nasal mask, nasal pillows, nasal prongs, nasal tubes and nasopharyngeal tubes.

Since the pacing is not strictly provided via invasive artificial airway (ETT or tracheostomy), it appears we cannot strictly count it as CVS?  If counting as NIV, it is then very difficult to calculate the CVS and NIV hours, with on/off times running to many pages in a long stay (and times not always well-documented!). 

Search Details: 
ACS 1006 Ventilatory Support - Definition.

Response:
VICC advises that diaphragmatic pacing is not a procedure and therefore it is not coded.  However, Z99.8 Dependence on other enabling machines and devices can be assigned if it meets ACS 0002 Additional diagnoses criteria, by following index entry 'Dependence, on, machine, enabling NEC'.


Query Text:
A patient is in Hospital in the Home (HITH) for administration of antibiotics for osteomyelitis and is transferred back into hospital and taken to theatre for insertion of a PICC line under LA.  

Coding the PICC procedure is contraindicated as no cerebral anaesthesia is given and technically this patient is a longer term patient and not a day stay. However it necessitated a visit to theatre and transfer back into a hospital ward and we feel it should be captured in some way.

Response:
Whilst the insertion of the PICC line was performed in theatre, this is not justification for assigning a code for the procedure.  In accordance with ACS 0042 Procedures not normally coded, insertion of a PICC line is not coded unless cerebral anaesthesia is required in order for the procedure to be performed.


Query Text:
Could you please confirm what the correct code assignment should be for newborns with subgaleal haematoma due to vacuum extraction?

Currently we are using:
P12.2 Epicranial subaponeurotic haemorrhage due to birth trauma
P03.3 Fetus and newborn affected by delivery by vacuum exctraction

Response:
Whilst the terms haematoma and haemorrhage may be used interchangably, as your documentation is subgaleal haematoma, you must follow the lead term haematoma in the Index to assign P12.3 Bruising of scalp due to birth trauma.  

P03.3 Fetus and newborn affected by delivery by vacuum exctraction is assigned in accordance with ACS 1609 Newborns affected by maternal causes and birth trauma.

You may wish to consider submitting a public submission to the NCCC requesting for improvements to the Index to include subgaleal haematoma.


Query Text:
Patient was admitted to our hospital for a re-rupture of their left ACL graft. They had a revision of their left knee ACL reconstruction with an arthroscopic tendon graft.  We are not sure what was used to replace the ACL in the previous reconstruction.

Could you please advise which of the following should be used to describe this scenario?
Should we use:
M23.51 Chronic instability of knee, anterior cruciate ligament or anterior horn of medial meniscus following index 
Rupture, Ruptured
- ligament (traumatic) (see also Sprain) 
- -cruciate (current injury) (knee) 
- - - old (chronic) M23.5- 

Or
A current injury code for the tendon used for the graft (in this case it’s unknown which tendon has been used, however an unspecified code S86.8 Injury of other muscles and tendons at lower leg level) 

Or
A complication of the graft T84.8 Other complications of other internal orthopaedic devices, implants and grafts as the graft has ruptured.

Response:
ACS 1904 Procedural complications defines a procedural complication as a condition or injury which is directly related to a surgical/procedural intervention.  As there is no documentation of a complication in the scenario cited it is not appropriate to assign T84.8 Other complications of other internal orthopaedic devices, implants and grafts.

The material used in the previous reconstruction is not relevant to the coding decision as the graft is a replacement of the native ligament and is therefore considered an ACL.

To determine whether the injury is current or old, consider ACS 1319 Meniscus/ligament tear of knee, NOS and ACS 1906 Current and old injuries and code accordingly.  Based on the information provided VICC considers that M23.5x Chronic instability of knee is the appropriate code to assign as per the Index default provided in the query.


Query Title:
Principal diagnosis for same day admission for removal of cervical suture

Query Text:
Could the committee please advise what the correct principal diagnosis is for obstetrics patients who have a same day admission for removal of cervical suture that has previously been inserted in another episode for cervical incompetence?

Are we to follow the index pathway of Maternal care for… and use O34.3 Maternal care for cervical incompetence?  Or do we use the index pathway of Admission for removal of suture and use Z48.0 Attention to sutures and dressings as the principal diagnosis, with O34.3 as an additional code?

Response:
VICC advises that the removal of the suture is part of the care for the abnormality of pelvic organs, in this case cervical incompetence.  Therefore follow ACS 1506 Fetal presentation, disproportion and abnormality of maternal pelvic organs and assign a code from range O32-O34.

Following index entry 'Maternal care (for) (known) (suspected), cervical incompetence' assign O34.3 Maternal care for cervical incompetence for the case cited.


Query Title:
Vaginal wall laceration with perineal laceration

Query Text:
Does the excludes note at O71.4 Obstetric high vaginal laceration alone “Excludes: with perineal laceration (O70.-)“ mean that if a patient has a high vaginal laceration as well as a perineal laceration, that only the perineal tear can be coded, even if the vaginal wall tear is completely separate to the perineal tear?

The same question applies for the repair of the lacerations, i.e. if the two tears are repaired separately, are we only able to assign either 90481-00 [1344] or 16573-00 [1344] and not 90479-00 [1344] Suture of current obstetric laceration of vagina?

I have noted that under O70.0 that this code includes perineal graze, laceration, rupture or tear (involving): fourchette, labia, skin, slight, vagina and vulva.  Under 90481-00 [1344] it includes repair of fourchette, labia, pelvic floor, skin, vaginal involvement NOS, and vulva.

However, in many cases a high vaginal wall tear is more significant than a perineal laceration and if we are only assigning a code for a perineal laceration, then it is not fully revealing the true extent and complexity of the patient’s laceration.

Is there a hierarchy of what code should be used?  Should we assign O71.4 with 90479-00 [1344] over a code from O70.- and 90481-00 [1344] or 16573-00 [1344]?

Response:
VICC confirms that the excludes note at O71.4 Obstetric high vaginal laceration alone 'Excludes: with perineal laceration (O70.-)'  means that you only assign O70.x Perineal laceration during delivery for documentation of Vaginal wall laceration with perineal laceration.

VICC also confirms that if the two tears are repaired separately the appropriate codes to assign are 90481-00 [1344] Suture of first or second degree tear of perineum or 16573-00 [1344] Suture of third or fourth degree tear of perineum and not 90479-00 [1344] Suture of current obstetric laceration of vagina as per the excludes note at 90479-00 [1344].  

There is no hierarchy as the excludes notes direct the coder to the appropriate codes from a classification point of view, however you may wish to consider submitting a public submission to the NCCC for review of the excludes notes.


Query Title:
Index entry Dislocation, elbow, prosthesis error

Query Text:
Please fix error page 120 hard copy of Alphabetic Index of Diseases ICD-10-AM at:
Dislocation
       -elbow (radioulnar)(ulnohumeral) S53.10
         --
    *   --prosthesis S73.0-
         ---mechanical complication  T84.0
         ---recurrent T84.-

Wrong entry has to be deleted

Response:
Thank you for bringing this inconsistency in the index to our attention.  

VICC notes the index entry is correct in the ebook but incorrect in the hard copy books and will refer this to the NCCC for review of the index entry.


Query Title:
Diagnostic angiography which results in angioplasty

Query Text:
Please clarify the coding of angiography under anaesthetic where the intent is diagnostic, but results in another procedure.

A typical scenario would be where a patient is admitted with severe leg pain at rest and is taken to theatre for a diagnostic peripheral angiography by DSA.  The angiography shows atherosclerosis and surgery then proceeds to a balloon angioplasty in the same operative episode.

Codes as follows:

I70.22  Atherosclerosis of arteries of extremities with rest pain

35303-06[754] Percutaneous transluminal balloon angioplasty
60048-00[1996] DSA of lower limb-= 3 data acquisition runs, unilateral
92515-99 (1910] Sedation

If the episode had not proceeded to angioplasty, the angiogram would be coded in accordance with ACS 0042 Procedures not normally coded note 'the listed procedures should be coded if a cerebral anaesthesia is required in order for the procedure to be performed'.

Is it therefore correct to code the angiogram with an angioplasty where the intent of the angiography was diagnostic and intent to perform an angioplasty was only established during the procedure?

Search Details: 
ACS 0042  Procedures normally not coded

Response:
As the cerebral anaesthesia was administered specifically for the angiogram, in accordance with ACS 0042 Procedures normally not coded, dot point two under 'note' which says 'the listed procedures should be coded if cerebral anaesthesia is required in order for the procedure to be performed (see ACS 0031 Anaesthesia)', VICC considers it appropriate to assign a code for the angiogram.


Query Title:
Replacement of polyethylene liner of a total knee replacement

Query Text:
Please provide advice on how to code replacement of the polyethylene liner component of a total knee replacement.

The procedure was performed during an arthrotomy and joint lavage for an infected total knee replacement. Documentation is as follows: 
The polyethylene insert was removed without difficulty and the back of the knee was debrided and thoroughly irrigated before reinserting a new polyethylene insert.

I elected to use code 49527-00 [1524] Revision of total knee replacement.

Is this code correct, or is there another code which better reflects the minor nature of the procedure, which was performed almost incidentally to the joint debridement.

Search Details: 
Revision
- joint replacement (prosthesis)
--knee, total (with removal of prosthesis) 49527-00 [1524]

Response:
As the polyethylene liner is a component of the prosthesis, VICC considers the replacement of the polyethylene liner is a revision of the arthoplasty. 

Therefore the appropriate code to assign for the procedure is 49527-00 [1524] Revision of total arthroplasty of knee by following index entry:
Revision (partial) (total) 
-joint replacement (prosthis)
--knee, total (with removal of prosthesis) 49527-00 [1524]

Note: This query has been superseded by VICC query #3445 Replacement of polyethylene liner of a total knee replacement.


Query Title:
Poorly controlled blood sugar levels (BSL)

Query Text:
We often get documentation of diabetic patients who have unstable BSL's or poorly controlled BSL's.  

As per ACS 0401 Diabetes mellitus and impaired glucose regulation we are instructed to code E1x.65 if there is documentation of uncontrolled or poor control.  Is documentation of unstable, erratic or poorly controlled BSLs enough to code E1x.65 Diabetes mellitus with poor control?

Search Details: 
ACS 0401 page 101

Response:
VICC has consulted several clinicians who are unanimous in their advice that documentation of uncontrolled blood sugar levels in diabetic patients is equal to uncontrolled diabetes in a diabetic patient.  

Therefore it is appropriate to assign E1x.65 Diabetes mellitus with poor control for documentation of unstable or poorly controlled BSLs in diabetic patients.


Query Text:
In accordance with ACS 1904 Procedural Complications we understand that when IV tissued is documented without any other signs of infection we cannot assign T82.7 Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts. 

Many of our neonates have IV tissued documented and according to our clinical staff they believe that it is a complication of the IV line. From a coding perspective it meets ACS 0002 because the line has to be resited for treatment to continue. Would it be appropriate to assign T82.8 other specified complications of cardiac and vascular prosthetic devices, implants and grafts for cases when “IV tissued” is documented?


Search Details: 
ACS 1904
ACS 0002

Response:
VICC sought updated clinical advice from general and neonatal clinicians who confirmed the following information published in the ICD Coding Newsletter - April 1998 edition is still current:
"The lCD Coding Committee has sought clinical advice on tissuing of intravenous lines and found that this process is a natural event which occurs normally and is not a complication of the intravenous line. Intravenous sites will eventually clot, with the state of the vein being the determinant in the speed of this. The process will eventually occur in a clean line in a clean vein and is likely to occur more quickly in diseased veins.

If intravenous fluids continue to be administered into a tissued intravenous site, the fluids will go into the tissues rather than the vein. Where there are complications due to the presence of an intravenous line, such as perforation or infection, these should be coded. However, if the only event is tissuing of the intravenous line, this would not be coded."

Therefore tissuing of an intravenous line with no documented complications is not to be coded regardless of whether the intravenous line needs repositioning or not.


Query Text:
We are wondering what code should be used for a diagnosis of Vulvadynia or vulvar vestibulardynia. We don't get any documentation of symptoms just one of these diagnosis. The procedure that usually accompanies this is a Fenton's Procedure or Vulvoplasty. 

Currently we are using N94.8 Other specified conditions associated with female genital organs and menstrual cycle.

Response:
As vulvadynia is defined as pain in the vulva, it is correct to assign N94.8 Other specified conditions associated with female genital organs and menstrual cycle by following index entry Pain, genital organ, female.


Query Text:
If a Mc Robert's Manoeuvre is performed to assist a spontaneous vaginal delivery, do we code O83 Other assisted delivery with procedure code 90477-00 [1343] Other procedures to assist delivery.

Response:
As per the advice in the ICD-10-AM/ACHI/ACS Seventh Edition - Education FAQs - October 2010 (question 3) available on the NCCC website, when 
Mc Robert's manoeuvre is performed during delivery, assign O83 Other assisted single delivery.

VICC considers that Mc Robert's manoeuvre does not meet the definition of a procedure as per ACS 0016 General procedure guidelines and therefore an ACHI code is not assigned.


Query Text:
A doctor has documented “upper airway resistance syndrome” for a sleep study investigation. The patient does not have OSAS. The hospital has coded the principal diagnosis as J98.8 Other specified respiratory disorders and 12203-00 [1828] Polysomnography.

However I believe the principal diagnosis code should be R06.5 as per standard 0635 Sleep apnoea and related disorders.

Response:
VICC advises that because there is no index entry for upper airway resistance syndrome, apply ACS 0013 Other and unspecified codes and follow index entry 'Disease, respiratory, upper' to assign J39.9 Disease of upper respiratory tract, unspecified.

The assignment of R06.5 Mouth breathing for documentation of upper airway resistance syndrome is not supported in ACS 0635 Sleep apnoea and related disorders.

You may wish to consider submitting a public submission to NCCC for creation of a new code for upper airway resistance syndrome.


Query Text:
Nerve blocks for example ring blocks and pudendal blocks.

If a person has a block (not documented on an anaesthetic form) immediately followed by a procedure, are you able to code the block as anaesthesia for a procedure or should you omit the code altogether?

Response:
VICC advises that if the block is documented on the anaesthetic form, it can be assumed it has been given for anaesthesia and is therefore coded.  If however, the block is not documented on the anaesthetic form, there needs to be documentation elsewhere in the record that the drug was given for anaesthesia before a code can be assigned for the nerve block.


Query Title:
Aspiration pneumonia and the need for external cause codes

Query Text:
Many years ago there were writings (sorry unable to find the exact document, probably an old NCCH query) that said it was not necessary to code external cause codes for Aspiration pneumonia, unless it added further information.  

There is an instructional note in the tabular that says to code the external cause codes for J69.0 Pneumonitis due to food and vomit.  I believe the use of J69.0 without an external cause does not generate a rejection on PRS2.   J69.0 is not on the list of codes not requiring an external cause code in ACS 2001 External cause code use and sequencing.

A quick survey of coders discovered that many coders do not add the external cause codes for J69.0 (probably because they remember being told it wasnt necessary) and many do.   

Could J69.0 be added to the list of codes not requiring external cause code unless they do add further information?

Response:
VICC does not consider it appropriate to add J69.0 Pneumonitis due to food and vomit to the list of codes not requiring an external cause code because J69.0 is the default code for aspiration pneumonia, which has various causes.

The 'code also' note at J69.0 should be followed to identify the cause, when the cause of the aspiration pneumonia is known.


Query Text:
In Sixth edition there was an includes note for suture of wound under code 30023-00 [1566] Excisional debridement of soft tissue.  In Seventh edition this includes note has been removed.  

Can you please confirm if the suture of the wound should be coded in addition to the debridement of soft tissue, or if the suture of wound is inherent in the debridement of soft tissue code?

If we need to assign an additional code for the suture in cases of excisional debridement of soft tissue, do we also need to assign an additional code for the suture of wound in cases where skin only is debrided?

Response:
VICC advises that in accordance with the advice published in Coding Matters Volume 16 Number 1 June 2009 under heading 'Excisional debridement', it is unnecessary to assign an additional code for suture of wound performed with excisional debridement as the suture is a component of the procedure.


Query Text:
Please advise on how to code a patch replacement of non-coronary sinus.  Patient admitted into hospital for an aortic valve replacement, during surgery it was noted the mechanical valve could not fit into the aortic root, therefore the non-coronary sinus was spilt to enlarge the aortic root.  As the wall of the non-coronary sinus was decalcified this made the residual tissue too thin and therefore a patch of bovine pericardium was used to repair the non-coronary sinus.  

This has been coded to repair of aorta 38706-00 [693] Repair of aorta with 33548-01 [707] Patch graft of artery using synthetic material or should 38553-03 [687] Replacement of ascending thoracic aorta with aortic valve replacement be used instead.

Response:
An aortic sinus is one of the anatomic dilations of the ascending aorta, which occurs just above the aortic valve. There are generally three aortic sinuses, the left, the right and the posterior.  The left aortic sinus gives rise to the left coronary artery.  The right aortic sinus gives rise to the right coronary artery. Usually, no vessels arise from the posterior aortic sinus, which is therefore known as the non-coronary sinus.

Clinical advice obtained by VICC confirms that the correct procedure code to assign for the case cited is 38553-01[684] Repair of ascending thoracic aorta with aortic valve replacement by following index entry:
Repair
-aorta
-aorta, aortic 38706-00 [693] 
↓
--thoracic 
---ascending — see block [684] 
----with aortic 
↓
-----valve repair or replacement — see block [684] 

Procedure code 38553-03 [687] Replacement of ascending thoracic aorta with aortic valve replacement is not appropriate as the thoracic aorta was not replaced.

VICC considers procedure code 33548-01[707] Patch graft of artery using synthetic material is not necssary because of the note at heading Arteries on page 106  of the ACHI tabular that says 'Note: See also procedures on aorta (see blocks [682] to [693])' which means that where a code exists for the aorta it would used in preference to a code from the arteries blocks.


Query Text:
Patient admitted into hospital for anterior chest wall resection.  The procedure included resection of Body of Sternum, ribs, soft tissue and cartilage.  The defect was reconstructed using a GORTEX/ Methyl Methacrylate patch.  How do we code this? 
 
Currently, coding resection of the chest wall includes lobectomy or pneumonectomy of the lung, however, no lung resection was performed in this operation.
Resection — see also Excision 
-chest wall 
--with 
---lobectomy of lung (radical) 38441-00 [552] 
---pneumonectomy (radical) 38441-01 [553] 

Please refer to attached operation report.  
Currently, this has been coded to: 
38456-03 [567] Other procedures on chest wall, mediastinum or diaphragm, intrathoracic approach (to incorporate the chest wall resection and gortex patch)
90572-00 [1563] Ostectomy, not elsewhere classified (to incorporate resection of ribs) and
38647-00 [644] Division of thoracic adhesions
Should a separate code be used for the gortex patch, if so, how should this be coded?

Currently, this groups to I23Z Local Excision and Removal of Internal Fixation Device Excl. Hip and Femur (WIES 0.8972).  The WIES seems quite low in comparsion to the procedure performed.

Response:
Based on the information in the operation report, VICC considers the appropriate codes to assign for the case cited are:
90175-00 [567] Other procedures on chest wall for the anterior chest wall resection by following Index entry 'Procedure, chest wall'.  VICC did not consider 38456-03 [567] appropriate because the procedure performed did not enter the thoracic cavity
38647-00 [644] Division of thoracic adhesions for the removal of the mediastinal adhesions by following Index entry 'Division, adhesions, thoracic cavity' in the absence of subterm mediastinum as the mediastinum is the central component of the thoracic cavity  
90176-00 [566] Repair of chest wall for the gortex reconstruction by following Index entry 'Repair, chest wall'.

VICC did not consider it necessary to assign 90572-00 [1563] Ostectomy, not elsewhere classified as the ribs were transected (not excised).


Query Text:
Patient admitted into hospital for excision of lipoma found on the chest wall.  According to the operation report the lesion was removed up to the muscular structure.  This has been coded to the following:
D17.4 Benign lipomatous neoplasm of intrathoracic organ with
M8856/0 Intramuscular Lipoma with the following procedure codes:
31350-00 [1566] Excision lesion of soft tissue with
38418-00 [561] Exploratory thoracotomy

or should we be coding this to 90175-00 [567] other procedures on chest wall?

Currently this groups to 801C.  How should the procedure be coded?  Please refer to attached operation report and histology report.

Response:
This query was originally published in the 2011-12 December Database as follows:

Whilst the procedure performed is documented as excision biopsy, based on our interpretation of the operation report which says 'lesion dissected and removed (intramuscular)', we consider only procedure code 31350-00 [1566] Excision lesion of soft tissue is required as the entire lesion was 
removed, by following Index entry Excision/lesion/soft tissue NEC. VICC followed this Index entry in accordance with the definition of soft tissue in ACS 1331 Soft tissue injuries which says 'soft tissue is defined as tissue that connects, supports or surrounds other structures and organs of the body. Soft tissue includes muscles, nerves, tendons, fat, blood or lymph vessels, fasciae and tissue around joints (synovial tissue) (that is, all tissue excluding skin, subcutaneous tissue, cartilage and bone)'.

The correct principal diagnosis code to assign is D17.7 Benign lipomatous neoplasm of other sites following Index entry 'Lipoma, specified site NEC'.  D17.4 is not considered appropriate as the chest wall is not an intrathoracic organ.  When assigning the principal diagnosis code D17.7 the case will group to J11Z Other Skin, Subcutaneous Tissue and Breast Procedures.

This query has been reviewed for currency and has been updated as follows:

Whilst the procedure performed is documented as excision biopsy, based on our interpretation of the operation report which says 'lesion dissected and removed (intramuscular)', we consider only procedure code 31350-00 [1566] Excision lesion of soft tissue is required as the entire lesion was removed. Following Index entry Excision/lesion(s)/soft tissue NEC. The correct principal diagnosis code to assign is D17.7 Benign lipomatous neoplasm of other sites following Index entry 'Lipoma, specified site NEC'. D17.4 is not considered appropriate as the chest wall is not an intrathoracic organ. When assigning the principal diagnosis code D17.7 the case will group to J11Z Other Skin, Subcutaneous Tissue and Breast Procedures


Query Title:
Hepatitis C in a liver transplant patient

Query Text:
A patient admitted to our hospital has a past history of HCV cirrhosis secondary to alcohol. He has subsequently had a liver transplant to treat the cirrhosis. Therefore in this admission the patient is stated as Hepatitis C positive and is currently asymptomatic. Once we have coded a patient as B18.2 can you go back to Z22.52 (Carrier of viral hepatitis C) as technically, the patient no longer has the manifestation (cirrhosis) of the disease? 
Coding matters Volume 17, number 1, June 2010 states to code Hepatitis C Cirrhosis to B18.2 (Chronic viral hepatitis C) with K74.6 (Other and unspecified cirrhosis of liver), however
ACS 0104 Viral Hepatitis states “When a patient is asymptomatic and ambiguous terms such as ‘hepatitis C’ or ‘hepatitis C positive’ are recorded assign the code for carrier of viral hepatitis C (Z22.51).” Should we follow this advice, as the patient no longer has the cirrhosis, or should we still be coding the patient as having Chronic Hepatitis C, because in essence they have chronic Hep C that has resulted in a manifestation of the disease – however does this change if you have now treated the manifestation?

Please clarify if, after a liver transplant a patient should go back to being a carrier of the disease or if they still should be coded as having the chronic condition?

Response:
Clinical advice obtained by VICC indicates that the diagnosis of chronic hepatitis C infection (which some also call being a “hepatitis C carrier”) requires a positive antibody test plus a positive test for detection of the viral genetic material (called HCV RNA). Some patients will resolve the infection (either through antiviral treatment or through their own immune system) and the viral genetic material will become negative or undetectable (these patients are then cured) but the antibody test will usually remain positive (because the antibody is made by the person, not the virus).  So the term 'Hep C positive' is confusing and probably not very useful.

Many people with hepatitis C infection have no symptoms at all; even some with cirrhosis from hepatitis C infection have no symptoms. However you could say they have ‘symptoms’  if chronic liver failure or cirrhosis are present. 

Therefore as this is a complex area to define, VICC suggests to code according to the documentation for each episode and seek clinical advice if possible.  VICC is aware that a public submission has been submitted to the NCCC to address the issues with ambiguious terms and defining symptoms (Reference number P118).  Public submissions received by the NCCC can be viewed through the NCCC Information Portal (NIP) at:
http://nccc.uow.edu.au/productservices/nip/index.html


Query Text:
Patient with bombay phenotype admitted for elective abdominal lipectomy . Can we seek clarification for coding Bombay Phenotype?

Codes considered are:
D75.8 Other specified diseases of blood and blood-forming organs
or
D58.1 Hereditary elliptocytosis

Response:
VICC advises that Bombay phenotype (a rare ABO blood group) is a risk factor rather than a condition or disorder and  ACS 0002 Additional diagnoses advises against coding risk factors unless they meet the criteria in ACS 0002.  

Our interpretation of the clinical notes provided is that the monitoring during the admission was for the patient's past history of anaemia rather than the Bombay phenotype.  Therefore we consider it is not necessary to assign a code for Bombay phenotype in this case.


Query Title:
Ventilatory support devices brought in by patient

Query Text:
If a patient brings in their own ventilatory support device, yet the patient does not operate the device themselves (that is, a nurse operates the device), is the ventilation therefore coded? 

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

If the patient is dependant on the hospital's nursing staff to operate the ventilation machine, are we then able to code the ventilation?

Response:
VICC confirms that if there is documentation of the nurse operating the device, a code can be assigned for the ventilation.


Query Title:
Morphology code for term 'ca' and 'cancer'

Query Text:
At our inhouse coders meeting, there was discussion about the morphology code for "ca" and "cancer". The query related to this (2066) was retired in June 2010 and we feel that this was brought up at the coding update last year. 

Although many clinicians use the terms carcinoma, ca and cancer interchangeably, can you please confirm that the morphology code for "ca" and "cancer"  is M8000/3?

Response:
VICC notes that whilst VICC query #2066 Ca has been retired, the advice contained in Coding Matters Volume 12 Number 3 December 2005 is still current and can therefore be applied to determine the correct morphology code for your medical statement.


Query Title:
Hepatitis C and ACS 0104 Viral Hepatitis

Query Text:
Could we please have the following clarified as the coding staff in our network are currently having difficulty applying "ACS 0104 Viral Hepatitis".

1. ACS 0104 suggests that if a patient has "symptoms" of Hep C and consultation with a physician is not possible, the code for chronic Hep C (B18.2) can be assigned.  Could the committee please advise us as to what constitutes "symptoms" of Hep C?   If there is currently documentation that a patient is Hep C positive and documentation that the patient also has chronic liver failure and/or cirrhosis, and we are unable to consult with a physician as to the patient's status, is it correct to assign a code for chronic Hep C?

2. Retired Vic Query 2110 stated that it was considered possible that with treatment, a person may go from having chronic HCV back to being a carrier. Can this advice still be considered current?   Does this mean that patients with previously documented HCV liver failure and/or cirrhosis, with treatment, may revert back to carrier status?  Do we still assign the code for chronic Hep C (B18.2), if it is not possible to consult with a physician and the patient is both Hep C positive and has liver failure?

3. Retired Vic Query 2110 stated that abnormal LFT's attributable to HCV was enough to distinguish chronic hepatitis from Hep C carrier status.  Can this advice still be considered current?

4. If a patient has alcoholic cirrhosis of the liver and Hep C positive documented, do we assign Z22.52 or B18.2?

Response:
VICC research indicates that symptoms of hepatitis C vary from non-specific to severe, therefore please follow the advice in ACS 0104 Viral Hepatitis.

Retired VICC query #2110 was answered with clinical advice received at the time and recent clinical advice doesn't necessarily support the advice in that query, so #2110 cannot be considered current.  You therefore need to code according to the documentation in the current episode and seek clinical advice for your specific questions.

In answer to your examples of documentation, there needs to be a documented link between the hepatitis C positive and the cirrhosis in order to assign B18.2 Chronic viral hepatitis C.  In the absence of the documented link, assign a code for carrier status.


Query Text:
Our hospital is doing a procedure called a pneumonostomy which doesn't have an index entry in ACHI.  The procedure involves insertion of a pneumonostomy tube called a Portaero device, usually for COPD.  An example of the operation description is:
Incision in the right second intercostal space anteriorly.
Visceral and parietal pleura of the right lung are stitched together in a circular manner.  Portaero device inserted in the right lung parenchyma and stiches tied over it.  Tissel glue applied to prevent air leak.  Wound closed in layers. Dressing applied.

(Patient in this case was a 64 year old male with COPD with a three day admission).

Further detail of this procedure can be found at:
http://ats.ctsnetjournals.org/cgi/content/full/89/3/899
http://www.anzctr.org.au/trial_view.aspx?id=335206

Our suggested code is: 38456-02 [558] Other procedures on lung and pleura, intrathoracic approach

Could you please clarify if this is the best code to use for this procedure.

Response:
As there is no specific Index entry for pneumonostomy, VICC agrees that the appropriate code to assign for the procedure is 38456-02 [558] Other procedures on lung or pleura, intrathoracic approach by following Index entry:
Procedure
↓
-lung 
--intrathoracic NEC 38456-02 [558] 

This is supported by the definition of NEC in ACS 0041 Conventions used in the alphabetic index of interventions.

Note: This query has been retired due to changes in classification rules.


Query Title:
ACS 1550 Discharge/transfer in labour and false Labour

Query Text:
Are you able to confirm whether the following advice in retired query #2146 is still current? 

The term ‘false labour’ should be documented before assigning the code O47.- False Labour. 

Can you also confirm whether or not coders should be referring to the definitions within the standard when determining code assignment?

Search Details: 
VICC query #2146 False labour
ACS 1550 Discharge/transfer in labour

Response:
VICC considers that the advice provided in retired VICC query #2146 False labour is still current and is reproduced below:
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:
We would like some clarification around the assignment of the indwelling catheter (IDC) removal code for trial of void admissions.

As per ACS 1436 Trial of Void the coder is directed to code either 36800-03 [1090] Endoscopic removal of indwelling urinary catheter OR 92119-00 [1902] Removal of other urinary drainage device.

Following the ACHI Interventions index, you can get to the following codes for the removal of IDC’s: 

Removal 
-Catheter 
- -Bladder 36800-03 [1090]

Removal 
-Catheter 
- -Bladder
- - - non-operative 92119-00[1902]

In the absence of the documentation ‘non-operative’, we have instructed our coders to use the default code in the index. Can you please advise if this is correct?

Search Details: 
ACS 1436 Trial of Void

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

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

For Tenth Edition advice, refer to #3293 Removal of indwelling urinary catheter.


Query Text:
In a recent audit we were directed to code D73.0 Hyposplenism when a patient has an acquired absence of spleen without it having to meet ACS 0002 Additional diagnoses. 

The auditor was not able to provide supporting advice for this coding change and we were also unable to find this directive. 

Are you able to confirm if this advice is still current and direct us to where it was originally published?

Response:
VICC is not aware of published advice directing the coder to always assign D73.0 Hyposplenism when a patient has an acquired absence of spleen.  Therefore, hyposplenism must meet ACS 0001 Principal diagnosis or ACS 0002 Additional diagnosis before D73.0 Hypoplenism can be assigned.


Query Title:
Anticoagulation as part of the management plan for atrial fibrillation

Query Text:
There is debate amongst the coders at our organisation regarding the coding of atrial fibrillation [AF] when anticoagulation is commenced/altered for the atrial fibrillation.

Clinicians often document that anticoagulation has been commenced due to AF, for example:  
•“Started on warfarin for AF and CHADS3”,
•“Start aspirin (AF)”.    
•“Reintroduce anticoagulation for AF”
•“Warfarinised for AF”

The current coding guideline at our organisation is that the AF cannot be coded as warfarin does not control/regulate heart rate and that the warfarin use is prophylactic and not therapeutic.    However, management of AF involves more than regulating the heart rate.  The Medical Journal of Australia [MJA 2007; 186 (4): 197-202] states that the “Objectives in the management of AF are to:
•Identify and treat associated and causative factors ....... 
•Decide on “rate control or rhythm control ............
•Prevent thromboembolism .............. “

ACS 0002 states that a condition should be coded if it requires:  “Commencement, alteration or adjustment of therapeutic treatment”.  We believe AF meets this requirement as the anticoagulant forms part of the overall therapeutic management plan for the AF [as per above], and anticoagulation would not have been commenced/necessary without the presence of AF.
In addition, if the AF code is omitted one of the main aims of coding will not be met, namely, to “Translate medical statements into code.”

Finally, we believe that the clinician is clearly documenting the reason for the anticoagulant commencement and that we should code it accordingly.

For the reasons discussed above, we consider that the AF meets criteria for ACS 0002 [and should be coded] when anticoagulation is commenced or adjusted as part of the management plan for the AF
We look forward to your advice regarding  this.

Response:
VICC considers that when documentation links the management of atrial fibrillation to the commencement or alteration of anticoagulant therapy, the atrial fibrillation meets ACS 0002 Additional diagnoses dot point 3 'increased clinical care and/or monitoring' and is therefore coded.

Adjustment of anticoagulant therapy to correct INR levels is not itself management of atrial fibrillation and therefore atrial fibrillation is not coded.  These cases are coded to Z92.1 Personal history of long term (current) use of anticoagulants as per ACS 0303 Abnormal coagulation profile due to anticoagulants.


Query Text:
Does alcohol withdrawal always need to be documented to be able to code it, or can you code it based on an alcohol withdrawal chart in correlation with the medication chart? 

For example, if an alcohol withdrawal chart is being completed and on a particular day the patient scores high and is given diazepam (which can be correlated in the medication chart) are you able to code F10.3 Mental and Behavioural disorders due to use of alcohol, withdrawal state?

Response:
VICC advises that there must be documentation of alcohol withdrawal in order to assign a code for the condition. Whilst high scores on the drug withdrawal chart and administration of diazepam may indicate withdrawal, the coder cannot make this assumption and needs to refer the record to the clinician for documentation of alcohol withdrawal.


Query Title:
Coding of peripheral angiogram (DSA) when performed with stent insertion

Query Text:
Can you please advise when a peripheral angiogram (DSA) is carried out in addition to peripheral stent whether the DSA needs to be also coded. 

Since Seventh edition where intraoperative peripheral angiogram was deleted, some coders believe we should still code the peripheral angiogram as well as the stent if it is diagnostic, some believe that if stent is done then no need to also code the DSA. VICC query #2626 Diagnostic angiography which results in angioplasty partly answered this but we would like to have clarification if the angiogram/stent insertion is not under IV sedation in these cases would the DSA not then be coded?

Search details:
#2626 Diagnostic angiography which results in angioplasty 2011-12 September VICC queries database

Response:
VICC advises that when the peripheral angiogram and stent insertion is not performed under IV sedation, the angiogram is not coded as per ACS 0042 Procedures normally not coded.  

VICC #2626 Diagnostic angiography which results in angioplasty is a different scenario in that the angiogram was coded because it was diagnostic and IV sedation was required to perform the angiogram.


Query Text:
Please advise on the appropriate code to use for injection of steroid into carpal tunnel, a procedure that we are performing more frequently here.  We had been using:
Injection
-joint 50124-01 [1552]

but are not sure if that is the correct code.

Internet searches such as: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001469/ provides the following advise:

Carpal tunnel syndrome is caused by compression of the median nerve which goes through the carpal tunnel in the wrist. Corticosteroid injections, given into the carpal tunnel area, may relieve symptoms for a period of time.

We are now not sure if Injection into Carpal Tunnel would be better coded as:

Injection
-soft tissue 90560-00 [1552]

The surgeons are usually performing a CTR on one hand and injecting into the other hand all under IV Sedation.

Response:
The carpal tunnel does not have articulating bone thus does not meet the definition of a joint.  Therefore VICC considers that the appropriate code for the case cited is 90560-00 [1552] Administration of other agent into soft tissue, not elsewhere classified  by following index entry:
Injection
↓
- soft tissue NEC


Query Text:
Query 1:
In our recent VAED audit we were given a DRG change on the basis of VICC query 2268 ACS 0303 Abnormal coagulation profile.  This query has not been retired.  

The auditor said that since the query was not retired nor has it been superseded the information contained therein it was still current.  However the query refers to ACS 0303 Abnormal coagulation profile from ACS Fifth Edition.  

ACS 0303 has changed and therefore it follows that the advice has also changed.  

In Fifth edition you are clearly advised to assign D68.8 Other specified coagulation defects for treatment of underwarfarinisation.  In Sixth and Seventh editions this advice has been removed.   Can you confirm how to code underwarfarinisation.  

Query 2:
The last paragraph in the current edition ACS 0303 Abnormal coagulation profile due to anticoagulants talks about underwarfarinisation.  'In these cases, assign a code for the condition first, followed by Z92.1'.   Is the condition referring to the diagnosis related to needing warfarinisation for example AF or does it refer to any complication that arose from underwarfarinisation for example DVT?

Response:
VICC advises that the response to scenario two in VICC #2268 ACS 0303 Abnormal coagulation profile has been superseded by the update to ACS 0303 Abnormal coagulation profile due to anticoagulants in Sixth Edition, however the responses to scenarios one and three still apply and are consistent with the updated standard.

In answer to query one, underwarfarinisation is  coded to Z92.1Personal history of long term (current) use of anticoagulants in Seventh Edition.

In answer to query two, the last paragraph of ACS 0303 refers to the condition that arises from the underwarfarisation, so for example if the patient develops a DVT as a result of underwarfarisation, assign a code for the DVT followed by Z92.1 Personal history of long term (current) use of anticoagulants.


Query Text:
I have received conflicting advice on how to code a greenlight laser of the prostate:

37203-02 Transurethral electrical vaporisation of prostate [1165]
or
37207-00 Endoscopic laser ablation of prostate [1166]

Researching this on the internet has made it no clearer.  Could we have some definitive advice on which is the most appropriate code to use?

Response:
Clinical advice received by VICC indicates that greenlight laser of the prostate is the same as vaporisation of the prostate.  Therefore when there is documentation of greenlight laser of prostate it is appropriate to follow Index entry 
Vaporisation
↓
- prostate (electrical) (transurethral) 
to assign 37203-02 [1165] Transurethral electrical vaporisation of prostate.


Query Text:
Clinicians at our hospital have started to document acute kidney injury (AKI) for patients who have acute renal failure (ARF). 

We have also started to see them respond to documentation queries with the new term even when we ask whether the patient has ARF.  

Literature explains that acute kidney injury has now replaced the term acute renal failure.

If you were to follow the index, you will end up with an injury code:

Injury
- kidney NEC S37.00

In the absence of trauma, should we be coding acute kidney injury to N17.9 Acute kidney failure, unspecified?

Search Details: 
http://www.renal.org/clinical/guidelinessection/AcuteKidneyInjury.aspx

Response:
VICC advises that in the absence of trauma, the term acute kidney injury can be used interchangably with the term acute kidney failure.  Coders however must ensure that before assigning N17.9 Acute kidney failure, unspecified for documentation of acute kidney injury that the term refers to a medical patient and is not trauma related.

VICC advises that the Alphabetic Index was changed for Ninth Edition to:
Injury
-kidney NEC S37.00
--nontraumatic – see Failure/kidney


Query Title:
Application of ACS 0019 Procedures not completed or interrupted in sterilisation via vaginal approach

Query Text:
Patient admitted for D&C, endometrial ablation and essure sterilisation due to dysfunctional uterine bleeding.

The Operation report states 'several attempts at essure failed bilaterally, device goes as far as 5mm but failed to advance'.

Referring to ACS 0019 Procedures not completed or interrupted, it says to code as far as the procedure progressed.  But under the examples it also states that clinical coders should be cautious when a procedure is recorded as 'failed' (eg 'failed CDE' can mean that the common bile duct was explored but that the dye could not be inserted).  In such circumstances, the procedure should be coded.

The procedure is 35688-01 [1257] Sterilisation via vaginal approach, so based on the standard, should we be still coding this as the procedure, as the fallopian tubes were explored even though insertion of the actual device causing sterilisation was unsuccessful?  Do we also need to code Z30.2 Sterilisation? 

Our concern is that this implies the sterilisation was successful.

Alternatively should we only be coding 35710-00 [1248] Falloposcopy and with T85.88 for the complication with the internal implant?

Response:
This query was originally published in the 2012-2013 September Database as follows:

VICC advises that 35688-01[1257] Sterilisation via vaginal approach cannot be assigned in the case cited because the procedure of sterilisation did not occur.  This is a different scenario to the example in ACS 0019 Procedures not completed or interrupted where the CDE exploration still occurred but the dye was not instilled.  

Applying the advice in ACS 0019 which says 'If a surgical procedure was interrupted or not completed for any reason, code to the extent of the procedure performed' VICC considers the appropriate code to assign is 35710-00 [1248] Falloposcopy.

It is not appropriate to assign T85.88 Other complications of internal prosthetic device, implant and graft, NEC for 
failure of the device to advance because it is not a complication of the device but rather it is a situation where the expected outcome was not achieved.

As you have provided information that indicates that the sterilisation was to treat the dysfunctional uterine bleeding, VICC considers that it is not necessary to assign Z30.2 Sterilisation.


This query has been updated for Eleventh Edition as follows:

VICC advises that 35688-01[1257] Sterilisation via vaginal approach cannot be assigned in the case cited because the procedure of sterilisation did not occur. This is a different scenario to the example in ACS 0019 Intervention abandoned, interrupted or not completed where the CDE exploration still occurred but the dye was not instilled.

Applying the advice in ACS 0019, which says 'If an intervention was abandoned, interrupted or not completed assign: ACHI codes as applicable, coded to the extent of the intervention performed’ (dot point four), VICC considers the appropriate code to assign is 35710-00 [1248] Falloposcopy.

It is not appropriate to assign T85.88 Other complications of internal prosthetic device, implant and graft, not elsewhere classified for failure of the device to advance because it is not a complication of the device but rather it is a situation where the expected outcome was not achieved.

As you have provided information that indicates that the sterilisation was to treat the dysfunctional uterine bleeding, VICC considers that it is not necessary to assign Z30.2 Sterilisation.


Query Title:
Coding of wound ooze in specific examples

Query Text:
In reference to VICC query #2508 Wound ooze, the response that states 'wound observation/monitoring and dressing management are routine post-operative care... you would need documentation of care or management of the wound that is beyond routine care'.  
Can you please provide some advice on whether or not wound ooze should be coded in the following examples:

1. Nursing notes 9/7 0610: POP L) leg – oozing on plaster marked.
Nursing notes 9/7 1440: L leg plaster insitu, has old ooze, elevated on pillow LMO notified on 7232 to review patient regarding old ooze and ?D/C.
Ortho Res 9/7 2130: “ATRP re slight ooze in plaster. S/B Registrar (ortho) patient okay for discharge.”

2. Nursing notes: Moderate ooze from graft site. Reinforced. No more ooze.

3. Nursing notes 9/12 1750: L) groin Dx – slightly oozing and marked. Small further oozing. Nil further oozing after 2nd time marking.
Nursing notes 10/12 0345: Dx to L) groin has old ooze – marked @ 2200.

4. Nursing notes: For change of dressing as wound is oozing.

Search Details: 
VICC Query #2508 Wound Ooze

Response:
VICC referred this query to ACCD who provided the following advice published in the December 2014 Coding Rules:

Postoperative wound ooze may refer to:
- Serous exudate – drainage of a clear, thin, watery fluid from a surgical wound. This type of wound ooze is a normal and expected part of the healing process
- Haemoserous (serosanguinous) exudate – drainage of a thin, watery, pink coloured fluid composed of blood and serum. This type of wound ooze is also a normal and expected part of the healing process
- Sanguinous exudate or haemorrhage – indicates a trauma to blood vessels
- Purulent (pussy) exudate – a yellow, grey or green odiferous discharge – indicates infection.

While small amounts of serous or serosanguinous exudate from a postprocedural wound is considered normal, excessive or increasing discharge may indicate a postprocedural complication.

The ACCD agrees that wound observation/monitoring and dressing management are routine postprocedural care and that wound ooze should only be coded when there is documentation of care or management of the wound that is beyond routine care.

Evidence that wound ooze has met the criteria for code assignment in ACS 0002 Additional diagnoses includes:
- Consultation/treatment by a clinician, including a wound specialist or stoma therapist (if this is outside of routine wound management in your facility)
- Application of vacuum dressing or other dressing/device outside of the routine type of dressing material (for example, stoma bags may be used in place of conventional dressings where there is excessive discharge of exudate)
- Unexpected/unplanned return to theatre for wound exploration/insertion of a drain.

The above list should not be considered exhaustive and each case must be considered on its own merits. Where there is uncertainty as to whether wound ooze is in excess of the normal healing process or is indicative of haemorrhage or infection (and these terms are not documented), confirmation should be sought from the treating clinician.

When the above guidelines have been followed and criteria have been met, assign the following codes for wound ooze NOS:

T81.8 Other complications of procedures, not elsewhere classified
Y83-Y84 Surgical and other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure
Y92.22 (Place of occurrence) Health service area

Assign codes for postoperative haemorrhage or infection by following the guidelines in ACS 1904 Procedural complications. [end of ACCD response]

In addition to the ACCD response, VICC has developed the following additional instructions to clarify what constitutes routine care and beyond routine care.   This advice must be followed for documentation of an intervention for wound ooze and is effective for separations on or after 1 April 2015.

1. Routine care – Wound ooze must not be coded for the following interventions:
- Dressings
- - scheduled changes of existing dressing e.g. third or fourth daily
- - non-scheduled changes of existing dressing
- - reinforcing of existing dressing
- - change of dressing from one type to another  - see point 2 below for exclusion
- icing 
- marking
- cleaning/cleansing
- wound swab
- elevation
- pressure

Note:  The types of care detailed above cannot be queried with clinicians to gain advice that these are beyond routine care.

2. Beyond routine care – Wound ooze should only be coded when there is consultation with a clinician resulting in a change of patient management, for example: 
- commencement of antibiotics
- delayed discharge
- debridement of wound 
- theatre management 
- change of dressing to negative pressure wound therapy (vacuum) or stoma bag

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


Query Text:
This query is just for the new diabetes coding rules from July 1 2012.  Do we have to code out diabetes for dialysis patients?  This would affect all the autocoding done across the country.

Response:
In accordance with advice in the ACS 0401 Diabetes mellitus and intermediate hyperglycaemia – 2012 Education Workshop FAQs, 15 June 2012, question 9 Diabetes mellitus and day only admissions, the NCCC recognises the  limitations of autogenerated software in terms of assigning additional diagnosis codes for specific patients and accepts 
that for now, that it will not be possible for many hospitals to comply with ACS 0001 Principal diagnosis, Problems and underlying conditions and ACS 0002 Additional diagnoses for these episodes.

Therefore VICC advises that if you currently autocode dialysis, continue to do so.


Query Title:
Documentation of anaesthesia for ring block

Query Text:
In reference to VICC query #2649 Ring block and the response 'provided you have documentation that the ring block has been given to achieve anaesthesia, you can code the ring block as a nerve block…' was the intent of this advice that the words ‘anaesthetic’ or ‘anaesthesia’ need to be documented before assigning a code for a nerve block? Or is the documentation of terms such as ‘under’ or ‘with’ sufficient enough to code a block when performed in conjunction with a procedure as demonstrated by the examples below.  

1.Ring block with Lignocaine 2%, toe pulled back into place and back slab applied

2.Subungual haematoma drained under ring block.

Response:
VICC advises that it was not the intent of the response of #2649 Ring block that the words ‘anaesthetic’ or ‘anaesthesia’ need to be documented before assigning a code for a nerve block.  

Documentation of  ‘under’ or ‘with’ or synonomous terms, is sufficient to code a ring block as a regional anaesthetic when it is associated with a procedure.


Query Text:
A patient was admitted to our hospital for an injection of local anaesthetic and steroid (under intravenous sedation) into their piriformis muscle for a diagnosis of piriformis syndrome. 

Our research has revealed that piriformis syndrome typically occurs due to tightness of the piriformis muscle causing irritation of the sciatic nerve.

Could VICC please advise if it is appropriate to code this condition to M54.3 Sciatica?

Response:
VICC advises that M54.3 Sciatica would only be assigned if sciatica was documented.  

As there is no evidence of sciatica being documented in the case cited, VICC considers the appropriate code to assign for documentation of piriformis syndrome is M62.85 Other specified disorders of muscle, pelvic region and thigh following Index entry:
Disorder
↓
- muscle
-- specified NEC M62.8x


Query Title:
Intimal hyperplasia of arteriovenous fistula (AVF)

Query Text:
Dialysis patients at our facility are often taken to theatre because of poor flow/blockage of their arteriovenous fistula (AVF). When the AVF is explored a diagnosis of intimal hyperplasia is noted and is usually excised from the AVF.

Our research indicates that intimal hyperplasia is the response of a blood vessel to an injury which causes thickening of the tunica (innermost lining of blood or lymphatic vessel). Intimal hyperplasia may result from arteriovenous fistula formation, endovascular intervention, vascular surgical procedures, long term vascular catheters and devices, or turbulent flow.  It may also arise following angioplasty, stent insertion and around long term venous catheters.

Could VICC please advise on how to code intimal hyperplasia?

Search details:
http://radiopaedia.org/articles/intimal-hyperplasia 
http://www.scielo.org.ar/pdf/laar/v37n2/v37n2a03.pdf

Response:
Clinical advice obtained by VICC supports that intimal hyperplasia is directly related to the procedure.

For documentation of intimal hyperplasia of an arteriovenous fistula follow Index entry
Complication(s) (from) (of)/ateriovenous fistula or shunt, surgically created/specified NEC to assign:

T82.89 Other specified complications of cardiac and vascular prosthetic devices, implants and grafts
Y84.1 Kidney dialysis as the cause of abnormal reaction, or of later complication, without mention of unintentional events at the time of the procedure
Appropriate Place of Occurrence code


Query Text:
We would like further explanation to what is meant by the following statement published in Coding matters Volume 16 Number 1 and repeated in VICC #2464 ACS 1808 Incontinence: 
'R32 Unspecified urinary incontinence and R15 Faecal incontinence should be assigned if they meet the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.

Additionally, advice in ACS 1808 Incontinence should be followed. ACS 1808 specifies that 'persistent' faecal and/or urinary incontinence should be coded, ie 'persistent prior to admission, is present at discharge or persists for at least seven days'.

Does 'Additionally' in the above sentence mean:
1. Unspecified incontinence can only be coded if it meets ACS 0001/ ACS 0002, AND ACS 1808?
2. Unspecified incontinence can only be coded if it meets ACS 0001/ ACS 0002, OR ACS 1808?

The examples in VICC 2464 don't meet ACS 0002 or ACS 0001 so it seems like option 2 is correct.

Search Details: 
VICC 2464 - ACS 1808 Incontinence 
Coding Matters Volume 16 No 1 - Incontinence

Response:
Whilst VICC agrees with the response in #2464 ACS 1808 Incontinence which states that incontinence needs to meet ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses and ACS 1808 Incontinence, we recognise that the scenarios in the query do not demonstrate how these standards are all met.

VICC advice remains that criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses must be met together with criteria ACS 1808 Incontinence before incontinence can be coded.

This advice is reinforced in the 10-AM Commandments, Volume 16, Number 3 (December 2009): ACS 0002 Additional diagnoses and specialty standards:
• If the condition meets ACS 0002, check for a specialty ACS which advises the condition/status should be coded only following specific criteria; for incontinence, there is a specialty ACS, ACS 1808 Incontinence; if the criteria in ACS 1808 are met, the code is assigned
• If the condition does not meet ACS 0002, check for a specialty ACS which advises the condition/status should be coded; for incontinence, ACS 1808 does not instruct to ‘always code’ incontinence, so no code is assigned. Examples of specialty ACS which advise the condition/status should be coded include ACS 0104 Viral hepatitis as it includes the statement: “Viral hepatitis or hepatitis carrier status should always be coded even if the criteria for additional diagnosis is not met”.


Query Title:
Microvascular/microsurgical repair of artery and vein

Query Text:
Could VICC please confirm that the use of 8/0 and above suture material to repair arteries and veins requires the use of the microscope and therefore should be classified to the codes in block [1694] to [1696]?

Our Head of Plastics Unit has confirmed this is the case and that plastic surgeons will not routinely document microsurgery on the operating report as it is inherent in the use of such fine suture material 8/0 and above. She has confirmed that 8/0 suture material is 8 times finer, so requires a microscope to be able to see the material to repair the damaged vessel.

1/0 means that the size of the suture material is equal to 0.1mm in size

2/0 means that the size of the suture is equal to 0.01mm in size....etc etc so, 8/0 means that the size of the suture material is equal to 0.00000001mm in size, and therefore requires a microscope to be seen.

I draw your attention to Appendix C - Clinical Coders' Creed (Aust. Coding Standards) which indicates one of the fundamental skills of a clinical coder is to read the clinical record and make decisions about the appropriate codes to assign, based on the clinical documentation.

Response:
VICC advises that the size of the suture material cannot be used to assign codes for microsurgical repair. There needs to be documentation in the medical record of microsurgical repair in order for the repair to be coded as such.

VICC acknowledges that microsurgical repair is widely practiced and suggests you consider submitting a public submission to the NCCC to default repair of artery and vein to microsurgical repair.

While coders should be aware of the Clincal Coders Creed, VICC advises that the Creed is about using the clinical documentation to confirm a diagnosis rather than allowing coders to make their own intepretation.


Query Title:
Caesarean section complicated by pelvic adhesions

Query Text:
In coding a caesarean section that was complicated by pelvic adhesions that required division, I was surprised to see that the code I had to use with N73.6 Female pelvic peritoneal adhesions from the obstetric chapter is O23.5 Infections of the genital tract in pregnancy - using the index look up 'Pregnancy, complicated by, N70-N73'. 

Is this correct or an indexing error?

Response:
As adhesions come under the category of inflammatory diseases as part of N70-N77 Inflammatory diseases of female pelvic organs, VICC considers it is correct to assign O23.5 Infections of the genital tract in pregnancy for the scenario cited.


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

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

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

K08.1 Loss of teeth due to accident, extraction or local periodontal disease

Z85.8 Personal history of malignant neoplasms of other organs and systems (where appropriate)

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

Search Details: 
Index look-up

-- Absence (complete or partial) (organ or part)
-  -  Absence (complete or partial) (organ or part) -- Tooth, teeth (congenital)
-  -  -  Absence of tooth and/or teeth (congenital) -- Acquired
-  -  -  -  Acquired absence of tooth or teeth (organ or part) (complete or partial) (congenital) -- Other/unspecified

K08.1 Loss of teeth due to accident, extraction or local periodontal disease

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

Response:
VICC agrees with the logic applied and code selection of K08.1 Loss of teeth due to accident, extraction or local periodontal disease for the scenario cited.  Z85.8 Personal history of malignant neoplasms of other organs and systems is added if it meets ACS 0002 Additional diagnoses.

Note: This query has been superseded by VICC query # 3378 Intraoral osseointegrated implants.


Query Text:
With the changes to the criteria for 'Diabetes with insulin resistance'. In regard to 'obesity', 'overweight', in a diabetic patient  would documentation of (up arrow) BMI be adequate to assign the insulin resistance code.

Response:
VICC advises that increased BMI does not necessarily meet the clinical definition of overweight or obesity. Therefore, whilst documentation of (up arrow) BMI may be indicative of obesity, there needs to be documentation of obesity or overweight before diabetes with insulin resistance can be coded.  

In accordance with ACS 0401, without documentation of obesity or overweight a code for insulin resistence cannot be assigned.


Query Text:
It has come to our attention that the interpretation of ACS 0110 Sepsis, severe sepsis and septic shock differs amongst many HIMs/clinical coders from various Melbourne Metropolitan Hospitals.  The misinterpretation relates to the sequencing of codes.  Some would always assign the localised infection as principal diagnosis followed by the sepsis code, which adds the severity of the infection; whilst others would apply ACS 0001 Principal diagnosis to determine the sequencing of localised when there is a generalised infection also present. 

Background information
The presentation by Olafr Steinum and Gunnar Henriksson at the NCCH Conference 12th March 2009 in Sydney “Sepsis, and a man with three buttocks” compared coding of sepsis in the “good old days” and how it is to be coded using 7th edition, ICD-10-AM.  The document makes it very clear that the condition causing sepsis should be coded first, followed by the sepsis codes (supplementary additional codes).  Was the 6th edition ACS 0110 Septicaemia not re-writtten for 7th edition to incorporate the new way of looking at sepsis?

ACS 0110 can be misinterpreted.  On page 70, under the Sepsis heading, it states “Where there is documentation of sepsis, assign a code for the localised and/or generalised infection”.  This could mean, the localised infection must be coded first followed by the generalised infection; and it could mean that both can be coded, and ACS 0001 Principal Diagnosis can be applied to determine Principal diagnosis.

We acknowledge that there are Index entries for the following, which means sepsis could be Pdx:
Pneumonia
-in (due to)
--sepsis A41.-+J17.0*

Pyelonephritis
-in (due to)
--sepsis NEC A41.-+N16.0*

ACS 0109 Neutropenia directs the clinical coder “when sepsis/septicaemia is recorded, the sepsis/septicaemia code should be sequenced before the neutropenia code.” and
ACS 0110 states in numerous places that “where there is no stated origin of the infection, assign a code for the generalised or systemic infection.”

We also acknowledge ACS 0110, p70 “when a patient has sepsis coded to O03-O07 …….T81.42 assign an additional code from A40.- A41.-…..etc”

Please note, that it is very rare for a hospital to have documentation of SIRS and severe sepsis; sometimes all we get is sepsis due to a localised infection and the only way to show the severity of the infection is to code A41.9 Sepsis, unspecified.

Please advise on the correct coding of the following examples:
Example 1
Pdx: Sepsis secondary to diverticulitis.  Treated with IV antibiotics.  Clinician has confirmed that the patient was systemically ill.

Example 2
Discharge summary lists the following as Pdx:
Sepsis
Cellulitis of LL

Progress notes confirm that the sepsis is due to cellulitis.  Blood cultures are positive for staph A.  Swabs taken from leg also confirms staph A infection.

Example 3
Discharge summary Pdx section states:
Septic shock from MSSA Bacteraemia

Progress notes mention sepsis from unknown cause, have eliminated various causes, then state likely PICC related MSSA bacteraemia.  Issues list: 1.Hypotensive 2.Sepsis BC grew GPC resembling staph.  Catheter tip grew MSSA – S to Vancomycin.  Infectious Diseases consultant confirms MSSA sepsis from PICC.

Would this case be required to have the diagnosis clarified by a clinician, or is the information in the progress notes enough to assign the T82.7 B956 Y848 Y9222 as Pdx followed by A41.0 and R57.2?

What happens if this case was sent to a clinician asking “Please confirm that Staph A sepsis is Pdx”?  The clinician replies “yes”.  Would this case then be coded to Pdx A41.0, R572, followed by PICC infection?  Even though the clinical notes link the PICC with sepsis?

Example 4
Discharge summary Pdx section states:
Sepsis due to pneumonia

Search Details: 
ACS 0110 ACS 0001

Response:
VICC referred this query to the ACCD who provided the following response.  Please note that the ACCD has not published this response as the advice will be effective for Ninth edition 1 July 2015:

Several queries and public submissions have been received in relation to the classification of SIRS and sepsis, which highlighted that the advice in ACS 0110 Sepsis, severe sepsis and septic shock is ambiguous and inconsistent. 

The standard was revised for Seventh Edition to incorporate classification advice for the contemporary concept of SIRS; however over time it became apparent that classification guidelines themselves were insufficient. 

Consequently the standard and ICD-10-AM codes for SIRS, sepsis, severe sepsis and septic shock were reviewed for the Ninth Edition. This review was conducted in consultation with clinicians to confirm clinical currency and with the ICD Technical Group (ITG) to ensure the accuracy and usefulness of the coding guidelines. The following guidelines have been implemented in the Ninth Edition:
Where there is documentation of sepsis, assign:
- an appropriate code for sepsis from Chapter 1 Certain infectious and parasitic diseases (A00-B99) OR
- an appropriate code from categories P36.- Bacterial sepsis of newborn OR P37.52 Invasive neonatal candidiasis for neonates.
When both sepsis and severe sepsis and/or septic shock are documented, assign first a code to identify the type of sepsis (as noted above) followed by R65.1 Systemic inflammatory response syndrome [SIRS] of infectious origin with acute organ failure or R57.2 Septic shock to indicate the severity of sepsis.

When both sepsis and an associated localised infection are documented, a code for sepsis (as noted above) and a code for a localised infection should both be assigned. Sequencing of codes should be determined by applying the criteria in ACS 0001 Principal diagnosis.

This advice has been specified in the revised ACS 0110 for Ninth Edition, reflecting clinical advice which indicated that the diagnosis of sepsis is typically a clinical diagnosis based on the early signs of a syndrome; it is a systemic response which cannot be adequately captured by coding a localised infection alone.

It must also be noted that many of the issues associated with coding sepsis, are related to what is documented in the clinical record. When there is documentation of vague diagnostic terms such as 'chest sepsis' or 'biliary sepsis', coders should clarify with the treating clinician to determine whether it is a case of sepsis.

As this guideline has a significant impact on coding practice it will not be introduced for Eighth Edition, rather it will be held over for implementation in Ninth Edition in July 2015, and therefore a query response will not be published and current coding practices should be continued until this time.


Query Text:
I would like some clarification around the application of ACS 0604 Stroke, in particular, interpretation of the following rule and the last line of the related example. This rule and example have only changed marginally since 1st Edition of ICD-10-AM. 

In accordance with VICC #2191 Dysphagia and ACS 0604, should this standard be referred to the NCCC for review?

I69.- Sequelae of cerebrovascular disease codes should only be used when the treatment period is complete but residual deficits are still manifest and meet the criteria for an additional diagnosis.

EXAMPLE 2:
Patient admitted for hemicolectomy. Mobility affected by residual hemiparesis from a previous stroke. No treatment of the residual hemiparesis occurs during the episode of care.

Assign an additional diagnosis code for hemiparesis and I69.- Sequelae of cerebrovascular disease, indicating that neither the stroke nor the hemiparesis is receiving treatment.

Search Details: 
VICC #2191 Dysphagia and ACS 0604 Stroke
VICC #2534 Stroke with hemiplegia which resolves prior to admission 
Coding Q&A - June 2012
ACS 0604 Stroke

Response:
As the enquirer has noted ACS 0604 Stroke states that residual deficits still manifest must meet the criteria for an additional diagnosis in order to be coded.  Example 2 in the standard illustrates how I69.- Sequelae of cerebrovascular disease is coded and VICC acknowledges the confusion created by this example.

VICC will send a public submission to the NCCC suggesting improvements to the standard.


Query Title:
Coding of cancer codes in post chemotherapy admissions

Query Text:
Can the Committee please give advice on the following scenario, as we are never sure which is the correct way to code:

Oncology patient admitted for treatment of a condition, often a complication of chemotherapy or radiotherapy, but the underlying malignancy isn't actually treated or assessed during the admission.

For example:
Patient admitted febrile, six days post chemotherapy. Stayed for three days and no source of infection was found. Patient admitted under their treating Oncologist to the Oncology Unit.

Do we just code the fever (there is no causal link to the chemotherapy mentioned) or can we add the cancer and morphology codes as the patient was treated by their Oncologist on the Oncology ward?

Another similar scenario is where the patient is admitted for dehydration, nausea & vomiting post chemotherapy.  Again their underlying malignancy isn't assessed or treated, do we just code the dehydration and nausea and vomiting?

Search Details: 
General Standards, Problems & underlying conditions, says if patient presents with a problem & underlying condition is known, code the problem first and other condition as an additional code. There is no mention that it needs to meet the criteria in ACS 0001 or ACS 0002.

Response:
VICC advises that the malignancy must meet ACS 0002 Additional diagnoses in order to be assigned as an additional code.  The location of the treatment, e.g. Oncology ward, or treating doctor or unit, e.g. Oncologist or Oncology Unit) are not part of the coding decision to determine if the malignancy code should be assigned.

Therefore based on the information provided, in answer to example one, only the fever would be coded.  In answer to example two, only the dehydration and nausea and vomiting would be coded. In neither case is the cancer documented as the underlying reason/condition for the fever or nausea and vomiting, and the cancer does not meet criteria for coding based on it being the reason for the chemotherapy being administered.


Query Title:
Incision and curettage of meibomian cyst

Query Text:
There is no Index entry for incision and curettage of meibomian cyst of the eyelid, or curettage of eyelid. 

We would like VICC to consider the following options and advise which is most appropriate, if any.

1. Incision of eyelid - 90084-00 [231]
2. Other procedure on eyelid NEC - 90086-00 [240] 
3. Excision of Chalazion - 42575-00 [233] 
4. Curettage single lesion of skin - 30195-00 [1612] 

If options 2-4 were selected, we would consider the incision to be an operative approach as per ACS 0016 General procedure guidelines and would not code out.

Response:
Clinical information reviewed by VICC indicates that a meibomian cyst is a chalazion and therefore the term chalazion can be used to assign the appropriate code. 

As the operation report provided with this query has documention of incision, VICC advises to follow Index entry Incision, chalazion to assign 90084-00 [231] Incision of eyelid.


Query Text:
Can the Committee please advise if the use of a Biliblanket for more than 12 hours is sufficient to assign the code 90677-00 [1611] for Phototherapy?

Interventions Index:

Phototherapy (skin)
-newborn 90677-00 [1611]

doesn't specify that a specific type of device needs to deliver the phototherapy.

Search Details: 
Internet search reveals that a Biliblankets is a portable phototherapy device:
http://en.wikipedia.org/wiki/Biliblanket

Response:
VICC advises that as a biliblanket is a portable phototherapy device, it is appropriate to assign 90677-00 [1611] Other phototherapy, skin when treatment with a biliblanket has been given for more than 12 hours.


Query Text:
I was wondering if coding of spasm of artery (currently I73.9 Peripheral vascular disease, unspecified) might be improved?

I have just coded a diabetic patient admitted for a coronary angiogram. During the procedure the patient had 'radial access complicated by radial artery spasm, converted to femoral'.

Coding complication of I73.9 in a diabetic patient who does not have PVD is awkward, ie. coding E11.9 with I73.9 and not having E11.51 looks strange.

I note old VICC query #2216 but that related to vasospasm of coronary arteries and this case is radial.

Search Details: 
VICC query #2216: Vasospasm of coronary arteries (2005-06)

Response:
VICC advises that despite the code title there are many conditions indexed to I73.9 Peripheral vascular disease, unspecified other than peripheral vascular disease (PVD) therefore it cannot be assumed that the patient has PVD when this code is assigned. 

This is an example of where ICD-10-AM, as a statistical classification does not have a specific code for every condition.

As there is no Index entry for Diabetes, with spasm there is no relationship between the diabetes and the spasm.  Also as there is no documentation of PVD the Index entry Diabetes, with PVD cannot be followed.


Query Text:
Female age 55 admission date 26/04/2008 17:49, discharge date 27/04/2008 00:18 transferred from emergency to ICU at 19:00.  Manually bagged from time arrived in ICU until time discharged.

Clinical Summary:
Patient was admitted with status asthmaticus, was hypercapnoeic and required intubation. She was unable to tolerate mechanical ventilation due to the high pressures required to achieve acceptable tidal volumes in spite of drug therapy including paralysis. Therefore the patient was manually ventilated throughout her stay and during retrieval to Melbourne.

There is nothing available either in the code set or in the value of the DRG that adequately covers the resource utilisation for a case such as this.

Response:
As per ACS 1006 Ventilatory support mechanical ventilation is defined as "the application of ventilation via an invasive artificial airway.  For the purpose of this standard, invasive artificial airway is that provided via an endotracheal tube (ETT) or a tracheostomy tube".  The fact that the patient was intubated means that this definition was met.  The method of providing the respiratory support (manual bagging) is not relevant to the decision. 

Therefore, in the scenario cited it is correct to assign:
13882-00 [569] 'Management of continuous ventilatory support, <=24hours.


Query Text:
At the recent Sixth edition workshop I asked a question about coding diabetes mellitus when hypertension meets the additional diagnosis criteria. I was told by the NCCH representatives taking the session that yes you would then code out diabetes.  I have since debated this with other coders who attended other work shops as they are saying that you can't do this as there is not an index connection between hypertension and diabetes. 

At the workshop that I attended they told us that the index entries for diabetes are not completely accurate so you need to look up conditions both ways, for example you look up hypertension and there is no entry under this for 'with Diabetes' so then you need to look up Diabetes with and look for the hypertension which is there.  Given that this is common and the FAQs from the NCCH may or may not address this issue could we please have some interim advice on this.

Response:
The VICC advises if the patient has a condition meeting ACS 0002 Additional diagnoses and that condition is associated with diabetes either under the lead term 'diabetes' or the lead term for the condition, code diabetes with condition.  Therefore the correct codes to assign are:
E1x.72 Diabetes mellitus with features of insulin resistance
I10 Essential (primary) hypertension

This advice is in accordance with the article titled 'Diabetes mellitus and impaired glucose regulation coding advice for Sixth Edition' (published on the HDSS website in January 2009) under dot point 2.3, example 6.


Query Text:
In coding out a same-day endoscopy it was noted that a patient had white plaques in their oesophagus.  This was biopsied and found to be candidiasis.

The index for candidiasis has an option for oesophagitis (B37.81).  Can I use this code if I don't have' oesophagitis' documented either on the scope report or this histology? This appears to be a better fit code for the findings than using B37.88 Candidiasis of other sites or B37.9 Candidiasis, unspecified.

I have checked the query database and Coding Matters but can find no further advice on this.

In the past I have always made an assumption that it must be oesophagitis but in training a new coder have found it hard to justify that logic when there is so much we cannot assume.  It is quite commonly documented as oesophageal candidiasis but not as candida oesophagitis.

Search Details: 
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1552563

Response:
As candidiasis is an infection, VICC considers candidiasis present in the oesophagus to be candidal oesophagitis and would assign B37.81 Candidal oesophagitis for documentation of oesophageal candidiasis.

This query will be referred to the NCCH for consideration to amending the index to include an entry for 'oesophageal' under Candidiasis for B37.81.


Query Text:
When coding a FDIU at 33 weeks, the standard appears to imply that we also code O60.1 Preterm spontaneous labour with preterm delivery (this is the default using 3M Encoder). 

However in our case, and I suspect many cases, the labour was induced (then proceeded to LUCSC) NOT spontaneous. Should we therefore use O60.3 Preterm delivery without spontaneous labour or not use any code? The ACS and the examples leave out the word 'spontaneous'..

Search Details: 
Tab list O60 page 313.
Standards 1511, 1518, 1530 and 1550.

Response:
Thank you for your query which has been forwarded to the NCCH as an example of already identified issues regarding early onset labour index entries and ACS 1530 Premature delivery. The NCCH has advised that an errata will be released in September.  In the meantime it is correct to assign O60.3 Preterm delivery without spontaneous labour


Query Title:
Iron deficiency secondary to renal impairment with past history of diabetes

Query Text:
Please advise how to code the following case in view of the changes to diabetes with Sixth edition coding:

Patient admitted for iron infusion for iron deficiency anaemia.  Iron deficiency secondary to renal impairment.  Past history: Type 2 diabetes, insulin requiring.  Past correspondence and previous admission lists patient has cataracts, hypertension, and CRF.

Response:
The NCCH provided the following advice in relation to this query:

"In the scenario cited the correct code assignment is N18.5† Chronic kidney diseases, stage 5 and D63.8* Anaemia in other chronic diseases classified elsewhere following the pathway:

Anaemia
- in 
- - chronic kidney disease 
- - - stage 5 N18.5† D63.8* 

Where documented the underlying cause of the kidney disease should also be coded as per ACS 1438 'Chronic kidney disease' which states:

"Assign a code for the underlying cause of the chronic kidney disease (e.g. IgA nephropathy) when documented."

Therefore, if the underlying cause of the kidney disease is diabetes then diabetes and it’s associated conditions should be coded following ACS 1438 Chronic kidney disease and ACS 0401 Diabetes mellitus and impaired glucose regulation."

The VICC notes for the case cited, diabetes is NOT coded as it has not been documented as the underlying cause of the chronic kidney disease.  The hypertension however is coded because of the 'code also' note at N18 Chronic kidney disease.  Therefore the correct codes to assign are:
N18.5† Chronic kidney disease, stage 5 
D63.8* Anaemia in other chronic diseases classified elsewhere
I10       Essential (primary) hypertension

This advice is in accordance with the article titled 'Diabetes mellitus and impaired glucose regulation coding advice for Sixth Edition' (published on the HDSS website in January 2009).


Query Text:
Is there is a special code to capture 3D imaging used in EPS and ablations?

Currently we are using 38212-00 [665] Cardiac electrophysiological study, >= 4 catheters (which includes intraoperative cardiac mapping).

Response:
The VICC advises to continue assigning 38212-00 [665] Cardiac electrophysiological study, >= 4 catheters as there is no special code to capture 3D imaging used in EPS and ablations.

Note: This query has been retired as the advice is no longer considered current as imaging is considered a procedural component as per ACS 0016 General procedure guidelines.


Query Text:
We are seeking clarification on the application of ACS 0010 General Abstraction Guidelines.  In particular our query relates to coding from test results where there are findings with an unclear, or no associated condition documented.

Example three on page 9 of the Australian Coding Standards lists examples of where conditions would not be coded based on test results.

We have three scenarios listed below that we would like advice on how to code:

1. Patient admitted for elective laparoscopic cholecystectomy for gallstones, histopathology of gallbladder shows chronic cholecystitis, cholelithiasis and moderately differentiated adenocarcinoma.  Should we assign codes for the adenocarcinoma?

2. Patient admitted for elective hysterectomy for menorrhagia, histopathology of uterus shows uterine carcinoma.  Should we assign codes for the carcinoma?

3. Patient presents with bowel obstruction, day two colonoscopy performed, histology: adenocarcinoma, transverse colon.  CT abdomen on day four shows liver metastases.  Can we assign codes for the liver metastases?

Response:
This query was originally published in the December 2008 VICC queries database release as follows:
The VICC notes the sentence in ACS 0002 Additional diagnoses which states that the purpose of the Admitted Patient Care National Minimum Data Set is to collect information about care provided to admitted patients in Australian hospitals.  This means that only conditions that are relevant to the episode of care are coded, rather than all conditions a patient has.  Additional findings need documentation of clinical significance to be able to be coded and this is supported by example three in ACS 0010 General abstraction guidelines. 

Therefore in answer to your scenarios one and two, unless the clinician has documented the clinical significance of the test results, the findings would not be coded.  In answer to your scenario three, if the clinician has confirmed that the adenocarcinoma has caused the bowel obstruction, the liver metastases would be coded in accordance with ACS 0236 Neoplasm coding and sequencing.

The response has been reviewed and the last paragraph has been updated as follows:

The VICC notes the sentence in ACS 0002 Additional diagnoses which states that the purpose of the Admitted Patient Care National Minimum Data Set is to collect information about care provided to admitted patients in Australian hospitals.  This means that only conditions that are relevant to the episode of care are coded, rather than all conditions a patient has.  Additional findings need documentation of clinical significance to be able to be coded and this is supported by example 3 in ACS 0010 General abstraction guidelines. 

Therefore in answer to your scenarios, unless the clinician has documented the clinical significance of the test results, the findings would not be coded.


Query Text:
Should conditions that arise during an operation be coded as misadventures?  

Could you please advise on how to code the following common scenarios.  In each case, there was no documentation indicating a direct link between the condition and the operation, other than that each condition arose during the surgery or was documented as 'intra-operative'.  

1. A patient undergoing CABG or cardiac valve replacement develops AF or VT when they come off CPB and are given DCR or medication.  Should the AF or VT be coded as misadventure (because they occurred intraoperatively)?  If so, which codes should be assigned? (see attached op report)

2. A patient develops hypotension intraoperatively which is assessed and treated, should this be coded as a misadventure?  Which codes should be assigned for the intraoperative hypotension?

3. A pt suffers a MI intraoperatively, should this be coded as a misadventure.  Which codes should be assigned for the intraoperative MI?
 
4. If a patient has an intra operative haemorrhage identified and managed during a procedure, should the external cause code be Y83.- or Y65.-?

Search Details: ACS 1904

Response:
This query was originally published in the December 2008 VICC queries database release as follows:
The VICC notes that whilst misadventures occur during surgery, not everything that occurs during surgery is a misadventure.  For a condition to be coded as a procedural complication, it has to meet the definition of a procedural complication.  ACS 1904 Procedural complications defines a procedural complication as 'A condition or injury which is directly related to a surgical/procedural intervention.'  The standard also states 'If it cannot be determined whether a condition meets the definition of a procedural complication, it should not be coded as such.  In these cases, assign a code(s) for the condition in accordance with ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.'  Therefore in scenarios 1, 2 and 3 the condition only would be coded because the conditions as described do not meet the definition in ACS 1904.

In scenario 4, the haemorrhage meets the definition of procedural complication and it meets the definition of misadventure because it occurred during surgery.  Therefore the correct external cause code is one from category Y60 Unintentional cut, puncture, perforation or haemorrhage during surgical and medical care by following index entry 'External causes, Misadventure(s) to patient(s) ..., - haemorrhage'.

Update to response:
When referring to Coding Matters Volume 16 Number 2 September 2009, FAQ Q23 note that the NCCH sought clinical advice which influenced their coding decision.


Query Text:
Patient admitted with NSTEMI.   Patient also has melaena with anaemia.  Documented as:
Principal diagnosis:  NSTEMI
Secondary Diagnoses:  Anaemia & malaena ?cause

Patient was transfused with 1 unit PRBC for anaemia. (Hb 92).

Patient has Prostate Cancer - not treated or investigated and did not meet ACS 0002 Additional diagnoses.

Question 1:
Do I code the anaemia component as D63.0 Anaemia in neoplastic disease, and then have to code the prostate cancer, or do I code from the anaemia codes (I have sent a query to doctor asking if anaemia was due to chronic/acute blood loss).   

Question 2:
Can I choose more than one anaemia code?  Would this give a better picture of the patients condition and treatment?

Response:
The NCCH provided the following advice in response to question 1 of this query:

"In relation to question 1 of this query the NCCH advises that the index pathway for ‘Anaemia, in neoplastic disease' should not be followed in the scenario cited where the 'anaemia' is clearly documented as due to an unknown cause. In this instance code the anaemia alone.

The NCCH acknowledges there has been difficulty in applying the advice in Coding Matters, Vol 6 No 1, particularly where the anaemia is unrelated to the neoplasm. It was not intended for this code to be assigned where anaemia has been documented as due to an unknown cause or a non-neoplastic condition.

The codes in category D63 Anaemia in chronic diseases classified elsewhere have been revised for ICD-10-AM Seventh Edition".

In regard to question 2, in accordance with the FAQs in Coding Matters Volume 15 No. 2 September 2008 it is not necessary to assign another code as the anaemia has already been captured in this code assignment.


Query Text:
Day stay urology cases have elevated PSA documented on discharge summary as principal diagnosis and as indication on operation report. Pathology comes back with hyperplasia, atrophy and small focus of adenocarcinoma, none of which are documented in admission as patient was discharged before results were through.

According to CM 12(3) page 7: 'when elevated PSA is the only documentation and no cause can be determined, assign: R79.8 Other specified abnormal findings of blood chemistry.'

Am I to therefore assume that as no causal link is documented by medical staff, we cannot assume the elevated PSA is due to the finding of adenocarcinoma despite the fact that PSA is a tumour marker? 

PSA is defined as a tumour marker; 'a simple blood test used to detect prostate cancer in men. The test measures a specific antigen normally secreted by the prostate. If cancer is developing, the prostate secretes greater amounts of prostate-specific antigen. This test is recommended for men with an enlarged prostate and an increased risk of prostate cancer.' 18/11/2007 cancerweb.ncl.ac.uk

Incidentally, R79.8 is the wrong code for elevated PSA. 'An antigen is a protein molecule that often protrudes from the surface of a cell that can induce an immune response. The epitope is the part of the molecule that is responsible for this feature, whereas the carrier molecule results in the activity as an antigen'. 18/11/2007 cancerweb.ncl.ac.uk.  

As PSA is a blood test and antigens are proteins, the correct code would be R77.8 Other specified abnormalities of plasma proteins.

Search Details: 
Coding Matters
VICC Query database
NCCH database now deleted, therefore not searched
Medical dictionary on line which led to the cancerweb site

Response:
The NCCH provided the following advice in response to this query:
"Prostate specific antigen (PSA) is a protein that is secreted into ejaculate which helps to nourish the sperm. Normally, only tiny amounts enter the bloodstream. However, cancer cells and other conditions can interfere with proper functioning and cause large amounts to enter the blood. It is currently the most widely used method to screen for prostate cancer. 

It is acknowledged that elevated PSA is also an indicator of other conditions such as benign prostatic hyperplasia (BPH), urinary tract infections and prostatitis. For the scenario cited, where histopathology has confirmed a diagnosis of adenocarcinoma, this should be assigned as the principal diagnosis. The adenocarcinoma should be coded as a finding that adds specificity to the diagnosis of 'elevated PSA' as per the guidelines in ACS 0010 General abstraction guidelines, Test Results.

Clinical advice has confirmed that R79.8 Other specified abnormal findings of blood chemistry is the correct code to assign for elevated PSA.

As stated above, PSA is a protein secreted into ejaculate, where normally, only small amounts enter the bloodstream. Therefore, elevated PSA is an abnormal blood chemistry finding. R77.8 Other specified abnormalities of plasma proteins is for specified abnormalities of plasma proteins such as albumin, immunoglobulins etc., which are proteins normally found in plasma."


Query Title:
Diabetes with unspecified renal failure and unspecified kidney impairment

Query Text:
Please advise how to code unspecified renal failure or unspecified renal/kidney impairment when patient has diabetes and cannot obtain further documentation from medical staff.

Previously published advice in Coding Matters (copy attached below) stated when confirmation was unable to be obtained, to default to E1-.23 and N18.90. Obviously these codes are no longer relevant, therefore new instructions need to be published.

As N19 Unspecified kidney failure is the indexed default code for unspecified kidney failure and kidney impairment, it does not link to diabetes as acute or chronic are essential modifiers.  Therefore do we follow previous logic and code to E1-.22 Diabetes mellitus with established diabetic nephropathy and N18.9 Chronic kidney disease, unspecified; add N18.9 Chronic kidney disease, unspecified to string of codes if diabetes with multiple microvascular complications or do we simply code N19 Unspecified kidney failure and not link it with diabetes at all?

CM 13(2):1 
Renal failure unspecified with diabetes mellitus
The NCCH received a query on the correct code assignment for unspecified renal failure with diabetes mellitus.
Classification
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

The NCCH will consider the addition of index entries for unspecified renal failure under Diabetes, diabetic (controlled)
(mellitus) to a future edition of ICD-10-AM.

Search Details: 
VICC #2132
CM 13(2):1

Response:
The VICC considers the logic of the Fifth edition advice published in Coding Matters Volume 13 Number 2 to be current.  Therefore when unspecified kidney failure or unspecified kidney impairment is documented in a patient with diabetes, it is correct to default to 'chronic' for the kidney disease or kidney impairment and assign:
E1-.22 Diabetes mellitus with established diabetic nephropathy
N18.9  Chronic kidney disease, unspecified 

The index entries to follow are:
Diabetes
-with
--failure 
---kidney 
----chronic — see Diabetes, with, chronic kidney disease

Disease
-kidney
--chronic N18.9


Query Title:
ACS 1438 Chronic kidney disease and diabetic nephropathy

Query Text:
On page 215 ACS 1438 Chronic kidney disease: Diabetic Nephropathy the following paragraph appears:

Diabetic nephropathy is also known as diabetic glomerulosclerosis. It is a common underlying condition for CKD. In this condition, the glomeruli of the kidney thicken reducing the ability of the glomeruli to filter the blood and allows more protein, in the form of albumin, into the urine. This is termed microalbuminuria and is one of the earliest markers of CKD (see also ACS 0401 Diabetes mellitus and impaired glucose regulation, page 93, Complications in diabetes and IGR, page 101, Kidney complications, page 103).

Nowhere in ACS 0401 Diabetes mellitus and impaired glucose regulation does it replicate this advice that diabetic nephropathy is also known as diabetic glomerulosclerosis, nor does it give you a specific code to assign for diabetic glomerulosclerosis NOS or diabetic nephropathy NOS anywhere in the index. (see below)

Index entries under:
Glomerulosclerosis (see also Sclerosis, kidney) N26
- with diabetes
- - diffuse E1-.22
- - intracapillary E1-.22
- - nodular E1-.22

Sclerosis, sclerotic
- kidney N26

Diabetes
- with
- - glomerulosclerosis
- - - with ESKD E1-.22
- - - diffuse E1-.22
- - - intracapillary E1-.22
- - - nodular E1-.22

Diabetes
- with
- - nephropathy E1-.22
- - - incipient E1-.21

Nephropathy (see also Nephritis) N28.9
- with
- - diabetes E1-.22

Nephritis, nephritic N05.-
- with
- - diabetes E1-.22

Is this statement on page 215 supposed to be instructing coders to assign N26 glomerulosclerosis where diabetic nephropathy is documented, instead of N28.9 Nephropathy NOS. 

For example if a patient has DM, diabetic retinopathy, diabetic nephropathy and polyneuropathy (when DM meets ACS 0002 criteria and is therefore coded) are we supposed to assign:
E1-.71
H35.0 Retinopathy
N28.9 Nephropathy
G62.9 Polyneuropathy
or 
E1-.71
H35.0 Retinopathy
N26 Glomerulosclerosis
G62.9 Polyneuropathy

Search Details: Raised at workshop - instructed to refer to state coding committee

Response:
VICC acknowledges that the paragraph on diabetic nephropathy in ACS 1438 Chronic kidney disease is not replicated in ACS 0401 Diabetes mellitus and impaired glucose regulation, however it is for information only and is not instructing coders to assign N26 Glomerulosclerosis for diabetic nephropathy.  When applying a standard, code assignment should be based on the information in the classification boxes.  In your example, if it is documented that the patient has nephropathy, assign N28.9.  Coders should use the documentation in the medical record to follow the index and assign the appropriate code accordingly.


Query Text:
Previous published advice on NCCH database (#2115) instructed to code intra-operative imaging when performed in conjunction with therapeutic treatment (not diagnostic procedures). This advice was incorporated into some of 6th edition classification, eg:

Block [768] Transcatheter embolisation of blood vessels:
Code also when performed:
- intraoperative angiography:
- artery (35200-00 [719])
- vein (35200-01 [739])

However, coronary interventions in blocks [669] to [671], contain a code also when performed note instructing to code also when performed coronary angiography 38215-00 [668], 38218-00 [668]. This stems from advice published in CM 14(2):1 as follows:
"Coronary angioplasty and angiogram
When coding a coronary angioplasty is it necessary to also code an angiogram?
Historically there have been inconsistencies in the assignment of coronary angiography when performed in conjunction with an angioplasty. In order to standardise coding practice and following clinical advice, the NCCH advises that whenever an angiogram is performed in conjunction with an angioplasty, the appropriate angiography code from [668] Coronary angiography should also be assigned.  This advice will be reflected in ACHI/ACS Sixth Edition." 

As there are now contradictory code also notes throughout the classification and the NCCH database has been deleted, can you please clarify if we are supposed to code intra-operative imaging when done in conjunction with a therapeutic procedure, or if we are simply supposed to code the relevant imaging code, non intra-operative, as we used to do when a procedure was done under anaesthetic with image intensification?

Also please clarify if this advice only applies to CT, MRI, & angiography or are we supposed to code all forms of imaging (including plain XRay) when done under anaesthesia in conjunction with a therapeutic procedure (such as plain XRay in OR with all # reductions).

Search Details: 
NCCH query 2115
CM 14(2): 1
VICC #2039 - referred to NCCH - incorporated into 2115

Response:
The VICC advises that although there are inconsistencies in the 'code also' notes at the present time, to follow the notes in the classification as they currently are.  Work is continuing by NCCH to standardise the intra operative 'code also' notes.   Therefore where a 'code also' note exists it must be followed, otherwise there is no requirement to assign a code for the imaging.

In accordance with ACS 0042 Procedures normally not coded ultrasounds and xrays only need to be coded if anaesthetic is required for the procedure.


Query Text:
Adult patient is admitted overnight with Gastroenteritis with no mention of it being infectious or noninfectious. Is it correct that this should now be coded to A09.9 Gastroenteritis and colitis of unspecified origin instead of K52.-.

ACS 1120 Gastroenteritis in Fifth edition instructed you to code this to K52.- for adult patients and A09 for children 15yrs and under admitted with Gastroenteritis unspecified (with no documentation stating if infectious or noninfectious). This paragraph in the standard has been deleted in Sixth edition.

Search Details: ACS 1120

Response:
As the instruction in ACS 1120 Gastroenteritis has changed in Sixth edition, it is correct to follow the index to assign A09.9 Gastroenteritis and colitis of unspecified origin for gastroenteritis in all patients.


Query Title:
Iron deficiency anaemia in a patient with chronic kidney disease

Query Text:
Patient is admitted  for iron infusion and scopes for investigation of iron deficiency anaemia. Patient is also a diabetic with chronic kidney disease (CKD).  Patient is given pre-operative hydration due to his CKD. Patient has a gastroscopy and colonoscopy which find no cause for the iron deficiency anaemia.

1. Should code D50.9 Iron deficiency anaemia be assigned in addition to code D63.8* Anaemia in other chronic diseases classified elsewhere?

2. As this patient was admitted for investigation of their anaemia and also has CKD and type 2 diabestes is it correct to assign E11.22 Type 2 diabetes mellitus with established nephropathy as the principal diagnosis?

Search Details: 
ACS 1438 Chronic kidney disease
ACS 0401 Diabetes mellitus and impaired glucose regulation

Response:
In response to question one, as per the FAQs (part 1) in Coding Matters Volume 15 No.2 September 2008 question 4 under Chronic kidney disease, it is not necessary to assign an additional code to specifiy the type of anaemia.  

In response to question two, if a condition meets ACS 0002 Additional diagnoses and that condition is associated with diabetes, code the diabetes with the condition. In this scenario, CKD meets ACS 0002 Additional diagnoses and there is an index entry linking diabetes with CKD, therefore E11.22 Type 2 diabetes mellitus with established nephropathy can be assigned. This information is in accordance with the article titled Diabetes mellitus and impaired glucose regulation coding advice for Sixth Edition published on the HDSS website at http://www.health.vic.gov.au/hdss/icdcoding/features/index.htm in January 2009.


Query Text:
Patient admitted for colonoscopy.  No indication of reason but finds diverticulosis and anal polyp.  Has a history of colonoscopy two years ago where a rectal polyp and diverticulosis were found.  This colonoscopy could be for follow-up of the previous rectal polyp, it could be for symptoms or even for family history.  Depending on the reason for this colonoscopy, I could end up with different DRGs but all I have is the findings. 

What should I code as principal diagnosis?

Response:
The VICC advises that in the first instance if possible the case should be referred to the clinician for further information.  If however, this is not possible and there is no documentation of a reason for admission or a principal diagnosis, VICC considers it appropriate to assign Z01.8 Other specified special examinations.  This advice has been sourced from Coding Matters Volume 8 Number 1 June 2001 point 4 of article titled Coding Same Day Endoscopy effective 1 July 2001.  While the VICC recognises the published standard doesn't include this point, we consider it to be valid advice.


Query Text:
Is the performance of a HBa1C test enough to code diabetes?

Under the second and third dot points in ACS 0002 diagnostic procedures and increased clinical care and/or monitoring it appears that it is.

However some coders believe that diabetic patients are routinely given a HBa1C test in hospital,  therefore like BSL's it can be considered standard care, and only coded if the results are outside the expected range and the patient receives further care for their diabetes (education, counselling,medication changes etc).

A small audit at our hospital has shown that HBa1C is not routinely ordered for diabetic patients, however this may not reflect usual practice in all hospitals.

Search Details: 
ACS0002

Response:
The VICC advises that the HBa1C test measures the amount of 'glycosylated haemoglobin' molecule present in the blood and like BSL readings it is used routinely to monitor diabetic control.  This in itself does not meet ACS 0002 Additional diagnoses.


Query Text:
Scenario one ACS 2111 Screening for specific disorders 
Patient presents for colonoscopy.  Indication for the procedure is screening for colon cancer as there is a family history.  The operative diagnosis is hyperplastic polyp in sigmoid colon and no sign of malignancy. Do I code: 

Z12.1  Screening
Z80.0  Family History
K63.53 Hyperplastic Colon
32093-00 Colonoscopy w Polypectomy
92515-99 Sedation

Or because an operative diagnosis was made code

K63.53  Hyperplastic Polyp
Z80.0    Family History
32093-00 Colonoscopy w Polypectomy
92515-99 Sedation

Scenario two ACS 2113 Follow-up examinations for specific disorders 
Patient presents for colonoscopy.  Indication for the procedure is follow up of previous history of colon cancer in 2002.  The operative diagnosis is tubulovillous adenoma of sigmoid colon and some diverticula but no evidence of malignancy recurrence.  Do I code:

Z08.0  Follow up
Z85.0  Personal history
D12.5  Benign neoplasm sigmoid colon
M8263/0  Tubullovillous adenoma NOS
K57.30  Diverticulosis
32093-00 Colonoscopy w Polypectomy
91515-99  Sedation  

Or

D12.5 - Benign neoplasm sigmoid colon
M8263/0 - Tubullovillous adenoma NOS
K57.30 - Diverticulosis
Z08.0 - Follow up
Z85.0 - Personal history
32093-00 - Colonoscopy w Polypectomy
92515-99 - Sedation

Response:
The VICC advises that for scenario one the correct diagnosis codes to assign are:
Z12.1  Special screening examination for neoplasm of intestinal tract
Z80.0  Family History of malignant neoplasm of digestive organs
K63.53 Hyperplastic Colon
The finding of hyperplastic polyp is coded because it was removed thus meeting ACS 0002 Additional diagnoses criteria.

For scenario two the correct diagnosis codes to assign are:
Z08.0  Follow up examination after surgery for malignant neoplasm
Z85.0  Personal history of malignant neoplasm of digestive organs
D12.5  Benign neoplasm sigmoid colon
M8263/0  Tubullovillous adenoma NOS
ACS 0046 Diagnosis selection for same-day endoscopy does not apply in this case, therefore the finding of diverticulosis is not coded.


Query Text:
Would the committee please review our chemotherapy coding guidelines provided.  I have consulted my fellow colleagues at many hospitals statewide and we all have different ideas about chemotherapy coding.

Would you also mind commenting on whether flushing and disconnecting of Vascular Access devices meet the admission criteria?  Once again many of my fellow colleagues have different answers.

Response:
The VICC cannot comment on hospitals internal coding guidelines but would be happy to respond to specific scenarios.  There is an article titled VADs, VCs and DDDs in Coding Matters Volume 15 No.1 June 2008 which may provide you with some valuable information.  Please note however that the information in the article is not an indication that the patient would be admitted to have the procedure.

The VICC does not consider that flushing and disconnecting of VADs alone, in fact any maintenance of VADs alone, meet criteria for admission and suggest you refer to the DHS Hospital Admission Policy effective 1 September 2008 available from http://www.health.vic.gov.au/hdss/vaed/adm_policy_1_sep2008.pdf for further information.


Query Text:
A patient is admitted with congestive cardiac failure.  During the course of their admission, their hypertension medication is altered. The patient also has diabetes. Do we need to code out all their diabetic problems  (eg. PVD, retinopathy, obesity, dyslipidaemia) or only the diabetes with hypertension?

Search Details: 
ACS 0401 Diabetes Mellitus and Impaired Glucose Regulation
Sixth Edition Education Session

Response:
The VICC advises that in accordance with ACS 0401 Diabetes mellitus and impaired glucose regulation, once diabetes is coded, all the diabetic complications are coded out.


Query Title:
Transferred babe >28 days with prematurity

Query Text:
A baby is transferred to our facility > 28 days old with prematurity as the diagnosis.  According to ACS 1615 Specific Interventions for the sick neonate (and Sixth edition education) we are now allowed to code conditions documented as arising in the birth episode.  However, if you attempt to code P07.22 Extreme Immaturity as the principal diagnosis, the DRG assignment is 963Z which is nil weighted.  Previously (in 5th Edition) ACS 1618 we were to use Z51.88.  Is this just a DRG assignment problem or incorrect interpretation of ACS 1615?

Search Details: 
ACS 1615 Specific Interventions for the sick neonate
ACS 1618  Low birth weight and gestational age 5th Edition
6th Edition education documentation

Response:
The VICC notes that the issue of conditions arising in the perinatal period grouping to DRG 963Z Neonatal Diagnosis Not Consistent W Age/Weight in infants aged >28 days is addressed in HDSS bulletin 132 item 7 Victorian modifications to AR-DRGs for 2008-09 under Neonatal diagnosis not consistent with age/weight.  It is reproduced below for your information:
"Neonatal diagnosis not consistent with age/weight 
Australian Coding Standard 1605 Conditions originating in the perinatal period states that diagnosis codes for some conditions arising in the perinatal period may be coded at any time in life (i.e. not limited to < 28 days age). However, the AR-DRG52 grouper allocates these episodes to the error AR-DRG52 of 963Z Neonatal Diagnosis Not Consistent W Age/Weight. The 5th edition Australian Coding Standard 1618 Low birth weight and gestational age advised coders to assign code Z51.88 Other specified medical care for babies > 28 days old and > 2500g on admission where prematurity was the only reason for admission. In 6th edition this instruction has been deleted and coders are advised to assign the appropriate codes for the prematurity. Changes to the AR-DRG60 grouper will allow these episodes to group to valid DRGs. However, the AR-DRG52 grouper allocates these episodes to the error AR-DRG52 of 963Z Neonatal Diagnosis Not Consistent W Age/Weight. To encourage accurate coding under the revised Sixth edition coding standard, a VIC-DRG52 of P67D Neonate, AdmWt > 2499 g W/O Significant OR Procedure W/O Problem will be assigned for episodes with:
(i) a principal diagnosis from the following ICD-10-AM Fifth edition (mapped) list: P07.01, P07.02, P07.03, P07.11, P07.12, P07.13, P07.21, P07.22, P07.30, P07.31, P07.32, (ii) Admission weight >2,499g AND
(iii) initial grouping to AR-DRG52 963Z Neonatal Diagnosis Not Consistent W Age/Weight."

Therefore unless your software supplier has implemented this modification, the hospital generated DRG will be different to the DHS generated DRG.


Query Text:
Patient with type 1 diabetes with arterial foot ulcers underwent left ATA - DPA bypass using left forearm radial artery graft. How do you code arterial bypass of leg? 

Lookup in ACHI Index:
Bypass
- arterial
- - with
- - - composite graft
- - - crossover (graft)
- - - sequential (skip graft)
- - - synthetic material
- - - vein
- - coronary (artery)

There is no look up for arterial bypass using artery, only vein or coronary artery.

Heading of block [711] is Arterial bypass graft using vein. Vein is not a non essential modifier and exclusion notes do not lead you to arterial graft unless of coronary artery.

Cannot show that the 'vein' graft is actually an arterial graft as there is no code for procurement of artery for bypass unless it is of the coronary artery.

Incidentally the MBS number the doctor provided was 38496 which maps to 38500 which is a coronary artery bypass graft, so I assume he had the same problem!

We have coded arterial bypass using vein 32763-00 [711] and ligation of radial artery 34106-11 [697] (despite the exclusion note for omit with any other vascular procedure) to try and capture the procedural components as best we can.

Operation report states:
The left radial artery was harvested through a longitudinal incision through routine exposure. The artery was harvested with the venae comitantes without it skeletonising. The artery was prepared using papaverine and blood mixture and was ligation divided at the trifurcation of the brachial artery. The radial artery harvest wound was then closed in two layers.

The left anterior tibial artery and mid-calf were exposed through a lateral exposure. The dorsalis pedis artery was exposed through a vertical anterior longitudinal incision involving partial division of the retinaculum.

The quality of both anterior tibial artery and dorsalis pedis artery was found to be quite calcified throughout its whole length, but there were segments which were operable just proximal and distal to the occlusion suggested by the angiogram.

An Esmarch tourniquet was then applied after intravenous administration of 5,000 units of IV heparin. The anterior tibial artery was exposed for operability and was found to be operable and the radial artery was anastomosed to the mid calf anterior tibial arteries using 6/0 Prolene continuous suture, carefully running the sutures inside out on the anterior tibial artery throughout the course of suturing.

The radial artery was then tunnelled anatomically to the dorsalis pedis exposure sites. An end-to-side anastomosis was also again performed using 6/0 Prolene running sutures. Again, the needles ran inside out in the dorsalis pedis artery throughout its length.

Haemostasis was achieved for both wounds and at the end of the procedure there was found to be a good dorsalis pedis pulse distally and therefore the decision was made not to proceed to on-table angiogram.

Heparin was not reversed at the end of the case. The wound was then closed in two layers with skin apposed using single continuous sutures.

Search Details: 
VICC query database - no similar queries identified
VICC Newsletter - nothing similar found
Tabular and index search criteria provided above

Response:
The VICC advises that because there is no code for arterial bypass graft using artery, the appropriate code to assign is 90222-00 [720] Other procedures on arteries following index entry Procedure, artery NEC.  The VICC acknowledges that this would mean that information regarding bypass would be lost and suggests you consider writing a public submission to NCCH for the creation of a code for arterial bypass graft using artery.

Note: This query has been retired due to changes in classification rules.


Query Title:
Noninvasive ventilation  and ACS 1006 Ventilatory support

Query Text:
I wish to obtain clarification of the new coding standard regarding  NIV please.  The NIV standard says:  Noninvasive ventilation refers to all modalities that assist ventilation without the use of an ETT or tracheostomy...includes face mask, mouthpiece, nasal mask, nasal pillows, nasal prongs, nasal tubes and nasopharyngeal tubes. 

I've spoken to nurse educators here in Intensive Care and they've stated that, as far as our practices here are concerned, the following is applicable:

- NIV refers to PEEP and pressure support.  This is given via CPAP with a mask providing positive end expiratory pressure - PEEP.  CPAP given via a mask with PEEP but without pressure support would not be defined as NIV. 

- It's possible that NIV could be given via a nasal mask, but not probable.  

- Nasal prongs are used to deliver oxygen.  There is no pressure support, although highflow oxygen delivered via humidified nasal prongs can generate PEEP.  

- Nasopharyngeal tubes are used for airway support in adults eg suctioning.  There is no pressure support.  The tubes may be used in paediatrics for NIV but are not used here for NIV in adults.

NIV, as defined above, is provided at this hospital in ICU and Emergency and may soon be introduced on our respiratory ward, but only under the supervision of ICU Liason nurses and after much staff education.

Is it the intention of the standard that nasal prongs, nasopharyngeal tubes, nasal masks, face masks etc., used in the ways outlined above (i.e. no pressure support), are to be considered NIV for coding purposes?

If so, collection of this data may be problematic eg. Patients all over the hospital are given oxygen via nasal prongs at any time on any ward during their stay.  Similarly, CPAP without pressure support can be given any time, anywhere. Instances of these types of ventilatory support are documented randomly in progress notes and duration would not easily calculated. 

Search Details: 
Have referred to ACS and article on CVS and NIV, recently issued by DHS.  Have spoken to Intensive Care Unit medical, nursing and physiotherapy staff.

Response:
The VICC advises that for coding purposes noninvasive ventilation (NIV) is defined as ventilation administered by one of the types/modes listed in ACS 1006 Ventilatory support section titled Noninvasive ventilation (NIV), under the heading Types/modes of ventilatory support.  Therefore CPAP administered noninvasively that is, not by ETT or tracheostomy is considered NIV.  Administration of oxygen however, is not considered NIV as oxygen is not listed in the standard as a type/mode of ventilatory support.  It is acknowledged that collection of NIV data may be problematic in some hospitals.


Query Text:
When a patient is sent to theatre for the purpose of intubation for mechanical ventilation,  (no other procedure performed) do you code the hours if there is less than 24 hours of ventillation?  The current guidelines assume that the patient was in theatre for any other procedure, and the intubation/ventilation relates to anaesthesia,  but this 19 year old male was sent to theatre just to be intubated, (airway obstruction due to peritonsillar abscess).  In this case the patient was intubated longer than 24 hours so the answer is clear cut, but what if he was extubated within 24 hours? Would I or should I code it?

Response:
The VICC advises that in accordance with ACS 1006 Ventilatory Support point (f) it is correct to assign a code for  ventilatory support less than or equal to 24 hours when the intubation is performed for respiratory support and not for anaesthesia.


Query Text:
Example 3 in the ACS 0048 Condition onset flag, relates to an obstetric episode.  Both the PPH and CRN have been coded in this example, without supporting evidence of how either of these conditions meet ACS 0002.  ACS 0002 indicates under 'Conditions noted in obstetric cases' that conditions noted by the clinician should not be coded unless they meet ACS 0002.  There are also obstetric examples in CM and the NCCH database which supported and were consistent with this latter view.  Could it be that the example 3 in ACS 0048 is to be used only as an example for condition onset flag usage, and not actual correct coding advice?  Example 4 is also an obstetric case, but all the conditions coded have documentation as to why they meet ACS 0002.  Our coders are finding it very difficult with conflicting advice like this in the ACS.

Response:
The VICC advises ACS 0048 Condition onset flag is purely about condition onset flags and not ACS 0002 Additional diagnoses criteria.  Therefore as per the enquirer's comment,  example 3 in ACS 0048 Condition onset flag is only to be used as an example of condition onset flag usage.  The VICC also notes that VIC 0048 overrides ACS 0048.


Query Text:
An ICU patient was extubated (end of CMV) and then proceeded to have nasal prongs/face mask/ Hudson mask ventilatory assistance and therefore I will code NIV for those hours.

The question arises for patients in the general wards with COAD or CF or any other respiratory condition who have oxygen via nasal prongs - is that NIV or does NIV have to be described as CPAP or BIPAP? On the ICU chart they have written "BIPAP failed" but there's no mention of BIPAP on the charts, just NP/FM/HM etc.


Query Text:
The patient was documented to have 'anaemia is likely secondary to methotrexate therapy'. Anaemia did not have any further specificity.  For anaemia due to methotrexate, can you follow the index for anaemia, toxic and assign D61.2 Aplastic anaemia due to other external agents (plus Y43.1 Antineoplastic antimetabolites and Y92.22 Health service area)?  

I usually code diarrhoea due to drugs to K52.1 Toxic gastroenteritis and colitis and hepatitis due to drugs to K71.6 Toxic liver disease with hepatitis, not elsewhere classified (plus the external agent codes).   It seems to have the same logic/reasoning, but I don't like the 'aplastic' term, as it was not documented as such in the record.

Search Details: 
Index entry Anaemia, toxic D61.2
Tabular entry - D61.2 Anaplastic anaemia due to other external agents.

Response:
The VICC advises that because 'toxic' has not been documented, the Index entry 'Anaemia, toxic' cannot be followed.  Therefore as the anaemia has not been further specified, assign the default code D64.9 Anaemia, unspecified followed by the external cause codes to describe the adverse effect.


Query Text:
Please instruct how to code diarrhoea due to antibiotics (drugs). This patient presented with Roxithromycin related diarrhoea. I have always assumed diarrhoea due to antibiotics should be coded to K52.1 Toxic gastroenteritis and colitis (with Y40.-Systemic antibiotics and Y92.22 Health Service Area) as that would be consistent with other conditions in the classification that are coded to toxic when drug induced. 

The instruction in ACS 1902 Adverse effects page 255, Volume 5 to code drug toxicity NOS to T88.7 Unspecified adverse effect of drug or medicament when the adverse effects are not specified, also supports the logic outlined above. (For example. coding digoxin toxicity, to T88.7 Unspecified adverse effect of drug or medicament, Y52.0 Cardiac-stimulant glycosides and drugs of similar action, Y92.22 Health Service Area.)  This practice is using the logic of toxicity as being an adverse effect of drugs, therefore toxicity due to antibiotics, where the manisfestation of the toxicity is specified as diarrhoea, should surely be coded as toxic diarrhoea. 

For example:
Nephropathy
- toxic (due to) NEC N14.4
- - drugs N14.2
- - - analgesic N14.0
- - - specified NEC N14.1
- - - heavy metals N14.3

Failure
- hepatic
- - due to drugs K71.1
Tabular listing for K71.1 is:
Toxic liver disease with hepatic necrosis
Hepatic failure (acute)(chronic) due to drugs

All, including K52.1, have the same instructional note to 'use additional external cause code (Chapter 20) to identify agent'.

However, during our recent audit in which an episode was audited where the patient had a drug induced diarrhoea, that had been coded as outlined above, we were instructed to follow the now defunct NCCH advice contained in NCCH Q2303, despite the fact this query was specifically asking about a child (so would normally have had to code infectious diarrhoea), therefore the query question was really should the advice in ACS 1120 Dehydration with gastroenteritis (instructing to default to infectious in children) be followed or not. 

I felt this query was incorrect in its application as well as the printed answer as it instructed to use other specified diarrhoea (K52.8 Other specified noninfective gastroenteritis and colitis) which didn't take into account the fact that a code exists for toxic. Use of toxic throughout the classification is consistent, so now that the NCCH query database is no longer in existence, can we apply that logic to drug induced diarrhoea and code it as toxic?

Search Details: 
Classification as outlined above
NCCH Q2303 (now no longer valid)
ACS 1902 Adverse effects

Response:
This query was originally published in the March 2009 VICC queries database release as follows:
The VICC advises that K52.1 Toxic gastroenteritis and colitis can only be assigned when there is documentation of 'toxic' in the clinical notes.  As the default code for diarrhoea is A09.9 and there is no index entry 'due to drugs' under this lead term as is in the other examples in your query, the VICC considers that for the case cited, the correct code to assign for the diarrhoea is A09.9 Gastroenteritis and colitis of unspecified origin followed by the external cause codes to describe the adverse effect.

Following publication of Coding Matters Volume 16 Number 3 December 2009 the VICC response is superseded by the following advice:

There is no specific code in ICD-10-AM for drug induced diarrhoea/gastroenteritis and ICD-10 defaults gastroenteritis to A09.9 Gastroenteritis and colitis of unspecified origin in category A09 Other gastroenteritis and colitis of infectious and unspecified origin. Due to the absence of a specific code and because the default code assigns a code from Chapter 1 Certain infectious and parasitic diseases there has been variation in code assignment for
this condition. Some coders have elected not to assign the default code in the absence of documentation of the condition being linked to an infectious agent. This has resulted in other code assignment, by selection of other essential modifiers in the index pathway, such as toxic or noninfectious.

Clinical advice was sought, both internationally and nationally, to ascertain correct code assignment for this condition, which indicates: ‘different drugs can cause diarrhoea via different
mechanisms and there may be either an infectious or toxic component involved, depending on the action of the drug. For example, if the drug modifies the intestinal flora it may result in a ‘pathogen’ taking over which then induces diarrhoea. Alternatively the drug may have a direct affect on the intestinal tissue
(mucosa, muscles, nerves etc.). The resultant affects being either increased intestinal motor activity causing diarrhoea or the excretion of fluid by the mucosal cells due to the toxic effect, which increases the volume of stools.’ Olafr Steinum, WHO-FIC Morbidity Reference Group (MbRG), Senior Consultant, Department of Infectious Diseases, NU-Sjukvården, Sweden (personal
communication).

Given the above advice, selecting ‘noninfectious’ from the index pathway or assigning A09.9 despite it being the default code is not correct. The preferred option of the Gastroenterology CCCG is K52.1 Toxic gastroenteritis and colitis, with an appropriate external cause code to specify the type of drug, if documented.

There is precedence in the classification to select ‘toxic’ for drug induced conditions, such as chronic liver disease due to drugs, which is assigned to K71.9 Toxic liver disease, unspecified. There are also other instances where the NCCH has given advice to use a more accurate code rather than the default code provided by ICD-10. However, coders should not make such decisions
without advice from the NCCH. Furthermore coders shouldn’t assume that all cases of drug induced conditions should be assigned to a toxic code because of the advice provided here. This advice is only provided after lengthy consideration and extensive clinical consultation.

A review of the classification of drug induced diarrhoea/ gastroenteritis is being considered for a future edition of ICD-10-AM, as a public submission concerning this issue has already been received.


Query Title:
Principal diagnosis in same day patients when operation form has an 'operative diagnosis'

Query Text:
Choice of principal diagnosis in same day patients where the operation form has a field for 'Operative Diagnosis'.

ACS 0046 Diagnosis selection for same-day endoscopy

1. If a causal link is established...(a clinician documents the link...)

Clinicians very rarely write the exact words that link a symptom to a finding.  However some hospitals have operation reports that have a subheading of 'operative diagnosis'. If the clinician writes his diagnosis under the heading of operative diagnosis is this enough to assume the link?

In this example I have a woman with PMB for investigation.  On the operation report, under the subheading of operative diagnosis (incidentally there is an additional note saying 'record indication if findings normal') the clinician has written Endometrial Polyp. The exact words linking the PMB and the polyp are not there.  I have discussed this scenario with two senior coders, including an auditor and have been given conflicting advice.  

One insists the words linking the two conditions must be documented, otherwise we are just assuming the link and we are not allowed to assume,  and the other disagrees and says the clinician has documented his diagnosis under the heading operative diagnosis and this is sufficient to code the diagnosis and not the symptom.  

If the latter is correct then it seems that all operation/day procedure records should simply have operative diagnosis provided as a subheading, thereby removing any doubt as to what to code.

Response:
If the condition has been documented under the heading of 'operative diagnosis' (as opposed to a heading of 'operative findings'), this means that the clinician has made a diagnosis after study and therefore documentation of a link between the symptom and the finding is not required.


Query Title:
Coding of diabetes and diabetic complications when medications withheld

Query Text:
Could you please advise whether or not it is appropriate to code the diabetes and diabetic complications in the following scenario?

67 year old man admitted for repair of a right inguinal hernia.  He is a Type 2 diabetic (with peripheral angiopathy and cataracts) controlled by oral medications.  BSLs were normal during his stay, but his NIDDM medications were withheld prior to surgery (as patient was nil by mouth prior to surgery).

If the diabetes is coded in this case, would it then also be the case that any condition that has medication withheld prior to surgery should also be coded?

Response:
The VICC advises that in this scenario the diabetes is not coded because the purpose of withholding the diabetic medications is because the patient is nil by mouth prior to surgery; not for commencement, alteration or adjustment of therapeutic treatment.


Query Text:
68 year old woman, ex-smoker admitted for routine colonoscopy and biopsy - her chronic diarrhoea having flared again after being in remission with Salazopyrin after an earlier diagnosis of lymphocytic colitis.

Clinical notes on histopathology : Chronic diarrhoea for investigation. Apparent past history of lymphocytic colitis.

Histopathology result : The appearances are consistent with collagenous colitis.

How to code diagnosis? Currently have used K52.8 Other specified noninfective gastroenteritis and colitis. Query linking it with M35.8 Other specified systemic involvement of connective tissue, however not an asterisk code and collagenous colitis could hardly be deemed systemic - there is no other mention of connective tissue disease.

K52.8   Other specified noninfective gastroenteritis and colitis  ?Anything better
M35.8  Other specified systemic involvement of connective tissue  ?Able to link to connective tissue chapter
Z86.43 Personal history of tobacco use disorder
32090-01 [911] fibreoptic colonoscopy to caecum, with biospy

Search Details: 
Better Health channel has a good explanation of collagenous colitis and lymphocytic colitis at www.betterhealth.vic.gov.au

Response:
The VICC notes that this case should be taken back to the clinician for a definitive diagnosis.  However, having reviewed the documentation provided with the query, although the referring letter is open to interpretation, the VICC considers the principal diagnosis to be colitis.  This is because the referring letter supports a diagnosis of colitis which has been confirmed on the histology report.  

The correct code to assign for the colitis would be A09.9 Gastroenteritis and colitis of unspecified origin because there is no index entry for collagenous under the lead term of colitis.  

If it were determined that the chronic diarrhoea was the principal diagnosis, the correct code to assign would be K52.9 Noninfective gastroenteritis and colitis, unspecified following index entry diarrhoea, chronic (noninfectious).

It is not correct to assign M35.8 Other specified systemic involvement of connective tissue because there is no information in the documentation to link the colitis to any connective tissue disorder.


Query Text:
Comments on VICC response to coding query #2324 Fistulogram and angioplasty

We would like the VICC to reconsider their response to coding query #2324 Fistulogram and angioplasty: in particular, the use of code 59739-03 [1988] Other sinography. In that query a patient had a R) radiocephalic fistula in situ (presumably for kidney dialysis) associated with a swollen R) arm. The procedure report notes a fistulogram and angioplasty performed. Besides the angioplasty code the VICC also advised the use of 59739-03 [1988] Other sinography for the fistulogram whether diagnostic or intraoperative. 

This may seem acceptable as the code does include the term fistulography, and the procedure report title does not specify that the fistulogram was a Digital Subtraction Angiogram (DSA).

However, the fistulogram code places the procedure in block 1988 Other radiography. This associates the fistulogram (of blood vessels) with sinograms that are taken of abnormal (infected) sinus tracts of various sites. Our Head of Radiology (please see supportive documentation) considers a fistulogram as a DSA; we endeavour to have our radiology reports documented in this way. We also note that part of the question in the original coding query did ask about coding a DSA (diagnostic vs. intraoperative).

The VICC note in their response: 'From the information provided, VICC members would not assign a code for the DSA.'  Did the VICC provide its fistulogram code answer purely on the fact that a DSA was not documented?  We acknowledge that it may be difficult to regularly get the documentation right; from our experience some radiologists will only call the procedure a 'fistulogram'. 

Ultimately, we believe the coding classification of 'fistulogram' [in this case meaning of a surgically-created AVF, typically for renal dialysis] is better served by using a code(s) from the Angiography section of the ACHI Tabular list [starting at block1989, but also consider blocks 719 & 739]. 


Search Details:       
DEPARTMENT OF RADIOLOGY 

Director
Professor XXXX MD, FRANZCR

When is a Fistulogram just an X-ray (with or without fluoroscopy) and when is it an angiogram with or without an angioplasty?

Definition of: fistula 
Pl. fistulae, fistulas; any abnormal, tubelike passage within body tissue, usually between two internal organs, or leading from an internal organ to the body surface. Some fistulae are created surgically, for diagnostic or therapeutic purposes; others occur as a result of injury or as congenital abnormalities. 

Fluoroscopic fistulograms are performed for:
blind f.  one open at one end only, opening on the skin (external blind fistula) or on an internal surface (internal blind fistula). 
branchial f.  a persisting branchial cleft. 
enterocutaneous f.  one in which there is communication between the intestinal tract and the skin. Some fistulae are created surgically, with gastrostomy, esophagostomy or colostomy. Others may result from surgical trauma, breakdown of an intestinal anastomosis, pancreatitis, or erosions around a surgical drain or tube. 
esophageal f.  communication between the esophagus and some portion of the respiratory tract, e.g. trachea, bronchi or pulmonary tissue. May be congenital or acquired as a result of trauma or inflammatory lesions, particularly esophageal foreign bodies.
Broncho-pleural f.  communication between a bronchus and the pleural cavity.

Digital Subtraction Angiograms are performed for:
Dialysis f.-  surgically created between an artery and a vein, usually for the purposes of dialysis or to provide the option of dialysis at short notice
Vascular malformation f.- congenital high or low flow connections between arteries and veins anywhere in the body.
Aorto-enteric f.- abnormal connections created by a disease process between the aorta or other large artery and the alimentary tract, usually the oesophagus.

There is a world of difference between sticking a tube into an (infected) hole in the skin, injecting contrast and taking a few pictures with a fluoroscope and the sterile puncture of an artery or an arterialised vein in a patient with renal failure followed by a series of angiograms to assess the site and severity of arterial or venous occlusions, stenoses or thromboses.

The CMBS schedule reflects this. 
[59739] Sinogram or Fistulogram is $73.75. 
[60039] A 4-6 run DSA of the upper limb is $827.10.

Response:
The VICC advises that for the fistulogram to be coded as a DSA, there does need to be documention of DSA.  Whilst it may not seem appropriate to classify fistulogram to Block [1988] Other radiography, coders must follow the Index and assign codes based on the information available.

The VICC will submit a public submission to improve the index entries for fistulogram performed by DSA.


Query Text:
Example 1:
Patient has Type 2 diabetes on insulin.
Nursing documentation of BSL 2.0 patient given orange juice and glucose paste. 
The clinician documentation mentions diabetes as a past history on the discharge summary and as a past history in the initial handover notes.  

Example 2:
Patient has Type 2 diabetes on oral hypoglycaemic agents.
Nursing documentation of BSL 3.7 half a glass of orange juice and sweet biscuits given with good effect.
The clinician documentation mentions diabetes as a past history on the discharge summary.

There are no arrows or terms documented by the nursing staff indicating that the patient has low blood sugar levels just the BSL readings.  As there are no terms qualifying the BSL levels eg hypo, hyper arrows, are we able to interpret these results as management of diabetes.

Is the treatment described above enough to meet the criteria in ACS 0002 Additional diagnosis under dot point 3 increased clinical care and/or monitoring or is it routine management of diabetes that a patient would be monitoring on their own at home and adjusting their oral intake as required.

Would diabetes (and therefore all manifestations) be coded in these cases.

Search Details: 
ACS 0002 Additional diagnosis

Response:
The VICC is unable to comment on whether the scenarios described in the query are routine management of diabetes as this may vary between patients and clinical practice differs over time and between hospitals.

Therefore coders need to be guided by the documentation in the medical record and apply the criteria in ACS 0002 Additional diagnoses to determine if a condition, in this case, diabetes can be coded.  That is, if treatment is given, there would need to be documentation of a diagnosis that is being treated.  Similarly, there would need to be documentation to support increased care and/or monitoring.


Query Text:
I have come across VICC query #1725 Infective exacerbation of asthma.  It advises that 'intrinsic' is synonymous with 'infective' and that infective asthma should be coded to J45.1 Nonallergic asthma.

I have been unable to find advice that is contrary to this and was wondering if this advice should still be applied or if there is subsequent advice (that I cannot find) that states we should not make this assumption.

Aside from this if a patient is admitted with 'infective exacerbation of asthma' and treated with antibiotics, and the actual infective component is not further clarified (eg URTI or chest infection) is there a code we can add such as 'J98.8 Other specified respiratory disorders' to capture that is more than just asthma?  

Search Details: 
Coding Matters/ VICC Newsletters

Response:
VICC research indicates that infection is no longer considered to be linked to intrinsic asthma, therefore for documentation of infective exacerbation of asthma the correct code to assign is J45.9 Asthma, unspecified.

When the infective component is not further clarified it is not appropriate to add another code such as J98.8 Other specified respiratory disorders as it does not add any further specificity.


Query Text:
Obstetrics coding changed for Sixth Edition with the addition of a paragraph in ACS 0002 Additional diagnoses.  However, there was very little in the NCCH education to explain how this paragraph impacts on chapter 15 Pregnancy, Childbirth and the Puerperium coding advice.  

Standards ACS 1524 Advanced maternal age, ACS 1525 Grand multiparity, ACS 1526 Hypertension in pregnancy, ACS 1527 Post-term delivery, ACS 1528 Postpartum haemorrhage, ACS 1529 Precipitate labour, ACS 1531 Premature rupture of membranes and ACS 1532 Prolonged labour in chapter 15 have a statement: 
•These conditions should be coded when documented by an obstetrician/clinician/midwife.
•If the criteria for the specific obstetric diagnosis is met but the relevant diagnosis is not documented, consult the clinician before assigning a code.

Standards ACS 1530 Premature delivery and ACS 1506 Malpresentation, disproportion and abnormality of maternal pelvic organs indicate that conditions should be coded but do not have the above statement.

The issue becomes more complex, as some of the standards with this statement are listed in ACS 0002 Additional diagnoses under Additional diagnosis reporting referred to in other standards and some are not.

As there appears to be little consistency in the application of the standards in Chapter 15, please could the committee answer these questions?

1. Coders are unsure of whether ACS 0002 overrides the ACS with the statement above in bold.  Does the committee have any more knowledge on the subject and would you be able to advise please.

2. Does the listing of ACS 1530 and 1549 in ACS 0002 in the section ‘Additional diagnosis reporting referred to in other standards’ mean that you would always code premature labour and GBS status?

Response:
The VICC considers that the obstetric coding specialty standards in Chapter 15 Pregnancy, Childbirth and the Puerperium referred to in the query override ACS 0002 Additional diagnoses because these standards contain an instruction to assign a code in the circumstance specified in the standard.

Where there are obstetric conditions to be coded that are outside the specialty standards noted in this query follow ACS 0002 Additional diagnoses - conditions noted in obstetric cases.

In answer to the question about the listing of ACS 1530 Premature delivery and ACS 1549 Streptococcal group B infection/carrier in pregnancy in ACS 0002 Additional diagnoses - Additional diagnosis reporting referred to in other standards, ACS 1530 is on the list because of the instruction to assign a code for duration of pregnancy and ACS 1549 is on the list because of the instruction to assign a code for GBS status when no infection has been documented. Their inclusion on this list does not constitute an instruction to always code these conditions.


Query Text:
A patient admitted with high blood pressure.  The patient also has diabetes which is not monitored and does not meet criteria for additional diagnoses.

Do you code the diabetes?

Response:
The VICC advises that in accordance with the Diabetes mellitus and impaired glucose regulation coding advice for Sixth Edition article published on the HDSS website in January 2009,  if the patient has diabetes, and another condition meets ACS 0001 and this condition appears in the ICD-10-AM Alphabetic Index as a subterm under ‘Diabetes with’ or has a subterm of ‘with diabetes’, then follow ACS 0401 Diabetes mellitus and impaired glucose regulation and code the diabetes as the principal diagnosis, followed by the associated condition code.

Therefore in the case cited, the correct codes to assign are:
E1-.72 Diabetes mellitus with features of insulin resistance
I10     Essential (primary) hypertension


Query Text:
Patient with type 2 diabetes presents to ED with pyelonephritis.

Do we code:
N12 Tubulo-interstitial nephritis NOS
or
E11.22 DM with nephritis
N12 Tubulo-interstitial nephritis NOS

Index look up:
Pyelonephritis (see also Nephritis, tubulo-interstitial) N12

No subterm for in diabetes, with diabetes, etc. under pyelonephritis to link it to diabetes.

If follow instruction: see also Nephritis, tubulo-interstitial

Nephritis, nephritic
- with
- - diabetes mellitus E1-.22
- tubulo-interstitial (in) N12

I assume we do not code diabetes with nephritis as the instructional note is to see Nephritis, tubulo-interstital. This particular entry has no subterm for in/with diabetes. However, as Nephritis does have  a prepositional subterm 'with diabetes mellitus', can you please clarify code assignment.

Response:
The VICC advises that as noted by the enquirer, the complete instructional note does have to be followed and because there is no documentation of tubulo-interstitial nephritis in the medical record, the index entries noted in the query cannot be followed.

When you look up Pyelonephritis there is no 'with diabetes' index entry (subterm).  If you follow the 'see also' note at lead term Pyelonephritis, it takes you to Nephritis, tubulo-interstitial.  Although there is an index entry 'with diabetes' under nephritis,  because you have to follow the complete instructional note, you must go to subterm tubulo-interstitial under which there is no index entry 'with diabetes'.  As there is also no index entry for pyelonephritis under lead term Diabetes, E11.22 Type 2 diabetes mellitus with established diabetic nephropathy cannot be assigned for the case cited.


Query Text:
Should VAC dressings be coded? If yes, could you please specify what code should be used.

Response:
In accordance with ACS 0042 Procedures normally not coded point 4, if the initial application or change of VAC dressing requires anaesthetic and no other procedure is performed, the correct code to assign is 90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue (or 90686-00 [1627] Non excisional debridement of burn). 

Research undertaken by VICC suggests that usually an excisional debridement is performed at the time of the application of the VAC dressing (to prepare the site) in which case only the excisional debridement is coded. 

If the change of VAC dressing is for a soft tissue abscess, it is appropriate to assign 30225-00 [1554] Reinsertion of soft tissue abscess drainage tube.


Query Title:
Asthma exacerbated by upper respiratory tract infection (URTI)

Query Text:
If patient is admitted with asthma that has been exacerbated by URTI , do we code the asthma followed by J06.9?  I thought there was a direction given to do this several years ago, but cannot find it?

Response:
The VICC advises that for the case cited, it is correct to assign J45.9 Asthma, unspecified and J06.9 Acute upper respiratory infection for documentation of asthma exacerbated by upper respiratory tract infection.  This is because both codes are required to translate the medical statement into code.

Refer to #3471 Asthma exacerbated by upper respiratory tract infection (URTI).


Query Text:
Could we please have a ruling on the following episode. 
 
Patient presented to A&E via ambulance. Patient complaint on arrival was light headed and clammy with a possible hypotensive collapse. It was noted on both the ambulance report and the triage notes that the patient had just given up smoking, had just started using nicobate patches and became light headed, clammy and collapsed after his carer left. There was no clear link between the symptoms and the patches at this stage. Progress notes from nurses reiterated the complaint for the next hour. When assessed by a doctor he noted that the patient had abdominal pain (colicky) for two days. He goes on to say that today after the carer left the patient had abdominal pain. He arranged for a CT of the abdomen and put the principal diagnosis as 'Abdo pain'. 
 
I believe as do the other HIMs/coders this should be coded as principal diagnosis of light headed and clammy (symptoms with no specific related condition) and then the abdominal pain as an additional whereas the clinician says that the ambulance and triage "got it wrong" and that the principal diagnosis should just be the abdominal pain. According to ACS 0001 Principal diagnosis, I do not believe the abdominal pain was chiefly responsible for occasioning the episode although the clinician believes it was the diagnosis established after study to be chiefly responsible for occasioning the episode.

Response:
After reviewing the emergency department (ED) record for this query, the VICC considers the principal diagnosis to be the abdominal pain.  This is because the condition has been documented as the principal diagnosis by the clinician after study and it is also supported in the hospital notes.


Query Title:
Principal diagnosis in screening colonoscopy

Query Text:
A patient is admitted for a screening colonoscopy due to a parental history of 'colon cancer' (not further specified).  The colonoscopy finds several polyps which are removed and sent to histology.  The histology comes back as 'tubular adenoma'.

In coding this out we would expect to code it as a straightforward screening episode as per ACS 2111 Screening for specific disorders however given that the polyps are a neoplasm and Z12 Special screening examination for neoplasms does not specify malignant, should we be coding the polyps as the principal diagnosis?  Explaining this to a new coder has made us question our own 'assumptions' about how this scenario should be coded. We are also conscious that this is a DRG change so we want to ensure that we are coding it correctly.

Response:
In accordance with ACS 2111 Screening for specific disorders, if the disease for which the patient is being screened is not detected or has never been detected assign codes from categories Z11, Z12 and Z13 Special screening examination for…

For the case cited, the documentation states that colon cancer is the condition for which the patient is being screened. As colon cancer has not been detected, the correct principal diagnosis code to assign is Z12.1 Special screening examination for neoplasm of intestinal tract.


Query Text:
Patient diagnosed with Delusional Parasitosis.  This diagnosis was listed on the discharge summary and throughout the notes.  There is no specific code for this condition.

We coded it to F22.0 Delusional disorder and added multiple superficial injury codes (arms, legs, scalp) to depict the lesions patient obtained from scratching and picking at her skin (S codes and external cause codes).

We seek your advice in regards to the accuracy of the coding of this admission as well as asking if this condition can be added to the index.

Search Details: 
Disorder, delusional - no further subset to parasitosis
Parasitosis - no entry

Response:
The VICC agrees that for documentation of delusional parasitosis the correct code to assign is F22.0 Delusional disorder by following Index entry disorder, delusional.  Additional codes for injuries can be assigned if appropriate.

The VICC suggests sending a public submission to the NCCH requesting the condition be added to the index.


Query Title:
Decompressive laminectomy of thoracic spinal cord via posterior approach

Query Text:
Please advise the code selection for decompressive laminectomy of thoracic spinal cord via posterior approach.  The following options are available in the index:

Decompression 
-spinal cord (canal) 
--thoracic 
---via 
----costotransversectomy (with thoracic dissection) 40345-00 [47] 
----thoracotomy (with thoracic discectomy) (with thoracic vertebrectomy) 40348-00 [47] 

The above codes are via anterior approach without posterior approach.

Laminectomy 
-decompressive 
--cervical 
---1 level 40331-00 [46] 
----with anterior fusion 40332-00 [46] 
---2 levels 40334-00 [46] 
----with anterior fusion 40335-00 [46]
--lumbar spinal canal (anterior) (posterior) 
---1 level 90024-00 [48] 
---2 levels 90024-01 [48]

The above codes do not include thoracic levels.

For the interim, we are assigning 90011-01 [59] Other procedures on spinal cord or spinal cord structures.  A neurosurgeon here stated that 90% of thoracic decompressions are via posterior approach.

The operation report is as follows: 
Operative Diagnosis:  THORACIC SPINAL CANAL STENOSIS T10/11 WITH CORD COMPRESSION
Operation:  DECOMPRESSIVE LAMINECTOMY AT T10/T11.
Anaesthetic:  GA.
PREOPERATIVE NOTE
The patient has been operated on twice for lumbar canal stenosis, last time about 2 years ago. He is complaining about neuropathic pain and disbalance while walking. He has some bilateral numbness around his feet and his lower limbs which is a constant appearance.

His workup included an MRI, nerve conduction studies and pain management.  His MRI showed multilevel canal stenosis but there is a significant canal stenosis in the lower thoracic region T10/T11 with signal changes within the spinal cord.
The decision is made for a decompression at that level.  The patient is consented and is aware of  the typical risks and complications.

OPERATIVE PROCEDURE.
The patient is placed in a prone position under GA.  The level of  surgery is marked pre-cut with x-ray and marking with a needle.  Then the  incision is  prepped and draped and LA is applied.

A midline approach is used to expose the laminae and spinous processes of  the lower thoracic region.  Then a decompressive laminectomy is carried out of  T10 and T11 where significant canal stenosis is found underneath, mainly caused by hypertrophic ligamentum flavum.  This is decompressed and resected and the cord is well decompressed.
The dura is intact at the end of  the decompression.  Then haemostasis is achieved and a suction drain is placed.

The wound is closed in layers using Vicryl and Monocryl for skin.  Dressing is applied.

Response:
The VICC considers the most appropriate procedure code for the case cited is 40345-00 [47] Decompression of thoracic spinal cord via costotransversectomy as clinical advice and research undertaken by VICC indicates that costotransversectomy uses a posterior approach.  

The VICC will write a public submission to NCCH for a more specific code for this procedure.


Query Text:
Which codes (if any) should be assigned when a patient has extravasation of contrast from an IV which requires additional nursing/medical care?  For example, arm elevated, 30mls contrast massaged from tissue.

Should this be coded as a complication of the infusion (T80.8 Other complications following infusion, transfusion and therapeutic injection) or to another code?

Response:
The VICC advises that the correct code to assign for extravasation of contrast is T82.52 Mechanical complication of peripheral vascular catheter because it is a leakage of the device, following Index entry:
Leak, leakage/device, implant or graft (see also Complications, by site and type)/catheter NEC/vascular infusion T82.52

It is not appropriate to assign T80.8 Other complications following infusion, transfusion and therapeutic injection because the codes in the T80 range indicate the complication caused by the therapeutic substance administered.


Query Title:
Diabetes mellitus management routine or otherwise

Query Text:
Please provide guidelines on what is considered routine, and what is considered extra monitoring, investigation or treatment of diabetes.

I have discussed this issue with HIMs from many different hospitals and there is still a lot of confusion.    

For example, some HIMs insist that HbA1c's are 'routine' tests,  whilst others will say (correctly) that HbA1c's are not routinely ordered for all diabetics, unlike BSL's which are routine for every diabetic patient.  Others say that more than one HbA1c is evidence of extra monitoring. 

Diabetic Education - some hospitals have the diabetic educator see all diabetic patients,  does this make it routine?  Diabetic education can be provided as a preventive measure and not treatment.  What if the diabetic educator makes no suggestions or changes to the patient's regimen, the patient's diabetes is well controlled?  Is the review enough to justify coding the diabetes?  What if the doctor has requested diabetic educator review but it didn't happen?

Discharge summary says 'diabetic screen conducted: nil remarkable'.  Investigations indicate that the diabetic screen consisted of a Hb1Ac test.  Does the fact the diabetes was investigated mean it met ACS 0002 Additional diagnoses? 

Diabetic diet - is this normal for all diabetic patients? Or are they allowed to eat what they like as long as their BSL's remain stable.

Sliding scale insulin - does this justify coding diabetes in all cases?

The point is that there is difficulty in determining the difference between routine diabetic care and extra diabetic care.  Different hospitals have different protocols.  Some hospitals have full time diabetic educators that see as many diabetic patients as possible.  Some doctors always order Hb1Ac tests for diabetic patients,  others don't.  

Please consider providing firm guidelines on what is considered routine and non-routine diabetic care.

Search Details:
ACS 0002 Additional diagnoses
ACS 0401 Diabetes mellitus and impaired glucose regulation

Response:
The VICC is unable to comment on whether the scenarios described in the query are routine management of diabetes as this may vary between patients and clinical practice differs over time and between hospitals.

Therefore coders need to be guided by the documentation in the medical record and apply the criteria in ACS 0002 Additional diagnoses to determine if a condition, in this case, diabetes can be coded.  That is, if treatment is given, there would need to be a documented diagnosis to support the treatment.  Similarly, there would need to be documentation to support increased care and/or monitoring.


Query Text:
What is the correct code to assign for a diagnosis of decreased conscious state?  This terminology is commonly used in hospitals and there is no specific code to assign. 

There is a VICC query from May 2000 that instructs coders to assign R41.8 Other and unspecified symptoms and signs involving cognitive functions and awareness. However this advice is very old. 

Many coders assign a code from R40 Somnolence, stupor and coma so there is inconsistency in the way this common diagnosis is assigned. 

Is the advice from 2000 still correct?

Search Details:  
VICC Query #1532 Decreased conscious state

Response:
The VICC advises that where possible, clarification should be sought from the clinician to ascertain if there is an underlying cause for the decreased conscious state.  If however, there is no other documentation available it is appropriate to assign R41.8 Other and unspecified symptoms and signs involving cognitive functions and awareness.

Coders should be careful not to confuse documentation of decreased conscious state with loss of consciousness.


Query Text:
In Fifth edition ACS 0031 Anaesthesia indicated that 92518-00 [1912] Intravenous postprocedural infusion, PCA, 92518-01 [1912] Intravenous postprocedural analgesic infusion and 90030-00 [1912] Subcutaneous postprocedural analgesic infusion (when initiated in the operating suite) may be assigned if required at local level.  

We note that Sixth edition has taken this option out.  Are we are now required to code these?  If this was an intentional change of coding practice, could NCCH possibly explain the background?

Response:
This query was originally published in the June 2009 VICC queries database release as follows:
The VICC advises that for Sixth edition, the procedures noted in the query must be coded in accordance with point 5 of ACS 0031 Anaesthesia, that is, when initiated in the labour ward and/or operating suite (theatre or recovery).

The VICC notes that reference to assigning codes if required at a local level was removed from all standards to eliminate differences in coding between hospitals.

Following publication of Coding Matters Volume 16 Number 2 September 2009 (Q22 of FAQs) the VICC response is superseded by the following advice:

Codes for PCAs in Fifth Edition were only assigned if ‘data was required at the local hospital level’. This entry was removed from ACS 0031 in Sixth Edition to reinforce coding consistency at a national level.  However no changes were made to the hierarchy
of codes in the ACS:
[1912] Postprocedural analgesia
i. Management of neuraxial block (92516-00)
ii.Management of regional block (codes 92517-00, 92517-01, 92517-02, 92517-03)
iii.Subcutaneous postprocedural analgesic infusion (90030-00)
iv. Intravenous postprocedural infusion, patient controlled analgesia (PCA) (92518-00)
v. Intravenous postprocedural analgesic infusion (92518-01)

Subcutaneous and intravenous postprocedural analgesic infusions should not be coded and ACS 0031 will be amended in Seventh Edition to reflect this advice with points iii–v being deleted in the
above hierarchy of codes.


Query Text:
We have many patients admitted to our hospital with evidence of incontinence written in the notes.

The following are cases in one of our audits, which have prompted these queries to you.

1.Patient with dementia, who has documentation on the bowel charts of incont/cont for the whole admission, and has IDC for atonic bladder.  Can a code for faecal incontinence be assigned?

2. Elderly patient with documentation on the progress notes in ED (from nursing home letter accompanying patient) of continent when taken to toilet regularly but otherwise incontinent (wears pads).  No bowel chart, notes just have 'BO'.  Can a code be assigned for urine incontinence?

3.  Patient with Wernicke's encephalopathy who has documented on the nursing care plan against  Elimination - 'Urine, cont/incont' for 8 days in a row, then 4 days of - 'Urine, cont'.  Can a code be assigned for urinary incontinence?

4.  Patient admitted confused, unable to give history.  Daughter states patient had been faecally incontinent for 3 months, and unable to cope.  Bowel chart has documentation of cont/incont for every entry for the 6 day stay.  Does the incontinence in this case meet the definition of 'persistent prior to admission'?

Response:
The NCCH provided the following response in relation to this query:

"Follow the advice published in 10-AM Commandments of Coding Matters, Vol 16, No 1, which states:

R32 Unspecified urinary incontinence and R15 Faecal incontinence should be assigned if they meet the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.

Additionally, advice in ACS 1808 Incontinence should be followed. ACS 1808 specifies that 'persistent' faecal and/or urinary incontinence should be coded, ie  'persistent prior to admission, is present at discharge or persists for at least seven days.'

In scenarios 1, 3 and 4 incontinence should be coded, but in scenario 2 evidence of incontinence is unclear. Documentation of incontinence in the current episode of care, would be required for code assignment.

ACS 1808 Incontinence has been flagged for review for a future edition of the ACS."


Query Text:
It is hospital protocol to isolate and barrier nurse certain patients who have had a resistant organism identified.  The organism may be identified in a previous or current episode.   One of the most common organisms that this applies to is vancomycin resistant enterococcus (VRE).  

If an 'infection' due to VRE is documented, this is coded as per ACS 0112 Infection with drug resistant microorganisms.  If only 'colonisation' is evident, the following codes are assigned in accordance with ACS 0002 Additional diagnoses:
Z22.3  Carrier of other specified bacterial diseases 
Z06.41 Vancomycin resistant agent
Z29.0  Isolation
 
In light of the note at Z06 (see below), is it appropriate to assign Z06.41 as an additional diagnosis for 'colonisation' of VRE?  Only bacterial 'infection', and not 'colonisation', is mentioned in the note below.

Z06 Bacterial agents resistant to antibiotics
Note: This category is intended for use as an additional code to identify the antibiotic to which a bacterial agent is resistant, in bacterial 'infection' classified elsewhere.

Response:
Although the note specifically mentions infection, there is no advice preventing the assignment of Z06 in cases of colonisation.  Therefore for the case cited, the VICC agrees with the codes assigned by the enquirer to translate the clinical statement into code.


Query Text:
VICC query # 2426 Intra-operative Imaging response states "where a 'code also' note exists it must be followed, otherwise there is no requirement to assign a code for the imaging".  This advice seems confusing and requires clarification.

Can you please clarify if we should only code an intraoperative imaging code when directed by the 'code also' note in the tabular list of interventions?

If there is no 'code also' note should we simply code the relevant imaging code non intraoperative when performed in conjunction with a therapeutic procedure?

Could you please advise the correct coding assignment for a patient admitted for CT guided biopsy of the femur bone?  Please note there is no 'code also' note listed under the biopsy of bone procedure code.

50200-00 [1560] Biopsy of bone NEC
57341-00 [1966] Intraoperative computerised tomography

Or 

50200-00 [1560] Biopsy of bone NEC
56619-00 [1965] Computerised tomography of limb

Is the response to VICC query # 2176 Coding of DSAs still correct or has this advice been overridden by Sixth edition 'code also' notes?

VICC #2176 Response:
A DSA performed with another interventional procedure (as described in the query) should be coded as an intraoperative angiography. 

If the DSA is performed for diagnostic purposes, and then the procedure proceeds to include intervention, for example DSA performed and proceeds to embolisation, the DSA should be coded as a diagnostic and not an intraoperative angiogram

Can you please clarify if the advice will apply to CT, MRI and angiography?  I understand that in accordance with ACS 0042 Procedures normally not coded ultrasounds and xrays only need to be coded if anaesthetic is required for the procedure.


Search Details: 
VICC queries #2426, #2039, #2176
Coding Matters, Volume 14, Number 2 Coronary angioplasty and angiogram

Response:
The VICC advises that unless there is a 'code also' note at the procedure code, there is no requirement to code the CT.  If however, you want to code the CT, in the scenario cited the correct code to assign is the intra-operative code as the CT is being performed as part of a procedure.

The response to VICC #2176 Coding of DSAs is still current and the advice applies to CT, MRI and angiography.


Query Title:
Chronic inflammatory demyelinating polyneuropathy (CIDP) with diabetes

Query Text:
We are seeking clarification/confirmation of code assignment for patients who have chronic inflammatory demyelinating polyneuropathy (CIDP) G61.8 but who also have diabetes or IGR.  This query is also relevant to all neuropathies and polyneuropathies that are not due to diabetes/IGR.

In the index (page 112) we have Diabetes with neuropathy followed by a list of subterms that includes neuropathy, polyneuropathy etc. Can you please confirm (or not) that the types of neuropathy/polyneuropathy listed as 'with diabetes' should be treated as essential modifiers and therefore other specified neuropathies and polyneuropathies not listed there such as hereditary or inflammatory, should not be coded to a diabetes 'with' code. 

This has become as issue here because coders have been interpreting any neuropathy/polyneuropathy as with diabetes if the patient has diabetes.  We have many patients admitted here for IV intragram which is treatment used for inflammatory polyneuropathy but not for diabetic neuropathy (per our Head of the Neurology Unit) and therefore we should not be coding the diabetes unless it meets ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses. 


Search Details: 
Sixth Edition Alphabetical Index
Clinical input from our Head of Neurology.

Response:
This query was originally published in the 2008-09 June Database as follows:

The VICC advises that the types of neuropathy/polyneuropathy listed as 'with diabetes' are essential modifiers and so should be treated as such.  As polyneuropathy is an essential modifier and is indexed 'with diabetes', follow the index and assign E1.-42 diabetes mellitus with diabetic polyneuropathy followed by G61.8 Other inflammatory polyneuropathies.


This query has been updated for clarity as follows:

The VICC advises that the types of neuropathy/polyneuropathy listed as 'with diabetes' are essential modifiers and so should be treated as such. As polyneuropathy is an essential modifier and is indexed 'with diabetes', follow the Index and assign E1-.42 diabetes mellitus with diabetic polyneuropathy and G61.8 Other inflammatory polyneuropathies.

Sequencing of the codes will be in accordance with ACS 0001 Principal diagnosis and ACS 0002 Additional diagnoses.


Query Text:
We would like to ask for help regarding the coding of Vitamin D Deficiency in neonates.  
We will often have obstetric patients who are Vitamin D deficient and therefore the baby will be commenced on Vitamin D as a preventative measure (Paediatric review - but no formal diagnosis is made) in their birth episode until bloods are conducted and reviewed in Ambulatory Care.  

We would like to flag these admissions with a code but are unsure what code to use.

Some possibilities include:
1.ACS 1611 Observation & Evaluation of newborn for suspected condition not found mentions that a Z03.7* Observation and evaluation of newborn can be coded if after study there is no need for further treatment which excludes our case because the Vitamin D deficiency has not been confirmed or excluded.

2. ACS 0012 Suspected conditions says if investigations and results are inconclusive yet treatment was initiated assign a code for the suspected condition ie E55.9 Vitamin D deficiency.

3. ACS 1617 Neonate Sepsis/Risk of Sepsis.  Can we use the same logic in this standard and code Z03.79 and Z29.2?

Search Details: 
VICC Query # 2219
ACS 1611 Observation & Evaluation of newborn for suspected condition not found
ACS 1617 Neonate Sepsis/Risk of Sepsis
ACS 0012 Suspected conditions

Response:
The VICC advises that because there is no diagnosis of a suspected condition ACS 1611 Observation & Evaluation of newborn for suspected condition not found and ACS 0012 Suspected conditons do not apply in this scenario.  

If there is appropriate documentation in the record, that is, not just an entry on the drug chart and the condition meets ACS 0002 Additional diagnosis, the VICC suggests to assign Z29.8 Other specified prophylactic measures by following index entry Prophylactic, measure, specified NEC. 

Please note that logic from one standard should not be applied to another scenario.


Query Text:
Patient presents three days after original injury.  Is M00.94 Pyogenic arthritis, hand the best code? The wound itself isn't treated, however since its only three days after original injury would it better to be coded as an infected wound (has been documented in the record as open dislocation, even though the laceration was small).  The patient presented again one day after discharge with identical condition/treatment and was coded differently by the second coder.  Have searched the VICC data base and 'cellulitis with infection' is the closest query I could find.

Patients discharge summary:
Fall in bathroom 3/7 prior to presentation. Dislocated thumb, reduced (prior to admission).  Small volar laceration.  Following days increased pain and swelling of thumb IP joint.  Presented to hospital.  Proceeded to washout and IV ABx. Monitoring of CRP and WCC. D/C with oral Abx.

Procedures/including invasive investigations 
Primary Procedure: 
Washout/debride thumb IP joint
 
DIAGNOSES 
Primary Diagnosis: 
Septic arthritis L thumb IP joint 

Search Details: 
VICC query #2194 Infected wound with cellulitis

Response:
The VICC advises that because the primary diagnosis has been clearly documented as septic arthritis, it should be coded as such.  Therefore the correct code to assign is M00.94 Pyogenic arthritis, unspecified, hand.


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

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

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

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

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


Query Title:
Anaemia in neoplastic disease with myelodysplastic syndromes

Query Text:
I am sure that there has been advice published in the past that D63.0 anaemia in neoplastic disease is not assigned with codes from D46.- Myelodysplastic Syndromes, as the anaemia is inherent in this condition.  I am now unable to find this advice and am wondering if it was on the NCCH query database.

Could you please confirm if this advice is still correct and current?

Search Details: 
VICC Database
Coding Matters

Response:
This query was referred to the NCCH who provided the following advice, which was published in Coding Matters Volume 16 Number 3:
"Refractory anaemia is symptomatic of myelodysplastic syndrome and therefore it is unnecessary to assign D63.0* Anaemia in neoplastic disease where refractory anaemia in myelodysplasia is assigned to D46.- Myelodysplastic syndromes.

This is confirmed by guidelines for the assignment of dagger and asterisk codes in ACS 0027 Multiple coding, which states:
‘Codes for aetiology (underlying cause) are annotated by a dagger symbol (†) and manifestation codes by an asterisk (*) symbol. Assign both codes in the same sequence in which they appear in the Alphabetic Index, that is, the aetiology followed by the manifestation code.’

The following index entry for Anaemia, myelodysplastic does not provide a dagger and asterisk combination, so it is incorrect to assign D63.0* Anaemia in neoplastic disease with D46.9 Myelodysplastic syndrome, unspecified:
Anaemia
- myelodysplastic (M9989/3) (see also Anaemia, refractory) D46.9

In contrast, the index entry for Anaemia, myelofibrosis assigns D47.1† Chronic myeloproliferative disease and D63.0* Anaemia in neoplastic disease:
Anaemia
- myelofibrosis (M9961/3) D47.1† D63.0*"

The VICC notes that the above advice may cause confusion if coders look up the index entry 'Anaemia, in, neoplastic disease NEC (M8000/1) (see also Neoplasm) D48.9† D63.0*' as Coding Matters Volume 7 Number 2 advises assigning the specific neoplasm code instead of D48.9 when the neoplasm is known.  Therefore do not follow Anaemia, in, neoplastic disease NEC (M8000/1) (see also Neoplasm) D48.9† D63.0* when coding anaemia in myelodysplastic disease as this condition has its own index entry.


Query Title:
Coding of mechanical ventilation hours of a transferred patient

Query Text:
A patient has been transferred to our hospital from a rural hospital following an incarcerated hernia repair.  The patient was ventilated in theatre at 2100 hours, was put in an ambulance at 2350 hours (ventilated) and was directly admitted to our ICU at 0150 hours.  The patient was then extubated in our ICU at 1100 hours.  This patient was therefore ventilated in our ICU for 10 hours rounded up.  Would we need to code mechanical ventilation (MV) in this scenario, seeing that this patient had less than 24 hours of MV following surgery? 

Search Details: 
DHS article Continuous Ventilatory Support and NIV Sixth edition ICD-10-AM.

Response:
The VICC advises that because the patient did not undergo surgery for the incarcerated hernia in this episode, point f. of ACS 1006 Ventilatory Support does not apply.  Rather, apply the advice in ACS 1006 under heading Admission of a ventilated patient, which states 'For those patients who are admitted with continuous ventilatory support in place, begin counting the duration at the time of admission. (See also 'Transferred intubated patients').'

Therefore a code for the total duration of CVS given at your hospital would be assigned.


Query Title:
Principal diagnosis for Mental Health Nursing Home Type episodes

Query Text:
Could you please confirm/clarify whether ACS 2105 Long Term/Nursing Home Type Inpatients applies to Care Type 5T patients?

Specifically, should the principal diagnosis for every episode of 5T patients, be from the category Z75 Problems related to medical facilities with all other conditions arising during the episode coded as additional diagnoses?

Response:
Although Care Type does not determine principal diagnosis, the VICC advises that ACS 2105 Long Term/Nursing Home Type Inpatients does apply to episodes with care type 5T (Mental health nursing home type) as these episodes are nursing home type episodes.  

Therefore in accordance with ACS 2105 which states ' in such cases, a code from the category Z75 Problems related to medical facilities and other health care should be assigned as the principal diagnosis', a code from category Z75 must be assigned as principal diagnosis for care type 5T episodes.


Query Text:
A boy has cellulitis to his knee after grazes from falling off his bike.  Do I code it as a sequelae due to his patella bursitis being treated with antibiotics previously?

Response:
Although bursitis has been treated previously (so is not a current condition) and cellulitis has occurred afterwards, there is no indication in the query that cellulitis is documented as a late effect as described in the five dot points in ACS 0008 Sequelae.

Cellulitis is assigned as principal diagnosis in accordance with ACS 0001 Principal diagnosis.  

ACS 1210 Cellulitis  does not apply in this scenario because there is no documentation of an open wound.


Query Text:
64 year old male patient presents left sided foot drop.  MRI reveals large free fragman of disc material below his L3/4 disc.  Surgeon performed L3/4 Microdiscetomy spinal rhizolysis and free fat grafts were taken from the wound margin and placed around the exposed L4 nerve root.  Procedure codes allocated:
40300-00 [052] Discectomy, 1 level
40330-00 [049] Spinal rhizolysis
45018-02 [1668] Procurement of fat for graft via separate incision

Are you able to confirm if coding of free fat graft in spinal surgery should be coded.  Review of NCCC and VICC Coding database does not provide current advice. Search of old NCCH query database has Q1553 which says that the NCCH will consider adding appropriate 'inclusion' and 'code also' notes for ICD-10-AM Fourth Edition.  Search of Vic Coding Commitee advice in query #1766 November 2002 ICD Coding Newsletter provides similar advice.

Appreciate if you are able to confirm that the advice provided in 2001/02 is still current, and if this is still flagged with NCCC for further development.

Response:
VICC considers that the advice published in VICC query #1766 in the November 2002 ICD Coding Newsletter is still current, therefore is it not necessary to code the fat graft itself as a separate procedure.  

As you have noted in your query, for cases where the fat is harvested from a different site, the correct code in Seventh edition is 45018-04 [1666] Procurement of fat for graft via separate incision.

VICC is aware that a public submission has been submitted to NCCC and consideration is being given to 'includes' notes and 'code also' notes in the ACHI Tabular.


Query Text:
This query relates to the DRG that the episode groups to.

Patient admitted with hallucinations both visual and auditory.

Patient treated with antipsychotics but no diagnosis of a psychosis made on discharge.

When you group this episode with the principal diagnosis of visual hallucinations it groups to DRG C63B Other disorders of the eye but if you sequence the auditory hallucinations as principal diagnosis it groups to DRG U65Z Anxiety disorders.

We are querying if this is a grouping error as we thought that the hallucinations would be more of an anxiety disorder rather than a disorder of eye.

Response:
VICC advises that this issue has been recognised previously and was rectified in Version 5.1 of the Grouper. Both codes now group to U65Z Anxiety Disorders (but visual hallucinations still groups to C63B in V4.2 of the Grouper).


Query Title:
Dissection of artery following a vascular procedure

Query Text:
Query #1646 in ICD coding newsletter November 2002 relates to dissection of coronary artery during angioplasty and advises to code to:
T81.7 Vascular complications following a procedure, not elsewhere classified
Y65.8 Other specified misadventures during surgical and medical care
Y92.22 Place of occurrence

Please confirm if this advice is still applicable and can these codes be used when there is a dissection of a peripheral artery.

Should the artery involved be identified by the use of an S code for, example, S25.8 Injury of other blood vessels of thorax?

Response:
VICC confirms that the advice in #1646 is no longer valid as it has been superseded by updates to ACS 1904 Procedural complications and the advice in the NCCC October 2010 Q&A query titled 'Post operative pain'.

The correct code to assign for dissection of coronary artery during angioplasty is T82.8 Other specified complications of cardiac and vascular prosthetic devices, implants and grafts following index entry:
Complications
↓
-balloon implant or device
↓
--vascular (counterpulsation)
↓
--- specified NEC T82.8

It is correct to assign an additional code to identify the injury to the blood vessel.

Therefore, in the case of dissection of coronary artery during angioplasty the codes assigned are:
T82.8 Other specified complications of cardiac and vascular prosthetic devices, implants and grafts
A code for the injury to the blood vessel
Y65.8 Other specified misadventures during surgical and medical care
Y92.22 Health service area

For dissection of peripheral artery following a vascular procedure assign codes according to your documentation following ACS 1904 Procedural complications.  If a peripheral vessel is injured during angioplasty, the same codes apply as for coronary artery dissection during angioplasty.


Query Text:
There has been recent discussions at our organisation on how to code Lacunar Stroke/Infarct. Currently there is no direct look up in our coding books under lacunar stroke/infarct, however there is a direct look up under syndrome, lacunar:
Syndrome
-lacunar NEC I67.9+ G46.7*

According to some websites 'Lacunar stroke/infarct  tend to occur in areas located away from the surface of the brain... Patients without diagnostic imaging who present with symptoms of a lacunar stroke may be described as suffering from a Lacunar Stroke Syndrome'.  In this instance are we able to assume the correct look up is Syndrome, lacunar or should we code this to either I64 Stroke, not specified as haemorrhage or infarction or I63.-  Cerebral infarction?

Also, if we are able to code the dagger and asterisk combination, are we able to assign the appropriate I63.- or I64 with G46.7*, as per code G46.7* Other lacunar syndromes (I60–I67†), or should we follow the index?

Response:
VICC advises that without documentation of lacunar syndrome, the Index entry Syndrome/lacunar NEC should not be followed.

Follow index entries according to your documented lead terms 'Stroke' or 'Infarct' and assign default codes unless you have further information in the medical record.

In regard to your question, if you were able to assign the dagger and asterisk combination by following the Index pathway, then yes, you are able to assign the appropriate I63.- or I64 with G46.7*.


Query Text:
Diagnosis:  Androgen insensitivity syndrome.  I have assigned code E25.9 Adrenogenital disorder, unspecified
Operative Laparoscopy: Bilateral Gonadectomy. 
Pathology:  Conclusion- Bilateral Gonadectomy: Histological features in keeping with Androgen insensitivity syndrome. 

I'm having a problem with coding the operation.

Response:
As gonadectomy can be surgical removal of testes or ovaries in the case cited VICC advises to assign a code from block [1184] Orchidectomy followed by 30390-00 [984] Laparoscopy, which is assigned in accordance with ACS 0023 Laparoscopic/arthroscopic/endoscopic surgery, that states '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'.

VICC research indicates that androgen insensitivity syndrome is when a person who is genetically male is resistant to male hormones.  Another term for androgen insensitivity syndrome is testicular feminisation and this term is an includes term at E34.5 Androgen resistance syndrome.  Therefore, in regard to the diagnosis code assigned, VICC considers the appropriate code is E34.5 Androgen resistance syndrome following index entry Syndrome, androgen resistance.

E25.9 Adrenogenital disorder, unspecified relates to an adrenal disorder, rather than an androgen disorder.


Query Title:
External cause code for injury caused by parent

Query Text:
Eight month old patient was admitted for subdural haemorrhage, temperoparietal skull fracture, traumatic retinal and vitreous haemorrhage, right hemiparesis and post-traumatic seizures.  The child’s father originally claimed that the child fell off a couch, but later during the admission confessed that he had caused the injuries.  There was also evidence of previous non-accidental head injury.

What is the appropriate external cause code to use in this scenario?

Y04.01 Assault by bodily force, parent 
or 
Y07.01 Other maltreatment syndromes, parent?

Both codes identify the parent as the cause of injury.  

We have looked at ACS 1909 Adult and Child Abuse, particularly the following paragraph:
In cases of abuse, where documentation states that the injury(ies) occurred as a result of neglect and/or maltreatment, the specific injury (eg fractured arm) should be coded as the principal diagnosis. An external cause code should also be assigned to describe the mechanism of the injury(ies). 

I also note this example from ACS 2008 Perpetrator of assault, abuse and neglect:

EXAMPLE 3: 

Mother and her noncohabiting partner assault her son with fists. Assign appropriate injury code and Y04.01 Assault by bodily force, parent, plus appropriate place of occurrence and activity codes. 

Historically, at the our hospital the Y07.01 Other maltreatment syndromes, parent external cause code has been used for cases of non accidental injury by parent cases.  However, we are now questioning why this has been the case.  

What is the difference, for coding purposes, between assault and maltreatment?
 
Does the age of the patient affect which code we should be using?

If we know the mechanism of the injury – for example, bodily force – should we be using the assault code rather than the maltreatment code?

In which scenarios should we use the Y07.01 Other maltreatment syndromes, parent external cause code versus the Y04.01 Assault by bodily force, parent (or other appropriate X85-Y09 Assault by “mechanism”, parent) external cause code?  

We would appreciate advice on which code is appropriate and on the rationale behind it.

Response:
VICC advises that ACS 1909 Adult and child abuse was revised in Third edtion to include the concepts of neglect and physical conditions that can result from abuse but are not injuries.  In cases of abuse with resulting injury(ies) the external cause code should reflect the mechanism of the injury.  

Therefore in cases where there is documentation of a physical condition other than an injury, assign Y07.x Other maltreatment.  When there is documentation of an injury, assign the appropriate external cause code from range X85 - Y09 Assault.  The age of the patient does not affect code assignment.

In the case cited follow external cause code index entry  'Injury, inflicted (by), other person, stated as' and select the appropriate code from range X85 - Y09 based on your documentation.


Query Text:
Please advise if the following documentation of pancytopenia can be coded to its component parts: anaemia, neutropenia and thrombocytopenia?

First Documentation type - Discharge Summary:
Pancytopenia secondary to chemotherapy
a. Hb 77, WCC 0.2 (N 0.0), Plt 68
b. Given 1* PRBC
c. Complicated by fevers post transfusion. Septic screen negative

Second Documentation type - Inpatient notes:
Pancytopenia
Hb 77; WCC 0.2; Nø 0; plt 68
D14 chemo today

Response:
In accordance with ACS 0304 Pancytopenia when pancytopenia is documented without further specification assign D61.9 Aplastic anaemia, unspecified.  A code for the specific blood abnormalities (anaemia, neutropenia and thrombocytopenia) can only be assigned when the specific blood abnormalities are documented.  Pathology results cannot be used to assign codes for conditions, they can only support already documented conditions or be used as the basis to query with clinicians to clarify documentation.

For the case cited VICC considers the correct code to assign is D61.9 Aplastic anaemia, unspecified.


Query Title:
ACS 1521 Conditions Complicating Pregnancy

Query Text:
Please find attached some examples of cases where pregnant women present to hospital with various medical complaints.

Scenario 1
Dyspnoea of Pregnancy

Is it correct to code this as:
O99.8 Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium 
R06.0 Dyspnoea

Following the Index:

Pregnancy
-complicated by
-- conditions in
--- R00-R99 O99.8

This is an example where the term “complicating” is not used in the record, but the discharge diagnosis has made the link to pregnancy.

None of the examples in ACS 1521 reflect the above scenario.


Scenario 2
Ax Likely ligamentous stretch

Patient 22/40 wks gestation presents to our delivery suite via ED and is assessed for her lower abdominal pain by O&G Reg.

Please advise on how to code this case and your reasons.

Scenario 3
Patient 39/40 wks gestation presents to Pregnancy Assessment and Review Day Stay after her Antenatal visit revealed headaches, oedema and a trace of protein.  After examination, there was no evidence of PET or PIH.

Please advise on how to code this case.

Scenario 4 & Scenario 5
I have provided 2 scenarios where a pregnant lady has presented with a UTI.  Some coders would use N39.0 UTI with Z34.x and others would use O23.4 UTI in pregnancy.

We are not sure what is meant by the following line In ACS1521; “Conditions that are known to occur commonly in pregnancy have specific codes in O20 – O29”.  Does this mean we can code UTIs to O23.4 or does documentation need to say that the UTI is complicating or exacerbating pregnancy.

The only way to find a pregnancy related code through the Index is:

Infection
- urinary (tract) NEC N39.0
-- complicating pregnancy O23.4

Pregnancy
- complicated by
--- urinary (tract) O23.4

Yet the Tabular description is O23.4 Unspecified infection of urinary tract in pregnancy.  It can get very confusing as to how the country would like these cases coded and I’m sure you would find inconsistencies, not to mention different DRGs and WIES values.  It is important to review the way we code antenatal cases and how they are grouped before ABF commences.

We don’t understand why O codes without delivery would be all grouped to an Antenatal DRG when management can be for different conditions such as infections and hypertension etc.

Example:
Pdx N390, Z348
DRG L63B WIES 0.1453 (same-day) or 0.5717

Pdx O234
DRG O66Z WIES 0.1621 (same-day) or 0.4369

Response:
VICC advises that if the documentation makes a link between the condition and the pregnancy it is appropriate to follow the various index entries linking the condition to the pregnancy.  Examples of index entries that can be followed when a link is documented between the pregnancy and the condition include ' complicating pregnancy', 'of pregnancy', 'in pregnancy' and 'complicated by'.

VICC considers that of the examples provided, the documentation in scenario one makes a link between the dyspnoea and the pregnancy, thus enabling an 'O' code to be assigned.  In all other scenarios VICC did not find evidence to support a link between the pregnancy and the condition but considers the documentation that the committee reviewed supports the assignment of Z34 Supervision of normal pregnancy as an additional diagnosis.

In regard to all episodes with an O code without a delivery code grouping to an antenatal DRG, this is because of the principles used in grouper development to group all antenatal episodes into one DRG.


Query Text:
Please see attachment for details of the case.  Here it is in brief:

The following case was coded at our last Coding Roundtable.  It was coded 3 different ways.

A patient was admitted for an Iron Infusion on 16/9/11.  The Notice of Admission states “Diagnosis – Anaemia Hb 81 + Iron deficiency”.

The Pregnancy Assessment and Review Day Stay form states “Indication for Referral: For Fe Infusion”.

On the same form under the heading “Action” you will see written that the patient is contracting – has Hx of precipitate labour, monitor Cs, if pick up to go to Birthing Suite.  Patient is discharged home after infusion.

This patient does not have a past history of anaemia and there is no mention of anaemia in her previous pregnancies.  At her antenatal appointment on 10/8/11, she was advised to start Fe tabs as her Hb on 30/6/11 was noted to be 91.

Coder 1
(P) E611 Iron deficiency
(P) Z348 Supervision of other normal pregnancy

9619909 IV administration of pharmacological agent

DRG K62B WIES 0.1556 (same day patient)

Coder 2
(P) D509 Iron deficiency anaemia, unspecified
(P) Z348 Supervision of other normal pregnancy

9619909 IV administration of pharmacological agent

DRG Q61B WIES 0.2113

Coder 3
(P) O9901 Anaemia complicating pregnancy
(P) D509 Iron deficiency anaemia, unspecified

9619909 IV administration of pharmacological agent

DRG O66Z WIES 0.1621

As you can see, three different Principal Diagnosis codes with three different results.

Issue 1
Iron deficiency was coded only as there is no link between anaemia and iron deficiency.  Clinical knowledge assumes that when a patient is very low in iron, it can lead to anaemia.  Coder 2 has used this knowledge to link the 2 conditions.  We believe that the Index needs to be improved to assist the new generation of clinical coders.  For example:

Deficiency
-iron E61.1
--with anaemia D50.x

Issue 2
Coder 3 has assumed the anaemia is complicating the pregnancy.  The word complicating or exacerbating has not been used, so you cannot get this code using the Index.  The coder has decided that because the patient was seen in the Pregnancy Assessment and Review Day Stay ward, has used ACS1521 where it states “or that are the main reason for obstetric care”. 

There is no documentation in the record that the anaemia is “complicating” or “exacerbating” the pregnancy.  In a recent VAED audit the auditors were rigid in coding conditions relating to pregnancy as there was no documentation of “complicating/complicated by” pregnancy.  Yet, in VICC Query 2397, based on the “increased CTG monitoring” the Committee felt there was sufficient evidence to support that the condition has complicated the pregnancy.

We’ve been told by VAED auditors if you can’t get to a code following the Index, then you should not assume.

ACS 1521 Conditions Complicating Pregnancy is up for interpretation (proven by VICC query VICC 2397).  The examples in this standard are useless as we have never been privileged with such documentation.

The Index is as follows:

Anaemia
- complicating pregnancy, childbirth or puerperium

Anaemia
- of or complicating pregnancy O99.01
--  with mention of pre-existing anaemia O99.02

Anaemia
- postpartum NEC O99.03
-- with mention of pre-existing anaemia O99.04
Anaemia
- puerperal NEC O99.03
-- with mention of pre-existing anaemia O99.04

Pregnancy
- complicated by
-- anaemia (conditions in D50 – D64) O99.01
--- with mention of pre-existing anaemia O99.02

Please advise on the correct coding of this case.

Response:
Regarding answer 1, VICC agrees with the codes assigned but would also assign code D64.9 Anaemia, unspecified.  Sequencing of D64.9 Anaemia, unspecified and E61.1 Iron deficiency will be determined in accordance ACS 0001 Principal diagnosis.  

VICC considers that answer 2 is incorrect because there is no documented link between the anaemia and the iron deficiency and answer 3 is incorrect because there is no documented link between the anaemia and the pregnancy.  

In regard to your comment related to VICC #2397 ACS 1521 Conditions complicating pregnancy the response to this query is supported by the following advice in Coding Matters Volume 15 Number 3 under heading ACS 1521 Conditions Complicating Pregnancy:

"a. ACS 1521 and adequate documentation to determine that a condition has complicated a pregnancy
In the following scenario a pregnant female is admitted with a diagnosis of cholestasis but there is no documentation to suggest that cholestasis has complicated the pregnancy except for a note on discharge which states ‘for antenatal clinic review next week with repeat LFTs and increased CTG monitoring,’ is this adequate documentation to determine the
condition has complicated the pregnancy?

A condition in pregnancy such as in the scenario cited above which requires increased CTG monitoring is sufficient documentation to indicate the condition has complicated the pregnancy.

Therefore the appropriate code from category 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 should be assigned for conditions such as those in the scenario above, together with an additional code from the other chapters of ICD-10-AM to identify the specific condition, as per ACS 1521."


Query Text:
The new code 30668-00 [1949] Endoscopic ultrasound (EUS) was created for the Seventh edition.  According to ACS 0042 Procedures not normally coded, procedures in chapter 20 should not normally be coded.  This includes 30668-00 [1949] Endoscopic ultrasound.  However, the endoscopic ultrasound code adds more specificity and captures the EUS gastroscopy patient data.

It is not common practice for all gastroscopies to be performed under EUS, therefore can we add 30668-00 [1949] Endoscopic ultrasound in addition to the gastroscopy code to capture this specific data?

Is there a reason why this code was created for 7th Edition when the advice in ACS 0042 is not to assign this code?

I spoke to the Gastroenterologist who conducts these procedures here and he explained the procedure. The gastroscope is inserted with the needle attached to the end of the scope. The needle is injected through the gastrointestinal wall and the organ eg. Pancreas or mediastinal mass is biopsied.

Search Details: 
ACS 0042 Procedures not normally coded states the following should not be coded:
13. Imaging services – all codes in ACHI Chapter 20 Imaging services and block [451] Dental radiological and interpretation except transoesophageal echocardiogram (TOE) (55118-00 [1942]

VICC query #2196 Gastroscopy with pancreas biopsy
Query:
How do you code gastroscopy with EUS (endoscopic ultrasound) and FNA (fine needle aspiration) of pancreas or mediastinal mass etc?   We think we should code out the aspiration of the pancreas/ mediastinal mass. There is no code for aspiration pancreas or mediastinal mass so we referred to 'biopsy' because the pathology of the aspiration includes cells. We have decided to code the following for the interim: 
30473-00 [1005] Panendoscopy to duodenum 
30075-16 [977] Biopsy of pancreas 
55054-00 [1949] Intra-operative ultrasound of other site 

The coding of the biopsy pancreas or mediastinal mass severly affects the WIES/ DRG. 

Response:
The procedure has been coded appropriately. The decision to code this way is based upon advice published by the NCCH in query Q1042 (17/11/1999), which advises that aspiration biopsy, refers to the removal of cells for histological diagnosis. 

It is correct to assign a code for the biopsy of the pancreas because the biopsy is not of the gastrointestinal tract. This code should be sequenced first. Therefore in your scenario code as follows: 
30075-16 [977] Biopsy of pancreas 
30473-00 [1005] Panendoscopy to duodenum 
55054-00 [1949] Intra-operative ultrasound of other site 

Publication Date - 2005-06 Third quarter ICD 10 AM Edition - Fourth edition 

ICD 10 Commandment Volume 16 Number 4
Radial endoscopic ultrasound (EUS)
Q. What is the correct code to assign for radial endoscopic ultrasound (EUS)?

A.  In ACHI Sixth Edition, radial endoscopic ultrasound (EUS) should be assigned a code from block 1949 Intraoperative ultrasound, as appropriate.  In ACHI Seventh Edition, radial endoscopic ultrasound should be assigned to the new code – 30668-00 [1949] Endoscopic ultrasound.  However, EUS should only be coded if it meets the criteria for code assignment as per the guidelines in ACS 0042 Procedures normally not coded.

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

VICC advises that the new code 30688-00 [1949] Endoscopic ultrasound was created as part of an MBS update. For classification purposes coders should follow the advice in ACS 0042 Procedures normally not coded point 13 which says not to assign codes from Chapter 20 unless an anaesthetic is required in order for the procedure to be performed.  Therefore in your scenario only assign codes for the gastroscopy and the biopsy.

This response is superseded by Ninth edition ACS 0042 Procedures normally not coded point 13 Imaging services and ACCD Coding Rules Q2939 titled Endoscopic ultrasound (EUS).


Query Text:
Patient presents in November 2011 for closure of loop ileostomy post low anterior resection in April 2011.  The patient is no longer receiving any care or treatment for their rectal cancer.

According to VICC query #2205 Coding of carcinoma post resection, Z43.2 is coded as the principal diagnosis with the cancer sequenced as an additional diagnosis as the closure of the ileostomy is done within 3 months of the resection.

What is the relevance of the time period post resection and what are the time constraints we should be applying when assigning cancer codes rather than past history codes?

With reference to ACS 1204 Plastic surgery, example three provides contradictory advice, advising coders to assign the deformity of the head (which is what the patient is being treated for) and then a past history of neoplasm code.

Could clarification be sought please with regards to what advice to follow?

Search Details: 
VICC query #2205 Coding of carcinoma post resection
ACS 1204 Plastic surgery

Response:
VICC notes that query #2205 Coding of carcinoma post resection has been superseded by revisions to ACS 0002 Additional diagnoses in July 2008 and substantial education related to the application of ACS 0002. Therefore for the case cited do not assign an additional code for the cancer.

The time period mentioned in #2205 has no relevance to the coding decision.

With regard to the example in ACS 1204 Plastic surgery, a history of neoplasm code can be assigned if it meets ACS 0002 Additional diagnoses.  Please note that examples in the standards simply demonstrate the use of codes; they do not replace the coder's obligation to make a decision about which conditions meet criteria for coding.


Query Title:
Wound washout with arthroscopic shoulder joint washout

Query Text:
Patient readmitted with wound infection post shoulder surgery (cuff repair). Procedure performed is washout shoulder wound and shoulder joint.  Operation report describes superficial infected/devitalised tissue washout and arthroscopic shoulder joint washout.

Our question is with the code for the wound washout.

ACHI index: Washout, see Lavage and Irrigation.

Lavage: no appropriate entry

Irrigation, wound (nonexcisional) NEC 90686-01 [1628].

When we go to this code, the description is debridement and there is ACS 1203 Debridement which states to assume excisional unless there is documentation of non-excisional.

Do I need to follow ACS 1203 Debridement given that my procedure description is washout (not debridement)?

Response:
VICC notes that ACS 1203 Debridement applies when there is documentation of debridement.  In the case cited because the procedure performed is a washout, the lead term is irrigation, so follow the index entries described in the query and stop at Irrigation, wound (nonexcisional) NEC where a default code is provided.  

Therefore the correct code to assign for wound washout is 90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue.


Query Text:
We have a patient who is admitted for removal of silicone oil. This is the primary reason they have been admitted. Advice from clinical staff indicates that it is expected that patients may have to have silicone oil removal after retinal detachment repair as this is not a complication of the surgery.

We have coded this as follows: 
Z48.8 Other specified surgical follow up care
42815-00 [205] Removal of silicone oil

Do we need to code the previous retinal detachment as an additional diagnosis? The patient does not currently have a retinal detachment as it has been treated and the patient is not being transferred from another hospital (ACS 2103 Admission for convalescence/aftercare).

Also is Z48.8 the correct principal diagnosis code?

Search Details: 
ACS 2103 Admission for convalescence/aftercare

Response:
VICC agrees that for the case cited the correct principal diagnosis to assign is Z48.8 Other specified surgical follow up care.  

As the patient was not transferred, ACS 2103 Admission for post acute care doesn't apply, therefore a code for the retinal detachment should not be assigned because it was not treated in this episode.


Query Title:
Preparatory care for subsequent treatment

Query Text:
When would we assign Z51.4 Preparatory care for subsequent treatment as principal diagnosis?

Scenario 1:
When a patient is admitted into hospital for work-up for a subsequent transplant, should Z51.4 be the principal diagnosis, or should the condition requiring the transplant be the principal diagnosis.  For example, patients undergoing a coronary angiogram as work-up before their transplant to ensure patient is “fit enough” for any future transplant. 

Scenario 2:
When a patient is admitted into hospital for a coronary angiogram for a work-up for a subsequent AVR, should the principal diagnosis be Z51.4 or the diseased aortic valve and/or any other findings found during angiogram, such as CAD.  Often a coronary angiogram is performed before aortic valve replacement to see whether the patient has CAD so both AVR and CABG be performed during the same operation.  

It has been brought to my attention that other organisations code Z51.4 as principal diagnosis rather than the condition describing the reason for the subsequent admission.

Search Details: 
Coding Matters Vol. 16 No.4 Brachytherapy planning.

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

As all your scenarios had a documented condition requiring treatment, that is, the reason for transplant or aortic valve replacement the principal diagnosis would be the documented condition.  Z51.4 Preparatory care for subsequent treatment, not elsewhere classified would only be assigned as an additional diagnosis when there is documentation of planning, work up or similar.  Findings on investigation would only be coded if they meet ACS 0002 Additional diagnoses.

For Tenth Edition advice refer to #3296 - VICC Query #2692 Preparatory care for subsequent treatment retired published in the 2017-18 March VICC queries database.


Query Text:
We were wondering if we could get an update on VICC #2263.  At a recent VAED audit this issue has come up again.  Our plastic surgeons have advised us that in order to repair digital arteries and veins it is necessary to use a microscope because the vessels are so small they are impossible to repair without the aid of a microscope.  We have a statement from our plastic surgeons that details this information but we have been advised that in accordance with VICC #2483 we cannot use a blanket letter in order to assign the correct code for these cases.

We note in the response to Query #2263 VICC has referred this case to the NCCH/NCCC for clarification and would like a definitive answer on this issue that has been longstanding for over 4 years so that we can assign the correct code from block [1694] to correctly code these cases and receive appropriate reimbursement.

Search Details: 
VICC #2263 Microsurgical digital repairs
VICC #2483 'Blanket' decisions

Response:
VICC advises that the advice in queries #2263 Microsurgical digital repairs and #2483 'Blanket' decisions is still current.  Therefore, there needs to be documentation in the medical record of microsurgical repair in order for the repair to be coded as such.

You may wish to consider submitting a public submission to the NCCC for consideration of this issue.


Query Title:
Admission for observation following fall from scooter

Query Text:
Patient who has fallen from a scooter and is admitted for observation (no injuries sustained). 

External cause code = W02.6 Fall involving scooter, nonpowered.

Is the correct Z04 code:
Z04.1 Examination and observation following transport accident
Or 
Z04.3 Examination and observation following other accident 

Is a pedestrian conveyance considered to be a transport accident?

Search Details: 
Tabular: the definition of a Transport Accident in the Definitions related to Transport Accidents is:
A transport accident (V00–V99) is any accident involving a device designed primarily for, or being used at the time primarily for, conveying persons or goods from one place to another.

There are Excludes notes from V00-V99 that state that a fall, not due to a collision with a pedestrian conveyance (e.g. a fall from a pedestrian conveyance without a collision), is classified outside of Transport Accident.

Response:
The classification makes a distinction between a fall and a collision in order to classify pedestrian transport accidents.  Therefore unless a pedestrian conveyance collides with another pedestrian conveyance, it is not classified as a transport accident.  

In accordance with the excludes note at V00-V09 Pedestrian injured in transport accidents, the correct principal diagnosis for the case cited is Z04.3 Examination and observation following other accident.


Query Title:
Hypertension due to acute kidney disease

Query Text:
NCCC Q&A December 2011 included the following:
Hypertension due to acute kidney disease 

Q: 
Can I15.0 Renovascular hypertension and I15.1 Hypertension secondary to other kidney disorders be caused by acute kidney disease? When can I15.0 and I15.1 be assigned? 

A: 
Hypertension can arise due to acute kidney disease, therefore I15.0 Renovascular hypertension and I15.1 Hypertension secondary to other kidney disorders can be assigned as per the guidelines in ACS 0928 Secondary hypertension (I15) which states, "Assign these codes when hypertension is stated to be 'due to' or 'secondary to' another condition".

Therefore, I15.0 may be assigned when hypertension is documented as being due to a renovascular disorder, such as renal artery stenosis and I15.1 may be assigned when hypertension is documented as being due to a kidney disorder NEC, such as nephrotic syndrome due to poststreptococcal glomerulonephritis. 

The Use additional code note at I15.0 and I15.1 should be followed in those instances where the presence of chronic kidney disease is also documented. [End of query]

Could you please clarify if the reference to 'acute kidney disease' also includes or is the same as acute kidney failure? That is, could you have hypertension due to acute kidney failure and assign I15.x with N17.x, or does the response only mean an acute kidney disease such as acute glomerulonephritis?

Search Details: 
NCCC Q&A December 2011

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

VICC interprets the NCCC advice to mean that if you have documentation that the hypertension is related to another condition for example, acute kidney failure, that 115.x can be assigned.  

This is in accordance with ACS 0928 Secondary hypertension (I15) which states 'Assign these codes when hypertension is stated to be 'due to' or 'secondary to' another condition.

For Eighth edition advice please refer to the ACCD Coding Rules published on 15 March 2014 advice titled Hypertension due to acute kidney failure:

[Q:  Coding Q&A December 2011 Hypertension due to acute kidney disease advised that:
“Hypertension can arise due to acute kidney disease, therefore I15.0 Renovascular hypertension and I15.1 Hypertension secondary to other kidney disorders can be assigned as per the guidelines in ACS 0925 Hypertension and related conditions”

Could you clarify whether the reference to ‘acute kidney disease’ in the Q&A above also includes acute kidney failure?

A: Unlike chronic kidney disease (CKD) which has a well-established definition, acute kidney disease is a general term with no exact definition being described in the literature, although it has occasionally been used
in reference to acute kidney failure, the term which is now widely called acute kidney injury.

The term acute kidney disease in the Q&A cited is used broadly to mean all acute kidney diseases and disorders which have been specified as the cause of hypertension including acute kidney failure and other acute kidney
diseases such as acute glomerulonephritis and acute interstitial nephritis.

Assign codes from category N17 Acute kidney failure and I15 Secondary hypertension when hypertension is documented as being 'due to' or 'secondary to' acute kidney failure following the guidelines in ACS 0925 Hypertension and related conditions/Secondary hypertension.


Query Text:
Can the committee please provide advice on the appropriate codes to use for the following scenario:

Patient diagnosed with Coeliac Disease in Dec 2009 and advised to follow a gluten free diet. Presented in Jan 2012 for a review gastroscopy to assess duodenal mucosal healing. Gastrocopy & histopatholgy all came back as normal.

According to Better Health Channel:
Coeliac disease is a permanent intestinal intolerance to gluten, a protein found in wheat, rye, barley and oats. The lining of the small intestine is damaged by gluten and this can interfere with the absorption of nutrients. A gluten free diet is the only treatment.

As the patient still has coeliac disease, even though no evidence of current complication is evident, do you code it back to K90.0, as you can never eradicate coeliac disease?

We're not sure if ACS 2113 Follow-up examinations for specific disorders applies, as technically the patient still has coeliac disease.

Response:
VICC advises that ACS 2113 Follow-up examinations for specific disorders doesn't apply in the case cited because as you have noted in the query the coeliac disease is an ongoing condition and the gastroscopy is part of the continuing care of the condition.  This is different to a condition that has been treated and there is follow up to check that the condition is no longer present for example, TCC bladder.  

Therefore, the correct principal diagnosis is K90.0 Coeliac disease.


Query Title:
Failed epidural or spinal anaesthetic leading to GA for caesarean section.

Query Text:
Would you code a failed neuraxial block leading to the use of a GA as a complication of spinal anaesthesia during labour and delivery to O74.6 Other complications of spinal and epidural anaesthesia during labour and delivery?  

There seems to be two schools of thought,  one is that it isn't a complication, and would only be coded to the point the procedure it got to, and the other is that it is a complication with a greater risk to the mother and fetus.

There are specific diagnosis and procedure codes for failed vacuum/forceps delivery leading to caesarean section. Why wouldn't you apply the same principal or logic to a failed epidural leading to a GA?

Response:
VICC considers that failed neuraxial block (whether it is due to an inability to insert the catheter or that it does not have the desired effect) is not a complication of anaesthesia but rather it is a situation where the expected outcome of the procedure did not occur.  Therefore as there is no complication, no diagnosis code can be assigned.

As there are no specific index entries or code for failed neuraxial block, VICC advises to apply ACS 0019 Intervention abandoned, interrupted or not completed and code the procedure to the extent that it was performed.


Query Title:
Emergency versus elective caesarean section

Query Text:
This patient had a caesarean section. It was listed on the Birth Summary as an emergency LUSCS and on the operation report as caesarean section for obstructed labour. 

Signed a consent form for a LUSCS two days before the operation but was admitted in early labour, labour was obstructed and went on to have a LUSCS. The obtetrician says 'booked for a LUSCS tomorrow and wanting that to continue'. Is this classified as an emergency or elective?

Search Details: 
ACS 1541 Elective and Emergency Caesarean

Response:
In the case cited, VICC considers the procedure to be an elective caesarean section.  This is because the decision to perform the caesarean had been made previously.  

Coding Matters Volume 10 Number 4 advice under heading Australian Coding Standard 1541 Elective and emergency caesarean provides the following advice:
'The NCCH has been alerted to the fact that some classification users find difficulty with interpreting and applying the definitions in Australian Coding Standard 1541 Elective and emergency caesarean.  The most important point separating the two definitions of elective and emergency caesarean section in ICD-10-AM is the timing of the decision to perform the procedure. The urgency to perform the caesarean is not significant when deciding between these two
definitions.

With an elective caesarean section, the decision to perform the procedure is made during the antenatal period. That is, there is never any intention that the patient will deliver vaginally.

With an emergency caesarean section, the intention was for the patient to deliver vaginally (that is, a caesarean was not considered necessary prior to the onset of labour), but an emergency situation has meant that a caesarean has become essential. This definition does not include any patient in whom delivery by caesarean section had previously been planned'.


Query Title:
Extraction of impacted molars and wisdom teeth

Query Text:
The index in ACHI Alphabetical Index leads us only to surgical extraction which we use when 'impacted' is documented, however VICC query #2179 states that unless 'surgical' or incision of mucosa is documented, it cannot be coded as surgical removal.

Could you please clarify?

Response:
VICC #2179 Removal of impacted wisdom teeth published in the 2006-07 March database has been superseded by updates made to the ACHI index in Sixth edition.  Therefore, follow the index entries based on your documentation.  If you have documentation of 'impacted', the index will lead you to surgical removal:
Extraction
↓
- tooth (fragment)
↓
--impacted (molar) — see Extraction, tooth, surgical, requiring removal of bone 

If however, you don't have documentation of impacted, you will need to have documentation of 'surgical' or 'incision of mucosa' in order to follow index entry:
Extraction
↓
- tooth (fragment)
↓
-- surgical (unspecified number of teeth)


Query Title:
Prefixing of diastasis recti of abdominal muscles ( DRAM)

Query Text:
There is currently disagreement between coders on the prefixing of diastasis recti of abdominal muscles (DRAM). 

Some believe it should be a C as it is only coded if it is a issue postnatally - 'a condition that arose during the episode of care'. Others believe it should be coded as a P as it is a condition that is present during pregnancy - 'is a previously existing condition that was not diagnosed until after the episode of care started'.

Response:
VICC advises that regardless of when the condition becomes an issue that meets criteria for coding, if the diastasis recti of abdominal muscles is present on admission, the condition is prefixed with a P Primary condition.  The condition would only be prefixed with a C Complicating condition, if the condition arose during the admission. 

If there is doubt about when the condition arose, in accordance with ACS 0048 Condition onset flag, Additional instructions, follow the hierarchy and default to prefix P Primary condition.


Query Title:
Principal diagnosis in same day patients

Query Text:
Can you please clarify the application of query #2444 Principal Diagnosis in same day patients when operation form has an 'operative diagnosis' as this query seems to be conflicting with query #2432 Screening and Follow up?

We regularly have patients admitted for screening colonoscopies because of a positive family history (mostly documented by the pre-admission nurse) but in the operative diagnosis the surgeon will put either diverticulosis, polyp etc.

So if we apply query #2444 we would code the disease/disorder as stated in the operative diagnosis and the screening code Z80.0 as an additional diagnosis.

However if we apply query #2432, Z80.0 would be the principal diagnosis and the disease or disorder would only be coded if it met ACS 0002.

Auditors recently told us that we should be following query #2444 but at the time we didn't know about query 2432 to ask them.

Response:
VICC #2444 Principal diagnosis in same day patients when operation form has an 'operative diagnosis' is relevant to same day episodes that are governed by ACS 0046 Diagnosis selection for same day endoscopy and therefore does not apply to your scenario.

Screening episodes are coded in accordance with ACS 2111 Screening for specific disorders and VICC #2432 Screening and follow up is also applicable to your scenario. 

VICC cannot comment on information available to both the auditor and the hospital at the time of audit.


Query Text:
A patient was taken to theatre for a colonoscopy and operative diagnosis was sigmoid diverticulosis with diverticulitis. 

We had coded just the diverticulitis only as the presence of diverticulosis is inherent in the diverticulitis code. 

During a recent audit, both conditions were coded by the auditors and although there are no exclusion/inclusion notes on either K57.30 or K57.32, we did not think it was necessary to code both.

Could you please clarify?

Response:
VICC considers that it is not necessary to assign a code for both the diverticulosis and the diverticulitis in the case cited as research indicates you cannot have diverticulitis without diverticulosis.


Query Text:
Patient admitted at term with SROM at 2330 30/11; labour induced with Syntocinon 2/12 and contractions commenced at 1137 2/12.

Documented as ‘pre-labour rupture of membranes’ on Discharge summary.

Pre-labour rupture of membranes is not indexed but premature rupture of membranes is and they seem to be the same (confirmed on internet  and from 6th edition ACS 1531 - 'When the membranes rupture before the onset of labour, this is known as 'premature rupture of membranes'. 

Can I code pre-labour rupture of membranes to premature rupture of membranes (O42.11)? Can 'pre-labour' also be indexed?

Search Details: 
internet: Term pre-labour rupture of membranes (PROM) Guideline - 
Definition - Spontaneous rupture of the membranes at or after 37 weeks gestation and before the onset of labour
http://www.southernhealth.org.au/icms_docs/1194_
Term_pre_labour_rupture_of_membranes_PROM.pdf
Pre-labour rupture of the membranes (PROM) ≥ 37 weeks
http://www.health.sa.gov.au/PPG/Default.aspx?PageContentMode=1&tabid=45
6th edition ACS 1531

Response:
VICC agrees that from the information contained in the previous ACS 1531 Premature rupture of membranes (now deleted) that the terms 'pre-labour rupture of membranes' and 'premature rupture of membranes' mean the same thing.  

For the case cited, VICC considers it is appropriate to code pre-labour rupture of membranes to O42.11 Premature rupture of membranes, onset of labour between 1–7 days later.

VICC will send a public submission to NCCC suggesting the creation of an Index entry for the subterm 'pre-labour' in the Index under lead term 'Rupture'.


Query Title:
Criteria for admission versus principal diagnosis

Query Text:
Patients at our facility frequently present for same day administration of bortezomib for treatment of their multiple myeloma. This drug is administered subcutaneously, so as per the current Victorian Hospital Admission Policy the patients are not admitted. However on occasion these patients also receive an IV infusion or blood products thereby qualifying as a valid inpatient admission. 

Should the principal diagnosis relate to the main intention of the episode, which in this case was the administration of subcutaneous chemotherapy? Or should it relate to the actual 'reason' that the patient's episode qualifies as an admission? 

Specifically should ACS 0044 Chemotherapy be applied in this scenario, with a principal diagnosis of Z51.1 Pharmacotherapy session for neoplasm? 


Search Details: 
ACS 0236 Neoplasm coding and sequencing
ACS 0044 Chemotherapy
Victorian Hospital Admission Policy July 2011

Response:
VICC advises that the principal diagnosis is determined by the condition that occasioned the episode of care, rather than the criteria used to determine eligibility for admission.  Once the episode has met a criterion for admission the entire episode is used to determine assignment of the principal diagnosis.

To answer your specific query, ACS 0044 Pharmacotherapy should be applied if the main intention of the episode was chemotherapy administration.

Note: The title of ACS 0044 has been updated to ACS 0044 Pharmacotherapy.


Query Title:
ACS 0001 Principal diagnosis - two or more diagnoses that equally meet principal diagnosis definition

Query Text:
When a doctor lists several conditions as principal diagnosis my understanding of this standard has always been that we take into consideration the circumstances of the admission when choosing the principal diagnosis, as per example 1 in the standard (where I interpret all diagnoses as meeting criteria for coding).  If, after viewing the notes, more than one diagnosis could equally be principal, as determined by admission circumstances, workup and therapy provided, we should refer to the clinician and, if no further information is available, choose the first listed as principal.

A recent in-house coding audit has revealed some coders consider that, provided all listed conditions meet the criteria for coding, they should refer the case to the doctor to advise which diagnosis is principal, otherwise, choose the first listed diagnosis.

A case in question involved the choice of NSTEMI or Acute on Chronic renal failure as principal, listed in that order by doctor.  Patient notes refer to:
- Patient admitted under Renal Unit for acute worsening of renal failure. He had dehydration, chest pain and raised troponin in ED.
- ED admitting diagnosis = ARF
- First admission note is by Renal physician 
- First nursing note-'transferred to ward from ED for ARF'
- Med. cover note - ATSP for chest pain while in ED. Admitted for acute on chronic renal failure due to dehydration
He certainly was treated for NSTEMI during admission.

1. Does the standard allow a coder to choose ARF as principal in this case, despite it being listed second by the doctor? 
2. Are coders expected to refer all of these types cases back to the doctor to tell us what should be principal?
3. Although we code for reasons other than casemix funding, I feel that not taking admission circumstances into consideration and choosing the first listed diagnosis will result in DRG funding and report anomalies eg. Renal physicians will question why cardiac patients are listed on their reports. 



Please advise on the general intent of this standard.

Response:
In accordance with ACS 0001 Principal diagnosis under heading 'Two or more diagnoses that equally meet the definition for principal diagnosis', you are correct in that after reviewing the clinical notes if there is more than one diagnosis that can equally be principal diagnosis, the case should be referred to the clinician to indicate the principal diagnosis.  If no further information is available, choose the first listed as principal diagnosis.  However please note that in example 1 of ACS 0001, not all conditions listed on the front sheet meet principal diagnosis definition.

In response to your specific questions for the case cited:
1. No, the standard doesn't allow the coder to choose ARF as principal in this case.  This is because there is evidence of both conditions being present on admission and after study both diagnoses were listed with NSTEMI as the first listed.

2. Only when there are two or more conditions equally meeting the criteria for principal diagnosis should the case be referred back to the clinician to to indicate which diagnosis best meets the principal diagnosis definition.

3. Codes should be assigned according to coding principles regardless of the DRG outcome.  The unit the patient is admitted to does not determine principal diagnosis decision.


Query Title:
Principal diagnosis selection in clinical trials

Query Text:
Can the committee please confirm the prinicpal diagnosis in the following scenarios:

1. Patient with metastatic colorectal cancer. Admitted for CS-1008 monoclonal antibody trial, to assess whether treatment with CS-1008 reduces tumour size (patient's cancer has not responded to standard chemotherapy drugs).

Should the principal diagnosis be Z00.6 Examination for normal comparison and control in clinical research programme or Z51.1 Pharmacotherapy session for neoplasm?

2. Patient who has developed osteopenia due to androgen deprivation therapy for his prostate cancer is admitted for zoledronic zcid/ placebo infusion who is a participant in the 'Prevention of bone decay in men with prostate cancer receiving androgen deprivation therapy' trial. Should the principal diagnosis be osteopenia or Z00.6? 

Search Details: 
ACS 0026 Admission for clinical trial, drug challenge or therapeutic drug monitoring
http://clinicaltrials.gov/ct2/show/NCT01220999

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

There is a distinction between a patient who is admitted to receive a drug as a trial in the hope that the patient responds to the drug and a patient whose reason for admission is stated as being for a clinical trial for the purposes of research as per ACS 0026 Admission for clinical trial, drug challenge or therapeutic drug monitoring which states:
Where the reason for admission is stated as being for a clinical trial for the purposes of research, Z00.6 Examination for normal comparison and control in clinical research programme should be assigned as the principal diagnosis'.

Based on the information provided in the scenarios, in answer to scenario one as there is no evidence of a clinical trial for the purposes of research do not apply ACS 0026.

In answer to scenario two, as the documentation supports that the reason for admission is a clinical trial for the purposes of research apply ACS 0026 and assign Z00.6 Examination for normal comparison and control in clinical research programme.

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


Query Text:
This query relates to coding sedation from the listing of a drug known to be used for sedation when not included on an Anaesthetic form.

In the following examples, is it reasonable that sedation could be coded or does this information need to be captured on an Anaesthetic form in order to code sedation?  

1. Patient undergoing Cardiac Angiogram and catheterisation, do not have an anaesthetic form completed, rather they have the drugs listed on the medication chart or included on the angiogram report such as Midazolam given IV.  

2. In the emergency department, a patient is given IV Midazolam for suture of open wound.

Response:
The VICC advises that before assigning a code for sedation, there needs to be documentation that the drug has been given for anaesthetic, rather than the coder interpreting the use of the drug.  It is not necessary for the drug to be written on the anaesthetic form provided there is documentation of sedation elsewhere in the record. 

Therefore for the examples cited in the query, the clinician would need to document that IV Midazolam was given as sedation before sedation could be coded.


Query Text:
Could the committee please advise on the following?

When nursing documentation indicates that a patient is 'unable to void' and has an IDC inserted, is it reasonable to code this as urinary retention or does 'urine retention' need to be documented?  If 'unable to void' or 'urine retention' is documented by nursing staff only, is it reasonable to say that this is appropriate to their discipline and can therefore be coded (provided it met criteria for coding)?

Response:
The VICC advises that urine retention needs to be documented in order to assign a code for urine retention as 'unable to void' is not a diagnosis.  Documentation of urine retention by nursing staff only is sufficient to enable the coding of urine retention provided it meets criteria for coding.


Query Title:
Fine needle aspiration (FNA) of lymph node

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

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

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


Query Title:
Stridulous croup versus croup with stridor

Query Text:
What should be coded for croup with stridor?  A clinician advised me that: 'Stridulous croup should not be confused with 'croup with stridor'.  They are different clinically (all croup has stridor; stridulous croup is severe croup and would be treated with Adrenalin)'.

Do I need to have 'stridulous croup' documented to code J38.5 Laryngeal spasm (instead of the default code at Croup of J05.0 Acute obstructive laryngitis [croup])?

Search Details: 
NCCH Q2186
Query: (summarised)  The  index  for  acute spasmodic croup leads to J05.0 'Acute obstructive laryngitis [croup]' (Croup, spasmodic, acute).

However, it is noted that code assignment for acute stridulous croup is not influenced  by  the  descriptor  'acute' as there is no sub index for acute within  ICD-10-AM.  Therefore,  code  assignment for acute stridulous croup leads to J38.5 'Laryngeal spasm' (Croup, stridulous).

As  the  terms  'acute  spasmodic'  and  'acute  stridulous'   croup appear synonymous,  please  confirm that there does not need to be a sub index for acute stridulous croup.

Answer:  Initial  response 14/6/2006: The NCCH agrees that acute stridulous croup  should  be  coded  to  J05.0  'Acute  obstructive  laryngitis'.  The indexing will be amended in a future edition  of ICD-10-AM.

Subsequent  response  8/8/06:   After  further review the NCCH has referred this  issue  to  the  WHO Update Reference Committee for advice, due to the inconsistency  in the indexing of croup in the ICD-10-AM disease index.  In the interim maintain current coding practice following the index.

Response:
VICC research also indicates that 'croup with stridor' is not the same as 'stridulous croup' and therefore advises to follow the index and the clinical advice you have received.  For documentation of 'croup with stridor' the correct code to assign is J05.0 Acute obstructive laryngitis [croup], which is the default code for Croup in the index.


Query Text:
Should 'blanket' decisions be accepted, for example when a clinician says 'all my patients have senile cataracts', does that mean this clinician's patients should all be coded as having senile cataracts, even if it is not documented in each patient's record?  

Search Details: 
Can't find anything searching by the word 'blanket' but I thought there had been previous Victorian Coding Committee advice to say 'blanket' decisions were not acceptable.

Response:
'Blanket' decisions such as letters, lists and statements from clincians are not acceptable for code assignment.  Code assignment must be supported by documentation in the medical record and reference to this can be found in:

1.  ACS 0010 General abstraction guidelines which states that 'the listing of diagnoses on the front sheet of the clinical record is the responsibility of the clinician. Before coding any diagnosis/procedure recorded, the clinical coder must verify information recorded on the front sheet by reviewing pertinent documents in the body of the clinical record'; and  

2. The introduction section of the Australian Coding Standards which states that 'the clinical record should be the primary source for the coding of inpatient morbidity data. Accurate coding is possible only after access to consistent and complete clinical information. Without good documentation, coding guidelines are difficult, if not impossible, to apply. It is assumed that coding decisions are not made solely based on information provided on the clinical record front sheet (or a copy of same) but that analysis of the entire clinical record is performed before code assignment'.


Query Title:
Selection of Principal diagnosis - first mentioned

Query Text:
ACS 0001 Principal diagnosis says that if you have two or more interrelated conditions, or two or more diagnoses, each meeting the definition of principal diagnosis, and no further information is available, to code the 'first mentioned diagnosis'.

Does first mentioned apply only when the diagnoses are written on a discharge summary (because it is then the diagnoses 'after study')?  

What should the principal diagnosis be in a same day endoscopy where there is no discharge summary (and no expectation that there will be one) and no final diagnosis after the endoscopy - is first mentioned applied to the conditions listed as indications for the procedure?  Example: indication on the booking form is GORD/dysphagia, no abnormal findings, no final diagnosis or summary. 

What should the principal diagnosis be in a multi-day stay with no discharge summary and the patient was admitted for AMI and CCF (both well documented throughout the notes), but with CCF written first in the notes?

Response:
As you have pointed out, to determine the principal diagnosis coders should first refer to the discharge summary.  If however, there is no discharge summary and you are unable to obtain documentation of the principal diagnosis from the clinician, there is no instruction as to which part of the record the decision should be based on.  

Therefore the VICC suggests to make a decision by applying the definition of ACS 0001 Principal diagnosis to the documentation that is available.


Query Title:
Extravasation of IV chemotherapy causing IV phlebitis

Query Text:
Please advise if correct codes for extravasation of IV chemotherapy causing IV phlebitis (forearm) and tissue necrosis are:

T80.1  Complication, vascular, following infusion
I80.8   Phlebitis, specified site, NEC
T80.8  Other complication following infusion
R02     Necrosis NEC
Y84.8  Complication, infusion procedure
Y92.22 Hospital

We have had similar extravasation problems previously where fluid leaks into tissue and requires drainage, or infusion of potassium causes pain and inflammation of vein or damage to surrounding tissue during transfusion. As these complications relate to the substance being infused and not the catheter itself, it seems application of VICC # 2460 Extravasation of contrast would be incorrect.

Search Details: 
Tabular entries:
Complication, vascular, following infusion, therapeutic injection of transfusion T80.1.
Phlebitis, following infusion, therapeutic injection or transfusion T80.1
Phlebitis, specified site NEC I80.8
Thrombophlebitis, following infusion, therapeutic injection or transfusion T80.1
Complication, transfusion, reaction NEC T80.8
Complication, infusion NEC T80.9 (tab browsed to T80.8)
Necrosis R02
Necrosis, skin or subcutaneous tissue R02
Gangrene, limb R02
Gangrene, connective tissue R02
EXT: Complication, infusion, procedure Y84.8
EXT: Compliation, injection, procedure Y84.8
EXT: Complication,transfusion, procedure Y84.8

VICC search: 
VICC #2460 Extravasation of contrast
VICC #2059 Post procedural fat necrosis
VICC # 1703 Infected IV site T80.2 or T82.7

ACS 1904 Procedural complications p 267 Infected intravenous (IV) site

Response:
VICC agrees with your comment that query #2460 Extravasation of contrast does not apply because there are documented complications related to the leaked substance. Whereas the scenario in query #2460 is about the complication of the device.  The codes you have assigned for this scenario are therefore correct.


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

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

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

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

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

Search Details: 
ACS 1511 Termination of Pregnancy

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

Please see ACS 1511 Termination of pregnancy for code sequencing.

Please note that as the patient was told to return in three days for completion of the abortion, VICC considers the patient should have been placed on leave.  This is in accordance with the VAED definition of Leave with permission (section 2 of the VAED manual 18th Edition July 2008) which states 'Leave with permission occurs when an overnight or multi-day patient leaves the hospital temporarily with the approval of the hospital and/or treating medical practitioner, with the intention that the patient will return within seven days to continue the current treatment.'

For Ninth edition advice please refer to VICC #3077 Late Termination of pregnancy published in the 2015-16 March Database.


Query Text:
Day stay patient with diagnosis of histiocytosis for chemotherapy.  The patient was given treatment of IV methotrexate and ondansetron.  The histiocytosis is coded to D76.3 Other histiocytosis syndromes

Given that the central cancer registry advise us to register D76 conditions should these admission be coded as:

Option one: 
Z51.1 Pharmacotherapy session for neoplasm
D76.3 Other histiocytosis syndromes
96199-00 Intravenous administration of pharmacological agent, antineoplastic agent

or

Option two:
D76.3 Other histiocytosis syndromes
96199-09 Intravenous administration of pharmacological agent, other and unspecified pharmacological agent

Search Details: 
Central Cancer Registry - List of VCR Notifiable Cancers May 2008

Response:
The VICC advises that regardless of the Victorian Cancer Registry registration requirements, the Australian coding standards should be applied for coding purposes.  

D76.3 Other histiocytosis syndromes has inclusion terms which may or may not be neoplastic so coders need to be guided by the index.  Having determined whether the condition is neoplastic or not, apply the relevant part of ACS 0044 Pharmacotherapy.  

Based on the information provided in the query, the coding in option two is correct.  

Note: the current procedure code is 96199-19 [1920] Intravenous administration of pharmacological agent, other and unspecified pharmacological agent.


Query Text:
If the type of abortion is not specified, can we assume it to be spontaneous or do we use O06.x Unspecified abortion which is the default in the index?

Response:
In the absence of any information to support the specified type of abortion, follow the default in the index to assign O06.x Unspecified abortion.  

Please be aware that there are lead terms other than abortion relevant to these scenarios.  For example, documentation of miscarriage leads to O03 Spontaneous abortion in the index.


Query Text:
This is a coding query that arose during a recent Audit of Patient Admitted Data in February 09.

Usually a TRUS patient is admitted as a day case, with the diagnosis on the Operation Sheet of raised PSA.  Following the procedure and after discharge, the histopathology results indicate that the patient has cancer.  Can you please confirm whether we should code the raised PSA or can we code the cancer diagnosed in the pathology?

Response:
NCCH advice published in Coding Matters Volume 16 Number 1, June 2009, states following:
"Prostate specific antigen (PSA) is a protein that is secreted into ejaculate which helps to nourish the sperm. Normally, only tiny amounts enter the bloodstream. However, cancer cells and other conditions can interfere with proper functioning and cause large amounts to enter the blood.  It is currently the most widely used method to screen for prostate cancer. 

It is acknowledged that elevated PSA is also an indicator of other conditions such as benign prostatic hyperplasia (BPH), urinary tract infections and prostatitis. For the scenario cited, where histopathology has confirmed a diagnosis of adenocarcinoma, this should be assigned as the principal diagnosis. The adenocarcinoma should be coded as a finding that adds specificity to the diagnosis of 'elevated PSA' as per the guidelines in ACS 0010 General abstraction guidelines, Test Results."

This advice therefore clarifies the changes made to ACS 0010 General abstraction guidelines allowing you to now code the cancer as the principal diagnosis.


Query Text:
Collagen cross-linking for treatment of kerataconus is a procedure whereby the epithelium is removed from the surface of the cornea, Riboflavin eye drops are applied and the area is subsequently exposed to ultraviolet A (UVA) light for 30 minutes.  

What is the correct way to code this procedure in the ACHI classification?

Response:
The VICC considers the appropriate codes to assign for collagen cross linking for keratoconus are:
42650-00 [172] Epithelial debridement of cornea, for the removal of the epithelium by following index entry Removal, corneal epithelium; and
14050-00 [1609] Psoralens and ultraviolet A therapy of other site, for the UVA light exposure by following index entry Therapy, ultraviolet (skin), A with psoralens (PUVA), specified site

The VICC notes that there is no procedure code for application of eye drops but believes this component of the procedure is included in code 42650-00 [172].


Query Text:
The distinction between sedation and general anaesthesia is often unclear from clinical documentation. For the purposes of classification in ACHI, 92515-XX [1910] Sedation may be assigned where the anaesthetic is administered as per general anaesthesia (ie intravenous or inhalational or both) and there is no documentation of the use of an artificial airway, such as an endotracheal tube, laryngeal mask or Guedel airway. 

I, and other coders, read this part of the standard as 2 statements of fact.  The first sentence says that the distinction is often unclear.  It then goes on to say for the purposes of classification if there is no artificial airway a code for sedation may be assigned.  

Others coders report their view that if the anaesthetist ticks a box stating GA, then, even in the absence of documentation of an artificial airway, a GA should be coded, as the documentation is clear.

Even though the anaesthetist might consider he/she has administered a GA without the use of an artificial airway, my interpretation, based on the second sentence, is that the artificial airway is the determining factor in deciding the code.

Could this please be clarified?  If a GA box is ticked but there is no artificial airway documented, can the committee please suggest that this is made clear in a future edition or errata?

Response:
The VICC notes that point 2 under the heading Cerebral anaesthesia in ACS 0031 Anaesthesia should be read in the context of point 1.  Coding Matters Volume 15 Number 3 article titled Anaesthestic coding confirms that where documentation is unclear as to the type of anaesthetic being administered follow the guidelines in ACS 0031 Anaesthesia.  In cases where the general anaesthetic box is ticked, the documentation is clear and therefore a code for general anaesthetic can be assigned.


Query Text:
Patient admitted for gastroscopy.

Indication: Resistant helicobacter pylori
Findings:   Examination was normal multiple biopsies taken for helicobacter culture and antibiotic sensitivity study.

Helicobacter found. No gastritis found.  What should the principal diagnosis be?

Search Details: 
ACS 1122 Helicobacter/Campylobacter states that H Pylori  should only be coded when in the presence of another condition, but when it is the only reason for admission and the only thing found I'm not sure how to code it.

Response:
Unless you can obtain clarification from a clinician regarding more specificity about the reason for the endoscopy, the VICC suggests assigning Z22.3 Carrier of other specified bacterial disease as principal diagnosis.  

B96.81 Helicobacter pylori [H. pylori] as the cause of diseases classified to other chapters would not be assigned as an additional diagnosis, as it has not been documented in association with another condition.


Query Text:
A patient with chronic lower back pain presents to hospital every month to have his implantable spinal infusion device loaded with a steroid/anaesthetic combination.

Is this considered adjustment/management of the drug delivey device or should the principal diagnosis be the condition actually being treated (lower back pain)?

Search Details: 
Coding Matters Article Vol 15 No 1 June 2008
Coding Matters FAQ Vol 15 No 2 September 2008

Response:
This query was originally published in the December 2009 VICC queries database release as follows:
The VICC advises that the correct principal diagnosis in this scenario is the lower back pain.  This is because the patient has been admitted for loading of the drug delivery device in order to treat the condition (in this case lower back pain), not for management of the device.

Following publication of Coding Matters Volume 17 Number 1 June 2010 the VICC response is superseded by the following advice titled Intrathecal pump refill:

The correct procedure code to assign for refilling of an intrathecal pump is 96209-XX [1920] Loading of drug delivery device…, following the index pathway:
Loading, drug delivery device (CADD) (external infusion pump) 96209 [1920]

To assign the principal diagnosis code (including when the refill is for pain management), follow the index pathway:
Admission
- adjustment (of)
- - device (related to) NEC
- - - drug delivery or pump (CADD) (external)(implantable spinal) Z45.1

The following advice was provided in 10-AM Commandments Vol 15 No 1:
“Where patients are admitted for adjustment, management, fitting or removal of a drug delivery device, (except for loading of a drug delivery device for same-day admission of chemotherapy to treat a neoplasm…) assign:
Z45.1 Adjustment and management of drug delivery device”

Please note that under the Victorian Hospital Admission Policy effective 1 July 2010 procedure code 96209-XX [1920] Loading of drug delivery device is on the not automatically qualified for admission list.


Query Text:
At the recent coding update at Geelong, it was discussed that documentation of premature rupture of membranes has not been happening and is unlikely to occur in the future as the majority of midwives do not consider premature to be applicable in any scenario unless prior to 37/40 gestation.  

On discussion with midwives at our hospital and at a number of other hospitals in the region, it is not considered to be a problem worth noting unless there is prolonged rupture of membranes. The general consensus was that the descriptive terminology of PROM be changed to PRE-LABOUR rupture of membranes as the midwives I spoke to felt that they would never flag premature ROM unless less than 37/40 despite our coding standards.  As three of the midwives stated 'it goes against what we have been taught is considered premature in the clinical setting'.

The speakers at Geelong indicated they would take this suggestion away with them. I hope I am correct in putting this query to you in the first instance.

Response:
Thank you for your advice which is in keeping with advice received by the NCCH.  The NCCH is currently reviewing the coding of PROM for Seventh Edition and is aware that PROM <24 hours at term delivery is considered clinically insignificant.  However, it is proposed that the codes for PROM will remain unchanged as PROM <24 hours at term delivery could be the reason for induction and would therefore need to be coded.


Query Text:
We have had a patient admitted with febrile neutropenia secondary to chemotherapy.

'Chemotherapy precautions' was documented and carried out during admission.  Do 'chemotherapy precautions' meet ACS 0002 Additional diagnoses for coding of cancer?

We have been recently audited and it was suggested we submit this query for further clarification.

Response:
The VICC does not consider that chemotherapy precautions justify the coding of cancer under ACS 0002 Additional diagnoses criteria because the precautions relate to waste disposal (such as disposal of body fluids) rather than to the patient's condition itself.

Note: This query has been superseded by classification updates to ACS 0236 Neoplasm coding and sequencing.


Query Text:
If you have documented 'cord around neck' in the record do you always code it? Or is it only coded if it is compressing, tight, causing distress etc and this is documented? Or do you only code it if they document that they did something in as far as loosened the cord, slipped it over the baby, untangled it?

Having been recently audited the issue that was debated was does this meet ACS 0002? I note previous VICC query #2094 but am unsure of NCCH query#255 refered to in this query as the query was for fourth edition and prior to that database closing.  Having asked other sites what they do I have had a mixed response and would love some guidance.

Response:
Cord around neck is not routinely coded.  It must meet one the criteria outlined in ACS 0002 Additional diagnoses as follows:
• commencement, alteration or adjustment of therapeutic treatment 
• diagnostic procedures
• increased clinical care and/or monitoring

Therefore there would need to be evidence in the delivery notes that an intervention or increased monitoring took place.

Please note that VICC query #2094 has been superseded by ACS 0002 review in Sixth Edition.


Query Title:
Clinical documentation or histology diagnosis

Query Text:
I have a patient admitted for the excision of a dermal cyst from the arm.  The surgeon has written the diagnosis pre and post surgery as 'dermal cyst'.  The histology shows the lesion to be angiomyoma.

ACS 0010 General abstraction guidelines says that 'In the event that an investigation result varies from the clinical documentation, such as a clinical diagnosis of gastric ulcer with 'no evidence of ulcer' reported on histopathology, the case should be referred to the clinician'. 

ACS 0010 also says 'Laboratory, x-ray, pathological and other diagnostic results should be coded where they clearly add specificity to already documented conditions'.

Do I code from the clinical documentation or the histology diagnosis?  I am not sure which part of ACS 0010 applies to this case.

Response:
In light of the advice in Coding Matters Volume 16 Number 1 June 2009 under Elevated prostate specific antigen (PSA), the VICC considers that the part of ACS 0010 General abstraction guidelines which applies in your example is  'Laboratory, x-ray, pathological and other diagnostic results should be coded where they clearly add specificity to already documented conditions'. In this case the histology is adding specificity to the clinical diagnosis of dermal cyst.

Therefore the correct codes to assign are:
D21.1 Connective and other soft tissue of upper limb, including shoulder
M8894/0 Angiomyoma

Please note that the procedure code differs for excision of cyst and angiomyoma.

Following publication of Coding Q&A December 2011 the original response to this query is superseded by the following advice under heading 'Clinical diagnosis versus histology'

Q:
A patient is admitted for excision of a 'dermal cyst' from the arm. The clinician documents 'dermal cyst' both pre and post surgery, however, the histology shows the lesion to be an angiomyoma. Should the guideline in ACS 0010 General abstraction guidelines, be followed, which states, "In the event that an investigation result varies from the clinical documentation, such as a clinical diagnosis of gastric ulcer with 'no evidence of ulcer' reported on histopathology, the case should be referred to the clinician." Or should the ACS 0010 guideline, be followed, which states, "Laboratory, x-ray, pathological and other diagnostic results should be coded where they clearly add specificity to already documented conditions." Particularly in light of previous advice published for elevated PSA which cites the latter guideline as justification for using the histopathology result for code assignment?

A:
In the scenario cited, the clinician has documented a clinical diagnosis of 'dermal cyst' in the absence of histological examination. However, histology reveals an 'angiomyoma', which appears contradictory to the original clinical diagnosis. If the clinician was asked to confirm the diagnosis with the benefit of the histology report, the question is, would the documentation be 'dermal cyst' or 'angiomyoma'? 

As per the guidelines in ACS 0010 General abstraction guidelines, "In the event that an investigation result varies from the clinical documentation..., the case should be referred to the clinician." ACS 0010 also states, "It is important to seek clinical advice where necessary for clarification of discrepancies between investigation results and clinical documentation." Therefore, where there is discrepancy between the clinical diagnosis and histology, as cited in this scenario, clinical verification should be sought prior to code assignment. 

The previous query response regarding elevated PSA, published in Coding Matters Vol 16 No 1 June 2009, is not the same, as elevated PSA is an abnormal test result indicative of other conditions not a clinical diagnosis in itself. The NCCC will consider amendments to ACS 0010 General abstraction guidelines in a future edition of ACS.


Query Text:
Please clarify advice in previously published VICC queries #2215 Foot debridement of diabetic patients and #2454 VAC dressings.

Patient is admitted with diabetic foot, is taken to theatre where VAC dressing is performed by surgeon and episode groups to non surgical K60A Diabetes + CSCC DRG with a WIES value of 1.7833. Whereas a patient with a diabetic foot that simply has 'debridement' by podiatrist performed on ward groups to K01Z Diabetic foot procedures DRG with a WIES value of 5.3621.

The advice in VICC #2454 to code VAC dressings as non excisional debridements causes these cases to group to a non surgical DRG. It also states that 'research undertaken by VICC suggests that usually an excisional debridement is performed at the time of application of the VAC dressing .... in which case only the excisional debridement is coded'. The preparatory excisional debridement is rarely documented on the operation report as it is considered by surgeons to be inherent, and 'seeking clarification or confirmation from the surgeon' is not always possible. Therefore being instructed to code VAC dressings as non-excisional appears to be in contradiction to the instruction in ACS 1203 Debridement to default to excisional debridement if nonexcisional is not documented when VICC itself has stated in this query that debridement is usually performed.

Patients are taken to OR to have the VAC dressing attached, usually taken back to theatre to have it taken down, and may return to OR several times to have the VAC reviewed, yet these cases group to a non surgical DRG because of the instruction to code them as non excisional debridement. Clearly VAC dressings are not typical dressings and should attract a surgical/OR weighting. Can the advice please be amended to default the coding of these to excisional debridement?

The advice in VICC #2215 instructing coders to code 'debridement' by podiatrists to excisional needs review. Surely 'debridement' performed on the ward by podiatrists should default to non excisional unless documentation supports excisional as often this is simply removal of dead skin and filing back of overgrown tissue. If a VAC dressing attached in the operating room is deemed to be non excisional, how is 'debridement' with no other clarification as to depth of tissue, instrumentation used, etc., performed on the ward by a podiatrist considered surgical? 

ACS 1203 Debridement was clearly aimed at debridements performed in operating theatres by surgeons when it was originally written. This is evident from the first sentence in the standard which states: If 'nonexcisional debridement' is documented or the surgeon confirms ... Extrapolating the advice in this ACS to include podiatrists seems extreme and is causing incorrect DRG assignment that will negatively impact average LOS and future trim points and cost weights. 

Surely this advice then extends to nursing staff. Australian coders should follow the example set by their American colleagues and code excisional debridement when performed on the ward by nursing staff. According to TMF Health Quality Institute, the Medicare Quality Improvement Organization for Texas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services, 'An excisional debridement can be coded when performed by a nurse, therapist, physician assistant or physician'.  What is to stop Australian coders coding excisional debridement every time a nurse does a wound dressing and documents debridement in the notes when removing debris or skin from the edges of the wound? They could just as easily be instructed to document debridement of wound as podiatrists have been to obtain a surgical DRG.

Response:
The VICC considers the advice in VICC query #2454 VAC dressings to be correct. The intent of the query is to suggest that when  debridement is performed, it should be coded.   The impact on the DRG outcome is acknowledged, however decisions regarding correct code assignment are not and should not be based on DRG outcome.

The advice in VICC query #2215 Foot debridement of diabetic patients is based on ACS 1203 Debridement, acknowledging that there is no distinction of practitioner and is considered to be correct.

VICC acknowledges however that the default to 'excisional' debridement may result in some cases not reflecting clinical practice.  You may wish to consider submitting a public submission to the NCCH to create more appropriate codes for VAC dressing.


Query Text:
Please advise as to the most appropriate diagnosis code to assign for fractured penis.

There is a specific procedure code for the repair of this injury: 
37408-01 [1200] Repair of fracture involving cavernous tissue of penis.

Male 41 year old presented with penile pain and haematoma suffered during sexual intercourse. Patient was able to urinate post injury and on examination in theatre was found to have a torn tunica albuginea of the corpus cavernosum (a fractured penis). There was no injury to the urethra or any other structure and a surgical repair was performed.

Codes assigned:
S37.88 Injury of other pelvic organ
X50     Overexertion and strenuous or repetitive movements
Y92.9  Unspecified place of occurrence
U73.8  Other specified activity.

Research indicates that this injury is unlike any other involving the pelvic organs and can result in long-term sexual and/or urinary dysfunction. It is suggested that an increasing usage of Viagra (sildenafil) in the community may see a corresponding increase in the occurrence of this injury.  

Search Details: 
There are no listings for this particular injury under Tear, torn (traumatic) or Fracture.  There are the following index entries:
Injury
- penis S39.9
- pudendum S39.9
- genital organ S39.9
- pelvic organ; specified site NEC S37.88

There are no listed inclusion notes to specifically indicate this injury.

Response:
As per ACS 0013 'Other' and 'unspecified' codes, in the absence of subterm of penis under lead term Fracture, look up lead term Injury to assign S39.9 Unspecified injury of abdomen, lower back and pelvis by following index entry 'Injury, penis S39.9'.

It is not correct to assign S37.88 Injury of other pelvic organ because the term penis is specifically indexed and is therefore not 'not elsewhere classified'.


Query Text:
Do we need to code newborns whose temperatures are monitered because of GBS+ mothers even if the mothers are given antibiotics in labour?  If yes which codes should we use?

Newborns of Vitamin D deficient mothers are given Ergocalciferol and or Pentavite routinely.  Do we need to code diagnoses for this and which codes do we use?

Babies of Hepatits B and C and HIV mothers are tested and monitored and given prophylatic drugs.  How do we code these diagnoses?

Response:
The VICC advises that when there is evidence that the newborn has received prophylactic treatment, the appropriate code to assign is Z29.8 Other specified prophylactic measures by following index entry Prophylactic, measure, specified NEC.

However, when no prophylactic treatment is given, assign Z76.2 Health supervision and care of other healthy infant and child.  This is in accordance with ACS 1609 Newborns Affected by Maternal Causes and Birth Trauma which states 'if the maternal cause has necessitated provision of more health services than is usual for a newborn, it may be appropriate to assign Z76.2 Health supervision and care of other healthy infant and child'.


Query Text:
Can you please provide some guidance around the correct assignment of diagnosis code for 'diarrhoea'.  The index default is A09.9 Gastroenteritis and colitis of unspecified origin but the excludes note at A09 includes 'noninfective diarrhoea K52.9'.

My question relates to patients admitted for colonoscopy for investigation of diarrhoea, but with no mention of length of time the diarrhoea has existed.  In these cases we can't assume chronic, but would assume the doctor thought it was noninfective to do a scope.

We feel that A09.9 should be used for 'acute' type admissions with a diagnosis of 'Gastro' or diarrhoea, but if the patient has presented for an elective scope for investigation of diarrhoea maybe K52.9 Noninfective gastroenteritis and colitis, unspecified is a better choice, and would welcome your comments.

I know that K52.9 comes up as a warning on PICQ, so we think we shouldn't be using it at all, but it doesn't seem right to use A09.9 either.

Search Details: 
A09 Other gastroenteritis and colitis of infectious and unspecified origin
Excludes: due to bacterial, protozoal, viral and other specified infectious agents (A00–A08)
noninfective (noninfectious) diarrhoea:
• neonatal (P78.3)
• NOS (K52.9)

Response:
When diarrhoea is documented without further specificity, follow the index to assign the default code A09.9 Gastroenteritis and colitis of unspecified origin.  VICC acknowleges that it may seem anomalous for diarrhoea NOS to be classified in Chapter 1 Certain infectious and parasitic diseases but ICD-10-AM is a statistical classification, therefore we must follow the index entries and assign a code accordingly.  

VICC also notes that the PICQ warning on K52.9 Noninfective gastroenteritis and colitis, unspecified is a W2 warning indicating that this code can be used in certain cases.


Query Text:
Can you please instruct when it is acceptable to code wound ooze?  There is often documentation in the record of 'wound ooze' or 'oozy wound' which is common post operatively, especially when patients are on anti-coagulants. However, an auditor has recently informed us that this is a codeable post-operative complication.

Wound observation/monitoring and dressing management are routine post-operative care, so what additional criteria would we be applying that would meet ACS 0002 Additional diagnoses to make wound ooze a codeable complication?

Should we instead be querying if the ooze is, in fact, due to an acquired coagulopathy due to the anti-coagulants the patient is on? In which case would we just be coding the coagulopathy or would we also code the post-operative complication of wound ooze?

Search Details: 
Coding Matters, VICC - no matches found on wound ooze.

Response:
The VICC agrees that wound observation/monitoring and dressing management are routine post-operative care.  Whilst we can't give specific examples of additional criteria, we advise that you would need documentation of care or management of the wound that is beyond routine care.

You may query with the clinician if the ooze is due to an acquired coagulopathy and could code both the coagulopathy and the wound ooze if both have supporting documentation that meet ACS 0002 Additional diagnoses criteria.


Query Text:
A 77 year old male was admitted for acute urinary retention and acute gastritis.  During the admission multiple renal cysts were diagnosed on ultrasound requiring further investigation / follow up with Urologist.  No past history of kidney problems or diseases. 

Index entry: 
Cyst
-kidney N28.1 (acquired cyst of kidney)
--multiple Q61.3 (polycystic kidney disease unspecified)

Is it correct to follow the index entry and code multiple kidney cysts to 'polycystic kidney disease' and single kidney cyst to 'acquired cyst of kidney?'

Response:
Unless the cysts are documented as acquired, it is correct to follow the index entry 'Cyst, kidney, multiple' to assign Q61.3 Polycystic kidney, unspecified.  There is an excludes note at Q61 Cystic kidney disease which says 'Excludes: acquired cyst of kidney (N28.1)', which should be followed if the cysts are known to be acquired.


Query Text:
Patient seen at outpatient appointment.  Endometrial polyp seen at outpatient hysteroscopy.

Booked for Hysteroscopy and polypectomy under GA.

At Hysteroscopy under GA - no polyp seen.

What code do we assign as principal diagnosis?

Response:
The VICC advises that the principal diagnosis will depend on what has been documented, therefore you need to be guided by the documentation and also seek clinical advice if possible.  

If the polyp has been documented as the operative diagnosis, it should be coded as the principal diagnosis as per ACS 0001 Principal diagnosis.  

If the polyp has been documented as a suspected condition, follow ACS 0012 Suspected conditions.  

If there is no documentation of polyp and there are no symptoms documented, assign Z03.8 Observation for other suspected diseases and conditions by following index entry 'Observation (for), suspected (undiagnosed) (unproven), condition NEC Z03.8'.


Query Title:
Operative diagnosis and symptom for same day endoscopy

Query Text:
We have been alerted to the query #2444 Principal diagnosis in same day patients when operation form has an 'operative diagnosis' by an auditor.  We have a patient who has been investigated for PR bleeding with an operative diagnosis on the colonoscopy report of diverticular disease.  Haemorrhoids were also found, which were banded. If we follow query 2444, we can assume a causal link has been established and then code the diverticular disease as the principal diagnosis. 

My question is, do we then code the symptom (PR bleeding) as an additional diagnosis?  I would have thought not, following standard 0046 Diagnosis selection for same-day endoscopy however this particular auditor seemed to indicate we should.

Response:
As the operative diagnosis is documented as diverticular disease it is assumed that the clinician has made a link between the presenting symptom (PR bleeding) and the finding (diverticular disease).  Therefore the principal diagnosis is K57.31 Diverticular disease of large intestine without perforation or abscess, with haemorrhage because the 'with haemorrhage' distinction is included in the code.  

Had the condition not had the 'with haemorrhage' distinction included in the code, it would be appropriate to assign an additional code of K92.x Other diseases of digestive system as per ACS 1103 Gastrointestinal (GI) haemorrhage.


Query Text:
Could you please clarify some issues raised by VICC query #2408  Neonatal sepsis/Risk of sepsis?

1. Could you please identify/elaborate on the symptoms of sepsis that are required before applying ACS 0012 Suspected sepsis? (e.g. are they limited to the manifestations listed in ACS 0110 Septicaemia involving temperature, heart rate etc or can they be symptoms as listed by the doctor such as those in the following cases?)

2. Could you please advise on how to code the following examples of documentation from discharge summaries?

Case 1
Presumed Sepsis - septic work was performed because of desaturation and the infant was commenced on penicillin and Gentamicin which were ceased 6 days later; cultures negative.

Case 2
Presumed sepsis - septic work was performed after birth because of tachypnoea and the infant was commenced on penicillin and Gentamicin which were ceased 2 days later; cultures negative.


3. Can you please clarify why we have been instructed (in VICC #2408) to apply ACS 0012 with the 'clause' that symptoms be present for the coding of presumed sepsis, even though there is no mention of symptoms needing to be present when applying ACS 0012 in general?

Response:
The VICC advises that the symptoms of sepsis are those listed by the clinician (they are not limited to the manifestations listed in ACS 0110 Septicaemia).

For the examples cited, it is appropriate to code sepsis as per ACS 0012 Suspected conditions.  This is because treatment was commenced for a diagnosis of presumed sepsis (with documentation of symptoms).  

The intent of the advice in VICC #2408 is to clarify that ACS 1617 Neonatal Sepsis/Risk of Sepsis is applied when there is clearly no sepsis and no condition (or symptoms).  The neonate may be treated with prophylactic antibiotics.  If there is documentation of a condition (or symptoms), ACS 1617 does not apply and you therefore follow ACS 0012 Suspected conditions.


Query Title:
Kidney transplant status with kidney transplant failure

Query Text:
ACS 1438 Chronic Kidney Disease page 213 Classification box under heading Kidney replacement therapy point 3 says that  'For patients who have received a kidney transplant and documentation pertaining to this status satisfies criteria for coding under ACS 0002, assign Z94.0 Kidney transplant status together with N18.3 Chronic kidney disease, stage 3 or higher, as indicated by an eGFR level'.

The codes at Z94.x have an excludes note for complications of transplanted organ of tissue.

Then, following the same logic (as ACS 1438) and as we are unable to assign Z94.0, should N18.3 Chronic kidney disease, stage 3 or higher, as indicated by an eGFR level also be assigned when T86.1 Kidney transplant failure and rejection satisfies criteria for coding?

T86.1 Kidney transplant failure and rejection also indicates that the patient has received a kidney transplant.

Response:
The VICC advises that in accordance with ACS 0027 Multiple coding it is appropriate to assign an additional code to identify the stage of chronic kidney disease in patients who have received a kidney transplant.  Following ACS 1438 Chronic Kidney Disease the additional code assigned would be N18.3 Chronic kidney disease, stage 3, or higher depending on the documentation available.


Query Text:
If a hernia is an incisional inguinal hernia, do you code to incisional or to inguinal?  That is, which overrides the other?  Is there a hierarchy for this?

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

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

VICC advises that there is no hierarchy in the classification to direct the coder to assign one code over the other and therefore suggests to seek clarification from the clinician as to which hernia code should be assigned in this scenario.

Coding Matters Volume 12 Number 2 article titled 'Incisional hernia' contains clinical and coding information which may assist.

Following publication of the ACCD Coding rules on 15 March 2014 the VICC response is superseded by the following advice titled Incisional inguinal hernia:
[Q:  How do you code an incisional inguinal hernia?
A:  Clinical advice indicates that incisional inguinal hernia is not a clinical concept. If this terminology is documented in the clinical record, clarification should be sought from the treating clinician.

If clinical clarification cannot be obtained, the following advice should be followed:
- Where incisional inguinal hernia is documented and there has been a previous inguinal hernia repair, it is a recurrent inguinal hernia and should be coded to K40 Inguinal hernia with a fifth character of 1 recurrent.

- Incisional hernias occur secondary to previous surgery, but NOT secondary to previous hernia surgery. Where incisional inguinal hernia is documented and there is no evidence in the clinical record that there was a previous inguinal hernia repair, assign a code from the range K43.0-K43.2.

(See also Coding Rules: Incisional hernia and Eighth Edition Education Workshop FAQs Part 1/Hernia)


Query Title:
Magnesium infusion for chronic regional pain syndrome

Query Text:
We have a patient with chronic regional pain syndrome, type 1, of leg. The patient has come in for a day visit to have an intravenous magnesium infusion. 
 
What procedure code would you apply in this case? I am wary to use 96199-xx [1920]  Intravenous administration of pharmacological agent as it has an exclusion note for pain management.

Response:
The VICC advises that the excludes note for pain management at block [1920] does not apply to this scenario because the codes referred to in the pain management blocks are for local effect.

As IV therapy has a systemic effect, it is correct to stay in block [1920] and assign 96199-08 [1920] Intravenous administration of pharmacological agent, electrolyte for the case cited.


Query Title:
Principal diagnosis for dental procedures when none is documented

Query Text:
At our hospital we have numerous dentists that come in and use our theatres for dental procedures. We are often unable to source additional information  (other than verbal via their receptionists) as to diagnostic information regarding these patients.  

In the absence of any diagnosis for a patient attending just for extractions and/or fillings are we able to use:
K03.9 Disease of hard tissues of teeth
or 
K08.9 Disorder of teeth and supporting structures, unspecified?

It is obviously a tooth problem that is being treated and it seems wrong to assign R69 Unknown and unspecified causes of morbidity in such a straightforward case like this.

Response:
A diagnosis should be documented by the clinician and this diagnosis may be found in any part of the record or hospital system such as the waiting list system.  When all courses of action to obtain a diagnosis have failed, the VICC considers R69 Unknown and unspecified causes of morbidity an appropriate diagnosis code to assign.

Alternative ways of obtaining the operative diagnosis could also be considered, for example having a list of probable diagnoses for the surgeon to select from on the operation report or booking form.  

The VICC notes that it can't be assumed that the extraction is due to a disorder of the teeth as sometimes teeth are extracted for other reasons such as radiotherapy preparation.


Query Title:
Intra-operative lavage of the peritoneal cavity when another procedure is performed

Query Text:
When an intra-operative lavage is performed of the peritoneal cavity is this a procedural component or is it something that should be coded in addition to the procedure performed? We have found that this is coded inconsistently at our health service.  See example below:
The patient was placed supine on the operating table and a general anaesthetic was administered.  The patient was then prepared and draped in the routine manner.  A Lanz muscle splitting incision was made on the right side.  In this way the peritoneal cavity was entered after incising the peritoneum carefully after lifting it with artery forceps.

The mesoappendix was divided after clipping and ligating with 2-0 Polysorb.  The appendix was clamped at it’s base with an artery clip.  Due to necrosis, the area was very friable making ligation impossible.  Therefore the appendix was resected at it’s base and removed from the operating field and sent for histopathology.  The appendiceal opening in the caecal pole was therefore closed with 3-0 PDS interrupted sutures.  This closure was then buried further using further 3-0 PDS sutures.
The peritoneal cavity was then thoroughly lavaged paying particular attention to washout the pelvis and right iliac fossa.  

The abdomen was then closed with a 2-0 Polysorb continuous suture to close the peritoneum.  2-0 Polysorb figure of 8 sutures were then placed in the muscle layers to approximate these.  At this point some 0.5% Marcain with Adrenaline was infiltrated.  O Polysorb continuous sutures were used to close the anterior sheath.  Scarpa’s fascia was approximated using 2-0 Polysorb interrupted sutures and the skin was closed with 4-0 Caprosyn subcuticular sutures.  A Cutifilm dressing was then applied.

Response:
VICC acknowledges that there is sometimes difficulty in determining whether a procedure is a component of another procedure. The significance of the lavage, and therefore whether the clinician feels it to be a significant procedure in its own right, may be evident in the way it is documented, for example, in the title of the operation report.  However, if you are still unsure refer to the clinician for clarification.


Query Title:
Elective termination of pregnancy with PV blood loss

Query Text:
30 year old patient presented to hospital for an elective termination of pregnancy at 14 weeks gestation. 

This patient was originally admitted to the ward where she was given Misoprostol per vaginally (PV) prior to having had dilation and evacuation (D&E).  Prior to being admitted to theatre for a D&E had a sudden PV blood loss of approximately 500ml. The patient was then taken to theatre immediately where a D&E was performed under general anaesthetic (GA).

After the D&E was performed the patient had an ongoing PV trickle and was taken back to theatre for a suction dilation and curettage (D&C) under GA, where a small amount of retained products of conception were found.

We have coded this to:

Diagnosis codes 
O04.1 Medical abortion, incomplete, complicated by delayed or excessive haemorrhage
O09.2 14–19 completed weeks

Procedure codes
35643-03 - Dilation and evacuation of uterus [D&E]
92514-xx - GA
35640-03 - Suction curettage of uterus
92514-xx - GA
90462-00 - Insertion of prostaglandin suppository for induction of abortion

We are unsure whether the O04.1 code is the correct code to assign as at time of admission the patient was coming in for a planned medical termination with no complication?

Response:
The note at the top of the abortion table in the index states that "an episode of care at which a disease or injury and resulting complications or manifestations are treated together" is a 'current episode' (note 2 in hard copy books).  Under 'current episode' there are two columns to select the fourth character from.  As the patient returned to theatre for retained products of conception, the fourth character should be chosen from the 'incomplete' column.

Therefore, following index entry Abortion, complicated by, haemorrhage (delayed) (excessive) and applying the note above, VICC considers the correct code for the scenario cited is O04.1 Medical abortion, incomplete, complicated by delayed or excessive haemorrhage.


Query Text:
Reference is made to Coding Matters Volume 16 Number 2 - Anaemia in neoplastic diease.  Advice is given that where the cause of anaemia is not known in the presence of a malignancy, the index entries should not be followed and the malignancy should not be coded.

Does this advice also apply to anaemia with renal failure, which is similarly indexed?

Search Details: 
Coding Matters Vol 16 No 2 page 1
ACS 1439 Chronic Kidney Disease page 214
ICD-10-AM Alphabetic Index of Diseases

Response:
The VICC advises that the advice in ACS 1438 Chronic kidney disease overrides the index in regard to anaemia and chronic kidney disease.  Please note that you can't apply Coding Matters advice from one specific scenario to another.

In answer to your specific question, apply the advice in ACS 1438 Chronic kidney disease under heading 'Anaemia in kidney disease', which states:
When anaemia is documented:
1. as linked to, or in the presence of, chronic kidney disease, stage 3 or higher, or chronic renal impairment/failure (CRI/F) with an eGFR <60mL/min, AND
2. it meets ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses,
assign N18.3 – N18.5 Chronic kidney disease stage 3 – stage 5 or N18.9 Chronic kidney disease, unspecified with D63.8* Anaemia in other chronic diseases classified elsewhere.

To clarify your query, the advice in Coding Matters Volume 16 Number 2 is that the index pathway for ‘Anaemia, in neoplastic disease’ should not be followed where the anaemia has been documented as due to an unknown cause or due to a nonneoplastic condition.


Query Title:
Admission for combined gastroscopy and colonoscopy (day only procedure)

Query Text:
Patient admitted for gastroscopy to investigate abdominal pain and colonoscopy to follow up previous polyps.

Gastroscopy - Abdominal pain, HH (no causal link documented)
Colonoscopy - No polyps found , internal haemorrhoids noted

Would the correct codes  be:
R10.4  Other and unspecified abdominal pain
K44.9  Diaphragmatic hernia without obstruction or gangrene
Z09.x  Follow-up examination after treatment for conditions other than malignant neoplasms
Z87.12 Personal history of colonic polyps
I84.2   Internal haemorrhoids without complication
and procedure codes

or would you NOT code I84.2, as the colonoscopy was for follow up and you would follow ACS 2113 Follow-up examinations for specific disorders?

Do you apply only one standard ACS 0046 Diagnosis selection for same-day endoscopy to the entire episode, or do you apply two different standards - ACS 0046 for the gastroscopy and ACS 2113 for the colonoscopy.

Are these standards mutually exclusive?

These standards dictate how you approach the medical record, unlike specialist standards that deal with particular diagnoses.

What if the documentation was reversed and the follow-up for the polyps was first mentioned?  

Remembering that when you translate codes back into medical statements you should be able to see what happened during that episode of care, would only applying one standard cause vital information to be missed?

Response:
The VICC advises that the standards are not mutally exclusive and therefore ACS 2113 Follow-up examinations for specific disorders applies for the colonoscopy and ACS 0046 Diagnosis selection for same-day endoscopy applies for the gastroscopy in the case cited.

When applying ACS 2113, any additional findings must meet ACS 0002 Additional diagnoses before being coded, therefore I84.2 Internal haemorrhoids without complication would not be coded in this scenario.

If the documentation were reversed and follow up for polyps was first mentioned, the follow up would be coded first, presuming it is documented on the discharge summary as per VICC # 2484 Principal diagnosis selection - first mentioned.


Query Text:
42year old lady presents for an endoscopic retrograde cholangiography (ERC) with sphincterotomy.  Operation report documents sphincterotomy was performed at 12 o'clock and there was some bleeding from the 12 o'clock position.  This required coagulation diathermy and lavage and then it stopped. 

What procedure code would be used for the diathermy coagulation and lavage?

Response:
The VICC considers the appropriate code to assign for the diathermy coagulation and lavage is 
30058-01 [777] Control of postoperative haemorrhage, not elsewhere classified, by following Index entry Arrest/haemorrhage/postoperative, site NEC.


Query Text:
Please provide clarification of the coding of Bubble CPAP in neonates.

Our Special Care Nursery (SCN) clinicians advise that Bubble CPAP can be delivered via nasophayngeal tube, nasal prongs or face mask.

We have been advised by SCN staff that a when a nasophayngeal tube is used, this is an invasive procedure.  It is not uncommon for this method to be used at this hospital.

Do we code Bubble CPAP via nasopharyngel tube as invasive ventilation?  Our Special Care Nursery is Level 2, so not normally involved in intubation of neonates, other than in emergencies in preparation for transfer.

Response:
When ACS 1006 Ventilatory Support was revised for Sixth Edition clinical advice was that a nasophayngeal tube is to be considered a non invasive ventilation modality.  

See ACS 1006 definition under heading Noninvasive ventilation (NIV) which says "Noninvasive ventilation refers to all modalities that assist ventilation without the use of an ETT or tracheostomy. For the purpose of this standard, noninvasive devices include: face mask, mouthpiece, nasal mask, nasal pillows, nasal prongs, nasal tubes and nasopharyngeal tubes."

Although you have received clinical advice at your hospital, the standard must be followed and CPAP delivered by nasopharyngeal tube must be coded as NIV.


Query Title:
Gestational diabetes diet controlled with insulin stabilisation

Query Text:
A woman with gestational diabetes (diet controlled) is admitted for insulin stabilisation.

I would use code O24.44 Diabetes mellitis arising during pregnancy, other as this reflects the condition on admission.

Is this correct, or should O24.42 Diabetes mellitis arising during pregnancy, insulin treated be used to reflect the treatment initiated during admission.

Response:
The VICC advises that the correct code to assign for the case cited is O24.42 Diabetes mellitis arising during pregnancy, insulin treated.  This is because of the hierarchy applied to the fifth character subdivisions for use with categories O24.1–O24.9 by the note under the subdivisions which says 'when multiple fifth characters apply, assign the one appearing highest on the list'.


Query Title:
Nitrofurantoin induced pulmonary hypersensitivity with exacerbation of Pulmonary Fibrosis

Query Text:
Principal diagnosis: Nitrofurantoin induced pulmonary hypersensitivity with exacerbation of Pulmonary Fibrosis

Do you code this adverse effect case as improper use or proper use?

Improper use groups to DRG X62B Poisoning/Toxic Effects of Drugs and Other Substances Age <60 W/O CC
T37.8 Other specified systemic anti-infectives and antiparasitics
J70.4  Drug-induced interstitial lung disorders, unspecified
Y14    Poisoning by and exposure to other and unspecified drugs, medicaments and biological substances, undetermined intent
Y92.09  Other and unspecified place in home

Proper use groups to DRG E75C Other Respiratory System Diagnosis Age <65 W/O CC
J70.4   Drug-induced interstitial lung disorders, unspecified
Y41.8  Other specified systemic anti-infectives and antiparasitics
Y92.09 Other and unspecified place in home

Background (prior to this admission):
Started nitrofurantoin 4 years ago for recurrent UTI. Saw Cardiologist who was not keen for patient to continue nitrofurantoin. Saw Urologist who suggested ceasing nitrofurantoin and taking cranberry juice / tablets instead.

During the previous episode (discharged a week before this admission) nitrofurantoin was ceased and not supplied on discharge, however patient continued taking it at home.

Nitrofurantoin was again ceased upon this current admission.

Given that it is not clear whether the patient was given a clear directive to cease nitrofurantoin prior to this admission, do we assume proper use due to the long term taking of the drug (by prescription), or improper use given the specialists had previously suggested ceasing the medication without evidence of actually ceasing it?

Response:
The VICC considers this scenario should be coded as an adverse effect because the clinician has described the pulmonary hypersensitivity as drug induced and there is no clear documentation to support improper use of the drug.  

Therefore the suggested codes to assign are:
J70.4  Drug-induced interstitial lung disorders, unspecified
Y41.8 Other specified systemic anti-infectives and antiparasitics
Y92.22 Health service area


Query Title:
Hyperstimulation of uterus due to syntocinon infusion

Query Text:
In a recent coding meeting HIMs reported that they are increasingly seeing documention in the medical record of hyperstimulation of the uterus due to syntocinon infusion. This often results in the syntocinon infusion being decreased or stopped completely

Currently this is coded to O62.4 Hypertonic, incoordinate, and prolonged uterine contractions as this is seen to be the best fit code.

Can the committee please advise whether the one code appropriately captures this diagnosis or whether coders should code this diagnosis as an adverse drug reaction as below.

O62.4  Hypertonic, incoordinate, and prolonged uterine contractions
Y55.0  Oxytocic drugs
Y92.22 Health service area

Response:
The intent of syntocinon is to stimulate the uterus and it is standard obstetric care to adjust the dose based on the patient's response.  Management of the dose is essential to prevent hyperstimulation while at the same time providing enough stimulation to achieve the desired outcome.

VICC considers O62.4 Hypertonic, incoordinate, and prolonged uterine contractions is the correct code to assign for documentation of hyperstimulation of the uterus following index entry Contraction, uterus, abnormal, hypertonic.  

If documentation supports a link between the hyperstimulation and the proper use of syntocinon, follow ACS 1902 Adverse effects and assign additional codes to indicate an adverse effect.


Query Title:
Mesh erosion post anterior-posterior vaginal repair

Query Text:
Please provide coding advice to the following case.

Principal diagnosis: Mesh erosion post anterior-posterior vaginal repair (with mesh implant) 
Procedure: Excision of mesh erosion, under GA (ASA 1)

We currently code the above case to: 
T83.8 Other complication of genito-urinary prosthetic device, implants and grafts
Y83.1 Surgical operation with implant of artificial internal device
Y92.22  Health service area 
90438-00 [1288] Other procedure on vagina
92514-19 [1910] General Anaesthesia, ASA 1
DRG  801C OR Procedure unrelated to Principal diagnosis W/O CC WIES 0.9079

Sometimes a histological report is provided, which may give further detail to the mesh erosion, for example the report may state “ulceration, inflammation and foreign material consistent with the mesh erosion.” In this example we would code the principal diagnosis to:
T83.6 Infection and inflammatory reaction due to prosthetic device, implant and graft in genital tract

Our query is in regards to the procedure code as it affects the DRG allocation to the case. In most cases, the eroded parts of the mesh are removed and sometimes the mesh resited but not completely removed. We have discussed the potential of other procedure codes which may apply to the case. These are listed below:
90606-01 [1661] Removal of other soft tissue implant
92116-00 [1900] Removal of other device from genital tract
30023-00 [1566] Excisional debridement of soft tissue

We understand that there needs to be documentation or confirmation of debridement before assigning the procedure code as per ACS 1203 Debridement. However, selection of a procedure code from the above will group the episode to a more suitable DRG than to 801C OR Procedure unrelated to Principal diagnosis W/O CC. Please advise a correct procedure code for excision of mesh erosion.

Response:
Research undertaken by VICC indicates that mesh erosion refers to the breakdown of internal tissue due to irritation or infection caused by a foreign material such as synthetic mesh and a lesion is defined as as an area of tissue damage.

Based on the information provided VICC considers the appropriate procedure codes to assign are:
35557-00 [1282] Excision of lesion of vagina following index entry Exision, lesion, vagina and 
92116-00 [1900] Removal of other device from genital tract for excision of mesh itself if it is excised.

VICC does not consider procedure codes 90606-01 [1661] Removal of other soft tissue implant and 30023-00 [1566] Excisional debridement of soft tissue to be appropriate as the vagina is an organ (not soft tissue) and there is no documentation of debridement.

DRG 801C is designed to accommodate cases where the principal diagnosis is in a different MDC to the procedure code, such as this case.


Query Text:
How should we code a 'high output stoma' (in this case a ileostomy) that is deferring a patients discharge and causing them to develop hypokalaemia? These patients often require a lot of stomal care while in hospital.

Is this a complication of the stoma, or a post-procedural complication of the GI tract or a 'disorder of the intestine'? 

We have spoken to one of our stomal therapy nurses and they stated that a stoma is considered 'high-output' once it goes above 1.5L per day. It will increase length of stay as patients require IV fluids to maintain hydration - oral fluids exacerbate the problem.  This would lead us to believe that the correct code for this problem would be:
K91.8 Other postprocedural disorders of digestive system, not elsewhere classified - followed by appropriate external cause codes. 

It would not be K91.4 Colostomy and enterostomy malfunction - as there is nothing wrong with the stoma itself. 

Could you please confirm that we have selected the correct code for the above scenario?

Search Details: 
http://www.o-wm.com/article/6018  goes through the complications associated with high output faecal stomas.

Response:
Research undertaken by VICC indicates that high output stoma is a functional complication of the stoma. The positioning of the stoma and which bits of intestine it involves are vital in determining how it functions. 

Based on this information, VICC suggests the appropriate code to assign is K91.4 Colostomy and enterostomy malfunction.


Query Title:
Delirium secondary to urinary tract infection (UTI)

Query Text:
We have a patient with a principal diagnosis of delirium secondary to UTI for which we are having difficulty deciding on the principal diagnosis code.

The patient was admitted with delirium and during the course of the admission a UTI was identified. The delirium resolved after treatment of the UTI.

Should the principal diagnosis be the N39.0 Urinary tract infection, site not specified or F05.9 Delirium, unspecified
or F05.0 Delirium not superimposed on dementia, so described?

Some coders are applying advice from the ICD Coding Newsletter November 2002 'Underlying condition as Principal Diagnosis' and coding the delirium as principal as it is the condition that occasioned the episode of care.  Is this advice still current?

Other coders are applying ACS 0001 Principal diagnosis 'Problems and underlying conditions' and coding UTI as the underlying condition and not coding the problem of delirium.

Response:
The VICC notes that in order to determine the principal diagnosis in this scenario, there are two parts of ACS 0001 Principal Diagnosis that can apply both providing direction for coders to make a decision:
- Problems and underlying conditions; or
- Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis

VICC suggests to apply the part of ACS 0001 appropriate to your case based on the documentation in the medical record as without access to the complete medical record VICC is unable to provide specific advice in this scenario.

VICC also notes that the ICD Coding Newsletter November 2002  article 'Underlying condition as Principal Diagnosis' has been superseded by revisions to the Australian Coding Standards.

With regard to the choice of delirium code, F05.0 Delirium not superimposed on dementia, so described seems appropriate as there is documentation linking the delirium to a medical condition, following Index entry Delirium, due to, general medical condition.


Query Text:
Our hospital is submitting a request to DH to do a trial of a new procedure called sinuplasty. We are wanting to be able to cost this procedure and so would like to be able to have an idea of the procedure codes that would be used.  The procedure description is: 
A sinuplasty is an alternative to a FESS; a balloon is used to open the blocked sinus ostium and in many cases without tissue or bone removal. The balloon is one similar to that used for angioplasty (but more robust as it stretches bony tissue). The sinuplasty patients are done under sedation rather than GA in most circumstance but can be combined with traditional FESS surgery. 

The procedures are to treat chronic sinusitis where facial pain and congestion occur. Patients are day cases unless combined with a FESS.  It can be performed on all sinuses except the Ethmoid sinus.  It will be performed via sinoscopy.

Could you please advise on an appropriate code for this procedure and / or how I would go about using the index to find the appropriate code. I am not sure if I should be using a sinus surgery codes such as:
41716-04 [370] Sinoscopy
41752-00 [389] Other intranasal procedure on sphenoidal sinus
41737-00 [389] Other intranasal procedures on frontal sinus

Or using codes to show they are using a balloon to open the sinus, but I am unsure how to go about using the index to find an appropriate code.

Response:
As there is no index entry available to look up sinuplasty, follow index entry 'Procedure, nasal sinus…' to assign the appropriate code for the sinus(es) treated. Based on the information provided the codes listed in the query seem correct.  However once the trial begins it is recommended you check the operation report and code in accordance with the documentation.


Query Title:
Stroke with hemiplegia which resolves prior to admission

Query Text:
A patient has a stroke with hemiplegia, the hemiplegia resolves prior to admission, but the patient is treated for the stroke do we still code the hemiplegia as per ACS 0604 Stroke  'While the patient is receiving continuing treatment, regardless of the period of time elapsed since the stroke, assign a code from I60-I64 with any applicable deficit codes (eg hemiplegia).  

Or does hemiplegia have to meet ACS 0002 in light of Coding Matters Volume 16 Number 1 Poisoning (OD with arrhythmia treated at the scene, arrhythmia must meet ACS 0001 or ACS 0002 to code it as a manifestation).


Search Details: 
ACS 0604 Stroke
Coding Matters Volume 16 Number 1 June 2009

Response:
This query was originally published in the 2011-12 September VICC queries database release as follows:
VICC referred this query to the NCCC who assigned the query a low priority (see the ICD/ACHI/ACS Evaluation Criteria Definitions on the NCCC website at: http://nccc.uow.edu.au/icd10am/submitquery/index.html).  Consequently it was referred back to VICC to answer as an interim measure.

VICC interprets 'applicable deficit' in the sentence in ACS 0604 Stroke which says 'While the patient is receiving continuing treatment, regardless of the period of time elapsed since the stroke, assign a code from I60-I64 with any applicable deficit codes (eg hemiplegia)' to mean that the deficit must meet ACS 0002 Additional diagnoses for a code to be assigned.

There is no note in ACS 0604 Stroke to say 'deficits should always be coded even if the criteria for additional diagnosis is not met' in the way such notes appear in some other ACS, such as 0104 Viral hepatitis.

As in your scenario the hemiplegia resolved prior to admission, the deficit does not meet ACS 0002 so therefore a code for hemiplegia is not assigned.

Following publication of Coding Q&A June 2012 the original response is supported by the following advice titled Stroke with hemiplegia:

Query : 
ACS 0604 Stroke, 1. Current, Sequelae (late effects) states: 
"While the patient is receiving continuing treatment, regardless of the period of time elapsed since the stroke, assign a code from categories I60-I64 (cerebrovascular diseases) with any applicable deficit codes (eg hemiplegia)." 

Given the above, should a code be assigned for hemiplegia where a patient is admitted for treatment of a stroke but the hemiplegia has resolved prior to admission? 

Answer: 
For the scenario cited, the hemiplegia should not be coded as the deficit (hemiplegia) is not an 'applicable' deficit when it has resolved and does not meet the criteria for assignment as per ACS 0002 Additional diagnoses.


Query Title:
Abdominoplasty for reduction of the excess skin

Query Text:
As a positive result of lap band surgery many patients represent for abdominoplasty for reduction of the excess skin. 

After checking the 10 AM Commandments Volume 8 Number 2 September 2001,  I refer to Abdominal Apron/overhang for the use of Code E65 Localised adiposity.

Whilst the wording of excess/loose skin or marked weight loss requiring abdominoplasty is not the same as 'abdominal apron' or 'abdominal overhang' can this code be applied for elective abdominoplasty? 

So far we have been using a code from the skin chapter from L98- Disorder of skin and subcutaneous tissue.  Is this the appropriate code?

Response:
Abdominal overhang refers to localised adiposity rather than to excess skin as per Coding Matters Volume 8 Number 2 September 2001, therefore the advice in Coding Matters is not relevant to the case cited.

VICC considers the appropriate diagnosis code to assign for these cases is Z42.2 Follow-up care involving plastic surgery of other parts of trunk in accordance with the advice in ACS 1204 Plastic surgery.


Query Title:
Index entry for urothelial papillary carcinoma

Query Text:
A patient with urothelial papillary carcinoma.  We have noticed that in the index if you look up under carcinoma, urothelial, papillary, it does not give you the further subindex of 'low grade malignancy potential', whereas if you look under carcinoma, papillary, urothelial it does give the 'low maligancy potential' further option. 

This appears to be an anomoly depending which you look up first.  Should coders be made aware of this and can it be passed onto NCCH for next edition if you think it warrants?

Response:
In Third Edition revisions were made to ICD-10-AM which incorporated codes from WHO's International Classification of Diseases for Oncology (ICD-O), Third Edition.  At that time NCCH acknowledged that the index to morphology codes was incomplete. Coders are therefore required to use all possible lead terms to look up morphology in the index to ensure code selection reflects the medical statement.


Query Text:
We have a patient who presented to the emergency department following an epsiode of loss of consciousness (LOC) whilst eating lunch at home. LOC lasted 15 minutes. Cause of LOC is unknown. 

Doctor's discharge diagnosis was Episode LOC, resolved spontaneously, no further events.

As S06.02 Loss of consciousness of brief duration [less than 30 minutes] is a chapter 19 injury code  an external cause code also needs to be assigned.  What is the correct external cause code to assign when the external cause is unknown?

Search Details: 
ACS 1905 Closed head injury/loss of consciousness/concussion

Response:
The VICC advises that because the loss of consciousness is unrelated to a head injury, in accordance with ACS 1905 Closed head injury/loss of consciousness/concussion the correct code to assign is R40.2 Coma, unspecified following index entry Unconscious(ness).  As this is a non-traumatic loss of consciousness an external cause code is not required.


Query Text:
Two week old readmitted with fever, diagnosed with UTI.  Commenced on antibiotics; planned for 48 hours of IV antibiotics. IV antibiotics started at 20:45 29/6, patient given another couple of doses, then at 14:00 30/6, antibiotics not given as the IV has tissued, but patient given IM antibiotics at 21:00 30/6. Discharged 1/7.  In total, patient had >24 hours of antibiotics as per ACS 1615 Specific interventions for the sick neonate but given by two routes, each < 24 hours.

ACS 1615 Specific interventions for the sick neonate under heading Parenteral antibiotics/anti-infectives says 'Procedure codes for injection of antibiotics and other anti-infectives should be assigned only when given for > 24 hours (see block [1920] Administration of pharmacotherapy with extension of -02).'

Does that mean that because I would have two separate codes (one IV, one IM and neither for > 24 hours), I can’t code the antibiotics?

Response:
The VICC advises that in the case cited, the administration of antibiotics has exceeded 24 hours therefore meeting the definition in ACS 1615 Specific interventions for the sick neonate.  As the antibiotics have been administered via two routes, it is appropriate to assign two procedure codes (one for IV and one for IM).


Query Title:
Injury and subsequent repair of tendon sheath of middle finger

Query Text:
What are the correct codes to assign for injury and subsequent repair of tendon sheath of middle finger? 

Clinically the actual tendon was deemed to be intact which was confirmed intra-operatively and only the tendon sheath was repaired.

I note that a code exists for open procedure on tendon sheath 47972-00 [1572] Open procedure on tendon sheath, not elsewhere classified but a specific code for injury to tendon sheath does not. 

Is an injury to a tendon sheath coded to injury of tendon S66.3 Injury of extensor muscle and tendon of other finger at wrist and hand level?

Search Details: 
tabular notes at beginning of chapter 19, specifically page 394 'Injury to muscle, fascia and tendon including...(tendon sheath is not specified)

Response:
Revised query response:

This query was originally published in the 2010-11 June Database as follows:

VICC research indicates that a tendon sheath is a membranous sleeve which envelops the tendon and creates a lubricated low friction environment for easy movement. In many parts of the classification the term sheath is classified with tendon as a non-essential modifier indicating that sheath should be classified to tendon.

Therefore in the absence of a specific code for tendon sheath in ICD-10-AM, it is appropriate to code to injury of tendon S66.3 Injury of extensor muscle and tendon of other finger at wrist and hand level.


This query has been reviewed for currency and has been updated as follows:

VICC research indicates that a tendon sheath is a membranous sleeve which envelops the tendon and creates a lubricated low friction environment for easy movement. In many parts of the classification the term sheath is classified with tendon as a non-essential modifier indicating that sheath should be classified to tendon.

Therefore in the absence of a specific code for injury of tendon sheath in ICD-10-AM, it is appropriate to code as injury of tendon. VICC advises, for an injury of tendon sheath of finger assign an appropriate code from category S66 Injury of muscle and tendon at wrist and hand level.


Query Title:
Principal diagnosis selection for patient transferred for active treatment

Query Text:
Can the committee please provide some advice on the correct codes to use in the following scenario:

Patient transfered from another regional hospital, where they had had an initial hemicolectomy, then re-opening of laparotomy site for division of adhesions. The patient was transfered to our hospital with the development of an ileus, hypoalbuminaemia and chest infection, for CVC, TPN and antibiotic treatment.

I'm not sure if the principal code should be Z48.8 Other specified surgical follow-up care or K91.3 Postprocedural intestinal obstruction.

In the Coding Commandments (below) it seems to indicate that you don't have to use Z48.8 for all post surgical transfers, but I'm not sure if I've interpreted that correctly.

Volume 10 Number 3 December 2003
Admission for convalescence/aftercare  ACS 2103
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

Are you able to give some guidance as to the correct codes to use when a patient is transfered from one hospital to another, for active treatment (usually due to lack of resources at the transfering hospital).

Response:
The VICC advises that in the case cited the correct principal diagnosis is the condition that necessitated the transfer.  This is because the patient was not transferred for post operative convalescence as described in the Coding Matters advice Volume 10 Number 3.  Therefore you have interpreted the advice correctly.


Query Text:
Please refer to VICC #2005 Diabetes with stenosis of iliac artery (4th edition). This query advises coders to assign I70.8 atherosclerosis of other arteries. 
 
We have clinical advice from our vascular surgeons that the iliac artery is a peripheral artery and therefore should be coded to I70.2- atherosclerosis of arteries of extremities. (Peripheral vascular disease refers to any disease or disorder of the circulatory system outside of the brain and heart. See link below)

In light of this will the Committee please reconsider the advice to code stenosis of the iliac artery to I70.8 and issue advice that iliac artery stenosis/ arteriosclerosis should be coded to PVD I70.2-.

Search Details: http://www.emedicinehealth.com/peripheral_vascular_disease/article_em.htm

Response:
The VICC notes that whilst clinical advice indicates that the iliac artery is a peripheral artery, the classification defines peripheral as extremities and nowhere in the classification is the position of the iliac artery classified as a peripheral site.  

Therefore for documentation of stenosis of the iliac artery, follow ACS 0941 Arterial disease to determine if it can be coded to atherosclerosis and if so, follow the Index entry Atherosclerosis/specified artery NEC I70.8.


Query Title:
Metabolic acidosis in a diabetic patient

Query Text:
Please advise on the coding of metabolic acidosis in a diabetic patient.  There is VICC #2125 requesting the same information, but this advice is a few years old and the Index has changed since this advice was published.

The answer to that query was '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'.  

However, there is now an Index entry for Diabetes, with, acidosis (See also Diabetes, with, ketoacidosis) and the part in brackets is new since the answer to VICC #2125.

This is causing much discussion at my hospital as some of the coders believe they should code according to the advice in #2125 and others believe that they should follow the index entry to 'see also Diabetes, with, ketoacidosis',

Response:
The VICC notes that the advice in VICC #2125 Metabolic acidosis with diabetes mellitus published in the 2004-05 Fourth quarter newsletter has been superseded by the changes in the index.  

Therefore it is now appropriate to follow index entry Diabetes, with, acidosis — see also Diabetes, with, ketoacidosis for documentation metabolic acidosis in a diabetic patient.  Refer to ACS 0401 Diabetes mellitus and impaired glucose regulation section titled Diabetes with ketoacidosis under heading Complications in Diabetes and IGR, Acute metabolic complications.


Query Title:
Coding of indwelling catheter (IDC) insertion

Query Text:
When should IDC insertion for continous bladder washout performed by doctor for haematuria/clot retention, be coded?

In this instance the IDC was inserted by a doctor on the ward under local anaesthetic (LA) and bladder washout commenced and run for four days continuously. Output is strictly monitored, catheter required replacing by medical staff when clotted off, and regular medical review performed.

Now defunct NCCH coding query Q2040 stated code only when it is a significant procedure. What is considered to be significant? 

Search Details: VICC
Previous NCCH Q2040 Bladder Washout

Response:
The VICC notes that the fact that the procedure was performed by medical staff is not relevant to the coding decision. Whilst the NCCH response to VICCs query #2016 (NCCH Q2040) dated 3/05/05 stated that bladder washout should only be assigned when it is a significant procedure, a subsequent response on 29/07/2005 advised not to code the procedure.

VICC does not consider this procedure should be coded and this is supported by Seventh edition ACS 0042 Procedures normally not coded point 2 Bladder washout via indwelling catheter.


Query Text:
I refer to VICC Query #2356 regarding laparoscopic sleeve gastrectomy.  The advice says to assign codes 30523-00 [879] Subtotal gastrectomy and 30390-00 [984] Laparoscopy.  

I have subsequently come across advice from the WA Coding Committee that advises to code Laparoscopic Tube Gastrectomy to 30511-01 [889] Laparoscopic gastric reduction.

To obtain nationally consistent advice to code this procedure could VICC please refer this to the NCCH?

Response:
The VICC notes the advice published in Coding Matters Volume 17 Number 1 June 2010 under Duodenal switch which says:
"The duodenal switch (DS) procedure is a modified biliopancreatic diversion, sometimes known as a biliopancreatic diversion with duodenal switch (BPD-DS).

Biliopancreatic diversion, or bypass procedures, are principally malabsorptive procedures, but may include an element of restrictive surgery to reduce the size of the stomach.
Both the unmodified biliopancreatic diversion and the BPD-DS include a partial gastrectomy.

In the unmodified biliopancreatic diversion, a distal gastrectomy is performed, while in the BPD-DS a ‘sleeve’ gastrectomy is performed along the vertical axis of the stomach, preserving the pylorus and initial segment of the duodenum, which is then anastomosed to a segment of the ileum.

The ‘sleeve’ gastrectomy keeps the pyloric valve intact and eliminates the possibility of dumping syndrome, marginal ulcers, stoma closures and blockages, all of which can occur with other bypass/diversion procedures. 
In addition, it keeps a portion of the duodenum in the food stream. The preservation of the pylorus/duodenum pathway means that food is digested normally in the stomach before being excreted by the pylorus into the small intestine. As a result, the DS procedure enables more ‘normal’ absorption of many nutrients than is seen after other bypass/diversion procedures. 

However, the basic principle of the DS procedure is the same as the unmodified biliopancreatic diversion i.e. producing selective malabsorption by limiting the food digestion and absorption to a short common ileal segment. 

Therefore, the correct procedure code to assign for the DS procedure is 30512-02 [889] Biliopancreatic diversion or 30512-01 [889] Laparoscopic biliopancreatic diversion as appropriate, following the index pathway:
Biliopancreatic diversion (open) 30512-02 [889]
- laparoscopic 30512-01 [889]

In addition, assign 30511-01 [889] Laparoscopic gastric reduction or 30511-00 [889] Gastric reduction as appropriate, to specify the gastrectomy (restrictive component of the procedure), following the index pathway:
Reduction
- gastric (for morbid obesity) 30511-00 [889]
- - laparoscopic 30511-01 [889]"

Therefore, in accordance with the above advice assign 30511-01 [889] Laparoscopic gastric reduction for documentation of laparoscopic sleeve gastrectomy.  VICC has amended the advice in #2356 Laparoscopic sleeve gastrectomy to align with this advice.


Query Title:
Additional diagnoses for adjustment, management, fitting or removal of VAD, VC or DDD sameday admissions

Query Text:
I refer to VICC Queries #2127 Coding of cancer with insertion/removal infusaport, #2148 Insertion and removal of infusaport, #1958 ACS 0236 Neoplasm coding and sequencing and # 2433 Chemotherapy.

I wish to obtain clarification on the assignment of additional diagnoses for same day admissions for the adjustment, management, fitting or removal of vascular access devices (VAD), venous catheters (VC) and drug delivery devices (DDD).  Do such same day admissions require the assignment of neoplasm or non-neoplastic codes as additonal diagnoses?

Search Details: 
ACS 0002 Additional Diagnoses
ACS 0236 Neoplasm coding and Sequencing
Coding Matters Volume 15 No.1 June 2008, VADs, VCs & DDDs
Coding Matters Volume 15 No.2 September 2008, ICD-10-AM Commandments, Frequently asked Questions, Pharmacotherapy

Response:
The VICC advises that the responses to all the queries cited in this query have been superseded by the advice article titled Vascular Access Devices, Venous Catheters And Drug Delivery Devices published in Coding Matters Volume 15 Number 1 June 2008.

Therefore, only assign additional diagnoses for same day admissions for the adjustment, management, fitting or removal of vascular access devices (VAD), venous catheters (VC) and drug delivery devices (DDD) if the condition meets ACS 0002 Additional diagnoses.


Query Title:
Anaemia in patient with blood loss and chronic kidney disease

Query Text:
A patient is admitted with per rectum (PR) bleeding post polypectomy two weeks ago. Required ICU attendance.  The ICU summary states Diagnosis: 1. PR bleed secondary to recent polypectomy  2. Anaemia secondary to PR bleed. Packed cells were administered and a Nuclear Med Bowel Haemorrhage Study was performed.  This study concluded an active, brisk bleeding site is identified in the caecum.  This patient also has NIDDM with CRF stage 5.  

My query is whether the anaemia should be coded to D63.8 Anaemia in other chronic diseases classified elsewhere as ACS 1438 Chronic Kidney Disease, page 214 states, or do we follow the Index for Anaemia, due to, loss of blood to assign D50.0 Iron deficiency anaemia secondary to blood loss (chronic) as described in the notes that the anaemia is due to PR bleed.  

This patient does not have a past history of anaemia.  We need to keep in mind that 'the main aim of coding is to translate medical statements into code' (ACS 0027 Multiple coding).

Search Details: 
ACS 1438 p 214 Anaemia in CKD
Index, Anaemia, due to, loss of blood

Response:
The VICC advises to follow ACS 1438 Chronic kidney disease under heading 'Anaemia in kidney disease', which states:
When anaemia is documented:
1. as linked to, or in the presence of, chronic kidney disease, stage 3 or higher, or chronic renal impairment/failure (CRI/F) with an eGFR <60mL/min, AND
2. it meets ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses,
assign N18.3 – N18.5 Chronic kidney disease stage 3 – stage 5 or N18.9 Chronic kidney disease, unspecified with D63.8* Anaemia in other chronic diseases classified elsewhere.

It is not necessary to assign an additional code to specify the type of anaemia.

Please note that D63.8* Anaemia in other chronic diseases classified elsewhere has been deactivated in Seventh edition.


Query Text:
Our hospital specialises in IVF and I have a question about whether the ultrasound code 55054-00 [1949] Intra-operative ultrasound of other site should also be assigned  for the following  procedures:
13212-00 [1297] Transvaginal oocyte retrieval
13215-01 [1297]  Embryo transfer to uterus

Search Details: 
ACS 0042 procedures normally not coded

Response:
In the ACHI tabular under the two procedure codes 13212-00 [1297] Transvaginal oocyte retrieval and 13215-01 [1297]  Embryo transfer to uterus there is an includes note for ultrasound assistance which means that the ultrasound does not have to be coded in addition to the  procedures performed.


Query Text:
PICQ indicator 101654 identifies records containing the re-operation for other cardiac procedure NEC code as the only cardiac procedure code. ACS 0934 Cardiac revision/re-operation procedures states that where there is no specific code for a re-operation, the actual procedure is coded followed by the re-operation code.  A note with the re-operation code also instructs to code first the surgical procedure(s) performed.

We have recently had two cases where this PICQ was triggered, and we believe the coding to be correct. The cases were very similar and involved the following scenario:
Patient had a history of cardiac surgery (open procedure) and admitted to us for insertion of new epicardial leads and pacemaker. The operation report states sternotomy re-opened.  Therefore the following codes were used: 

Case 1 - 
38353-01 [655] REPLACEMENT CARDIAC PACEMAKER GENERATOR 
38456-24 [654] REPLACE EPICARDL ELEC PCMKR THMY STMY 
38470-00 [649] INS PERM EPICARDL ELEC PCMKR STMY /THMY 
38640-00 [664] RE-OPERATION FOR OTHER CARDIAC PROC, NEC 
92514-39 [1910] GENERAL ANAESTHESIA, ASA 39

Case 2 - 
38353-01 [655] REPLACEMENT CARDIAC PACEMAKER GENERATOR 
38640-00 [664] RE-OPERATION FOR OTHER CARDIAC PROC, NEC  
92514-49 [1910] GENERAL ANAESTHESIA, ASA 49 
 
We were wondering if this error should be reclassified as a warning (W1), and could you please advise on how we should be coding these cases in the meantime?

Response:
ACS 0934 Cardiac revision/reoperation procedures states that 'Where no specific revision or reoperation code exists in the ACHI Tabular List for a particular cardiac procedure, assign the code for the procedure type followed by 38640-00 [664] Reoperation for other cardiac procedure, not elsewhere classified.'

As the code titles of the codes assigned for both cases cited in the query describe that the original procedure has been re-performed,  VICC does not consider that the addition of 38640-00 [664] Reoperation for other cardiac procedure provides any further information.  VICC therefore advises the code for re-operation is not required and that therefore the PICQ error triggers correctly.


Query Title:
Coronary angioplasty with rotablator and stent insertion

Query Text:
What is the correct code to assign for a coronary angioplasty with rotablator and stent insertion?  For example, PCI with rotablator and stent to the proximal circumflex lesion.  Is it 38306-00 [671] or 38312-00 [669]?

The index for angioplasty includes 'by rotablator' as an non-essential modifier so most of our coders assign codes from blocks [670] or [671].  However in the tabular list of blocks [671] and [670] there is an excludes note 'with atherectomy of coronary artery (see block [669]).

According to a coding feature in ICD Coding newsletter August 2001 the rotablator is a high speed mechanical rotational arterectomy device.  Therefore should a code from block [669] be assigned when rotablator is documented?

Search details:
Coding feature ICD coding newsletter 2001 (out of date but very useful in educating new coders re these procedures).
Angioplasty index entry

Response:
The VICC agrees that for documentation of coronary angioplasty with rotablator and stent insertion, the correct code to assign is 38312-00 [669] Percutaneous transluminal coronary rotational atherectomy [PTCRA], 1 artery with insertion of 1 stent. The term 'rotablator' should be an essential modifier in the index.  

The VICC will send a public submission to NCCH requesting that the index is corrected.


Query Text:
How do you code a hair tourniquet?

Discharge summary said that mother had been bathing baby and had created a hair torniquet of toe, right foot.  Baby needed to be taken to theatre for incision of toe down to bone and removal of foreign body toe.  Baby was 8 weeks old.  

I have coded the following:
S90.84 Superficial foreign body (splinter) of ankle and foot
Y29 Contact with blunt object, undetermined intent
Y92.03 Bathroom
U73.2 While resting, sleeping, eating or engaging in other vital activities

30223-02 [1606] Other incision and drainage of skin and subcutaneous tissue
30064-00 [1605] Removal of foreign body from skin and subcutaneous tissue with incision
92514-19 [1910] General anaesthesia, ASA 19

Response:
In the absence of an operation report, VICC considers the appropriate codes to assign based on the information detailed in the query are:
S90.84 Superficial foreign body (splinter) of ankle and foot
W45.9 Foreign body or object entering through skin (by following index entry Foreign body, skin)
Y92.03 Bathroom
U73.2 While resting, sleeping, eating or engaging in other vital activities

For the procedure code, assign a code for removal of foreign body with incision to the appropriate level (for example, skin and subcutaneous tissue or soft tissue) as indicated on the operation report; and
92514-19 [1910] General anaesthesia, ASA 19

A separate code for incision is not required if the incision is included in the removal of foreign body code.


Query Title:
Neonatal documentation and coding practices for ventilatory support

Query Text:
Over the past month HIMs in consultation with senior medical staff been involved in the auditing and clarification of neonatal documentation/coding practices. 

One thing that we have concentrated on in some detail is the fact that procedures 13882-02 [569] Management of continuous ventilatory support, >= 96 hours or 92209-02 [570] Management of noninvasive ventilatory support, >= 96 hours
will change the DRG from a medical DRG to a significant OR procedure DRGfor babies over 1000g. The fact that the patient has 95 hours of Mechanical ventilation and then another 95 hours of CPAP will not put these patients into a higher DRG even though the length of ventilation is over 96 hours.

Senior neonatal staff were involved in the analysis of current coding standards and agreed with ASC 1614 - Respiratory distress Syndrome (RDS)/Hyaline membrane disease (HMD) that when diagnosed with primary lung disease it is expected the baby will deteriorate and the plateau within the first 60 hours of life, at this stage they often need increased ventilator support (often mechanical ventilation), after this point RDS/HMD will resolve in which time the baby is weaned to CPAP and then to air.

ACS 1006 Ventilatory Support states “Do not code methods of weaning (eg CPAP, IMV) from ventilatory support separately. Weaning is included in calculating the length of time that a patient is on ventilatory support. There may be several attempts to wean the patient off the ventilator. Weaning may include changing the type of ventilation from CVS to CPAP or BiPAP; include the duration of CPAP or BiPAP weaning in the cumulative hours for the CVS.”

Our Neonatal consultants have raised concerns that the coding standards were somewhat outdated in relation to current neonatal clinical practice. The clinical issue they raise is that adults (whose weaning is part of the CVS) are weaned via ETT CPAP, whereas neonates are not weaned via ETT CPAP because of the airways resistance through their small diameter tubes and the risk of blockage by secretions; thus neonates are more effectively and safely weaned using nasal CPAP; other than the airway device.

See comments from one of our Senior Neonatal Consultants – “this highlights the problem of coding semantics versus good clinical practice. In neonates with HMD, which correctly is noted to take 5-7 days for full recovery, in previous years we did wean from ETT CVS to ETT CPAP; however it was then shown that weaning to NIV CPAP was more effective and had less complications than weaning to ETT CPAP, hence the change in practice. But for babies with a diagnosis of HMD this is still weaning. If this is not allowed, then there is an encouragement to go back to weaning via an ETT, which would be a retrograde step - and one which I don't believe clinicians would accept. To deny NIV CPAP during the weaning process as part of 96 hour continuous support is penalizing good clinical practice. And, by the way, the care of a baby on nasal CPAP is often every bit as complex as care on ETT CPAP, and sometimes more so.

The above comments relate specifically to babies with an established diagnosis of HMD (RDS). I believe that weaning via NIV CPAP should be deemed to be true weaning, and that this ruling should be put in place now.

There is a further issue of whether hours on NIV and hours on CVS can be combined. If a baby who has >= 96 hours on NIV is raised into a DRG with OR procedure as is a baby with >= 96 hrs CVS, I fail to see the logic in denying the same DRG status to babies who have <= 96 hours on either mode of support but >=96 hours when combined. I believe we should ask those that determine the rules around these issues to review urgently this particular issue in newborns.  Again this is in the context that NIV support can be every bit as complex as stable CVS via ETT."

From a coding perspective can the committe please clarify whether it is correct to include the hours of NIV as 'weaning from CVS'when a baby is weaned from CSV to NIV for continuing treatment of primary lung disease. Should these NIV hours therefore be included in the total number of CVS hours instead of assigning a separate code for NIV because 'weaning' was done via a non-invasive mechanism instead of via the ETT.

Search Details: 
ACS 1006 Ventilatory Support 
ASC 1614 Respiratory distress Syndrome/HMD
Neonatal consultants at the Royal Women's Hospital

Response:
The VICC advises that in accordance with ACS 1006 Ventilatory support NIV not performed for weaning from CVS cannot be included in the total number of CVS hours.  

The Department of Health will be asking hospitals that have a NICU to routinely report NIV hours in the Duration of Non-invasive Ventilation field via PRS/2 to enable monitoring of cases where the combined total of ventilatory support is ≥ 96 hours. 

In the meantime you may wish to consider sending a public submission to the National Casemix and Classification Centre (NCCC) to suggest a change to the coding rules for ventilatory support.


Query Title:
Morphology code for Non Small Cell Lung Carcinoma (NSCLC)

Query Text:
If a patient has a Non Small Cell Lung Carcinoma (NSCLC) documented all through notes and histopathology states 'large cell carcinoma' should we be coding this as:
a) M8012/3 Large Cell Carcinoma based on actual histopathology results as per ACS 0010 General abstraction guidelines; or b) M8046/3 Non-small Cell Carcinoma as it has a higher morphology code as per ACS 0233 Morphology

Response:
Clinical advice obtained by VICC indicates that lung cancers are generally divided into small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC).  Non-small cell lung cancer is divided further into adenocarcinoma, squamous cell carcinoma and large cell carcinoma histologies.  Sometimes the phrase non-small cell lung cancer (not otherwise specified or NOS) is used generically, usually when a more specific diagnosis cannot be made.  

Therefore for the case cited assign the morphology code for large cell carcinoma in accordance with ACS 0010 Clinical documentation and general abstraction guidelines under test results which says 'Laboratory, x-ray, pathological and other diagnostic results should be coded where they clearly add specificity to already documented conditions that meet the criteria for a principal diagnosis (see ACS 0001 Principal diagnosis) or an additional diagnosis (see ACS 0002 Additional diagnoses)'.  

VICC considers that ACS 0233 Morphology does not apply to this scenario because this is not a case of one morphological diagnosis with two histological terms.


Query Title:
Breast disorders with/without attachment difficulties

Query Text:
At a recent coding meeting we were looking at coding consistency and found that HIMs/clinical coders were coding breast disorders with/without attachment difficulties differently.  

The O91 Infections of breast associated with childbirth and O92 Other disorders of breast and lactation associated with childbirth codes require a 5th character to specify an attachment difficulty.  

Do we need to see written in the record 'baby has difficulty attaching to breast' before we assign the 'with' option?  Are we able to assign the 'with' option based on the following documentation?  This mother has grazed/cracked nipples.  On a postnatal care plan there is a section that states 'Mother demonstrates optimal positioning and attachment of baby with assistance'.  The variation form states 'baby very unsettled ++ and feeding 3/24, assistance with breastfeeding given very unsettled shift+++ mother crying from pain when attempting to feed or express'.  Lactation Consultant was asked to see mother 'Mother is anxious about breastfeeding and nipples are sensitive and tender. Baby was having a shallow latch as mother tends to not hold baby in close enough. Shown football hold and appeared to be happier with this.  Shown proper positioning etc. Needs reassurance and ongoing assistance to reinforce good attachment. Mother has grazed nipple and is tender.'

Are you able to advise if the above documentation supports coding 'with attachment difficulty'? We understand that most mothers require assistance with breastfeeding. Does the use of a nipple shield for grazed nipples justify coding with attachment difficulty?

Response:
VICC advises that the examples provided above do not represent sufficient documentation to support code assignment for attachment difficulty.  VICC does not consider documentation of the use of a nipple shield alone sufficient to assign a code for attachment difficulty.


Query Text:
Can you please advise of the correct code to assign for digital mucous cyst of the finger/thumb?
There is no Index entry under Cyst for digital. The internet site emedicine describes them as ganglion cysts of the digits. Should they just be coded to ganglions?

It seems odd that there is no disease code for this condition, but in the Inverventions Index there are entries for:
Excision
 -cyst
 --mucous
 ---finger 46495-00
 ---thumb  46495-00
These are described as excision of digit mucous cysts, not ganglionectomies.

Can you please advise of the best disease code to use for this condition (we seem to get a few each year of these).

Response:
VICC acknowledges that the Index is deficient in this area.  Clinical information indicates that a mucous cyst occurs in a joint, tendon or skin for which there are index entries.  Therefore we suggest you try to ascertain in which of the aforementioned structures the cyst occurs by reviewing the operation report or in consultation with the clinician and then code accordingly.

VICC will refer this query to the NCCC requesting that consideration be given to creating an index entry for Cyst, mucous with a default code.

Note: This query has been retired due to edition updates to the ICD-10-AM Alphabetic Index.


Query Title:
Exploratory laparotomy in trauma episodes

Query Text:
We would appreciate the Committee's guidance on the assignment of ACHI code 30373-00 [985] Exploratory laparotomy, particularly in trauma episodes.

At present coders follow:- 
1 ) Index entry - laparotomy - as operative approach - omit code and/or 
2)  Tabular Excludes note: exploration incidental to intra-abdominal surgery 
and do not assign the code for all cases where intra-abdominal repair has been done.

However, when a trauma patient has a suspected intra-abdominal injury, the entire abdominal cavity and all it's contents are explored to identify any injury that may need repair. 

We contend that this is not the same type of laparotomy (always documented as exploratory laparotomy) as an operative incision/approach laparotomy that is incidental to an intra-abdominal procedure for a known condition, for which the abdomen has to be opened to deal with a known condition.

Response:
VICC considers that 30373-00 [985] Exploratory laparotomy should only be assigned when the abdomen is explored and no further surgery is performed.  When an injury is found and repaired the exploratory laparotomy becomes the operative approach and is therefore incidental and not coded.

VICC acknowledges that the index entry for exploratory laparotomy is unclear and will send a suggestion to NCCC asking that the index entry be amended to be the same as that for exploratory thoracotomy.


Query Title:
Neotract Transurethral resection of prostate (TURP)

Query Text:
How do we code Neotract TURP?  A patient is admitted into hospital to have a Neotract TURP for treating his benign prostatic hypertrophy (BPH).  According to the operation report no TURP is performed.  Currently we are all coding this procedure differently, some of us code this to 90395-00 [1170] Other procedures on prostate; other people include code 
37203-00 [1165] Transurethral resection of prostate and other people code this to 37223-00 [1160] Insertion of prostatic stent/coil under ultrasound control.  

When codes 90395-00 [1170] or 37223-00 [1160] are assigned this groups to M06B Other Male Reproductive System OR Proc. W/O CC (WIES 2.8846).

If we include a TURP code this groups into M02B Transurethral Prostatectomy W/O Cats. or Sev. CC (WIES 1.0785).

A neotract TURP is a surgical device that directly opens the urethra in order to relieve urinary symptoms without the need to cut any prostate tissue. Small customised sutures are placed on either side of the prostate to lift the excess prostate tissue out of the way and restore the urethral opening.

Response:
Although TURP is documented in the title of the operation report, a prostatectomy was not performed and no stent/coil was inserted.  Therefore procedure codes 37203-00 [1165] Transurethral resection of prostate and 37223-00 [1160] Insertion of prostatic stent/coil under ultrasound control suggested in the query are not appropriate to assign for the case cited.

As there is no index entry for neotract TURP, VICC considers the appropriate code to assign for neotract TURP is 90395-00 [1170] Other procedures on prostate by following index entry 'Procedure, prostate NEC' in accordance with the definition of NEC in ACS 0041 Conventions used in the alphabetic index of interventions.  Review of the operation report indicates that a cystoscopy was performed so a code for the cystoscopy must also be assigned as per ACS 0023 Laparoscopic/arthroscopic/endoscopic surgery.


Query Title:
Seventh Edition ACS 0042 Procedures normally not coded and vascular access devices

Query Text:
With the Seventh Edition changes to ACS 0042 Procedures normally not coded in regard to arterial or venous catheterisation it is not very clear if VAD's are still be coded (given that they are a form of catheter).  

Does the fact that a reservoir insertion is performed exclude it from being just a catheter?  There was no discussion around this at the NCCH workshops and there is nothing in the education material, or the standard to clearly indicate one way or the other what we should be doing.

Response:
The VICC advises that ACS 0042 Procedures not normally coded, point 5 refers to catheterisation only.  As vascular access devices involve more than just catheterisation, they continue to be coded in Seventh Edition.


Query Text:
Patient has been admitted for a core biopsy of their liver. Referral to hospital states liver lesion suggestive of hepatic adenoma and liver biopsy for multiple arterially enhancing liver lesions with features atypical of haemangioma or focal  nodular  hyperplasia. All tumour markers negative.

Pathology came back with: 
Liver biopsy, needle cores, segment 8 lesion - features consistent with telangiectatic focal nodular hyperplasia (TFNH).  TFNH is now recognised as a morphologic variant of hepatocellular adenoma.

There is no other documentation for this case (Final diagosis, D/C summary, outpatient notes).

I have three questions:
1. We have coded this to:
D13.4 Liver
M8170/0 Liver cell adenoma
rather than following the index for FNH and coding it to K76.8 Other specified diseases of the liver:
Hyperplasia, hyperplastic 
-liver
--nodular, focal K76.8 

Is this correct?

2. If yes, are we able to assume from now on that a histological diagnosis of TFNH, with no other documentation, should be coded to a hepatocellular adenoma; as per the above histology - that TFNH is classified as a morphological variant of hepatocellular adenoma? (I have contacted the pathologist and a hepatobiliary surgeon and they both stated that they would classify and code the lesion to hepatocellular adenoma, as they now recognise and classify TFNH as a variant of hepatocellular adenoma).

3. If TFNH is now seen as a morphological variant of hepatocellular adenoma, can the index entry be varied to include telangiectatic and direct you to D13.4 and M8170/0 rather than K76.8 Other specified diseases of the liver (or do we need a new morphology code)?:
Hyperplasia, hyperplastic 
-liver
--nodular, focal K76.8 
---telangiectatic D13.4, M8170/0 or (M81_ _/0)?

Response:
In response to question one, although there is a comment on the histology that telangiectatic focal nodular hyperplasia (TFNH) is a morphological variant of hepatocellular adenoma, the actual diagnosis is TFNH.  Therefore coders should follow the classification guidelines and use the index entry 'Hyperplasia, hyperplastic, liver, nodular, focal' to assign K76.8 Other specified diseases of the liver.

In response to question two, it cannot be assumed that a diagnosis of TFNH with no further documentation can be coded to hepatocellular adenoma as you need to code according to the documentation.

In response to question three, VICC will forward your suggestion for an index entry of 'Hyperplasia, liver, nodular, focal, telangiectatic' leading to D13.4 Liver, to the NCCC.


Query Title:
Laparoscopic right hemi-colectomy and adhesiolysis

Query Text:
We are having trouble deciding on the correct codes to assign for the following scenario:
OPERATION: Laparoscopic right hemi-colectomy and adhesiolysis.  

PREOPERATIVE NOTE: This man had undergone a colonoscopy which had identified a tubulovillous adenoma with dysplasia around the caecal pole.  An attempted mucosal lift and endoscopic resection had been made but abandoned due to failure of the lesion to lift.  He was brought forward for a right hemi-colectomy to be performed laparoscopically.  

OPERATIVE DETAILS: Under general anaesthesia the patient was prepped and draped to expose the abdomen and an umbilical incision made and a Hasson cannula inserted with direct vision.

The pneumoperitoneum was established and two 5mm ports were inserted in the suprapubic and the left flank area and a left iliac fossa 12mm port.  

The laparoscopy revealed no obvious tumour in the pole of the caecum and no obvious spot tattoo.  There were no lesions in the liver and the remainder of the colon appeared normal.  There were adhesions of the appendix to the right pelvic wall and of the ileum to the pelvic brim and the right colon to the right abdominal wall.  It was necessary to divide these adhesions prior to commencing mobilization of the right colon.  This adhesiolysis took approximately 45 minutes.  

The right colon was then mobilized exposing the second part of the duodenum.  The hepatic flexure was then fully taken down.  Once good mobilization had been achieved the ileocolic vessels were divided using an ATW stapler.  

The bowel was then exteriorized through an extended umbilical incision whilst being protected with an Alexis plastic wound retractor.  A stapled side-to-side anastomosis was then performed between the ileum and the transverse colon at areas of well perfused bowel.  There was good bleeding from the staple line both internally which was sutured to control and externally after the second firing of the staple line.  Once some 3/0 PDS had been used to under-run these areas there was good haemostasis.  The staple lines were all reinforced and the staple lines buried in a purse-string manner at the crossed staple line.  The anastomosis was returned to the abdomen and a PDS used to close the fascia and 3/0 Monocryl for skin.


We're not sure if the operation codes used should be:
Option 1.
32003-01 [913] Right hemicolectomy with anastomosis
30390-00 [984] Laparoscopy 
30393-00 [986] Laparoscopic division of abdominal adhesions
to indicate that the right hemicolectomy was performed laparoscopically, 

OR
2.
32003-01 [913] Right hemicolectomy with anastomosis
30393-00 [986] Laparoscopic division of abdominal adhesions
as the laparoscopic division of adhesions shows that a laparoscope has been used.

Our problem is that for example, a patient had a laparoscopy with the intention of doing a right hemicolectomy, but the division of adhesions was too complicated, so an open procedure was performed, then the codes would be the same as in 2. above, so it doesn't truly reflect the operation performed.

Is it over coding to use both 30390-00 to show the right hemicolectomy was performed laparoscopically and 30393-00 for the division of adhesions?

We have actually had a number of similar procedures lately, and have been unsure as to the correct codes to assign.

Response:
VICC considers the appropriate codes to assign for the case cited are 
32003-01 [913] Right hemicolectomy with anastomosis and 30393-00 [986] Laparoscopic division of abdominal adhesions as suggested in option 2 of the query.  The medical statement is sufficiently converted to code and meets the requirements of ACS 0023 Laparoscopic/arthroscopic/endoscopic surgery.

Note: This query has been retired due to classification updates for laparoscopic hemi-colectomy.


Query Text:
Patient has been admitted to our hospital to have an intestinal transplant for Short-Gut-Syndrome, on a background of previous colectomies for Hirschprung’s disease.

Patient has been on TPN secondary to his short-gut syndrome and has subsequently developed TPN induced Cholestatic Liver Failure.

Patient underwent a multi-organ transplant which consisted of an en bloc small bowel transplant with end ileostomy, liver, pancreas and duodenal transplants and a duodenojejunal anastomosis. Patient’s own duodenum and pancreas were left in situ and the transplanted duodenum and pancreas were grafted on to the patients’ own. (Currently this is the only information we have in terms of the extensive procedure).

Our question is, as there is no ACHI code to cover the intestinal transplant, what are the best fit codes for this procedure?

This patient is not yet discharged, but so far we have thought of using:

30565-00 [895] Resection of small intestine with formation of stoma 
90307-00 [903] Other procedures on small intestine
14203-01 [1906] Direct living tissue implantation 
30515-02 [897] Enteroenterostomy

And then the liver and pancreas transplants; 90317-00 [954] and 90324-00[981] respectively. We have not found codes that describe the grafting of the transplanted pancreas or duodenum on to the patients’ own, but do we really need extra codes? Are they inherent in some transplant procedures when the failed organ has not been removed?

This no-where near captures the severity of the procedure however and we were wondering if there were any other codes that we could use to capture the procedure better?

Response:
VICC advises that as there is no specific procedure code for intestinal transplant, assign codes for the components of the surgery.  The following codes may be appropriate:
30565-00 [895] Resection of small intestine with formation of stoma for the resection and ileostomy
43807-00 [897] Duodenoduodenostomy for the duodenojejunal anastomosis
90307-00 [903] Other procedures on small intestine for the transplant component

VICC agrees with the codes assigned by the enquirer for the liver and pancreas transplants.


Query Text:
Principal diagnosis on D/C summary is Charcot's arthropathy

The patient also has cellulits of the toe and was seen by the Diabetic Educator.  

Is the principal diagnosis for this patient:
G98 Other disorders of nervous system, not elsewhere classified 
M14.6* Neuropathic arthropathy 
or
E11.73 Type 2 diabetes mellitus with foot ulcer due to multiple causes
G98 Other disorders of nervous system, not elsewhere classified 
M14.6* Neuropathic arthropathy 
L03.11 Cellulitis of lower limb

The patient also has peripheral neuropathy secondary to NIDDM.  Do you add the specific code for peripheral neuropathy also?

Response:
VICC advises that because the patient was seen by the diabetic educator, diabetes meets ACS 0002 Additional diagnoses, which means you search the index under lead term 'diabetes'.  The patient also has cellulitis and Charcot's arthropathy which meets the diabetic foot definition.  

ACS 0401 Diabetes mellitus and impaired glucose regulation provides instruction for coding of diabetic foot in the classification box on page 109 which indicates that you would code the peripheral neuropathy.  Therefore, the appropriate codes to assign for the case cited are:
E11.73 Type 2 diabetes mellitus with foot ulcer due to multiple causes
G98      Other disorders of nervous system, not elsewhere classified 
M14.6* Neuropathic arthropathy 
L03.02  Cellulitis of toe
G62.9   Polyneuropathy, unspecified


Query Text:
Discharge summary principal diagnosis documented as ‘Infective Exacerbation of Asthma.’  Additional primary diagnoses on discharge summary listed as COPD and hypokalaemia.    The body of the medical record describes the asthma as Acute Severe Asthma.

The COPD and hypokalaemia are not documented within the body of the medical record.  Pathology indicates a low reading which is initialled and ticked by doctor. Medication chart shows that patient given a stat dose of Slow K.  

We have coded J46 Status asthmaticus

1. Is this correct ?  
2. Are we able to link the COPD with Asthma  to assign J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection?
3. Are we able to use our clinical coders creed and code the hypokalaemia ?

Search Details: 
Relevant Documentation read: ACS 0010 and HDSS bulletin Issue 13 Education for clinical coders 13.1 and ACS Appendix C Clinical Coders Creed.

Response:
This query was originally published in the 2010-11 December Database as follows:

In accordance with ACS 1008 Chronic obstructive pulmonary disease (COPD), asthma documented with COPD should be assigned a code from J44.x.  As you have documentation of infective exacerbation, the correct code to assign is J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection.  The preposition 'with' in the alphabetical index take precedence (as per Coding Matters Vol 15 No 3) and supports the assignment of J44.0 even though the COPD may not meet ACS 0002 Additional diagnoses.  

The decision to assign a code for hypokalaemia should be based on ACS 0002 Additional diagnoses criteria.  As you have hypokalaemia documented on the discharge summary and there is evidence in the medical record that it was treated, VICC considers a code can be assigned for the hypokalaemia.


This query has been updated for clarity as follows:

ACS 0010 Clinical documentation and general abstraction guidelines states ‘Before classifying any documented clinical concept, the clinical coder must verify information on the front sheet and/or the discharge summary (or equivalent) by reviewing pertinent documents/data within the body of the current episode of care. Therefore, provided the diagnosis of COPD can be substatiated within medical record, this may include correspondence, in accordance with ACS 1008 Chronic obstructive pulmonary disease (COPD), asthma documented with COPD should be assigned a code from J44.x. As you have documentation of infective exacerbation, the correct code to assign is J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection. The preposition 'with' in the alphabetical index take precedence (as per Coding Matters Vol 15 No 3) and supports the assignment of J44.0 even though the COPD may not meet ACS 0002 Additional diagnoses.

The decision to assign a code for hypokalaemia should be based on ACS 0002 Additional diagnoses criteria. As you have hypokalaemia documented on the discharge summary and there is evidence in the medical record that it was treated, VICC considers a code can be assigned for the hypokalaemia.


Query Text:
We get this regularly documented but there is no index lookup for this.  Our Respiratory doctors say code E66.2 Extreme obesity with alveolar hypoventilation (Pickwickian syndrome) is the correct code, though neither terminology used here. They have offered to document it for us as 'obesity (alveolar) hypoventilation syndrome'.

My queries are:

1. Since Pickwickian syndrome appears to be an alternative name for OHS (sample search result below), is it acceptable to get to E66.2 that way?

2. Do you know of any submission to include OHS in the books, as it appears to be in common use and increasingly so?

Search Details: 
http://www.nlm.nih.gov/medlineplus/ency/article/000085.htm

Response:
VICC agrees that E66.2 Extreme obesity with alveolar hypoventilation is the correct code to assign for obesity hypoventilation syndrome and that documentation of either Pickwickian syndrome and obesity (alveolar) hypoventilation syndrome is appropriate to lead to this code in the index.

VICC is not aware of any public submission regarding the indexing of this syndrome but will forward a request to amend the index to the NCCC.


Query Title:
Tabular and index inconsistency for Acute myeloid leukaemia with multilineage dysplasia

Query Text:
The following is a new code for Seventh edition:
 
C92.8 Acute myeloid leukaemia with multilineage dysplasia
         Acute myeloid leukaemia with dysplasia of remaining haematopoesis and/or myelodysplastic disease in its history
 
As per the Tabular entry above, this code includes AML with multilineage dysplasia and/or myelodysplastic disease in its history, however the following Index entry leads AML with prior MDS to C92.0-
 
Leukaemia
- myeloid
- - acute 
- - - with 
- - - - multilineage dysplasia (M9895/3) C92.8-
- - - - prior myelodysplastic syndrome (M9895/3) C92.0-
 
The morphology code provided at index entry AML with prior MDS also appears to be correct for C92.8 rather than for C92.0.

Response:
VICC agrees that the index entry Leukaemia, with prior myelodysplastic syndrome (M9895/3) C92.0- leads to the incorrect code and that the correct code is C92.8 Acute myeloid leukaemia with multilineage dysplasia.  VICC will forward this query to the NCCC for correction of the index entry.


Query Text:
We would like clarification on what procedure codes are to be assigned when a patient is admitted for loading of a CADD with an anti-neoplastic agent as per the following advice from the Hospital Admission Policy Chemotherapy Fact Sheet 1.7.10:
"...However, there is a 'code also' instruction against the load drug delivery device codes, which requires health services to code for the administration of a specific agent. The department anticipates that the majority of 9620900 admissions should also have 9619900 coded. As such, these episodes would be Automatically Admitted."
 
Does this mean we can routinely assign 96209-00 [1920] and 96199-00 [1920] when a patient is admitted for loading of a CADD only?

Response:
VICC advises that if the patient only has their CADD loaded (even if it starts infusing whilst the patient is still in hospital) only 96209-00 [1920] Loading of drug delivery device is assigned.  

If the patient has both their CADD loaded and a separate IV infusion of an anti-neoplastic agent, both 96209-00 [1920] Loading of drug delivery device and 96199-00 [1920] Intravenous administration of pharmacological agent is assigned.

Please note that 96209-00 [1920] Loading of drug delivery device is on the not automatically qualified for admission list of the Victorian Hospital Admission Policy effective 1 July 2010.


Query Title:
ACS 0002 Additional diagnoses and ACS 0010 General abstraction guidelines

Query Text:
We have a case where hypokalaemia is recorded as an additional diagnosis on the discharge summary, blood tests show low potassium and the administration of slow k is documented on the drug chart.  There is no documentation of hypokalaemia within the body of the medical record.

The standard 0010 General abstraction Guidelines infers that conditions need to be supported within the body of the medical record before the coder can assign a code for the condition. 

The following is an excerpt from a previous HDSS bulletin:
“…the important point to remember is that in each case, the coder must decide whether or not the condition meets 0002.  Note that documentation refers to written documentation,… the coder needs to see evidence that the test is performed for investigation of the particular condition…” Source- HDSS Bulletin Issue 13 Page 5  (unsure of date)

Can you please verify if the bulletin advice still applies? And, can you define what the term ‘supported’ means within the ACS 0010.   Does this mean written documentation within the medical record?

Response:
ACS 0010 General abstraction guidelines states that the clinical coder must verify information recorded on the front sheet and/or the discharge summary by reviewing pertinent documents in the body of the clinical record.  VICC interprets the 'body' of the record as all information regarding the patient for an episode which includes test results and medication charts; ACS 0010 also includes test results in its discussion and examples.  

Whilst hypokalemia may not be documented in the progress notes, there is evidence in the body of the record (test results and medication chart) that links to (supports) the diagnosis of hypokalaemia listed on the discharge summary. This evidence is used to determine if the hypokalaemia meets ACS 0002 Additional diagnoses.  In this case because there was commencement of treatment, the hypokalaemia does meet ACS 0002 and is therefore coded.

Please note that the advice in HDSS Bulletin 13 has been superseded by further updates to ACS 0002 Additional diagnoses and ACS 0010 General abstraction guidelines.


Query Title:
Acute renal failure secondary to E.Coli Sepsis

Query Text:
Patient diagnosis on discharge summary states Acute renal failure secondary to E.Coli Sepsis.

There is no documentation in notes of severity of sepsis, ie SIRS, septic shock or severe sepsis.  

In the body of the progress notes pneumonia is documented, as well as E.Coli Sepsis ?source biliary disease. Also acute renal failure/hepatic failure secondary ?sepsis.  No documentation of pneumonia on the discharge summary.  As it is unclear what the localised infection is do we code A41.51 as PDx (E.Coli Sepsis) followed by pneumonia and the organ failures?

Response:
With regard to the code for sepsis, review of the progress notes showed no documentation providing the source of the infection.  Therefore in accordance with ACS 0110 Sepsis, severe sepsis and septic shock assign a code for sepsis by searching the index under lead term Sepsis, which in this case is A41.51 Sepsis due to Escherichia coli [E. Coli]. 

Pneumonia and organ failure must meet criteria for coding in order to be coded.

As the diagnosis on the discharge summary is ARF secondary to sepsis, one of these conditions will be the principal diagnosis and a decision must be made accordingly based on ACS 0001 Principal diagnosis.


Query Title:
Seventh Edition obstetrics coding changes

Query Text:
Please refer to page 384 of the ICD-10-AM /ACHI/ ACS Seventh Edition Education.

Postpartum haemorrhage
Precipitate labour
Prolonged labour

Can all of these conditions be coded regardless of meeting ACS 0001 or ACS 0002?

The notes that accompany these deleted standards say .... (the condition) needs to be documented for it to be coded. There is no reference to following ACS 0001 or ACS 0002.    As a comparison,  notes that accompany ACS 1526 or ACS 1527 instruct coders to follow ACS 0001 or ACS 0002.

There are two views on this.
1. These notes are simply a summary of changes,  they are not instructional notes.  If there is no instructional note within the tabular volume or specialty standard instructing you to code these conditions then they cannot be coded just because they are documented.

2. These notes are instructional and should be followed. This is why there are differences in the wording of the changes that apply to the various standards.

Search Details: 
Page 384 of the ICD-10-AM /ACHI/ ACS Seventh Edition Education.

Response:
VICC advises that the conditions listed in your query must meet ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses before they can be assigned and considers the notes in the ICD-10-AM /ACHI/ACS Seventh Edition Education to be a summary of changes only.  This is supported by the advice in ACS 0002 under heading Conditions noted in obstetric cases which says that 'some conditions are noted by the clinician or midwife in antenatal, delivery or postnatal episodes of care which should not be coded unless they meet the criteria in ACS 0002'.


Query Title:
Family history of mental illness on newborn's record

Query Text:
Is it acceptable to use Z81 - Family History of Mental Illness when coding newborn baby's history with parental history of substance or alcohol abuse which has affected the baby's care and/or length of stay. 

Currently these episodes come up as fatal errors via the PICQ report. Please advise regarding the use of these codes or alternative codes.

Response:
According to ACS 0520 Family history of mental illness  Z81.- Family history of mental and behavioural disorders should never be assigned.  Alternative codes that may be appropriate are Z76.2 Health supervision and care of other healthy infant and child or Z03.7- Observation and evaluation of newborn for suspected condition not found in accordance with ACS 1609 Newborns Affected by Maternal Causes and Birth Trauma.


Query Title:
Renovascular disease stated as underlying cause of end stage kidney disease

Query Text:
Please clarify the correct code (I12.0 or I15.0) to use for renovascular disease (stated as underlying cause of ESKD).

Index pathway:
Disease, renovascular (arteriosclerotic)(see also Hypertension, kidney) I12.9

Hypertension
- kidney (disease) I12.9
- - with
- - - CKD stage 5 (kidney failure) I12.0

Yet, if you look further down the index, there is an entry for:
Hypertension
- renovascular I15.0

However, by following the index as instructed with the documentation provided (ESRF secondary to renovascular disease) there is no way of using the code for renovascular hypertension (I15.0).  

Search Details: 
ACS 0925, 0926, 0927 & 0928
No relevant VICC query found
No relevant information found in Coding Matters

Response:
Coders may find it useful to think about the difference in these codes in the following terms:
I12 'Hypertensive kidney disease' - renal conditions caused by hypertension
I15 'Secondary hypertenson' - hypertension caused by other conditions

You are correct to follow the 'see also' note at Disease, renovascular but unless you have a diagnosis of renovascular hypertension, you cannot follow Index entry Hypertension, renovascular.

Therefore for the case cited the correct code to assign is I12.0 Hypertensive kidney disease with kidney failure.


