Coding Rule is effective for event records with an event end date on or after 1 July 2015



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Australian Consortium for Classification Development

ACCD Classification Information Portal



Coding Rule is effective for event records with an event end date on or after 1 July 2015

Ref No: Q2897 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: ACS 0002 Additional diagnoses and alteration to treatment

Q: 


NOT APPLICABLE TO NEW ZEALAND
Does a condition meet the criteria in ACS 0002 Additional diagnoses when the medication to treat the condition has been altered to manage an adverse effect or another condition, as in the following scenarios? 


    1. Principal diagnosis of acute on chronic renal failure secondary to frusemide, with a past history of congestive cardiac failure treated with frusemide 80mg BD. Dose of frusemide was decreased to 40mg BD.

    1. Principal diagnosis of aspirin induced ulcers throughout upper gastrointestinal tract, with a past history of atrial fibrillation for which the patient had been commenced on aspirin. Aspirin was withheld for two days, and the patient was commenced on medication to treat the ulcers.

A:

Based on the limited information in the scenarios described, the conditions listed in the past history/background (congestive cardiac failure and atrial fibrillation) where medication to treat these conditions has been altered should be coded, as per the criteria in ACS 0002 Additional diagnoses; specifically dot point 1, ‘commencement, alteration or adjustment of therapeutic treatment’.



Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2933 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Interpretation of ACS 0020 Bilateral/multiple procedures for bilateral insertion of ureteric stents

Q:

How do you apply ACS 0020 Bilateral/multiple procedures when coding bilateral insertion of ureteric stents? Is the procedure coded once or twice?



A:

Insertion of bilateral ureteric stents meets the definition of bilateral procedures in ACS 0020 Bilateral/multiple procedures:



Bilateral procedures are those which involve the same organ/structure on different sides of the body at the same operative episode.

Therefore assign 36821-01 [1114] Endoscopic insertion of ureteric stent twice as per Bilateral Procedures, 3. Procedures with no code option for bilateral.

ACS 0020 Bilateral/multiple procedures has been flagged for review in a future edition of the Australian Coding Standards.

Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2837 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Retroperitoneal fibrosis without ureteric obstruction.

Q:

How do you code retroperitoneal fibrosis without ureteric obstruction?



A:

Retroperitoneal fibrosis (RPF) (Ormond’s disease) is a rare condition that results in inflammation and fibrosis within the retroperitoneal space. The inflammation and fibrosis usually begins around the distal aorta and spreads toward the inferior vena cava, kidneys and surrounding structures, resulting in compression.

Signs and symptoms of RPF are dependent upon the specific body structure that is being compressed by the fibrotic mass. When RPF surrounds and compresses the ureters it causes obstruction and may lead to hydronephrosis and consequently kidney failure if left untreated. Compression of the inferior vena cava results in deep venous thrombosis and lower extremity oedema. Impaired blood flow in the intestines may lead to necrosis.

Approximately 70% of the cases of RPF are idiopathic. Other causes include drug-induced, malignancies, complication of external beam radiotherapy, certain infections (tuberculosis, histoplasmosis) or complication of previous abdominal surgery or trauma.

The indexing and classification of idiopathic retroperitoneal fibrosis (Ormond’s disease) in ICD-10-AM is consistent with ICD-10 and other ICD-10 modifications (ICD-10-CM, ICD-10-CA), which defaults to N13.5 Kinking and stricture of ureter without hydronephrosis via the index pathways:

Fibrosis, fibrotic

- retroperitoneal, idiopathic (with ureteral obstruction) N13.5



Ormond’s disease (with ureteral obstruction) N13.5

DO NOT follow the above index pathways to classify retroperitoneal fibrosis.

The default is a specific manifestation of the retroperitoneal fibrosis (that is, ureteric obstruction); there is no code option for retroperitoneal fibrosis without ureteric obstruction.

The WHO is considering creating a unique code for retroperitoneal fibrosis in a future edition of ICD-10. In the interim, assign the following code for retroperitoneal fibrosis (Ormond’s disease):

K66.8 Other specified disorders of peritoneum

by following the index pathway:



Disease, diseased

- peritoneum

- - specified NEC K66.8

If there is documentation of ureteric obstruction associated with retroperitoneal fibrosis, assign a code for the manifestation (as well as K66.8) by following the index pathway:



Obstruction, obstructed, obstructive

- ureter


Note: where retroperitoneal fibrosis is documented as a manifestation of another condition (for example, IgG4 related disease), assign a code for the aetiology by following the relevant index pathways and the guidelines in ACS 0001 Principal diagnosis, Problems and underlying conditions and ACS 0002 Additional diagnoses.

(See also Coding Rules IgG4-related disease).



Published 15 June 2015,
for implementation 01 July 2015.

Note: refer to NZCA coding query Retroperitoneal fibrosis with ureteric obstruction and hydronephrosis

Ref No: Q2965 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Procurement of iliac vessels with multiple organs for transplantation

Q:

How do you code procurement of iliac artery and vein, harvested with multiple organs for transplantation?



A:

Procurement of iliac vessels is inherent in procurement of multiple organs for transplantation.

Iliac vessels (common, external and internal iliac artery and vein) are commonly collected to provide ‘backup’ material for the reconstruction of vessels in the retrieved organ and/or in the recipient. The ‘backup’ vessels are most often used with liver, pancreas, small intestine or kidney transplantation. For example, harvested iliac vessels may be used if kidney vessels are damaged during procurement. Clinical advice agrees that iliac vasculature is not harvested with the intention of being a “free standing” transplant in its own right.

Therefore, it is not necessary to assign a specific code for iliac vessels harvested as part of multiple organ procurement for transplantation. Assign procurement procedure codes for the specific organs harvested – see ACS 0030 Organ and tissue procurement and transplantation, Organ/tissue procurement and transplantation table.

Enhancements to ACHI will be considered for a future edition.

Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2888 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Cerebellar ataxia secondary to previous petrol sniffing

Q:

What is the correct code assignment for a patient presenting with ataxia which after investigation is diagnosed as being due to cerebellar atrophy secondary to previous petrol sniffing?



A:

Ataxia is an inability to coordinate muscle activity during voluntary movement and is often a symptom of an underlying disorder of the cerebellum. Where a diagnosis of ataxia and cerebellar atrophy secondary to previous petrol sniffing is made during an admission, a code for the ataxia is not required as per the guidelines in ACS 0001 Principal diagnosis, Problems and underlying conditions, point 1.

Assign:

G31.9   Degenerative disease of nervous system, unspecified following the index pathway:



Atrophy, atrophic

- brain (cortex) (progressive) (see also Degeneration/brain) G31.9

and

F18.1    Mental and behavioural disorders due to use of volatile solvents, harmful use as it is the underlying cause of cerebellar atrophy, following the index pathway:



Use (of)

- harmful

- - inhalants F18.1

Sequelae codes are not assigned as cerebellar atrophy is not a late effect but a direct result from the harmful use of petrol sniffing (refer to ACS 0008 Sequelae).

Index amendments will be considered for a future edition of ICD-10-AM.

Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2823 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Trial of void admissions in the puerperium

Q:

What codes should be assigned for an obstetric patient who is re-admitted in the puerperal period for a trial of void (TOV) following a forceps delivery under local anaesthetic in her previous admission? Would the TOV be considered to be postoperative?



A:

There are many reasons why a patient may develop urinary retention in the postpartum period, including:



    1. changes in the bladder during pregnancy

    2. primiparity

    3. prolonged labour, particularly second stage

    4. assisted/instrumental delivery

    5. perineal injury.

Therefore, unless the clinical documentation indicates that the urinary retention is directly related to the use of instrumentation during delivery, the trial of void should be coded as non postop, as in the guidelines in ACS 1904 Procedural complications, which state that:

            ‘if it cannot be determined whether a condition meets the definition of a procedural complication, it should not be coded as such’.

Assign the following codes for a postpartum admission for trial of void - non postoperative:

TOV – successful

Z46.6 Fitting and adjustment of urinary device

Z39.0- Postpartum care and examination immediately after delivery (see ACS 1548 Postpartum condition or complication)

TOV - unsuccessful

Z46.6 Fitting and adjustment of urinary device

O99.8 Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium (following the index pathway Puerperal,puerperium/disorder/nonobstetric NEC)

R33 Retention of urine

Z39.0- Postpartum care and examination immediately after delivery (see ACS 1548 Postpartum condition or complication)

Also assign procedural codes as instructed in ACS 1436 Admission for trial of void/non postop.

ACS 1436 Admission for trial of void will be reviewed for a future edition of the Australian Coding Standards.

Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2740 | Published On: 15-Jun-2015 | Status: Current

SUBJECT:   Assigning Z38.- as the principal diagnosis

Q:

What codes, if any, can be assigned as additional diagnoses with Z38.- Liveborn infants according to place of birth as the principal diagnosis.



A:

Codes for newborns should be assigned following the guidelines in ACS 1607 Newborn/neonate which state:

 ‘A code from category Z38 Liveborn infants according to place of birth should be sequenced as the principal diagnosis only when the newborn is completely well (including those babies who have had a circumcision performed).’

Therefore, Z38.- should be sequenced as the principal diagnosis only in those circumstances where there are no additional morbidity codes that qualify for assignment to classify neonatal morbidity or suspected morbidity. Suspected morbidity would include Z03.71 Observation of newborn for suspected infectious condition.



Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2922 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Subgaleal haematoma

Q:

What is the correct code to assign for a subgaleal haematoma not due to birth trauma?



A:

Subgaleal haematoma occurs when there is bleeding into the space between the skull periosteum and the scalp galea aponeurosis. This condition is commonly seen after traumatic birth in neonates but it may also occur after a fall or blow to the head. As the haemorrhage occurs outside the cranium it is not regarded as intracranial injury although an extensive subgaleal haematoma may require monitoring for signs of neurological deficits to exclude intracranial injury, especially where there is loss of consciousness.

A subgaleal haematoma should be coded to S00.05 Superficial injury of scalp, contusion following the index pathways:
Haematoma (skin surface intact) (traumatic) (see also Contusion)

and


Contusion (skin surface intact)

- scalp S00.05

with appropriate external cause codes.

Code also any closed head injury/loss of consciousness as per ACS 1905 Closed head injury/loss of consciousness/concussion.

Improvements to ICD-10-AM will be considered for a future edition.

References:

Agrawal, A. et al (2006). Delayed extensive subgaleal haematoma following head injury. Paediatric Oncall Journal. Retrieved from: http://www.pediatriconcall.com/Journal/Article/FullText.aspx?artid=798&type=J&tid=&imgid=&reportid=158&tbltype

Luijkx,T., Jones, J. et al (2015). Subgaleal haematoma. Radiopaedia.org. Retrieved from: http://radiopaedia.org/articles/sub-galeal-haematoma



Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2926 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Classifying a procedure under investigation in a randomised and placebo-controlled clinical trial

Q:

Is it necessary to assign a procedure code or a Z code to identify patients who are undergoing treatment as part of a clinical trial that is both randomised and placebo-controlled? For example, a patient with acute myocardial infarction who is participating in a placebo-controlled clinical trial (AMICI: Allogeneic Mesenchymal Precursor Cell Infusion in Myocardial Infarction), where the patient may receive either an infusion of stem cells or a placebo directly into a diseased coronary artery following angioplasty.



A:

A placebo-controlled clinical trial is a method of study in which both investigators and participants are blinded as to who received an intervention or a placebo.

Do not assign a code for a procedure that is part of a clinical trial that is placebo-controlled as:


    1. the purpose and methodology for collecting data for clinical trials are different to data collected for the Admitted Patient Care National Minimum Data Set (APC NMDS)

    1. information related to clinical trials are gathered and managed through clinical trial data collection systems

    2. clinical trials are usually reimbursable through separate grants

    3. there is no uniform policy or practice across hospitals and jurisdictions that requires clinical trial related activity to be recorded in clinical records.

Do not assign Z00.6 Examination for normal comparison and control in clinical research programme to flag patients undergoing treatment as part of a clinical trial. Codes in category Z00 are intended to classify individuals undergoing examination for specific purposes without complaint or reported diagnosis. Codes from this category should not be assigned when there is a documented definitive diagnosis as the indication for treatment.

See also Coding Rules: Same-day chemotherapy for neoplasm; participant in clinical drug trial.

Improvement to ACS 0026 Admission for clinical trial or therapeutic drug monitoring will be considered for a future edition.

Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2939 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Endoscopic ultrasound (EUS)

NOTE: this may be a change in coding practice

Q:

What is the correct procedure code for biopsy of a lesion using EUS guidance?



A:

Endoscopic ultrasound (EUS) is similar to other endoscopies but with an ultrasound probe attached at the end of the endoscope, which permits both visualisation and tissue sampling of gastrointestinal walls and structures surrounding the gastrointestinal tract. EUS is primarily used for assessing lesions in the gastrointestinal tract, but has increasingly been used for evaluating lesions of adjacent organs such as lung, mediastinum, left kidney, adrenal gland and lymph nodes (intra-thoracic and intra-abdominal).

When biopsy of a lesion is performed under EUS guidance, assign an appropriate code for the type of endoscopy (e.g. gastroscopy, gastroscopy with biopsy) and 30688-00 [1949] Endoscopic ultrasound. For example, EUS guided FNA (fine needle aspiration) biopsy of pancreas, assign:

30075-16 [977] Biopsy of pancreas

30473-00 [1005] Panendoscopy to duodenum

30688-00 [1949] Endoscopic ultrasound

Improvements to ACHI will be considered for a future edition.

Reference

Vilmann, P. & Saftoiu, A. (2006). Endoscopic ultrasound-guided fine needle aspiration biopsy: equipment and technique. J Gastroenterol Hepatol. Vol 21(11), pages 1646-55. DOI: 10.1111/j.1440-1746.2006.04475.x

Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2931 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Anal fistula plug

Q:

What is the correct procedure code for insertion of anal fistula plug?



A:

Anal fistula plug is a relatively new type of procedure used for the treatment of an anal fistula. The procedure involves implantation of a plug into the tract of a fistula and suturing it in place. The plug, composing of a biocompatible material, is capable of forming a collagen scaffold which promotes tissue regeneration and facilitates healing and closure of the anal fistula.

Where insertion of perianal fistula plug is performed, assign 90344-02 [929] Administration of agent to lesion or tissue of anorectal region, by following the index pathway: 

Closure

- fistula 

- - with biological sealant

- - - anorectal 90344-02 [929]

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

References:

The National Institute for Health and Clinical Excellence (NICE) (2011). Interventional procedure overview of closure of anal fistula using a suturable bioprosthetic plug. Retrieved from: https://www.nice.org.uk/guidance/ipg410/evidence/closure-of-anorectal-fistula-using-a-suturable-bioprosthetic-plug-overview2

Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2900 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Baby born prior to admission with placenta delivered in hospital

Q:

What should be the principal diagnosis where a patient delivers a baby prior to admission, but the placenta is delivered following admission? Is delivery of the placenta part of the delivery episode, that is, the delivery is not complete until the placenta is delivered? 



A:


NOT APPLICABLE TO NEW ZEALAND

The period between the delivery of the fetus and expulsion of the placenta and fetal membranes is the third and final stage of labour/delivery. Therefore where a patient has delivered a baby prior to the admitted episode of care but the placenta is expelled during the admitted episode of care assign:

    1. the appropriate code from O80 – O84 Delivery (also see Coding Rule Manual removal of placenta in a single vaginal delivery, published June 2014)

    2. the appropriate code from Z37.- Outcome of delivery

    3. Z39.03 Postpartum care after unplanned, out of hospital delivery to indicate that stage two has occurred prior to admission (this is an exception to the guidelines in ACS 1548 Postpartum condition or complication).

The reference to the delivery of ‘a baby prior to admission to hospital’ in ACS 1519 Delivery prior to admission should be considered to also include the delivery of the placenta. The wording in this standard and ACS 1548 Postpartum condition or complication will be reviewed for a future edition of the Australian Coding Standards (ACS) to clarify ‘delivery’.

Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2861 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Same-day endoscopy for chronic incurable diseases

Q: 


What is the appropriate principal diagnosis for same-day endoscopic examination for chronic incurable conditions such as coeliac disease?

A:

Coeliac disease is a permanent intolerance to gluten proteins, present in wheat, rye, and barley. It is an autoimmune disorder, characterised by a chronic inflammatory state of the small intestinal mucosa and submucosa, which can impair digestion and absorption of nutrients, leading to malnutrition. Coeliac disease is diagnosed by small bowel biopsy in conjunction with specific blood tests. The only treatment is a strict lifetime gluten-free diet, which in a significant number of patients manages the disease, by allowing the small intestine mucosa to heal. A small percentage of patients will have refractory or treatment resistant coeliac disease.



Chronic incurable diseases, such as coeliac disease, Crohn’s disease or ulcerative colitis, that require ongoing treatment such as lifelong dietary restrictions or ongoing medication to manage the disease may be admitted for endoscopic surveillance or follow up. While the follow up examination may appear normal it does not mean the disease has been eradicated or cured.

ACS 2113 Follow up examinations for specific disorders provides guidance for the assignment of codes in categories Z08 and Z09 for conditions which may be cured or eradicated after treatment such as bladder cancer and gastric ulcer:

“Codes from category Z08 Follow-up examination after treatment for malignant neoplasms or Z09 Follow-up examination after treatment for conditions other than malignant neoplasms should be assigned as the principal diagnosis when a patient is admitted for follow-up of a condition and no residual condition or recurrences are found.

The appropriate code describing the type of previous treatment from category Z08 or Z09 should be assigned as the principal diagnosis.”



Chronic conditions such as coeliac disease, Crohn’s disease and ulcerative colitis cannot be eradicated or cured and with treatment/management ongoing, assignment of codes from these categories is inappropriate.

Therefore for chronic incurable conditions such as these, assign a code for the disease following the principles of ACS 0001 Principal diagnosis.

In the scenario cited the correct code to assign as principal diagnosis is K90.0 Coeliac disease.

Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2976 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Assignment of the condition onset flag for multiple conditions/sites classifiable to one ICD-10-AM code.

Q: 


Where a patient has multiple conditions/sites classifiable to a single ICD-10-AM code that qualifies for different condition onset flag values, which condition onset flag value should be assigned? For example, a stage I pressure injury on the ankle (arising during admission) and a stage I pressure injury on the foot (present on admission). Both are discrete pressure injuries classifiable to one ICD-10-AM code, L89.09 Pressure injury, stage I, other site of lower extremity (excluding heel and toe).

A:

The goal of the condition onset flag (COF) is to provide:



an insight into the kinds of conditions patients already have when entering hospital and those conditions that arise during the episode of admitted patient care. A better understanding of those conditions arising during the episode of admitted patient care may inform prevention strategies particularly in relation to complications of medical care (ACS 0048 Condition onset flag.)

Therefore, where multiple conditions/sites are classifiable to a single ICD-10-AM code that qualifies for different condition onset flag values, assign COF 1 Condition with onset during the episode of admitted patient care.

Improvements to the ACS will be considered for a future edition.

Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2952 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: High output ileostomy

NOTE: this may be a change in coding practice

Q:

Is high output ileostomy classified as a procedural complication?



A: 

High output ileostomy (HOS) refers to excessive effluent (> 2000ml per day) from an ileostomy, resulting in fluid, sodium and magnesium depletion, with malnutrition as an extreme late complication.  HOS is a likely outcome when there is less than 200cm of residual small intestine and no colon. Other causes include: intra-abdominal sepsis, partial bowel obstruction, (infectious) enteritis and recurrence of disease in the remaining intestine (eg Crohn’s disease). HOS management includes treatment of the underlying cause, replacement of water and electrolyte imbalances, anti-diarrhoeal medications and nutritional support.

HOS is considered a procedural complication as per the definition in ACS 1904 Procedural complications:

A condition or injury which is directly related to a surgical/procedural intervention.

Therefore, follow the guidelines in ACS 1904 and assign:

K91.4 Colostomy and enterostomy malfunction

with additional code(s) for any manifestation(s) (eg dehydration, electrolyte imbalance)

followed by:

Y83.3 Surgical operation with formation of external stoma

Y92.22 (Place of occurrence) Health service area

References:

Baker, M., Williams, R., and Nightingale, J. (2009). Causes and management of high-output stoma. Doi: 10.1111/j.1463-1318.2009.02107.x



Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2950 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Admission for subtherapeutic INR (underwarfarinisation) and bridging therapy for temporary cessation of an anticoagulant

Q:

What is the correct principal diagnosis to assign when a patient on a long-term oral anticoagulant is admitted due to subtherapeutic INR?



A:

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



Abnormal, abnormality, abnormalities

- chemistry, blood

- - specified NEC R79.8

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

Q: 

What is the correct code assignment for bridging therapy for temporary cessation of an anticoagulant?



A:

Bridging therapy is a recent term used to describe the temporary discontinuation of long term oral anticoagulants (eg warfarin) and replacing with a short action agent such as clexane or heparin.

Patients on long term oral anticoagulants undergoing bridging therapy may be admitted because their INR levels are significantly lower than the therapeutic range (i.e. subtherapeutic INR or underwarfarinisation) in which case assign R79.8 as specified above.

When patients are admitted for a planned surgery and they receive bridging therapy prior to the surgery, assign a code for the condition requiring surgery as the principal diagnosis, followed by Z92.1 Personal history of long term (current) use of anticoagulant as per ACS 0303 Abnormal coagulation profile due to anticoagulants (See also Coding Rules: Anticoagulant therapy pre and post surgery).

Improvements to ICD-10-AM for abnormal coagulation profile due to anticoagulants will be considered for a future edition.

Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2947 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Latent tuberculosis (TB)

Q:

How do you code latent tuberculosis (TB)?



A:

Latent tuberculosis infection (LTBI) refers to infection with Mycobacterium tuberculosis, without clinical symptoms/manifestations of tuberculosis. Carriers exhibit a positive reaction to the tuberculin skin (Mantoux) test or TB blood test. Carriers who are immunosuppressed, especially those with HIV infection, are at greater risk of developing active TB and may be treated prophylactically. The World Health Organization (WHO) estimates that approximately 10% of people with LTBI will develop active TB.

Assign Z22.3 Carrier of other specified bacterial diseases in ICD-10-AM for latent tuberculosis, by following the index pathway:

Carrier (suspected) of

- bacterial disease NEC Z22.3

 To add further specificity, assign R76.1 Abnormal reaction to tuberculin test by following the index pathway:

 Test(s)

- tuberculin, abnormal result R76.1

 Enhancements to ICD-10-AM will be considered for a future edition.

References:

World Health Organization. (2015). Guidelines on the management of latent tuberculosis infection (WHO reference number: WHO/HTM/TB/2015.01). Retrieved from http://www.who.int/tb/publications/ltbi_document_page/en/



Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2934 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Acute bronchitis with COPD

Q:

How do you code acute streptococcal bronchitis with chronic obstructive pulmonary disease?



A:

In ICD-10-AM, acute bronchitis is classified to J20-J22 Other acute lower respiratory infections, which excludes J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection. Chronic obstructive pulmonary disease (COPD) includes chronic bronchitis with obstruction, therefore J44.0 classifies acute on chronic bronchitis with obstruction.

ACS 1008 Chronic obstructive pulmonary disease (COPD) states:

Infective exacerbation of COPD does not require an additional code to reflect the infective description unless the infective condition is a condition in its own right, such as pneumonia (see COPD with pneumonia). If there is no documented infective disorder, a diagnosis of 'infective exacerbation of COPD' or 'chest infection exacerbating COPD' should be assigned the code J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection.

Where there is documentation of acute bronchitis due to a specific organism (eg acute streptococcal bronchitis) exacerbating COPD, assign the following codes:

J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection

B95.5 Unspecified streptococcus as the cause of diseases classified to other chapters

by following the above guidelines in ACS 1008 and the index pathways:



Bronchitis

- with


- - obstruction (airway) (lung) J44.8

- - - with (acute)

- - - - exacerbation NEC J44.1

- - - - - infective J44.0

- - - - lower respiratory infection J44.0 

Infection

- Streptococcus, streptococcal NEC A49.1

- - as cause of disease classified elsewhere B95.5

A review of ACS 1008 Chronic obstructive pulmonary disease (COPD) will be considered for a future edition.



Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2929 | Published On: 15-Jun-2015 | Status: Current

SUBJECT:  Closure of nasal septal perforation with cartilage graft

Q:

How do you code a cartilage graft when coding closure of perforation of nasal septum?



A:

For repair of nasal septal perforation with cartilage graft assign:

 41671-01 [379] Closure of perforation of nasal septum

alone, following the index pathway:



Closure

- perforation

- - nasal septum 41671-01[379]

A locally harvested cartilage graft is inherent in the above code and therefore does not require a separate code to be assigned for the graft component.

Amendments to ACHI will be considered for a future edition.

Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2923 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Radial scar of breast

Q:

What is the correct code assignment for radial scar of the breast?



A:

Radial scar also called complex sclerosing lesion is a benign breast lesion with a stellate architecture that may simulate invasive carcinoma mammographically, clinically, grossly and microscopically (Kempson, R, 2006). Despite being considered benign lesions, radial scars of the breast often demonstrate suspicious imaging features that prompt imaging-guided core needle biopsy as a significant percentage of these lesions are known to be associated with malignancy.

 Assign N64.8 Other specified disorders of breast for radial scar of the breast following the index pathway:

Disease, diseased

- breast


- - specified NEC N64.8

Indexing improvements will be considered for a future edition of ICD-10-AM.

References:

Kempson, R, (2006). Radial scar of the breast. Stanford University School of Medicine. Retrieved from:http://surgpathcriteria.stanford.edu/breast/radscar/printable.html

Knipe, H and Jones, J (2014). Radial scar. Radiopedia.org. Retrieved from: http://radiopaedia.org/articles/radial-scar

Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2915 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Injection of SpaceOAR® (spacing organs at risk) via TRUS

Q:

What is the correct procedure code for injection of SpaceOAR® under TRUS (transrectal ultrasound) guidance?



A:

Injection of SpaceOAR® is a rectal separation technique performed prior to radiation therapy to protect rectal tissue from radiation. This is achieved by injecting a water based gel (SpaceOAR®) into the anterior perirectal fat under TRUS guidance. The gel solidifies once injected, forming a mass/barrier separating the prostate and rectum.

The correct code for SpaceOAR® via TRUS is 90560-00 [1552] Administration of other agent into soft tissue, not elsewhere classified, by following the index pathway:

Injection 

- soft tissue NEC 90560-00 [1552]

Improvements to the Alphabetic Index will be considered for a future edition of ACHI

References:

ASERNIPS (Australian Safety and Efficacy Register of New Interventional Procedures – Surgical) (2010). Inert liquid-to-solid gels for prostate-rectum separation during prostate radiation therapy. ASERNIP, Department of Health and Ageing, ACT. Retrieved from: http://www.surgeons.org/media/305258/prostate_rectum_separation.pdf

Augmenix, Inc. Products (2015). Retrieved from: http://www.augmenix.com/products/spaceoar/



Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2914 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Synonymous terms for palliative care

Q: 


What are acceptable synonymous terms for palliative care?  Some terms are clearly synonymous with palliative care such as 'end of life care' and 'terminal care’; however is documentation of 'comfort measures only' considered synonymous with palliative care?

A:

The ACS for palliative care has been revised and relocated in Ninth Edition and has clarified that terminology such as ‘end of life care’ and ‘terminal care’ are synonymous terms used to describe episodes of palliative care.  However, the phrase ‘comfort measures’ may be more widely applied and therefore on its own does not qualify for assignment of Z51.5 Palliative care



Clinical coders should refer to ACS 2116 Palliative care to determine code assignment. If the documentation is unclear, Z51.5 should not be assigned.

*Please note the 8th Edition coding standard is ACS 0224 Palliative care

Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2864 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Posterior cerebral artery syndrome with infarction 

Q:

What is the correct code assignment for posterior cerebral artery syndrome with infarction:



I66.2† Occlusion and stenosis of posterior cerebral artery and G46.2* Posterior cerebral artery syndrome (I66.2†) 

or 


I63.5 Cerebral infarction due to unspecified occlusion or stenosis of cerebral arteries

A:

The dagger and asterisk pair I66.2† Occlusion and stenosis of posterior cerebral artery and G46.2* Posterior cerebral artery syndrome (I66.2†) can only be assigned following the index pathway:



Syndrome

- cerebral artery

- - posterior I66.2†, G46.2*

For posterior cerebral artery syndrome with infarction there is no legitimate dagger and asterisk pair that can be assigned. Codes from category I66 are clearly excluded when resulting in cerebral infarction.

Therefore the correct code to assign for posterior cerebral artery syndrome with infarction NOS is I63.5 Cerebral infarction due to unspecified occlusion or stenosis of cerebral arteries.

Do not assign G46.2* Posterior cerebral artery syndrome (I66.2†) as an additional code as an asterisk code can only be assigned with its corresponding dagger code as specified in the Alphabetic Index.

A proposal to update ICD-10 has been submitted to the World Health Organization.

Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2870 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Cellulitis with recent injury

Q:

The following scenarios are examples that relate to patients who are admitted with a diagnosis of cellulitis secondary to a recent injury:



    1. Small punctuate like ulcer on dorsum just proximal to IP joint with surrounding erythema. Patient had cut left thumb on nail clippers one week ago.

    1. Knee hot to touch with pus like exudate from a superficial graze. Patient had fallen two days ago. 

    1. Finger swollen and red post removal of a splinter six days ago. Wound cleaned with saline, aspirated with fine needle, small incision made with scalpel, 1ml pus drained and given IV flucloxacillin. 

    1. Swelling and tenderness of foot at laceration site the day after the sutures were removed.

    1. Finger cellulitis with ulceration at site of a burn a week previously.

What codes should be assigned for these scenarios?

A:

Cellulitis is a spreading infection of the dermis and subcutaneous tissues caused by certain types of bacteria entering the skin, and may result from insect bites, blistering, penetrating foreign bodies, burns, cuts etc. When coding cellulitis associated with a recent injury, apply the principles in ACS 0001 Principal diagnosis and ACS 0002 Additional diagnoses to determine code assignment and sequence.



Where cellulitis is chiefly responsible for occasioning the episode of care, it should be sequenced as the principal diagnosis. Assign other codes as appropriate following the guidelines in ACS 1911 Burns, ACS 1916 Superficial injuries, ACS 1917 Open wounds and instructional notes in the Tabular List as appropriate. The principles of ACS 0001 and ACS 0002 must be applied on their merits.

Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2873 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: IgG4-related disease

Q:

How do you code immunoglobulin G4-related disease?



A:

Immunoglobulin G4-related disease (IgG4-related disease) (IgG4-RD) is synonymously known as:



    1. IgG4-related systemic disease or IgG4-related sclerosing disease (IgG4-RSD)

    2. IgG4-related autoimmune disease

    3. IgG4-related multiorgan lymphoproliferative syndrome (IgG4-MOLPS)

    4. IgG4-associated multifocal systemic fibrosis

    5. systemic IgG4 plasmacytic syndrome (SIPS)

IgG4-RD is a fibroinflammatory condition characterised by elevated levels of IgG4-positive plasma cells in affected organ tissue, with fibrosis and with or without elevated serum IgG4 concentrations. Elevated serum IgG4 concentrations were first recognised in patients with autoimmune pancreatitis; manifestations outside of the pancreas were later identified and the condition was recognised as a systemic condition in 2003.

IgG4-RD may manifest in the; pancreas, hepatobiliary tract, salivary glands, periorbital tissues, kidneys, lungs, lymph nodes, meninges, aorta, breast, prostate, thyroid, pericardium, retroperitoneum and skin. Many conditions that were previously considered to be confined to single organs are now recognised as part of the spectrum of IgG4-RD, for example, Mikulicz’s syndrome, Riedels’ thyroiditis and retroperitoneal fibrosis. Symptoms of IgG4-RD are dependent upon the organ in which it manifests. There may be organ swelling (due to the presence of a fibrotic mass), damage or failure of the target organ. For example, patients may present with urinary symptoms due to obstruction of the ureter(s) from extensive retroperitoneal fibrosis.

Diagnosis of IgG4-RD includes histopathological identification of the presence of extensive numbers of IgG4-positive plasma cells in the affected tissue. Elevated serum IgG4 concentrations are suggestive but not a definitive diagnosis of IgG4-RD. Treatment includes administration of glucocorticoids, but immunosuppressive or B-cell depleting therapy may also be required.

The classification of IgG4-related disease is currently being considered internationally.

In the interim, assign the following code for IgG4-related disease (and all synonymous terms):

D89.8 Other specified disorders involving the immune mechanism, not elsewhere classified

by following the index pathway:

Disorder

- immune mechanism

- - specified type NEC D89.8

Also assign codes for specific manifestations (for example, retroperitoneal fibrosis), with sequencing as per the guidelines in ACS 0001 Principal diagnosis and ACS 0002 Additional diagnoses.

(See also Coding Rules: Retroperitoneal fibrosis).

References:

Guma, M., and Firestein, G. (2012). IgG4-related diseases. Best Practice and Research Clinical Rheumatology. Volume 26, Issue 4, August 2012, pages 425-438. doi:10.1016/j.berh.2012.07.001

Khosroshahi, A., and Stone, J. (2011). A clinical overview of IgG4-related systemic disease. Current Opinion in Rheumatology. Volume 23(1), January 2011, p57-66. doi 10.1097/BOR.0b013e3283418057

Stone, J., Zen, Y., and Deshpande, V. (2012). IgG4-related disease. The New England Journal of Medicine 2012; 366:539-551. February 9, 2012 doi: 10.1056/NEJMra1104650

Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2889 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Posterior reversible encephalopathy syndrome

Q:

How do you code posterior reversible encephalopathy syndrome?



A:

Posterior reversible encephalopathy syndrome (PRES) (also known as reversible posterior leukoencephalopathy syndrome) presents with symptoms such as headaches, altered mental state, seizures and visual disturbances. The exact cause is unclear, but most cases of PRES occur with or are due to hypertension (including eclampsia), immunosuppression (including secondary to immunosuppressive treatment), autoimmune disease, antineoplastic agents and renal failure. Radiological (MRI) findings of oedema involving the posterior occipital and parietal lobes of the brain are indicative of PRES and are essential for diagnosis, as PRES is difficult to diagnose clinically. Early diagnosis and treatment is vital to prevent sequelae. Complete reversal of clinical symptoms within weeks is possible if treatment is commenced immediately; which includes withdrawing causative agents and treating severe hypertension and seizures.

The correct code to assign for posterior reversible encephalopathy syndrome is:

I67.8 Other specified cerebrovascular diseases

by following the index pathway:

Disease, diseased

- cerebrovascular

- - specified NEC I67.8

Enhancements to ICD-10-AM will be considered for a future edition.

References:

Lee, H-J. (2007). Posterior reversible encephalopathy syndrome. Applied radiology. 2007; 36(5):42-43. Retrieved from http://www.medscape.com/viewarticle/559553

Moratalla, M. (2010). Posterior reversible encephalopathy syndrome. Emergency medicine journal. 2010; 27:547 doi: 10.1136/emj.2008.069765

Staykov, D. and Schwab, S. (2012). Progressive reversible encephalopathy syndrome. Journal of intensive care medicine. Vol. 27. No. 1 11-24. doi: 10.1177/0885066610393634



Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2960 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Revision procedure for obesity 

Q:

What codes are assigned for laparoscopic gastric bypass performed on a patient who previously had a sleeve gastrectomy?



A:

As per the instructional note at 30514-01 [889] Revision procedure for obesity, assign first a code for the obesity procedure performed, followed by 30514-01 [889]:

30512-03 [889] Laparoscopic gastric bypass

30514-01 [889] Revision procedure for obesity

The following inclusion terms have been added to 30514-01 [889] for ACHI Ninth Edition, to clarify code assignment:

Revision (reoperation) of:



    1.  biliopancreatic diversion

    2.  duodenal jejunal bypass

    3.  gastric bypass

    4.  gastroplasty

    5.  ileal interposition

    6.  sleeve gastrectomy

30514-01 [889] should not be assigned for revision/replacement of gastric band or gastric band reservoir.


Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2980 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Z58.7 Exposure to tobacco smoke (passive smoking)

Q:

Can Z58.7 Exposure to tobacco smoke be assigned when passive smoking is documented as the cause of a condition?



A:


NOT APPLICABLE TO NEW ZEALAND
Z58.7 Exposure to tobacco smoke is a WHO code that was implemented in ICD-10-AM Fifth Edition. The decision at the time of implementation, which was included in the pre-implementation education, was that the code should not be assigned because there was no accompanying standard to guide its assignment, and this has been supported and reinforced by a number of states in the intervening years.

The above advice was never officially included in the Australian Coding Standards (ACS). Therefore, a decision was made to list Z58.7 Exposure to tobacco smoke in the new Ninth Edition ACS 0049 Disease codes that must never be assigned to support the original advice. An ACS 0049 symbol has been added to Z58.7 in the ICD-10-AM Tabular List.

The above is an interim measure; ACCD has tentatively included the creation of specific guidelines for the assignment of Z58.7 on its work program for Tenth Edition. Until such guidelines are developed, Z58.7 must never be assigned for inpatient morbidity coding, as per the instructions in ACS 0049.

Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2881 | Published On: 15-Jun-2015 | Status: Current

SUBJECT:  Hoarding disorder

Q:

What is the correct code to assign for hoarding disorder?



A:

Hoarding disorder is characterized by persistent difficulty discarding or parting with possessions, regardless of their actual value, as a result of a strong perceived need to save the items and to distress associated with discarding them. Hoarding disorder results in the accumulation of a large number of possessions that congest and clutter active living areas to the extent that their intended use is substantially compromised (DSM-5, 2013).

ICD-10-AM and its parent classification ICD-10 do not have a specific code for hoarding disorder. Both the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5), published by the American Psychiatric Association and the World Health Organization (WHO) ICD-11 Beta Draft classify hoarding disorder to obsessive compulsive and related disorders.

Therefore, hoarding disorder should be classified to F42.8 Other obsessive-compulsive disorders following the index pathway:



Disorder (of)

- obsessive-compulsive

- - specified NEC F42.8

Additional codes such as Z58.8 Other problems related to physical environment and Z59.1 Inadequate housing should also be assigned where these situations are documented and meet the criteria in ACS 0002 Additional diagnoses.

Improvements to ICD-10-AM will be considered for a future edition.

References:

American Psychiatric Association (2013), Diagnostic and statistical manual of mental disorders, Fifth edition,(DSM-5). doi, 10.1176/9780890425596

Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2894 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Pulsed dose rate cervical and uterine brachytherapy 

Q:

What is the correct code to assign for cervical and uterine pulsed dose rate brachytherapy?



A:

Clinical advice indicates that the radiobiology of pulsed dose rate brachytherapy (PDRB) is similar to low dose rate brachytherapy (LDRB).

For PDRB administration to cervical and uterine cancers, assign the appropriate low dose rate brachytherapy code from block [1790] Brachytherapy, intracavitary, gynaecological.

Q:

What is the correct code to assign for insertion of applicator(s) for cervical and intrauterine brachytherapy?



A:

There is no site specific code for insertion of brachytherapy applicator(s) into cervix or uterus as there is for the eye and prostate.

For consistency with the classification of brachytherapy applicator implantation for other sites assign 90442-00 [1299] Other procedures on female genital organs to indicate insertion of the applicators.

Improvements to ACHI will be considered for a future edition.



Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2895 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Coding from documentation in previous admissions

Q:

There is a Coding Rule relating to diabetes mellitus which states that the condition must be documented in the current admission in order to assign a code for the diabetes. Should that rule be applied to all conditions where there is a coding instruction in a specialty standard to ‘code where documented’?



A:

The Coding Rule Documentation of diabetes mellitus, published in June 2012, states that:

‘…previous admissions and correspondence can be used to inform assignment of diabetes mellitus codes. However, previous admissions and correspondence should not be used:



    1. to assign diabetes mellitus if it has not been documented in the current admission...’

This instruction is relevant for all specialty standards instructing that certain conditions must be coded when documented (HIV/AIDS, viral hepatitis and tobacco use), that is, the conditions must be documented within the episode of care in order to be assigned a code.


Published 15 June 2015,
for implementation 01 July 2015.
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