Coding Rules Publication
As you may have noticed, there has been an increase over the past few quarters in the number of Coding Rules being published by the ACCD. For example, this quarter includes the publication of 46 Coding Rules (43 new coding rules, and 3 updated).
The graphic below demonstrates the rise in queries received by ACCD, from 66 in 2013/2014 to 133 in 2016/2017.
ACCD has received 58 queries in the 2017/2018 year to date, indicating that this financial year’s total queries may again be higher than previous years.
The graphic below demonstrates the rise in queries answered by ACCD, from 59 in 2013/2014 to 104 in 2016/2017.
ACCD endeavours to ensure a timely response to all coding queries. However, it is noted that there are some quarters with greater numbers of published Coding Rules. For example, in quarters where there is an ICD-10-AM/ACHI/ACS edition change, activity is higher. That is, more coding queries are received and answered, and the FAQs following the online education are published in addition to the Coding Rules.
HIMAA NCCH Conference Questions
In the two NCCH sessions at the 2017 conference, the NCCH retained some questions for further internal deliberation and advised that responses to these questions would be published in the next Newsletter. It is always best to receive a considered response from the NCCH to ensure consistency in application of coding advice.
Question 1:
Can patient completed admission forms be used to assign codes such as smoker status or U codes (U78-U88 Supplementary codes for chronic conditions)?
Coding Rule: Assignment of U codes from patient documentation
Q:
On the patient's preoperative questionnaire, in response to the question "Are you being treated for high blood pressure", the answer is 'Yes' and anti-hypertensive medication is included in the list of current medications. There is no other mention of hypertension in the record (same-day episode). Should a 'U' code for hypertension be assigned when it has not been documented by the clinician?
A:
The Introduction to the Australian Coding Standards states:
“The responsibility for recording accurate diagnoses and procedures, in particular principal diagnosis, lies with the clinician, not the clinical coder.
A joint effort between the clinician and clinical coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures”.
Assignment of codes for diagnoses and procedures assumes that these have been documented by a clinician. This principle applies to the assignment of supplementary codes for chronic conditions.
While it is not expected that clinical coders should follow-up clinicians for assignment of 'U' codes, it is assumed they should be allocated to conditions that have been documented by a clinician.
Therefore, in the absence of supporting clinical documentation, a 'U' code should not be assigned based on documentation of patient response(s) alone. This includes where the form has been signed by a clinician, which confirms the form has been completed or sighted but does not necessarily corroborate the clinical content.
As per the Ninth Edition Education FAQs, it is not necessary to review medication charts to inform code assignment. Medications may be more than one diagnosis, and the presence of a prescribed medication is not an indication of a diagnosis. ACS 0003 Supplementary codes for chronic conditions (Errata 3 update) also confirms that conditions may be assumed to be current unless there is documentation that indicates otherwise.
(Coding Rules, December 2015)
ACCD Response
The above coding rule is explicit in that a 'U' code should not
be assigned based on documentation of patient response(s) alone. This includes
where the form has been signed by a clinician, which confirms the form has been
completed or sighted but does not necessarily validate the clinical content.
Therefore, if conditions indicated by the patient are not validated
elsewhere in the clinical record, then they should not be coded.
The above directive does not apply to Z86.43 Personal history of tobacco use disorder
and Z72.0 Tobacco use, current. These
are status codes with public health significance. Therefore, a patient completed admission form
may be used to assign Z86.43 and Z72.0 in accordance with ACS 0503 Drug, alcohol and tobacco use disorders.
Question 2:
In Scenario 15 of the coding exercises why was Z09 coded?
ACCD Response:
(from the Coding Exercises HIMAA NCCH Conference workbook)
Case Scenario 15 Answer:
I85.9 Oesophageal varices without bleeding
Z09.9 Follow-up examination after unspecified treatment for other conditions
30476-02 [856] Endoscopic banding of oesophageal varices
92515-99 [1910] Sedation, ASA 99
The Addenda to Errata 2, which was published in September 2017 (for implementation October 1, 2017), included errata to ACS 0052 Same-day endoscopy – surveillance/Classification which states:
Assign as additional diagnosis:
…
- codes from Z08 or Z09 Follow-up examination after treatment for… or Z11, Z12 and Z13
Special screening examination for…as appropriate.
The original instruction to not code Z08/Z09/Z11/Z12/Z13 was included in ACS 0052 Same-day endoscopy – surveillance due to inconsistent use of the terminology ‘follow-up’ and ‘screening’. Therefore, the addition of these codes may provide little value in the data. However, this was reconsidered in the context of multiple endoscopies performed in the one operative episode, and was amended as above, to allow assignment of these codes as additional diagnoses, as appropriate.
In Scenario 15 there is very clear documentation of ‘follow-up varices’, which were found to have increased in size and were banded.
Question 3:
Is there a ‘blanket rule’ for sequencing of multiple same-day endoscopies?
ACCD Response:
As per the advice published in the Tenth Edition FAQs, mutual exclusivity does not apply to coding standards. Multiple standards may however, apply when coding a particular case.
For example:
ACS 0051 Same-day endoscopy - diagnostic and ACS 0052 Same-day endoscopy - surveillance may apply to the same episode of care, in addition to the general standards for diseases. There is no hierarchy for ACS 0051 and ACS 0052 when assigning the principal diagnosis.
Follow the guidelines in ACS 0051 and ACS 0052 where there are both diagnostic and surveillance endoscopies in the one episode. Then, apply the general principles in ACS 0001 to determine the principal diagnosis.
This has always been the case for these scenarios and has not changed with Tenth Edition.
Question 4:
With regard to the answers for Scenario 18 of the coding exercises - if a patient had a coronary artery bypass graft (CABG) and a leg wound breakdown, what external cause code is assigned?
ACCD Response:
(from the Coding Exercises HIMAA NCCH Conference workbook)
Case Scenario 18 Answer:
K91.82 Stenosis of surgical anastomosis of digestive tract
Y83.6 Removal of other organ (partial)(total)
Y92.23 Health service area, not specified as this facility
32090-00 [905] Fibreoptic colonoscopy to caecum
92515-99 [1910] Sedation, ASA 99
Category Y83 codes are assigned to indicate the primary purpose of the operation performed. In scenario 18 this was a hemicolectomy, in which anastomosis is inherent. Using the same logic, if a patient has a leg wound breakdown following CABG, the Y83 code assigned indicates the primary purpose of the procedure (i.e. CABG). Therefore, assign Y83.2 Surgical operation with anastomosis, bypass or graft as the external cause code.
Question 5:
Adjustment of warfarin in a patient with AF, why do we code the AF?
If warfarin (for AF) is adjusted pre and post surgery and monitored. Do we code AF?
ACCD Response:
Where a patient is on a specified medication as a result of having a clinical condition, and that specified medication has been altered during an episode of care, the clinical condition should be coded, as per the criteria in ACS 0002 Additional diagnoses; specifically dot point 1, 'commencement, alteration or adjustment of therapeutic treatment'.
The concept of ‘therapeutic treatment’ does not mean that the condition is necessarily treated by the specified medication; the specified medication may be required to negate a manifestation or associated condition. Specific examples include the use of warfarin and aspirin in patients with atrial fibrillation.
See also Coding Rule: ACS 0002 Additional diagnoses and alteration to treatment (published June 2015).
ACS 0002 Additional diagnoses is scheduled for review in the Eleventh Edition of ICD-10-AM/ACHI/ACS and this issue will be taken into consideration for clarification purposes.
Question 6:
Published advice – concern was expressed that the quarterly updates can become burdensome for coders/educators/auditors and IT staff to keep up with changes.
ACCD Response:
ACCD publishes coding advice on a quarterly basis (March, June, September and December) each year.
This advice includes Coding Rules based on coding queries received from the jurisdictions, errata for ICD-10-AM/ACHI/ACS (published 4 times; June, September, December and March following release of a new edition), and new edition education items such as the FAQs.
In quarters where there is an edition change in ICD-10-AM/ACHI/ACS activity is higher (i.e. more coding queries will be received and answered) and the FAQs and errata will be published, as well as Coding Rules.
The implementation date of coding advice (that is, the first of the following month) is intended to allow coders and other staff time to educate themselves, and implement the advice into coding practice.
Inclusion of the amendments into software products is outside the scope of the ACCD, and should be addressed with the software provider.
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