Independent Hospital Pricing Authority
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code it! - ACCD Newsletter Vol 1, No 2, March 2014

Welcome to the second edition of our code it! Newsletter.


What's New

Public Submission Guidelines (AR-DRG and ICD-10-AM/ACHI/ACS) as well as Query Submission Guidelines have been updated. Please take the time to read them.

Quarterly Coding Exercise
The second series of coding exercises to reinforce the ICD-10-AM/ACHI/ACS Eighth Edition changes introduced from 1 July 2013 are now available and can be found on our ACCD website.

Any queries arising from these exercises should be addressed through the normal coding query channels.
Attention Health Information Managers and Clinical Coders!
We are seeking copies of de-identified medical records for educational purposes. If you have a discharge summary, operation report or medical record that would be suitable for highlighting the changes in ICD-10-AM/ACHI/ACS Eighth Edition, please email or mail us a de-identified copy. Any questions should be directed to Belinda Miguel at
About CLIP and Web Browsers
The ACCD Classification Information Portal (CLIP) works best in more recent browsers and versions of Windows. If you are experiencing difficulties with CLIP, you should install the latest version of Internet Explorer, Google Chrome or Mozilla Firefox.
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ACCD Activities in Short

ACCD's technical and advisory groups including the Classifications Clinical Advisory Group (CCAG), the DRG Technical Group (DTG) and the ICD Technical Group (ITG) have now been established and have had their first meetings. Both the DTG and ITG had their inaugural meeting in December last year and CCAG's introductory teleconference was held in mid-February this year.

Content development for ICD-10-AM/ACHI/ACS is well under way. With respect to progress on AR-DRG Development, please see the article below relating to the Patient Complication and Comorbidity Level (PCCL) review.

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AR-DRG Update

ACCD's work on Version 8.0 of the Australian Refined Diagnosis Related Groups (AR-DRGs) is now well underway. The work is led by Stuart McAlister, who worked on AR-DRG development at the Commonwealth Department of Health and the Independent Hospital Pricing Authority (IHPA) for many years, Dr Trent Yeend who has been seconded from IHPA where he has led price modelling developments and Dr Qingsheng Zhou, who joined NCCH after a career as a policy researcher and data analyst in a number of NSW government agencies.

The Eighth Edition of the International Statistical Classification of Diseases and Related Health Problems - Tenth Revision - Australian Modification, the Australian Classification of Health Interventions (ICD-10-AM/ACHI) and the associated Australian Coding Standards (ACS) form the basis of the development and refinement of AR-DRG Version 8.0. Our team of Classification Specialists and our Principal Clinical Advisor are working closely with the AR-DRG Development team in relation to one of our major tasks in reviewing the Patient Clinical Complexity Levels (PCCLs) within the AR-DRGs. Our team will also be assessing the impact of changes proposed within ICD-10-AM/ACHI/ACS Ninth Edition as part of the process. This combined team approach maximises efficiency and ultimately improvements in both classifications without jeopardising the integrity of ICD-10-AM/ACHI/ACS.

Our main work has been on the review of the Complications and Comorbidities (CC) component of AR-DRGs. It was developed in the 1990s, drawing on previous development in the United States. In short, diagnoses are given severity weights which vary according to the Adjacent DRG (ADRG) which applies to a specific hospital in-patient episode. The Australian development process is described in Volume 3 of the AR-DRG Classification Version 4 (Department of Health and Aged Care, 2000).

Given the amount of time which has elapsed since its inception, a review of the system is long overdue. The availability of patient-level data and associated cost information is much improved, and the computing capacity to analyse big data sets is many times greater than it was in the 1990s.

ACCD has assembled a comprehensive data set covering admitted patient characteristics and costs, for the six years from 2006-07 to 2011-12, based on the Australian Institute of Health and Welfare's (AIHW's) admitted patient collection (APC) and IHPA's National Hospital Cost Data Collection (NHCDC). Our initial review of the data shows that the existing CC system is inadequate at measuring additional resource use due to complications and comorbidities.

Subsequently, ACCD is considering alternative methods. A first proposal was discussed on 27 February by ACCD's DRG Technical Group (DTG). Using the available data for public hospitals for 2009-10, 2010-11 and 2011-12, a standardised relative cost (SRC) has been compiled for each diagnosis within each adjacent DRG (ADRG). DTG members welcomed this innovative approach, recognising that the work to date is preliminary, with some issues of detail remaining to be settled.

The work raised the important question of whether the principal diagnosis within an ADRG could affect severity loadings as well as complications and comorbidities (additional diagnoses). The analysis shows that there is considerable variation in cost within some ADRGs according to the principal diagnosis.

In light of the DTG discussion, development of a revised approach is continuing. Once a draft list of SRCs has been developed, substantial clinical review will be required to consider the appropriateness of the list and also the exclusion rules that should apply to related/associated diagnoses. This review will be led by ACCD's Classification Clinical Advisory Group (CCAG).

The ACCD review of the CC system is to be submitted to IHPA by 30 June 2014.

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Impact of ICD-10-AM/ACS Seventh Edition Obstetric Code Changes to AR-DRG V7.0


In early February 2014, ACCD was made aware of a significant change in the distribution of cases within Adjacent DRG (ADRG) O60 Vaginal delivery in AR-DRG V7.0. ADRG O60 contains three complexity levels for DRGs. These are:

O60A Vaginal delivery with catastrophic or severe complication or comorbidity.
O60B Vaginal delivery without catastrophic or severe complication or comorbidity.
O60C Vaginal delivery, single uncomplicated.

The matter was investigated to determine the underlying cause and whether changes to AR-DRG V7.0 were required, prior to implementation on 1 July 2014.

Reason for change in distribution of cases within ADRG O60 Vaginal delivery

The significant change in the distribution of episodes within ADRG O60 is a result of updates to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) and the Australian Coding Standards (ACS) undertaken for Seventh Edition. ICD-10-AM and the ACS Seventh Edition were implemented in 2010 without an accompanying AR-DRG version.

AR-DRG V6.0 and V6x were both developed for ICD-10-AM Sixth Edition. Therefore, for AR-DRG grouping purposes, ICD-10-AM Seventh Edition coded data was mapped back to Sixth Edition codes to maintain the DRG assignment when using AR-DRG V6x or earlier DRG versions. Consequently, the obstetric ICD-10- AM classification changes in Seventh Edition have not yet been reflected in the AR-DRG classification.

AR-DRG V7.0 will be the first version of DRGs where these ICD-10-AM obstetric classification changes will become active. AR-DRG V7.0 was developed for ICD- 10-AM Eighth Edition and the obstetric classification changes implemented in ICD-10-AM Seventh Edition have been maintained in ICD-10-AM Eighth Edition.

The following points summarise the background leading to this issue:

These updates resulted from a review of national inconsistencies in coding of obstetric episodes as well as evolving clinical views on what constitutes a normal uncomplicated delivery. The World Health Organization's ICD-10 codes between O80 - O84 were used as a base for these changes.
Updates were also made to the Australian Coding Standards (ACS) to clarify the coding of principal diagnosis in episodes with a delivery. The aim was to ensure all obstetric episodes had a delivery code as the principal diagnosis to reflect the reason for admission, except in circumstances where a mother was admitted specifically for management of an antepartum condition.
Previous editions of ICD-10-AM forced the assignment of O80 Single spontaneous delivery only in the absence of other codes classifiable elsewhere in Chapter 15 Pregnancy, childbirth and the puerperium, assuming O80 alone was equivalent to a normal delivery. However clinical advice indicated that there is non-consensus as to the definition of a normal delivery and that single spontaneous deliveries can occur with a range of comorbidities and complications.
Modifications to ICD-10-AM Seventh Edition more accurately distinguish spontaneous vaginal deliveries with minimal or no assistance from those with assistance by manipulation, instrumentation or surgery (e.g. forceps, vacuum, caesarean sections and other assisted deliveries). This was achieved by allowing O80 Single spontaneous delivery to be assigned in conjunction with other codes classifiable elsewhere within Chapter 15 Pregnancy, childbirth and the puerperium.
Delivery episodes now allow O80 to be assigned as the principal diagnosis with additional diagnosis codes assigned to describe antepartum, delivery and postpartum conditions that occur with a spontaneous vaginal delivery (e.g. gestational diabetes, premature rupture of membranes, perineal lacerations, postpartum haemorrhage, etc).
The ICD-10-AM changes went through the usual extensive consultation process at the time. This included clinical consultation, the creation of a sub-committee of the Coding Standards Advisory Committee (CSAC) to examine the issues with obstetric coding and a trial of the new obstetric codes and associated ACS. Following this development work, CSAC endorsed the modifications for implementation in ICD-10-AM Seventh Edition in 2010.

Impact of ICD-10-AM/ACS coding changes on O60 Vaginal delivery

The Seventh Edition ICD-10-AM/ACS coding changes have resulted in a considerable number of cases moving from the more resource intensive O60A and O60B DRGs to the less resource-intensive O60C DRG. These DRG changes are due to a higher proportion of episodes being assigned a principal diagnosis of O80 Single spontaneous delivery as a result of the Seventh Edition coding changes detailed above. The following points illustrate the current criteria used to split ADRG O60:

Episodes with a principal diagnosis of O80 automatically group to O60C in AR-DRG V7.0, regardless of the number and type of additional diagnoses assigned to each episode.
Episodes with a principal diagnosis from Chapter 15 (other than O80) but with an additional diagnosis with a Patient Clinical Complexity Level (PCCL) of >2 group to O60A.
All other episodes with a principal diagnosis from Chapter 15 (other than O80) group to O60B.

Investigation of 2011/12 data shows that in AR-DRG V7.0, the number of cases in O60A and O60B have dropped when compared to AR-DRG V6x. However the distribution of cases, mean cost and average length of stay (LOS) between O60A, O60B and O60C is more consistent with the instinctive pattern of cases within ADRGs across the AR-DRG classification (ie lower partitions have a greater volume of cases than the partition above them with the "A" partition having the smallest volume of cases).

The mean cost of O60A and O60B has increased, which reflects the cheaper and less complex cases being assigned to O60C. The mean cost of O60C has also increased due to the increase in more costly episodes transferring from O60A and O60B. This transfer of episodes and changes in costs has been taken into account for weight calculations as data coded in ICD-10-AM Seventh Edition has been used in these calculations.


There has been a change in the distribution of cases within ADRG O60 Vaginal delivery for AR-DRG V7.0. This is as a result of an intentional change to the underlying ICD-10-AM/ACS classification to reflect the current clinical situation in obstetrics.

The Seventh Edition ICD-10-AM/ACS changes went through an extensive consultation process at the time. This included clinical consultation, the creation of a sub-committee of the Coding Standards Advisory Committee to examine the issues with obstetric coding and a trial of the new codes and coding standards across several jurisdictions, including New Zealand.

Following an analysis of the impact of ICD-10-AM/ACS Seventh Edition changes to the obstetric codes (maintained in Eighth Edition in which AR-DRG V7.0 is based), DRG O60A, O60B and O60C appear to be performing as expected. The average LOS within these DRGs are indicative of the level of severity/resource consumption, with O60A being the most severe/resource consuming within this ADRG.

The Independent Hospital Pricing Authority has agreed that the current classification structure for ADRG O60 Vaginal delivery in AR-DRG V7.0 is to be maintained. Further work will occur on ADRG O60 as part of the wider review of the PCCLs being carried out by ACCD for the development of AR-DRG V8.0.

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ACCD Stakeholder Survey Results

ACCD conducted a survey during October/November 2013 to assist in our understanding of the needs and expectations of our stakeholders. The feedback from the survey will help to inform our planning and development for the ongoing development of the ICD-10-AM/ACHI/ACS classifications.

The survey was distributed at the National Health Information Management Association of Australia (HIMAA) Conference in October 2013 and was also available through the ACCD website for completion online. The survey questions related to the ACCD website, the Classification Information Portal (CLIP), the newsletter, communication from ACCD, and delivery of education.

There were a total of 350 respondents, with the breakdown of respondents' roles as follows:

Respondents by Role

The following is a summary of the survey results and the action taken by ACCD to date in response to the feedback.

ACCD Website

62% of respondents had visited the ACCD website. Of those who had not yet visited the website, the majority indicated time constraints or a lack of awareness of the website as the main reasons.

The HIMAA Conference introduced ACCD to the Health Information Management and clinical/coder workforce through keynote presentations and an information booth to raise awareness of the AR-DRG Classification System development and refinement project.

Of the respondents who had visited the website, 75% thought the design and layout of the website was good/excellent. However some respondents identified difficulties when locating the Coding Rules, previous editions of Coding Matters and Errata. The website menu layout has since been modified and a "Quick Links" option included on the top of the screen to enable users to easily locate this type of information.

70% of respondents were unaware of a link to provide website feedback to the ACCD. This link is now available under the Contacts menu and clearly labelled "Website Feedback".


Pleasingly, 69% of survey respondents had already registered with CLIP and many of those who had not yet done so, were able to register at the ACCD booth at the HIMAA Conference. Changes were also made to the ACCD website to ensure that the link to CLIP was more obvious.

Survey respondents raised issues with functionality including searching, printing and saving Coding Rules within CLIP. Investigation of these issues highlighted potential problems with different browsers and versions of browsers being used by stakeholders. Enhancements have now been made to CLIP to help overcome these issues and streamline functionality. Detailed instructions for searching/printing and saving/exporting were published in the December issue of the code it! newsletter.

Comments from respondents in relation to the formatting of the Coding Rules and in particular the print version have been taken on board and addressed by changes to the print functionality within CLIP.


Approximately 90% of respondents indicated their preference for clinical updates and coding exercises to be incorporated in the newsletter. The first edition of our quarterly code it! newsletter was published in December 2013 and included a link to a coding exercise. This will now become a regular inclusion. Clinical updates are also planned for future editions. Regular updates on the ACCD's work program was requested by 85% of survey respondents. This edition of code it! communicates some important background information about the AR-DRG Classification System development and refinement project.

Updates on training and upcoming conferences, and the progress of ICD-11 development were also suggestions made by respondents, and this information will be included in code it! as it becomes available. Other respondents requested profiles of ACCD staff, and these are available on the ACCD website.


The vast majority of respondents indicated that their preference for communication from ACCD was via email (to CLIP registrants). ACCD is currently and will continue to provide notifications via email to CLIP registrants about the publication of coding advice (Coding Rules), release of errata etc. Over 70% of respondents were happy to receive information via ACCD website updates and through the newsletter. These channels of communication will continue to be used, including updates in the "What's New" section on the ACCD website. There was very little demand for communication via social media, with less than 7% of respondents indicating an interest in using this method as a communication tool. At this stage ACCD is not pursuing the social media option.


Regarding alternative options for education delivery, online tutorials were the most preferred method, selected by 87% of respondents, followed by 65% preferring conference coding workshops. Nearly 40% of respondents selected video conferencing/webinars, however it was noted by some respondents that there can be limitations to accessing this technology at present.

ACCD is exploring innovative options for the delivery of education in the future. Coding workshops are currently planned for the combined HIMAA/NCCH National Conference to be held in Darwin in October 2014.

The survey feedback has provided a valuable resource to the ACCD. Thank you to everyone who contributed by completing the survey!

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Upcoming Events

Activity Based Funding Conference 2014

Melbourne Convention Exhibition Centre (MCEC)
23-25 June

IHPA will organise and promote the Activity Based Funding Conference (ABF) 2014 as a forum for the dissemination of ABF-related education, training and research. The conference aims to provide high quality education in ABF and the underlying classification, costing and data collection systems to key health sector personnel. It will include major plenary sessions, concurrent smaller presentations, workshops/training, exhibitions and social activities.

More information is available at their conference website.

HIMAA/NCCH 2014 National Conference - "Health information management: driving the information highway"

Double Tree by Hilton Hotel, Esplanade Darwin
7-9 October

This year, HIMAA is teaming up with the National Centre for Classification in Health (NCCH) to deliver an informational and learning opportunity for HIMs, Clinical Coders and other professionals associated with the management and use of health information.

The 2014 HIMAA/NCCH conference will explore how local and international health information professionals are navigating eHealth initiatives and funding reform through a dynamic period of change. As well as an important networking opportunity, the joint conference will include presentations and workshops in the areas of clinical coding, data governance, financial management, performance reporting, eHealth standards, workforce challenges, quality and safety and international classifications - all in the context of the HIM and Clinical Coding streams.

Call for Abstracts is now open.

HIC Conference 2014

11-14 August

Please visit the conference website.

AHIMA Convention & Exhibit 2014

San Diego, USA
27 September-2 October 2014

Watch this space.

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What's New in CLIP - Coding Rules

Recently, ACCD was alerted to instances where coding advice should have been retired/superseded as well as instances where advice was inadvertently retired. Consequently over December 2013/January 2014 ACCD undertook a thorough review of all Coding Rules in CLIP to ensure that it only contains current coding advice. This review resulted in the reinstatement of some Coding Rules and the removal or updating of other Coding Rules. Please note that if you have exported and printed the Coding Rules prior to February 2014 they will no longer be current.

Since removing the retired and superseded coding advice from CLIP we have had requests for access to a listing of all the retired and superseded advice from some stakeholders. To this end, we now have two pdf files available in the Downloads section of the ACCD website. One pdf file contains a listing of the superseded advice and the other contains a listing of the retired advice.

New Coding Rules

22 new Coding Rules have been published in CLIP as at 15 March 2014. Click here to view them.

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