Clinical Coding Standards Flashcards
What is DRule.1: Axis of the classification & rules of chapter prioritisation?
Where there is any doubt as to where a condition should be coded the ‘special group’ chapters must take priority
What are the three types of standards?
General coding standards, chapter standards, coding standards
Other than coding standards, what else do the standards include?
Index of standards, summary of changes, updated or deleted rules
What are the three dimensions of Coding accuracy?
Individual codes, totality of codes, Sequencing of codes
What does NOS mean?
Not Otherwise Specified
What are the two types of modifiers?
Essential & non-essential
How many dagger & asterisk codes are there?
83
Describe the coding process…
Translation of medical terminology into codes
Who made observations on the weekly bills of mortality in the 17th century?
John Graunt
On which date was the ICD 10 5th edition mandated?
1st April 2016
Which volume of the ICD 10 5th edition is referred to as the alphabetical index?
Volume 3
What does a block represent in the ICD 10 5th edition?
A level of grouping between chapters & categories
What is the correct definition of a hospital provider spell?
The total length of stay from admission to discharge of the patient
What is step 1 of the four step coding process?
Analyse the medical terminology to determine the lead terms & modifiers
What does the lead term identify?
Refers to the name of the disease/pathological condition
Which type of modifier appears in parentheses (curvy brackets) alongside the lead term?
Non essential modifiers
What is step 3 of the four step coding process?
Assignment of a tentative code using the alphabetical index
What are the two cross references found in the alphabetical index (volume 3)?
“See” & “See Also”
Which system relates to ‘Aetiology & manifestation’?
Dagger & Asterisk
What is the definition of an intervention (OPCS)?
Interventions are those aspects of clinical care carried out on patients undergoing treatment of: A surgical nature Carries procedural risks Anaesthetic risk Requires specialist training Requires special facilities or equipment
What can be said about ‘overflow’ categories on OPCS?
They start with the letter O
Appear at the end of the full chapter
Found in chapters L,W,Y & Z
What are the sections of OPCS?
1: Alphabetical Procedures (P)
2: Surgical Eponyms (E)
3: Abbreviations (A)
4: Common Surgical Suffixes (S)
Think: PEAS
What are primary actions of operations you’d search for in OPCS?
Aspiration Excision Drainage Placement Removal
Step 3 of the 4 Step coding process, is Assign a tentative code. How do you do this?
WHAT / WHERE / HOW Must action of procedure Identify the site of procedure Identify pathological Action qualifier
What is a lesion?
Any lump, bump that should not be present in the body (cyst, tumour, ganglion)
What does the abbreviation in OPCS HFQ mean?
However Further Qualified
What chapter includes < less than & >greater than in OPCS?
Chapter Y
What chapter includes < less than & >greater than in OPCS?
Chapter Y
What does the term radical mean in OPCS?
It can imply an operation on more than one site & will often involve more than one code
What is a medical record?
Information about the physical or mental health or condition of an individual made by, or behalf of, a health professional in connection with the care of the individual
What does EHR mean?
Electronic health record
What does EPR mean?
Electronic patient record
What do you record in the absence of a definitive diagnosis?
Code the diagnosis recorded as being treated or investigated.
In the absence of this, code the main symptoms
What is a co-morbiditie?
Any condition which co-exists in conjuction with another disease that I’d currently being treated at the time of the admission or develops subsequently, and,
Affects the management of the patients current consultant episode
What is important to note about diagnostic test results?
Test results must not be interpreted by the coder to arrive at a diagnosis; this is the role of the responsible consultant
What are sequelae codes used for?
To indicate that a current condition or disease has been caused by a previously occurring disease or injury which has been treated & is no longer present
When can a sequelae code used?
Only in 2nd position, directly after the code for the current condition/disease
Never on their own
What is the general rule for Acute on Chronic conditions?
Acute Before Chronic (ABC)
Where separate codes for each are available, code BOTH conditions with the Acute state being sequenced first, UNLESS Chronic condition is the main condition being treated
NEVER assume a link between diseases
What does ‘if desired’ mean in OPCS?
Never optional if additional information is available
What is the QRD system?
Query Resolution Database
Before assigning a code from chapter XVIII, (R), what must I ask?
Can the cause be determined?
Is there a confirmed diagnosis?
Is the sign or symptom receiving treatment in its own right?
What can be said about Y/Z chapters in OPCS?
A rule would be Y before Z
PCSY13
Insertion/removal of mesh
What must be included if procedure includes ‘mesh’ or ‘tape’?
&
What chapters does this apply to
When code description contains ‘mesh’ or ‘tape’ Y28.1/Y28.2/Y28.3 must only be assigned in addition where the type of mesh is known & adds further information
Applys to chapters M/P & Q
PCSY2
When should Y36.8 Insertion of adhesion barrier code be applied?
Must be assigned in addition to main procedure code
When should an image control code must NOT be used?
An image control code must not be assigned when image control has been used merely as a method of checking an anatomical position, the position of a Prosthesis/Fixator after Insertion, or confirm a procedure is complete
How should laterality be coded?
Laterality only needs to be coded once if multiple procedures are done at the same site
What are come lead term examples of chapter XXI (Z)?
Examination Aftercare Observation Screening History of Problem
What are congenital malformations, deformations, & chromosomal abnormalities?
They exist at birth
Can never be acquired
Unless corrected, they persist throughout life
What should be remembered about chapter XVII (Q)?
Codes are applicable to patients of any age
What are lead terms of chapter XVII (Q)?
Defect Deformity Malformation Syndrome Anomaly
How should you index syndrome?
Look under syndrome
Look under name of syndrome
What should the coder do if the syndrome cannot be found in the alphabetical index?
Clarify with the responsible consultant whether the syndrome is congential or acquired in order to determine the most appropriate codes
Determine if it is of chromosomal origin or not will assist in the code assignment as not all congenital anomalies are of chromosomal origin
The Note instructional notes provide instructions for coding; describe how they may be used
• To advise coders to include or omit additional or subsidiary codes
• To direct coders elsewhere in the classification for more appropriate
categories
• To clarify the intended use of codes in a particular chapter, category or
subcategory
• To provide specific instruction on the correct sequencing of codes when
used together (paired codes)
Describe the use of surgical eponyms for the assignment of procedural codes
Section II Alphabetical Index of Surgical Eponyms within Volume II -
Alphabetical Index must only be used as a guide when coding.
Where an eponym is used in the medical record the coder must analyse the procedural information and ensure that code assignment fully reflects the procedure performed.
Where the coder is unsure what procedure the eponym describes, they must seek advice from the responsible consultant to ensure that the correct codes are assigned.
Within the OPCS-4 classification what does HFQ stand for and describe its use?
HFQ (However Further Qualified)
Signifies that a statement may be further qualified/described in a number of
ways, which will not affect the code assignment, It refers to the part of the
procedural statement that immediately precedes the abbreviation HFQ.
Describe the coding standard for the removal of bypass grafts in Chapter L Arteries and Veins.
The removal of bypass grafts must be coded to the original operation bypass
category with the fourth-character to describe an ‘other specified’ procedure
(.8) plus a code from Chapter Y to specify the removal of repair material
(Y26.4 Removal of other repair material from organ NOC) unless there is
a specific fourth-character code that classifies removal of the bypass graft.
Describe when it is acceptable to code interventions on specifically
classifiable arteries in Chapter L Arteries and Veins, and what must be
done when they aren’t specifically classifiable.
Only when an artery or its branches is specified in the category/code
description or at the category inclusions can these codes be assigned. A site
code must be assigned in addition when the artery is listed as an inclusion
term.
Where the artery is not specifically referred to within the code description or
inclusion, even if the origin is known, do not assign a code from these
categories. A code from categories L65–L72 must be used instead with the
addition of a site code from Chapter Z where available.
Describe the standard for the assignment of site codes during diagnostic
endoscopic procedures, including those involving a biopsy
Where multiple organs are examined during a diagnostic endoscopy, a site
code from Chapter Z must be added to identify the furthest site examined.
During a diagnostic endoscopy if a biopsy is performed at the same time as
other multiple sites are examined, the site of the biopsy is of greater
importance than the other sites examined and the site of the biopsy is the
only site code required. This includes if the site of biopsy is not the furthest
site examined.
Where multiple biopsies are taken, it is only necessary to site code the
furthest point biopsied.
When should site codes from Chapter Z be assigned?
They must always be assigned when this adds further information about the site on which the procedure was performed
What does the Cross reference “see also” used in the icd 10 alphabetical index instruct the coder to do?
This is a reminder to look under another lead term if the term the coder is looking for cannot be found modified in any way under the first lead term
Describe the standard that mist be applied when assigning opcs codes for maintenance and attention to procedures
A supplementary code from chapter Y must be added in addition to the maintenance/attention to code, when doing so adds further information
When is it applicable to assign icd 10 code z75.1 person awaiting admission to adequate facility elsewhere in a secondary position?
When the medical record clearly states that they are ‘bed blocking’ or medically fit for discharge (MFD) but awaiting suitable accommodation elsewhere, such as nursing home or residential home
