Coding Terms to know

Question 1

NOS

Answer 1

Not otherwise specified

Question 2

NEC

Answer 2

Not elsewhere classified

Question 3

And

Answer 3

Means - And/Or

Question 4

+

Answer 4

Aetiology
Cause of Disease

Question 5

*

Answer 5

Manifestation of a Disease
= The signs indicating an underlying disease

Question 6

Symbol - Upside down triangle - what does this mean?

Answer 6

This symbol indicates that an Australian Coding Standard applies to a particular code or codes.

Question 7

What does the symbol with the circle and x inside it mean?

Answer 7

This symbol indicates and Australian Code.

Question 8

What does ‘other’ and ‘unspecified’ codes mean?

Answer 8

These codes are assigned for conditions that are specifically indexed to those codes.

Question 9

DRG

Answer 9

Diagnosis Related Group
=Patient classification system that categorises clinically similar types of patients into groups. Provides a clinically meaningful way of relating the number and type of patients treated to the resources required by a hospital.

Question 10

ADRG

Answer 10

Adjacent Diagnosis Related Group
=Consists of more than one DRG’s generally defined by the same diagnsis or intervention codes.

Question 11

Data items that affect a DRG

Answer 11

-Diagnosis
-Procedures
-Sex
-Age
-Event and type
-Length of Stay
-Leave Days
-Admission Weight
-Mental health legal status
-Same-day status

Question 12

AR-DRG

Answer 12

Australia Refined Diagnosis Related Groups

Question 13

NMDS

Answer 13

National Minimum Dataset

Question 14

What does ‘MAAD’ mean

Answer 14

M - Indicates the broad group (the MDC - major diagnostic categories) to which the DRG belongs.

AA - identifies the adjacent DRG (ADRG) within the MDC and the partition to which the ADRG belongs. An ADRG consists of one or more DRGs generally defined by the same diagnosis or intervention codes. DRGs within an ADRG have differing levels of complexity, and are partitioned on the basis of several factors, including diagnoses/procedures used as a severity split, sameday, and level of comorbid disease and/or clinical complication.

The second and third characters (AA) identify the ADRG grouping and partition to which the ADRG belongs. These ranges are:

01 to 59 = to indicate the Intervention Partition
60 to 99 = to indicate the Medical Partition.

D - is a split indicator that ranks DRGs within an ADRG on the basis of their clinical complexity. The values are:

A = highest clinical complexity
B = second highest clinical complexity
C = third highest clinical complexity
D = fourth highest clinical complexity
Z = no split for the ADRG (ie, no subgroups).

Question 15

MDC

Answer 15

Major Diagnostic Categories
The MDC is a category generally based on a single body system or aetiology that is associated with a particular health specialty. MDCs are assigned according to the principal diagnosis.

Question 16

ECC

Answer 16

Episode Clinical Complexity
The Episode Clinical Complexity model was introduced in AR-DRG v8.0 and has continued to be refined in later AR-DRG classification systems. The new ECC model was introduced for determining clinical complexity. The ECC model assigns diagnosis complexity level (DCL) weights and episode clinical complexity scores (ECCS). The episode clinical complexity scores quantify relative levels of resource utilisation within each ADRG and are used to split ADRGs into DRGs on the basis of resource homogeneity.

The ECCS determines the final DRG to which an episode of care is assigned within an ADRG.

An ECCS is an output from the grouper software and is a value between 0 and 32 with decimals of .5 (eg, 21.5)

The complexity terms listed are used in the naming of DRGs where an episode clinical complexity score has been used as a splitting variable:

Minor complexity
Intermediate complexity
Major complexity
Extreme complexity.

Question 17

DCL

Answer 17

Diagnosis complexity level

Question 18

ECCS

Answer 18

Episode clinical complexity scores

Question 19

What year was ICD-10AM Introduced?

Answer 19

1998

Question 20

Who developed ICD-10

Answer 20

WHO - World Health Organisation

Question 21

PMS

Answer 21

Patient Management System

Question 22

NCCH

Answer 22

National Centre for Classification in Health - The university of Sydney which was responsible for the development of the classification products ICD-10-AM/MBS-E/ACHI/ACS

Question 23

DOHA

Answer 23

Department of Health and Ageing - Australia

Question 24

NCCC

Answer 24

National Casemix and Classification Centre - University of Wollongong

Question 25

ACCD

Answer 25

Australian Consortium for Classification Development - Responsible for 9th to 12th Edition of ICD-10-AM/ACHI/ACS

Question 26

ACS

Answer 26

Australian Coding Standards

Question 27

NZCC

Answer 27

New Zealand Coding Conventions

Question 28

NZCA

Answer 28

New Zealand Coding Authority

Question 29

ACHI

Answer 29

Australian Classificatio of Health Interventions

Question 30

HIMA

Answer 30

Health Information Management Association of Australia

Question 31

CCSA

Answer 31

Clinical Coders Society of Australia

Question 32

What are the 3 sections in the ICD-10-AM Alphabetic Index

Answer 32

Section 1. Alphabetic Index of Diseases and Nature of Injury
Section 2. External Causes of Injury
Section 3. Table of drugs and chemicals

Question 33

Lead Terms

Answer 33

The Alphabetic Index of Diseases is organised alphabetically by lead terms. Lead terms mainly identify the name of a disease or condition.

Question 34

Subterms

Answer 34

Always look at the number of hyphens when looking at a subterm. The number of hyphens will indicate whether the term you are looking at modfies the lead term or a subterm. The number of hyphens increases in accordance with the level of detail about the condition required to assign a particular code.

Question 35

Non-essential Modifier

Answer 35

These are terms in parentheses aka brackets, that follow a lead term or subterm and do NOT affect code selection.

Question 36

Default Code

Answer 36

Where the lead term takes you with no more detail.

Question 37

Prepositional Terms

Answer 37

If it follows the lead term or subterm then it takes priority; as, by, for, with, without. If multiple prepositional terms are listed then they are sequenced in alphabetic order.

Question 38

What do the terms ‘See’ and ‘See also” mean?

Answer 38

They are used to tell you to look at alternatives before assigning a code. ‘See’ is and instruction you must follow.

Question 39

How long are code numbers?

Answer 39

Three, four or five character codes.

Question 40

What is a code structure?

Answer 40

The first character is a letter. The rest of the characters in the code are digists.

Question 41

What is multiple condition coding?

Answer 41

When coding a condition with an underlying cause, assign codes for both the condition and underlying cause.

Question 42

Aetiology

Answer 42

Cause of a diseases (dagger)

Question 43

Manifestation

Answer 43

The signs indicating a symptom of an ailment (Astrix)

Question 44

Is the dagger or astrix assigned as the principal diagnosis?

Answer 44

Either one can be assigned as principal diagnosis.

Question 45

Inclusion Terms and Include notes

Answer 45

Inclusion terms are listed under a block heading glossary heading or code. Includes notes are listed under a chapter, block, category or code. They are a guide only and do not need to be present to assign a code.

Question 46

What does the note do?

Answer 46

Clarifies the use of a code or codes.

Question 47

What does an exclusion note mean?

Answer 47

Exclusion notes at the beginning of the chapter applies to all codes within the chapter. An exclusion note at the beginning of a block applies to all codes within the block. An exclusion note at category or subcategory level only appplies to the codes within that category (Or subcategory)

Question 48

Text box
What does a grey box mean?

Answer 48

Grey box around a 4-character sub category, needs another character to complete and is NOT a valid code.

Question 49

Text Box
What does a black box mean?

Answer 49

Black box around a 3-character category, needs one or two further characters to complete and is NOT a valid code.

Question 50

Text Box
What does a white box mean?

Answer 50

White box around a 3-character category, code is complete and IS a valid code.C

Question 51

What does Code first mean?

Answer 51

A sequencing instruction under codes that require more than one code to identify a single clinical concept.

Question 52

What does ‘Code also’ and ‘Use additional code’ mean?

Answer 52

Shows that an additional code MAY be assigned but is not always assigned.

Question 53

ACHI is structured by three levels

Answer 53

1. Anatomical Site Axis
2. Intervention type Axis
3. Block Axis

Procedures are listed from least invasive to most invasive.

Question 54

What is an Omit Code?

Answer 54

The omit code instruction in the Alphabetic Index applies when certain procedures performed with other interventions are not coded.

Question 55

What does ‘See Block’ instruction refer to?

Answer 55

Refers the coder directly to the ACHI Tabular list of Interventions to find the correct code.

Question 56

What are Eponyms?

Answer 56

Interventions named after people. An Eponym can sometimes refer to different procedures.

Question 57

What does ‘And’ in procedure/Interventions mean?

Answer 57

It just means And not And/Or

Question 58

What is a combination code?

Answer 58

A single code used to classify two diagnoses or a diagnosis with a manifestation or an associated complication is called a combination code. You don’t need to assign multiple codes if there is a code that fully describes all elements.

Question 59

What is a principle diagnosis?

Answer 59

The diagnosis established after study to be chiefly responsible for occasioning an episode of admitted patient care, an episode of residential care or an attendance at the health care establishment, as represented by a code.

If a patient presents with a problem, and the underlying condition is known at the time of admission, and only the problem is being treated, then the problem should be assigned as the principal diagnosis code. The underlying condition should be sequenced as an additional diagnosis code.

When a patient presents with a problem, and during the episode of care the underlying condition is identified, then the underlying condition is assigned as the principal diagnosis code and the problem should not be coded.

When there are two or more interrelated conditions (such as diseases in the same ICD-10-AM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, the clinician should be asked to indicate which diagnosis best meets the principal diagnosis definition.
If no further information is available, code as the principal diagnosis the first mentioned diagnosis (WHO 2016).

Question 60

Acute and Chronic conditions

Answer 60

If a condition is described as both acute (subacute) and chronic and separate subterms exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first.
This criterion should not be used when:

a. ICD-10-AM has an instruction to the contrary.
b. ICD-10-AM indicates that only one code is required.

Question 61

Suspected Conditions

Answer 61

Clinicians may document conditions using terms that indicate uncertainty about the final diagnosis (such as probable, suspected, possible, likely, query, ?) or other similar qualifying expressions. This applies to diagnoses that have not been confirmed nor ruled out, either as principal diagnosis or additional diagnoses.

Where clinical documentation clearly indicates uncertainty about the final diagnosis at discharge, assign a code based on the following criteria:

• If a single condition is suspected, assign a code for the suspected condition.
• For more than one suspected condition, assign codes for the symptoms
• For more than one suspected condition with no smptoms, assign codes for all suspected conditions.

If a patient is transferred to another hospital for a suspected condition, assign Z75.6 Transfer for suspected condition sequenced directly under the code to which it relates. Remember not to assign this code for all transferred patients, the transfer status is reported in the discharge type.

Question 62

Unacceptable principle diagnosis codes

Answer 62

Some ICD-10-AM codes that must never be assigned as a principal diagnosis. This includes, but is not limited to, all external cause, place of occurrence, activity and morphology codes.

A number of codes from Chapter 21 Factors influencing health status and contact with health services (Z00–Z99) have been flagged as unacceptable principal diagnoses, however it should be noted that there are many other codes from this chapter that will rarely be appropriate to assign as a principal diagnosis in an admitted episode of care.

Question 63

Disease codes that must never be assigned for inpatient coding

Answer 63

• F65.0 Fetishism
• F65.1 Fetishistic transvestism
• F65.5 Sadomasochism
• F65.6 Multiple paraphilia disorders
• F90.1 Hyperkinetic conduct disorder
• G26* Extrapyramidal and movement disorders in diseases classified elsewhere
• L14* Bullous disorders in diseases classified elsewhere
• L45* Papulosquamous disorders in diseases classified elsewhere
• M09.8-* Juvenile arthritis in other diseases classified elsewhere
• M15.9 Polyarthrosis, unspecified
• M16.9 Coxarthrosis, unspecified
• M17.9 Gonarthrosis, unspecified
• M18.9 Arthrosis of first carpometacarpal joint, unspecified
• M19.9- Arthrosis, unspecified – classify osteoarthritis/arthrosis/osteoarthrosis NOS as primary osteoarthritis
• M99.- Biomechanical lesions, not elsewhere classified
• N22.-* Calculus of urinary tract in diseases classified elsewhere
• R65.0 Systemic inflammatory response syndrome [SIRS] of infectious origin without acute organ failure
• R65.1 Severe sepsis
• S39.6 Injury of intra-abdominal organ(s) with pelvic organ(s)
• T76 Unspecified effects of external causes
• Y90.9 Presence of alcohol in blood, level not specified – see also ACS 0503 Drug, alcohol and tobacco use disorders
• Y91.- Evidence of alcohol involvement determined by level of intoxication – see also ACS 0503 Drug, alcohol and tobacco use disorders
• Z50.2 Alcohol rehabilitation
• Z50.3 Drug rehabilitation
• Z81.- Family history of mental and behavioural disorders

Question 64

Additional Diagnosis

Answer 64

‘A condition or complaint either coexisting with the principal diagnosis or arising during the episode of admitted patient care, episode of residential care or attendance at a health care establishment, as represented by a code’.

ADDITIONAL DIAGNOSIS CRITERIA

Additional diagnoses are conditions that significantly affect patient management in an episode of care in terms of requiring any of the following:
* commencement, alteration or adjustment of therapeutic treatment
* diagnostic interventions
* increased clinical care.
These criteria are not mutually exclusive. Conditions must meet at least one of these criteria and be evidenced by clinical documentation

Commencement, alteration or adjustment of therapeutic treatment:
* Do not assign an additional diagnosis code for a condition that is managed by administration of medication that is initiated as part of general nursing care without the need for clinician consultation (review) or follow-up (eg Mylanta for heartburn; paracetamol for headache.
* Do not assign an additional diagnosis code for a condition that is referred for follow up care after discharge only.
* Do not assign an additional diagnosis code for a pre-existing condition where existing treatment is not altered or adjusted; this includes where:
* ongoing medication is continued
* ongoing medication for a condition is only adjusted or altered to manage another condition such as:
* reducing a diuretic (prescribed for pre-existing congestive cardiac failure) due to acute kidney injury
* reducing an antihypertensive (prescribed for pre-existing hypertension) due to onset of hypotension.

Assign an additional diagnosis code where a condition requires increased clinical care (ie care that is beyond routine) and is not already precluded by the ‘do not assign’ instructions under the Commencement, alteration or adjustment of therapeutic treatment criterion. Increased clinical care under this criterion is evidenced by a clinical consultation (review) and a care plan to manage a condition within the episode of care. The care plan may include increased monitoring and/or observationconfirmation to continue with an existing care plan , or transfer to another facility with documentation of the reason(s) for transfer.

You don’t assign a code for the following:
General nursing care
Assesment of vital signs and assesment of pre-existing conditions where there is no care plan.
Pre and Post op management e.g. checking drains or catheters.

Question 65

Diagnostic Interventions

Answer 65

Assign an additional diagnosis code for a condition if a diagnostic intervention is performed for the purpose of investigating a symptom to determine a diagnosis (or to provide specificity to an established diagnosis such as;

• CT scan to determine extent of ankle fractures
• GFR test to determine stage of chronic kidney disease
• ECG to determine type of myocardial infarction

Don’t assign a code for an additional diagnosis for:
Routine lab investigations or antibiotic resistant organism screening e.g. FBC
Rountine functional tests e.g. liver or kidney function tests.

Question 66

Double Coding

Answer 66

The same intervention code may be assigned more than once in an episode of care.

Question 67

What are the three the three criteria for determining whether to code an additional diagnosis?

Answer 67

• Commencement, alteration or adjustment of therapeutic treatment
• Diagnostic interventions
• Increased clinical care

Question 68

Should a diagnosis code be repeated if it is for bilateral sites?

Answer 68

No

Question 69

Would you assign an additional diagnosis code for a change in medication for a pre-existing condition?

Answer 69

“Do not assign an additional diagnosis code for a pre-existing condition requiring administration of ongoing medication. This includes where the ongoing medication is adjusted due to the management of another condition”

Question 70

Tobacco use will always be coded when documented?

Answer 70

Yes

Question 71

What are Incidental findings?

Answer 71

An abnormal finding or condition (such as those noted on clinical assessment, laboratory, x-ray, pathology, and other diagnostic result) may be identified and/or documented during an episode of care. Each case must be assessed on its own merits to determine if the documentation sufficiently describes a condition that meets the additional diagnosis criteria.

Question 72

What conditions are mandatory for coding?

Answer 72

• coronavirus disease 2019
• diabetes mellitus and intermediate hyperglycaemia
• HIV/AIDS
• tobacco use disorders
• viral hepatitis
  A number of specialty standards also direct clinical coders to assign additional diagnosis codes for certain conditions or statuses that do not normally meet the additional diagnosis criteria. Examples of these conditions or statuses include multiple injuries, carrier status, and ‘flag’ codes such as duration of pregnancy and outcome of delivery.

Question 73

Is an incidental finding coded?

Answer 73

No

Question 74

A problem with a known underlying cause is being treated, should both conditions should be coded?

Answer 74

Yes

Question 75

Supplementary codes for chronic conditions

Answer 75

Supplementary codes was created for chronic conditions that are present on admission, but the condition does not meet the criteria for coding.
Codes from U78–U88 are only assigned where the condition is part of the current health status of the patient. The U codes represent chronic conditions that may be assumed to be current unless there is documentation that indicates otherwise.
Documentation of a condition on a referral letter/form alone is insufficinet for a code assignment. The condition must be documented within the current episode of admitted patient care.

Question 76

Assignment of U codes from patient documentation

Answer 76

Should a U code for hypertension be assigned when it has not been documented by the clinician?

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. A U code should not be assigned based on patient response alone.

Question 77

Osteoarthritis and ACS 0003 Supplementary codes for chronic conditions

Answer 77

patient is admitted for a total knee replacement due to osteoarthritis (OA) in the knee, but also has clinical documentation of OA in the shoulder (which does not meet the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses). Should U86.2 Arthritis and osteoarthritis [primary] be assigned in addition to M17.1 Other primary gonarthrosis?

Osteoarthritis (OA) is a degenerative disease that may affect any joint of the body. Depending on the progression, it may affect different joints at different times.

ACS 0003 Supplementary codes for chronic conditions states that the supplementary codes are not to be assigned in addition to another chapter code for the same condition.

Therefore, once OA of a specific site meets the criteria for code assignment as per ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses, do not assign U86.2 Arthritis and osteoarthritis [primary] for OA of another site.

Question 78

Where should U codes be sequenced?

Answer 78

Last, after all other ICD-10_AM codes.

Question 79

General Procedure Guidelines

Answer 79

A procedure is defined as “a clinical intervention represented by a code that:

• is surgical in nature, and/or
• carries a procedural risk, and/or
• carries an anaesthetic risk, and/or
• requires specialised training, and/or
• requires special facilities or equipment only available in an admitted patient care setting

Question 80

What are the order of codes?

Answer 80

• procedure performed for treatment of the principal diagnosis
• procedure performed for treatment of an additional diagnosis
• diagnostic/exploratory procedure related to the principal diagnosis
• diagnostic/exploratory procedure related to an additional diagnosis for the episode of care.

**This does not tell you to code surgical procedures before nonsurgical procedures, although this will often be the case as usually any surgical procedure is for treatment of the principal diagnosis.

Question 81

ACHI

Answer 81

Australian Classification of Health Interventions

Question 82

What procedures do you not code?

Answer 82

Procedures which are an inherent part of the the procedure. E.g. suture of skin following repair of tendon at same site.

Question 83

What procedure is coded?

Answer 83

• Any procedure done under GA or IV sedation
• Incision and drainage on ward/ED
• Transfusions
• Biopsies
• Mechanical Ventilation
• Non-invasive ventilation e.g. C-PAP
• Lumbar puncture
• Thoracentesis
• Angioplasty
• Chemotherapy
• Radiotherapy
  -Dialysis

Question 84

Is a procedure coded if done under cerebral anaesthesia or IV sedation?

Answer 84

Yes always.
For example, MRIs are not usually coded but an MRI under IV sedation would have both procedures assigned.

Question 85

What is the correct code to assign for insulin delivered via an insulin pump?

Answer 85

Administration of insulin via an insulin pump is not normally coded.
However, where insulin is administered via an insulin pump as the principal treatment in same-day episodes of care, assign a code.

Question 86

Should an ACHI code be assigned when Angio-seal™ (or another vascular closure device) is used following an arterial catheterisation?

Answer 86

It is not necessary to assign a procedure code for use of a vascular closure device, as it is an inherent part of a catheterisation procedure, as per the guidelines in ACS 0016 General procedure guidelines, Procedure components:

Do not code procedures which are individual components of another procedure. These components would usually be considered a routine or inherent part of the more significant procedure being performed.

Question 87

Bilateral Procedures

Answer 87

Bilateral procedures are those which involve the same organ/structure on different sides of the body at the same operative episode. Procedures can be repeated more than once (Unlike diagnosis codes)So this standard is to aid with bilateral/multiple coding for procedures.

Where a code is provided for a bilateral procedure, assign the code once.

Question 88

Inherently bilateral procedures

Answer 88

Another group of ‘pseudo-bilateral’ procedures which are not explicitly described as bilateral in ACHI, include diagnostic or therapeutic interventions which have one entry point but affect bilateral structures, usually vessels, for example, coronary angiography or tonsillectomy.

Where a procedure is inherently bilateral, assign the code once.

Question 89

Procedures with no code option for bilateral

Answer 89

ACHI does not provide a bilateral option for all procedures on bilateral organs/structures. For example, there are no bilateral procedure codes for the following:

• cataract extraction
• iris procedures
• mastoidectomy
• stapedectomy
• fracture reduction – eg maxilla, humerus

Where no single code is provided for the bilateral procedure, assign the code twice for example, stapedectomy, cataract extraction, reduction of fractures of both humeri.

Question 90

Multiple Procedures

Answer 90

ACHI generally refers to organs, diseases and sites using the singular tense. This is done for consistency and ease of updating. For example, the code title intranasal removal of polyp from maxillary antrum includes where one, or more than one, polyp is removed. Thus polyp can be interpreted as polyp or polyps.

Question 91

How do you code: The SAME PROCEDURE repeated during the episode of care at DIFFERENT visits to theatre

Answer 91

A procedure which is repeated during the episode of care at different visits to theatre should be coded as many times as it is performed.
Exceptions to this rule are:
-procedures included in ACS 0042 Procedures normally not coded
-procedures with specific rules in other coding standards, such as:
* burn dressings (see ACS 1911 Burns)
* pharmacotherapy (see ACS 0044 Pharmacotherapy)
* blood transfusions (see ACS 0302 Blood transfusions)
* allied health interventions (see ACS 0032 Allied health interventions)
* dialysis (see ACS 1404 Admission for kidney dialysis)
* mental health interventions (see ACS 0534 Specific interventions related to mental health care services)
* radiotherapy (see ACS 0229 Radiotherapy)

Question 92

How do you code: The SAME PROCEDURE repeated during a visit to theatre involving ONE ENTRY POINT/APPROACH and similar/same lesions

Answer 92

Assign one code for these procedure types. For example:
* multiple meniscectomy of one knee
* embolisation involving multiple vessels (eg left and right uterine arteries)
* colonoscopy with polypectomies (ACHI provides some specific codes for multiple procedures (eg rigid sigmoidoscopy with polypectomy involving removal of 1 to 9 polyps) and where these are provided they should be assigned appropriately).
* cystoscopy with bladder biopsies
* laparoscopic aspiration of ovarian cysts
* intranasal removal of polyps from maxillary antrum
* endoscopic excision of lesions or tissue of anus
* insertion of multiple vascular stents

Question 93

How do you code: The SAME PROCEDURE repeated during a visit to theatre involving ONE ENTRY POINT/APPROACH and different lesions

Answer 93

Assign a code for each site. For example:
* suture of a tendon and an artery in the hand through a single incision requires two codes.

Question 94

How do you code: The SAME PROCEDURE repeated during a visit to theatre involving MORE THAN ONE ENTRY POINT/APPROACH and more than one non-bilateral site

Answer 94

Assign a code for each procedure as there is a separate entry point/approach for each one. Examples of procedures in this category are:
* arthrodesis of multiple joints
* release of tendons on different body regions

Question 95

How do you code: Skin or subcutaneous lesion removal, excision or biopsy

Answer 95

For multiple excisions or biopsies or removals performed on:
* separate skin lesions: assign relevant code(s) as many times as it is performed
* same lesion: assign relevant code once.

Question 96

If Haemodialysis is performed on days 2, 4, 6 & 8 of the event. How do you code this?

Answer 96

Only one code even though multiple days performed- ACS 0020, Multiple Procedures point 1 tells us that haemodialysis and transfusions are coded once per event.

Question 97

Dental procedures - How are these coded for multiple procedures?

Answer 97

• Codes that include reference to a number of teeth are assigned once.
  For example, 97311-03 [457] Removal of 3 teeth or part(s) thereof specifies the removal of 3 teeth, therefore this code is assigned once for each visit to theatre.
• Codes that specify ‘per tooth’, ‘per root’ or ‘per cusp’ (etc) are assigned as many times as they are performed.
  For example, 97171-00 [455] Odontoplasty, per tooth performed on six teeth is assigned six times.
• Codes that do not specify the number of teeth are assigned as many times as performed.
  For example, 97414-00 [462] Pulpotomy performed on four teeth is assigned four times.

Question 98

ASA

Answer 98

American Society of Anesthesiologists

Question 99

What is the ASA physical status classification system?

Answer 99

A system for assessing the fitness of patients before surgery, developed by teh American Society of Anesthesiologists.

Question 100

The first character of the ASA score is represented by what?
(There are 6)

Answer 100

1. Healthy person
2. Mild systemic (means affecting the entire body, rather than a single organ or body part) disease.
3. Severe Systemic disease
4. Severe systemic disease that is a constant threat to life
5. A moribund person who is not expected to survive without the operation.
6. A declared brain-dead person whose organs are being removed for donor purposes.

Question 101

What does the second character of the ASA score represent?

Answer 101

Represents if the procedure was an Emergency or not. It is defined as ‘when a delay in treatment would significantly increase the threat to the patients life or body part’.

‘E’ must be documented on the anaesthesia form at the time the procedure took place before assigning it, a pre-admission form is not enough. The modifier ‘E’ is represented by the digit ‘0’. Where there is no documentation of ASA score or the emergency modifier is not indicated, the digit ‘9’ is assigned. If there are two ASA scores given then assign the higher of the two.

Question 102

If there is no ASA score, what should you code as?

Answer 102

If there is no ASA score documented, we default to 99 (no documentation of ASA score and non-emergency or not known)

Question 103

Cerebral anaesthesia

Answer 103

The term ‘cerebral anaesthesia’ in ACHI encompasses the anaesthetic procedures of general anaesthesia and sedation.

Question 104

General anaesthesia

Answer 104

General anaesthesia is to be assigned for all types of general anaesthesia. This includes intravenous anaesthesia, inhalational anaesthesia or a combination of both.

Question 105

Sedation

Answer 105

The distinction between sedation and general anaesthesia is often unclear from clinical documentation. For the purposes of classification in ACHI, 92515-XX [1910] Sedation may be assigned where the anaesthetic is administered as per general anaesthesia (ie intravenous or inhalational or both) and there is no documentation of the use of an artificial airway, such as an endotracheal tube, laryngeal mask (eg LM3, LMA4), pharyngeal mask (eg PM3) or Guedel airway.

Oral sedation is not coded.

Question 106

Is Oral sedation coded?

Answer 106

No

Question 107

What is Conduction anaesthesia?

Answer 107

The term ‘conduction anaesthesia’ in ACHI encompasses the anaesthetic procedures of neuraxial block, regional block and infiltration of local anaesthesia.

Question 108

What is a Neuraxial block?

Answer 108

Neuraxial block is to be assigned for epidural, spinal or caudal (or any combination) anaesthesia, and includes both injection and infusion. The type of drug (opioid, local anaesthetic or other therapeutic substance) administered is not required for assignment of the code.

Question 109

What is a regional block?

Answer 109

The codes for regional blocks are divided on the general anatomical area of the field of anaesthesia rather than the point of administration, ie the actual nerve involved is not required for assignment of the correct code.

Question 110

What is Infiltration of local anaesthesia?

Answer 110

Infiltration of local anaesthetic is assigned for administration of local anaesthetic, where the effect of the anaesthesia is at localised tissue level.

Question 111

What is Postprocedural analgesia?

Answer 111

The term ‘postprocedural analgesia’ in ACHI encompasses only those procedures which provide ongoing postprocedural analgesia via continuous infusion AND were initiated in the operating suite (theatre or recovery).

Question 112

Is local anaesthesia coded?

Answer 112

No

Question 113

Postprocedural analgesia

Answer 113

• Assign only one code from block [1910] Cerebral anaesthesia for each ‘visit to theatre’ regardless of where in the hospital the procedure is performed, for example operating theatre, endoscopy suite, emergency department, catheter laboratory using the hierarchy (listed from highest to lowest priority) below:

               [1910]      Cerebral anaesthesia 
                             i.      General anaesthesia (92514-XX) 
                             ii.     Sedation (92515-XX)

• Assign a code(s) from block [1909] Conduction anaesthesia (excluding 92513-XX [1909] Infiltration of local anaesthetic) for each ‘visit to theatre’ regardless of where in the hospital the procedure is performed, for example operating theatre, endoscopy suite, emergency department, catheter laboratory. Each type of conduction anaesthesia should only be assigned once (see Example 5):

Question 114

How many times should anaesthetic be coded if administered more than once during different ‘visits to theatre’, with the total episode of care (for example, two general anaesthetics)?

Answer 114

If the same anaesthetic is administered more than once during different ‘visits to theatre’, within the total episode of care (eg two general anaesthetics), it should be coded as many times as performed.

Question 115

Neuraxial and regional block codes

Answer 115

Neuraxial blocks during labour are assigned one code from block [1333] ‘Analgesia and anaesthesia during labour and delivery procedure’. 92506-XX [1333] ‘Neuraxial block during labour’ is assigned where a caudal, epidural and/or spinal block is administered, either via injection or infusion, for pain relief during labour. Where the labour progresses to delivery via a caesarean section, and the neuraxial block is continued for that procedure or any other delivery procedure assign 92507-XX [1333] ‘Neuraxial block during labour and delivery procedure’. This code may also be assigned where, following a vaginal delivery, the same neuraxial block is continued for postpartum procedures such as removal of retained placenta and/or repair of obstetrical trauma.

In cases where a neuraxial block is administered only for anaesthesia for caesarean section or delivery procedure, assign 92508-XX [1909] ‘Neuraxial block’.

Question 116

How do you sequence anaesthetic codes?

Answer 116

After the procedure code to which it relates.
If more than one code is required to capture all the components of the procedure, then sequence the anaesthetic code(s) immediately following the string of codes.

Question 117

Should a procedure that is not normally coded, be coded if cerebral anaesthesia is required?

Answer 117

Yes

Question 118

Neuraxial and regional block codes

Answer 118

The neuraxial and regional block codes in block [1912] ‘Postprocedural analgesia’ should be assigned only for management (continuing infusion/bolus injection/top up) of blocks that were previously administered for pain relief/anaesthesia in the labour ward and/or operating suite (theatre or recovery). The initial insertion of the neuraxial/regional block is not inherent in these codes, and should be represented by the appropriate code from block [1909] ‘Conduction anaesthesia’ or [1333] ‘Analgesia and anaesthesia during labour and delivery procedure’.

Do not assign codes from this block when the infusion is initiated after leaving the operating suite (theatre or recovery). Where more than one type of infusion is administered in the postoperative period, assign appropriate codes from block [1912] ‘Postprocedural analgesia’ from the list below:

[1912] Postprocedural analgesia
i. Management of neuraxial block (92516-00)
ii. Management of regional block (codes 92517-00, 92517-01, 92517-02, 92517-03)

Question 119

Relevent codes for anaethetics

Answer 119

The codes for anaesthetics that are relevant to this standard are found in the following blocks:
[1333] Analgesia and anaesthesia during labour and delivery procedure

   [1909]       Conduction anaesthesia 

   [1910]       Cerebral anaesthesia 

   [1912]       Postprocedural analgesia

Question 120

Should a sedation code be assigned when sedation is administered for initiation of ventilation?

Answer 120

Sedation may be assigned where the anaesthetic is administered as per general anaesthesia (ie intravenous or inhalational or both) and there is no documentation of the use of an artificial airway, such as an endotracheal tube, laryngeal mask (eg LM3, LMA4), pharyngeal mask (eg PM3) or Guedel airway.

Oral sedation is not coded.

Question 121

Should a sedation code be assigned when ongoing sedation is administered with ventilation?

Answer 121

Ongoing sedation is administered with many procedures for patient’s comfort, control of anxiety and pain relief and should not be coded.

Question 122

Should sedation administered intramuscularly (IM) be coded (eg a paediatric patient with a fractured radius reduced under IM sedation)?

Answer 122

YES -Intramuscular (IM) sedation is given where rapid onset/short term anaesthesia is required, without a full general anaesthetic effect (ie without loss of respiratory drive or protective airway tone). This is often administered in paediatric patients, or other patients who require sedation to evaluate and treat their injuries whilst limiting distress. IM sedation is used to facilitate patient cooperation during imaging studies or during painful procedures such as fracture reductions, abscess incision and drainage, lumbar puncture, or complex laceration repair.

Anaesthesia instructs that sedation may be assigned where anaesthetic is administered as per general anaesthesia (intravenous or inhalational or both) and there is no documentation of the use of an artificial airway. It also instructs that oral sedation is not to be coded, however there is no instruction regarding intramuscular sedation.

Given the increasing use of sedation administered intramuscularly 92515-XX [1910] Sedation is to be assigned for intramuscular sedation, when administered for anaesthetic effect.

Question 123

Should intranasal or oral sedation for anaesthesia be coded?

Answer 123

NO - Intranasal and oral sedation are both administered via a transmucosal delivery. They are used for management in minor procedures or for reduction of anxiety in children preoperatively. Oral sedation is not coded as per the guidelines in ACS 0031 Anaesthesia. Other transmucosal delivery methods (eg buccal, sublingual) are inherently similar to oral sedation, and as such also should not be coded.

Question 124

If the nerve block is continued for pain post-op do you code it?

Answer 124

Yes - under management, block, postprocedural, regional, nerve of and select region.

Question 125

LA

Answer 125

Local Anaesthesia - not coded.

Question 126

ERCP

Answer 126

Endoscopic Retrograde Cholangio Pancreatography. This is a test that uses a type of X-ray. It is used to diagnose and treat problems with your biliary system.

Question 127

D & C

Answer 127

Dilution and Curettage
A Dilation and curettage procedure, also called a D&C, is a surgical procedure in which the cervix (lower, narrow part of the uterus) is dilated (expanded) so that the uterine lining (endometrium) can be scraped with a curette (spoon-shaped instrument) to remove abnormal tissues.

Question 128

TAH

Answer 128

Total Abdominal Hysterectomy

Question 129

Do we code epidural injection of local anaesthetic?

Answer 129

We don’t code LA but we do code all epidurals (which often have LA). It’s the route not the substance.
Block, neuraxial, for operative anaesthesia 92508-99 [1909]

Question 130

What is EUA

Answer 130

Examination under anaesthesia (EUA)
It is only coded if it is the only procedure being performed.

Question 131

Minimally Invasive Interventions

Answer 131

Minimally invasive interventions may be performed by a surgeon with the aid of robotic technology (robotic) or manually (non-robotic).

If an intervention is performed laparoscopically, arthroscopically or endoscopically, and there is no code provided which encompasses both the minimally invasive approach and the intervention, assign codes for both the intervention and the minimally invasive approach.

Question 132

MINIMALLY INVASIVE INTERVENTION PROCEEDING TO OPEN INTERVENTION

Answer 132

When an intended minimally invasive intervention proceeds to an open intervention, assign first a code for the open intervention followed by an appropriate code below:

• 90343-00 [1011] Endoscopic procedure proceeding to open procedure
• 90343-01 [1011] Laparoscopic procedure proceeding to open procedure
• 90613-00 [1579] Arthroscopic procedure proceeding to open procedure.

Note: While codes 90343-00 and 90343-01 are located in Chapter 10 Procedures on digestive system they are assigned with codes from any chapter to identify an endoscopic or laparoscopic intervention proceeding to an open intervention.

Question 133

ORGAN, TISSUE AND CELL PROCUREMENT AND TRANSPLANTATION

Answer 133

Autologous donation
An autologous donor is a patient with a known disease (eg a malignancy) who is admitted to donate their own cells for reinfusion/transplantation at a later stage.
Assign:
* an ICD-10-AM code for the condition to be treated by the harvested cells
* ACHI codes, as applicable

Allogeneic donation
An allogeneic donor provides organ(s)/tissue/cells for infusion/transplantation into another person

Question 134

What is a Autologous Donation?

Answer 134

An autologous donor is a patient with a known disease (eg a malignancy) who is admitted to donate their own cells for reinfusion/transplantation at a later stage.

Question 135

What is an Allogeneic Donation?

Answer 135

An allogeneic donor provides organ(s)/tissue/cells for infusion/transplantation into another person.

Question 136

Live Donors

Answer 136

Patients admitted to donate organ(s)/tissue/cells usually have a principal diagnosis assigned from category
Z52 Donors of organs and tissues or Z51.81 Apheresis – see also Allogeneic organ/tissue/cell procurement and transplantation table.

Also assign ACHI code(s) performed during the episode of care.

Question 137

Donation following death in hospital

Answer 137

The following guidelines apply to the classification of organ(s)/tissue/cells procurement from deceased donors:
a. In the episode during which the patient dies:
* assign as principal diagnosis the condition that occasioned the admission
* assign Z00.5 Examination of potential donor of organ and tissue as an additional diagnosis to indicate intent to procure, even if the organs are not subsequently procured
* do not assign the ACHI code(s) for procurement during this episode

In the procurement episode:
* assign as principal diagnosis the appropriate code from category Z52 Donors of organs and tissues, even if the organs are not subsequently transplanted.
Do not assign diagnoses from the initial episode or cause of death as these will already have been coded in the initial episode
* assign ACHI code(s) for procurement performed during the episode
* assign 96231-00 [1886] Machine perfusion for organ transplantation as an additional code where machine perfusion is used during organ procurement; assign this code once only for an episode of care, irrespective of the number of organs procured.

Question 138

Patients Receiving the transplanted organ(s)/tissue/cells

Answer 138

• assign a code for the condition requiring the transplanted organ(s)/tissue/cells
• assign appropriate ACHI transplantation code(s)
• do not assign codes for the removal of the diseased organ(s)

Domino transplant patients (ie when the patient receives and donates organs during the same episode of care, eg receives heart and lung, and donates lung):
* assign additional diagnosis code(s) from category Z52 Donors of organs and tissues
* assign additional ACHI code(s) for the procurement procedures

Question 139

PROCEDURES DISTINGUISHED ON THE BASIS OF SIZE, TIME, NUMBER OF LESIONS OR SITES

Answer 139

Certain procedures in ACHI are distinguished on the basis of size, time or the number of lesions removed or sites affected.

Use the Index as a guide. Generally it will have a default code listed to enable assignment of a code.

Where there is no documentation in the clinical record, no further information can be obtained from the clinician and there is no default in the index, assign the code for the smallest size, the least duration, the least number of lesions or sites, as appropriate.

Question 140

Are there any definitions or criteria in ACHI for the terms small and extensive split skin grafts?

Answer 140

The terms small, extensive and granulating are included in ACHI codes due to the MBS item descriptors that they are based on:
· 45400 FREE GRAFTING (split skin) of a granulating area, small
· 45403 FREE GRAFTING (split skin) of a granulating area, extensive
· 45439 FREE GRAFTING (split skin) to 1 defect, including elective dissection, small
· 45442 FREE GRAFTING (split skin) to 1 defect, including elective dissection, extensive

These terms are applied in ACHI differently for split skin graft (SSG) to burn and non-burn wounds.

Split skin graft to burn

Codes for SSG to burn are located in blocks:

· [1643] Split skin graft to burn of specific sites

· [1641] Split skin graft to granulating burn site.

The terms small and extensive for SSG to burn are only applicable to block [1641]:
· small is applicable to (unspecified or) less than 3 per cent of body surface area (BSA) grafted:

45400-01 [1641] Split skin graft of small granulating burn site, less than 3 per cent of body surface area grafted
· extensive is applicable 3 per cent or more of BSA grafted:

45403-01 [1641] Split skin graft of extensive granulating burn site, 3 per cent or more of body surface area grafted

Follow the ACHI Alphabetic Index:

Graft

• skin
• • for burn
• • • specified site NEC
• • • • split thickness (less than 3 per cent body surface area (BSA))
• • • • • granulating 45400-01 [1641]
• • • • • • 3 per cent or more of BSA 45403-01 [1641]

(See also Split skin graft to granulating area, below).

Split skin graft to non-burn wounds

Codes for SSG of non-burn wounds are located in blocks:

· [1645] Other split skin graft, small,

· [1646] Other split skin grafts, extensive

· [1642] Other split skin graft to granulating area.

There are no definitions or criteria in ACHI for small and extensive SSG to non-burn wounds. Where these terms are not documented in the clinical record/operation report, clinical coders should clarify with clinicians to determine if a grafted area is small or extensive, or apply the guidelines in ACS 0038 Procedures distinguished on the basis of size, time, number of lesions or sites:

Where there is no documentation in the clinical record, no further information can be obtained from the clinician and there is no default in the index, assign the code for the smallest size, the least duration, the least number of lesions or sites, as appropriate.

Split skin graft to granulating area

Although there is no definition in ACHI for granulating area, the clinical definition is healing skin/tissue; granulation tissue is a normal part of the wound healing process. For some wounds, particularly burns, the process of granulation is undesirable, as granulation tissue is excessively vascular and therefore prone to haemorrhaging. Granulation tissue may also cause shrinkage at the burn/wound site and may slow the rate of healing. As a result, granulation tissue may require surgical removal and application of grafted skin to promote healing and avoid localised blood loss. ACHI codes for SSG to non-burn wound specifying granulating area are only assigned when this term is documented, or following advice from a clinician. Assign either of the following codes for SSG to granulating area of a non-burn wound (see above for advice regarding assignment of SSG to granulating burn site):

45400-00 [1642] Split skin graft of small granulating area

45403-00 [1642] Split skin graft of extensive granulating area

Follow the index pathways:

Graft

• skin
• • granulating area
• • • extensive 45403-00 [1642]
• • • small 45400-00 [1642]

Question 141

CODING OF CONTRACTED PROCEDURES

Answer 141

This standard relates to hospital treatment being carried out under contracting or subcontracting arrangements between two hospitals.

In NZ only one hospital is to record and code the treatment provided under the contract arrangement and report to the NMDS (National Minimum Dataset. If it is a private hospital it’s preferred that the public hospital reports the event. The contract should specify which hospital is responsible for reporting the event.

21 day reporting requirement to report to the NMDS

Question 142

OGD

Answer 142

Oesophago-Gastro-Duodenoscopy
Known more simply as gastroscopy or endoscopy.

Question 143

BPH

Answer 143

Benign Prostatic Hyperplasia
A condition in men in which the prostate gland is enlarged and not cancerous.

Question 144

SPC

Answer 144

Suprapubic catheter
A device that’s inserted into your bladder to drain urine if you can’t urinate on your own.

Question 145

Clinical coding has three key phases

Answer 145

1. Abstraction - involves reading all the information related to the event. This includes discharge summary, ED notes, operation and procedure reports. The coder must analyse what conditions and procedures the patient had during the event.
2. Assignment - Finding the correct codes and entering the codes into the patient management system.
3. Reviewing - Coder should review all the codes to make sure they are correct.

Question 146

AKI

Answer 146

Acute Kidney Infection

Question 147

PMB

Answer 147

Postmenopausal Bleeding

Question 148

COAD

Answer 148

Chronic Obstructive Airway Disease -
COPD - Chronic Obstructive Pulmonary Disease.
Chronic bronchitis and emphysema is the commonest cause of shortness of breath in the elderly, especially those with history of smoking or passive smoking.

Question 149

CHF

Answer 149

Congestive heart failure, or heart failure, is a long-term condition in which your heart can’t pump blood well enough to meet your body’s needs.

Question 150

DKA

Answer 150

Diabetic ketoacidosis - a serious complication of diabetes. The condition develops when the body can’t produce enough insulin.

Question 151

Thrombocytopenia

Answer 151

A condition that occurs when the platelet count in your blood is too low.

Question 152

HB

Answer 152

Hemoglobin
Also known as Anaemia

Question 153

IDA

Answer 153

Iron deficiency anaemia = Asiderotic

Question 154

MCA

Answer 154

Middle Cerebral Artery (MCA) is the most common artery involved in acute stroke.

Question 155

ERCP

Answer 155

Endoscopic Retrograde Cholangiopancreatography
A procedure that combines upper gastrointestinal (GI) endoscopy and x-rays to treat problems of the bile and pancreatic ducts.

Question 156

D & C

Answer 156

Dilation and curettage (D&C) is a procedure in which material from the inside of the uterus is removed. The “dilation” refers to dilation (opening) of the cervix, the lower part of the uterus that opens into the vagina.

Question 157

SYMPTOMS, SIGNS AND ABNORMAL CLINICAL AND LABORATORY FINDINGS, NOT ELSEWHERE CLASSIFIED (R00 - R99)

Answer 157

Chapter 18
In general, categories in this chapter include the less well-defined conditions and symptoms that, without the necessary study of the case to establish a final diagnosis, point perhaps equally to two or more diseases or to two or more systems of the body. Practically all categories in the chapter could be designated ‘not otherwise specified’, ‘unknown aetiology’ or ‘transient’. The Alphabetic Index should be consulted to determine which symptoms and signs are to be allocated here and which to other chapters. The residual subcategories, numbered .8, are generally provided for other relevant symptoms that cannot be allocated elsewhere in the classification.

The conditions and signs or symptoms included in categories R00–R99 consist of:

(a)
cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated;

(b)
signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined;

(c)
provisional diagnoses in a patient who failed to return for further investigation or care;

(d)
cases referred elsewhere for investigation or treatment before the diagnosis was made;

(e)
cases in which a more precise diagnosis was not available for any other reason;

(f)
certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right.

Question 158

What is Acopia?

Answer 158

‘Acopia’ is an inappropriate term and clinical coders should seek clinical advice to ascertain a more appropriate diagnosis to reflect the patient’s reason for admission. ‘Immobility’ and ‘frailty’ are in the same category and should also be discussed with the appropriate clinician.

Question 159

R52.0 Acute Pain

Answer 159

This is rarely assigned as a code as usually the site or underlying cause is documented. E.g. ‘acute abdominal pain’ is assigned R10.4 other and unspecified abdominal pain.

Question 160

R52.2 Chronic Pain

Answer 160

Is assigned as an additional diagnosis as per the note at R52.2. E.g. ‘chronic, low back pain’ is assigned both M54.5 Low back pain and R52.2 chronic pain. Always sequence the R52.2 underneath the code to which it relates.

Question 161

RIF

Answer 161

Right iliac fossa (RIF) pain is one of the most common presentations to acute general surgical services.
Causes include appendicitis, other gastrointestinal, urological, gynaecological, vascular and musculoskeletal pathologies.

Question 162

What does ICD-10 stand for?

Answer 162

International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification

Question 163

Name the three key phases in clinical coding in order.

Answer 163

Abstraction, Assignment, Review

Question 164

Additional diagnoses should be interpreted as conditions that significantly affect patient management in terms of requiring any of the following criteria:

Answer 164

Commencement, alteration or adjustment of therapeutic [treatment]
diagnostic [interventions]
increased [clinical] [care]

Question 165

A procedure is defined as “a clinical intervention represented by a code that:

Answer 165

· is [surgical] in nature and/or

· carries a procedural [risk] and/or

· carries an [anaesthetic] risk and/or

· requires specialised [training] and/or

· requires [special] facilities or equipment

Question 166

What are external cause codes?

Answer 166

The codes used to clarify injury events by mechanism and intent of injury. They describe how it happened, e.g. fall, motor vehicle traffic accident, burns, poisoning. And it describes the intent of the injury e.g. unintentional, homicide/assault, suicide/intentional harm, legar intervention or war operations and undetermined intent.

Question 167

If there is both a sports and leisure code, what should you assign?

Answer 167

When both a sports (U50-U71) and leisure (U72) code apply, assign the activity code for sport.

Question 168

What external cause codes cannot be used for principle diagnosis?

Answer 168

The codes U50–Y98 are not to be used as the principal diagnosis.
They are intended for use as additional codes to identify the external cause of conditions classified in Chapter 19 Injury, poisoning and certain other consequences of external causes and may also be used as additional codes with conditions classified in any other chapter but having an external cause.

Question 169

External cause codes must be used with what codes?

Answer 169

Codes from S00–T98 and Z04.1–Z04.5 and for complications and abnormal reactions which are classified outside the Injury Chapter (S00–T98).

Question 170

External cause codes should be sequenced after the diagnosis code(s) to which they relate?

Answer 170

Yes - external cause codes should be sequenced directly after the diagnosis codes to which they relate.

Question 171

When should U73.8 Other specified activity be assigned?

Answer 171

Where an activity is specified but it is not listed under the lead term Activity and it cannot be classified to any of the above categories, assign U73.8 Other specified activity.

Note that for the code range V00–V99 Transport accidents, where the activity at the time of the accident is not specified as sport, leisure or working for an income, assign U73.9 Unspecified activity

Question 172

What code can you assign for walking the dog?

Answer 172

U72 ‘Leisure activity, not elsewhere classified’ may be assigned for a wide range of activities that are not classified as sport (U50–U71) or work (U73.0 and U73.1), for example, walking the dog.

Question 173

What can you assign for sexual intercourse?

Answer 173

Assign U73.2 ‘While resting, sleeping, eating or engaging in other vital activities’.

Question 174

If there is no information regarding the details of what the activity was, what code can you use?

Answer 174

U73.9 ‘Unspecified activity’

Question 175

What is the correct external cause code for a fall on the same level while pushing an adult walker with wheels?

Answer 175

ACS 2009 Mode of pedestrian conveyance states: “A pedestrian conveyance can be defined as ‘something that serves as a means of transportation’ and includes scooters, rollerskates, wheelchairs, skateboards, etc.”

An adult walker with wheels does NOT meet the above definition of a pedestrian conveyance. That is, it is not used as a means of transportation but rather as an aid to walking.

Therefore, the correct external cause code for a fall, on the same level, while pushing an adult walker with wheels, is either W18.8 Other specified fall on same level or the appropriate code from category W01 Fall on same level from slipping, tripping and stumbling, depending on the circumstances of the fall.

Question 176

What is the correct external cause of injury code to assign for a passenger falling from a golf buggy (cart)?

Answer 176

Golf buggies (carts) use specially designed tyres that can manoeuvre the different terrains of a golf course such as turf, bitumen, smooth paved surfaces, wooded areas, sand and mud and therefore meet the definition of a special all-terrain vehicle in the Tabular List/External Causes of Morbidity and Mortality/Accidents/Transport Accidents, under point (x) of Definitions Related to Transport which states:

A special all-terrain vehicle is a motor vehicle of special design to enable it to negotiate rough or soft terrain or snow…

The appropriate external cause of injury code to assign for a passenger falling from a golf buggy (cart) is V86.62 ‘Passenger of all-terrain or other off-road motor vehicle injured in nontraffic accident, four-wheeled special all-terrain or other off-road motor vehicle’.

Question 177

What is the correct external cause code to assign for fall causing injury (other than drowning/submersion injury) while water skiing?

Answer 177

The correct external cause code to assign for fall from water skis causing injury (other than drowning/submersion injury) is W02.2 ‘Fall involving water ski’.

Question 178

Where does a traffic accident occur?

Answer 178

A traffic accident is any vehicle accident occurring on the public highway [ie originating on, terminating on, or involving a vehicle partially on the highway]. A vehicle accident is assumed to have occurred on the public highway unless another place is specified, except in the case of accidents involving only off-road motor vehicles, which are classified as nontraffic accidents unless the contrary is stated.

Question 179

Multiple Injuries

Answer 179

When coding the initial admission of a multiple trauma, all injuries documented must be coded to represent the totality of multiple trauma. However, superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site (see also ACS 1916 Superficial and soft tissue injuries).

For subsequent admissions, only code the injuries that meet the criteria in ACS 0001 Principal diagnosis or
ACS 0002 Additional diagnoses.

Injuries should be coded to the individual site/type whenever possible.

Combination categories for multiple injuries T00–T07 Injuries involving multiple body regions and injury codes commonly assigned a fourth character of ‘.7’ are to be used only where the number of injuries to be coded exceeds the maximum number of diagnosis code fields available. In these cases, use the individual site/type codes for significant injuries and the multiple categories to code the less severe injuries (eg superficial injury to multiple sites, open wounds to multiple sites and sprain and strain injury). This will ensure all significant conditions are accounted for and that the exact nature of the injury is reflected in the codes.

Question 180

What is an open wound?

Answer 180

An open wound is generally defined as a wound that penetrates the skin and directly communicates with the tissues beneath. These include animal bite, cut, laceration and puncture wound (with or without a penetrating foreign body).

The open wound section for each body region is also used to describe open wounds communicating with a fracture or dislocation and injuries where internal body cavities have been penetrated through the skin (ie intracranial wounds, intrathoracic wounds and intra-abdominal wounds).

The open wound should be coded in addition to the injury.

Refer to ACS 1918 Fracture and dislocation, ACS 1919 Open intracranial injury and ACS 1920 Open intrathoracic/intra-abdominal injury.

If an open wound is described as complicated due to infection (including post traumatic infection), foreign body or due to delayed healing or treatment, assign a code for ‘open wound by site’, followed by:

T89.0- Complications of open wound

Where an open wound has a foreign body and an infection, assign to:

T89.01 Open wound with foreign body (with or without infection)

Use an additional code to identify the infectious agent.

Question 181

When principle diagnosis cannot be determined.

Answer 181

Where the principal diagnosis cannot be determined after referring to ACS 0001 and ACS 1907 Multiple injuries, the clinician should be consulted as to the correct sequencing. Where this is not possible sequence the diagnosis using the following hierarchy:

• artery injury
• nerve injury
• tendon injury
• open wound.

Question 182

What is a degloving injury?

Answer 182

A degloving injury is a peeling away of the skin and subcutaneous tissue from the fascia related to trauma. This may be complete or incomplete.

The complete type implies the flap of skin and subcutaneous tissue is completely torn away or is hanging by a few thread-like attachments such that the tissue is not viable and is excised.

The incomplete type implies the flap remains attached by a pedicle of significant size such that all or part of the flap is viable. Depending upon viability the flap may require excision of ischaemic tissue.

A closed degloving injury can occur when devitalised skin separates some days after the accident. An example would be where a person’s finger may suffer a shearing injury, severing blood vessels in the finger, when their hand is run over by a bus. Whilst the mechanism is the same, there is no association with an external wound.

       Complete degloving injury:  Assign a code for ‘open wound of the site'. 

Assign a code for ‘injury to blood vessel’ of the site, if applicable.

Assign a code for excision of the tissue, if performed.

Assign a code for graft or flap repair, if performed.

        Incomplete degloving injury:  Assign a code for ‘open wound of the site'. 

Assign a code for excision of the tissue, if performed.

Assign a code for graft or flap repair, if performed.

        Closed degloving injury:  Assign a code for ‘injury to blood vessel' of the site. 

*Do not assign a code for open wound.

Assign a code for excision of the tissue, if performed.

Assign a code for graft or flap repair, if performed.

Question 183

What is a closed reduction?

Answer 183

Involves correction of a dislocation/fracture without operative exposure and includes additional external fixation

Question 184

What is a closed reduction with internal fixation?

Answer 184

Involves correction of a dislocation/fracture without operative exposure and includes internal fixation. Includes that with additional external fixation

Question 185

What is an open reduction?

Answer 185

Involves correction of a dislocation/fracture by operative exposure and includes the use of external fixation and debridement of open fracture site

Question 186

What is an open reduction with internal fixation

Answer 186

Involves correction of a dislocation/fracture by operative exposure and includes the use of internal fixation and includes that with additional external fixation and debridement of open fracture site

Question 187

What does an internal fixation include?

Answer 187

bio-implant

cerclage

intramedullary nail

nonsegmental fixation (Harrington rod)

pin

plate

ring fixator

rod

screws (facetal)

segmental fixation (CD) (Dwyer) (Luque) (Zielke)

sliding nail

wire

Question 188

What does an external fixation include?

Answer 188

arch bars

bandaging

brace

cast

calipers

circumosseous fixation

halo

plaster jacket (Minerva)

sling, spica

splint (acrylic) (cap) (cast metal) (silver)

strapping

wiring of teeth

Question 189

ACL

Answer 189

The anterior cruciate ligament (ACL) is a ligament in the center of the knee that prevents the shin bone (tibia) from moving forward on the thigh bone (femur).

Question 190

MCL

Answer 190

The medial collateral ligament (MCL) runs from the inside surface of the upper shin bone to the inner surface of the bottom thigh bone. This ligament keeps your shin bone (tibia) in place. The MCL is usually injured by pressure or stress on the outside part of the knee.

Question 191

If the description says ‘tear’ then this is found under what heading in the index?

Answer 191

Rupture

Question 192

MCP Joint

Answer 192

The metacarpophalangeal joints (MCP) are situated between the metacarpal bones and the proximal phalanges of the fingers.

Question 193

LMF

Answer 193

Left middle finger

Question 194

LIF

Question 195

IPJ

Answer 195

Interphalangeal joints of the hand - are the hinge joints between the phalanges of the fingers that provide flexion towards the palm of the hand.

Question 196

SAH

Answer 196

Subarachnoid hemorrhage (SAH) - results from a medical aneurysmal rupture or traumatic head injury.

Question 197

FDS Tendon

Answer 197

The flexor digitorum superficialis (FDS), formerly known as the flexor digitorum sublimis, is the largest of the extrinsic flexors of the forearm.

Question 198

A compound fracture is also known as a

Answer 198

Open fracture.