ICD-10 Coding standards Chapters XVI - XXII

Question 1

DChS.XVI.1: Liveborn infants according to place of birth (Z38)

Answer 1

A code from category Z38.- Liveborn infants according to place of birth must always be coded on the birth episode for every liveborn infant and be sequenced as follows:
• If the baby is a completely well baby and has no morbid conditions that have been
treated or investigated, a code from Z38.- must be assigned as the primary
diagnosis.
• If the baby is not completely well, and a morbid condition(s) is present which has
been treated or investigated, a code from Z38.- must be assigned in the first
secondary position.

Question 2

DChS.XVI.2: Coding perinatal conditions

Answer 2

The perinatal period must be regarded as the period before birth through to the 27th day, 23rd hour and 59th minute of life, i.e. the period before the start of the 28th day.

A code from Chapter XVI must only be used for conditions that originate in the perinatal period.
Where a condition originates in the perinatal period it must always be coded to chapter XVI, even if this condition persists beyond the perinatal period. An addition code form outside of chapter XVI must be assigned where this adds further information to the condition which is not contained in the chapter XVI code.

This excludes conditions classified to the following codes, when a condition classifies to these codes arises in the perinatal period only a code from these chapters or categories is required:
• Congenital malformations, deformities and chromosomal abnormalities (Q00-Q99)
• Endocrine, nutritional and metabolic diseases (E00-E90)
• Injury, poisoning and certain other consequences of external causes (S00-T98)
• Neoplasms (C00-D48)
• Tetanus neonatorum (A33)
• Symptoms, signs and abnormal clinical and laboratory finding, not elsewhere classified.

Question 3

DCS.XVI.1: Fetus and newborn affected by maternal factors and by complications of
pregnancy, labour and delivery (P00-P04)

Answer 3

Codes in range P00-P04 must be assigned when the underlying maternal cause or external cause for the baby’s morbid condition is known. They must be sequenced in a secondary position to the code that classifies the morbid condition.

Codes in P00-P04 must never be used in the primary diagnosis position except when the baby is stillborn, and the cause is known.

Question 4

DCS.XVI.2: Disorders related to length of gestation and fetal growth (P05-P08)

Answer 4

If low birth weight and short gestational age documented in the medical record two codes from P07.- must be assigned. The low-birth-weight codes must be sequenced before the code for the short gestational age.

When a condition(s) classified to categories P07 or P08 and condition(s) classified to category P05 are present, codes from both categories must be assigned. The exclusion note P07 does not preclude this.

Question 5

DCS.XVI.3: Low Apgar score and birth asphyxia (P21)

Answer 5

A diagnosis of ‘low apgar score’ alone is not classified in ICD-10 and codes must not be assigned when this diagnosis alone is made.

If the responsible consultant records the apgar score in a newborn with asphyxia the apgar score is used to assign the fourth character from category P21.-

Question 6

DCS.XVI.7: Stillbirths (P95.X)

Answer 6

Stillbirths must be coded as follows:
• If the cause for the stillbirth is known, the cause must be coded as the primary diagnosis. Code P95.X is not required in any diagnostic position.
• If the cause of the stillbirth is not known, P95.X must be assigned as the primary diagnosis.
• A code from Z38.- must not be assigned on a stillborn baby’s episode.

Question 7

DCS.XVI.8: Jittery baby (R25.8)

Answer 7

Jittery baby must be coded using code R25.8 Other and unspecified abnormal involuntary movements.

Question 8

DCS.XVI.9: Sudden infant death syndrome (R95)

Answer 8

Codes in category R95.- Sudden infant death syndrome (SIDS, cot death) must only be
assigned when no cause has been recorded in the medical record and the responsible consultant records the diagnosis as
‘a sudden infant death’
‘sudden infant death syndrome’
‘cot death’
‘SIDS’

Question 9

DCS.XVII.1: Triple M syndrome

Answer 9

Triple M syndrome must be coded using:

Q87.1 Congenital malformation syndromes predominantly associated with short stature

Question 10

DChS.XVIII.1: Signs, symptoms and abnormal laboratory findings

Answer 10

If a specific diagnosis is identified from a sign, symptom or abnormal laboratory finding classifiable to chapter XVIII, a code for the diagnosis must be assigned instead.
Codes in Chapter XVIII must only be assigned when:
• A specific diagnosis from the sign, symptom or abnormal laboratory finding has not been made.
• There is a specific standard which states that a sign or symptom must always be coded.
• The cause for the sign, symptom or abnormal laboratory finding is known, but it is treated as a problem in its own right. In this instance the code from R00-R99 must be assigned in a secondary position to the known cause.

Question 11

DCS.XVIII.3: Immobility and reduced mobility (R26.3, R26.8)

Answer 11

The terms ‘immobility, ‘chairfast’, ‘bedfast’, ‘bedbound’ and ‘bedridden’ must be classified to code R26.3 Immobility when documented in the medical record.

Terms such as ‘reduced mobility’ and ‘poor mobility’ must be classified to R26.8 Other and unspecified abnormalities of gait and mobility

Question 12

How must geriatric falls be coded?

Answer 12

Geriatric and elderly falls must be coded as follows:
Geriatric and elderly fall without injury:

R29.6 Tendency to fall, not elsewhere classified

Geriatric and elderly fall with injury:

Code classifying the injury sustained from Chapter XIX
External cause code from categories W00-W19
R29.6 Tendency to fall, not elsewhere classified

If the patient remains in hospital for investigation of the falls and this becomes the primary focus of care, then code R29.6 must be sequenced before the codes for the injury.

Question 13

DCS.XVIII.5: Chronic intractable pain (R52.1)

Answer 13

When a patient is admitted for treatment of generalised chronic pain affecting more than one organ or body system cause by a more specific condition, code R52.1 must be assigned in addition to the code classifying the specific condition.

Must not be coded if the pain is limited to one organ or body system as a result from a specific condition, in these cases only the code for the specific condition is required.

Question 14

DCS.XVIII.6: Off legs (R54.X)

Answer 14

The diagnosis of ‘off legs’ in an elderly patient must be classified to code R54.X Senility.

Question 15

DCS.XVIII.8: Systemic Inflammatory Response Syndrome [SIRS] (R65)

Answer 15

Codes within category R65.- Systemic Inflammatory Response Syndrome [SIRS] must only be used in a secondary position following the condition or underlying disease causing SIRS. The appropriate codes for the organ failure, if present, must also be coded in addition.

Question 16

DCS.XVIII.10: Multiple organ failure (R68.8)

Answer 16

When multiple organ failure is recorded in the medical record, the coder must seek clarification about which individual organs have failed and code each organ failure separately. If no further clarification is provided and the only information available is that the patient has multiple organ failure, the code R68.8 Other specified general symptoms and signs must be assigned.

Question 17

DCS.XVIII.11: Unknown and unspecified causes of morbidity (R69.X) and Ill-defined
and unknown causes of mortality (R96–R99)

Answer 17

The codes in categories R69.x, R96.-, R98.X and R99.X must only be used when no further information about the patient’s condition is available.

Question 18

DCS.XVIII.12: Raised International Normalised Ratio [INR] (R79.8)

Answer 18

Raised INR must be coded as follows:

Code classifying the condition being treated by the anticoagulant
R79.8 Other specified abnormal findings of blood chemistry
Z92.1 Personal history of long-term (current) use of anticoagulants (if thepatient is currently taking anticoagulants or if they have a personal history
of anticoagulation therapy)

If the patient undergoes investigations/treatment of the raised INR during the consultant
episode, therefore becoming the main condition treated, R79.8 must be sequenced before
the code classifying the condition being treated by the anticoagulants, in line with DGCS.1:
Primary diagnosis.

Question 19

DChS.XIX.1: Multiple injuries

Answer 19

Multiple injuries must be coded separately where the specific sites and types of injuries are
documented. The injury that is clearly the most severe and demanding of resources must
be sequenced in the primary position as per the primary diagnosis definition (See DGCS.1:
Primary diagnosis). Where no one condition obviously predominates, the responsible
consultant’s advice must be sought.

Codes in Chapter XIX that classify ‘multiple injuries’ must only be used where no detail is
documented in the medical record about the individual sites or types of the injury.

The exceptions are bilateral injuries involving the same body site.

When multiple injuries are caused by the same event, only one external cause code is
assigned directly after the final injury code

Question 20

DChS.XIX.2: Fifth characters in Chapter XIX

Answer 20

Supplementary characters at chapter XIX indicate:

• Open or closed fracture’s
• Intracranial injuries with or without intracranial wound
• Internal injuries with or without open wound into cavity

An injury not specified as open or closed must be recorded using the fifth character .0

Question 21

DChS.XIX.3: Infected open wounds

Answer 21

Infected open wounds must be coded in the same way as a non-infected open wound, i.e.
code assignment is the same but if the organism causing the infection is known, a code
from categories B95–B98 Bacterial, viral and other infectious agents must be coded in
addition.

Question 22

DCS.XIX.1: Skull fracture with intracranial injuries (S02 and S06)

Answer 22

When coding skull fractures (S02.-) associated with intracranial injuries (S06.-); the intracranial injury (S06.-) must be sequenced first.

Question 23

DCS.XIX.3: Bilateral injuries involving the same body site (T00-T07)

Answer 23

Codes in categories T00-T07 Injuries involving multiple body regions must only be used for bilateral injuries involving the same body site where the type and site of injury are identical on both sides.

Question 24

DCS.XIX.4: Foreign bodies (T15-T19)

Answer 24

Foreign body injuries must be classified according to the site where the foreign body is currently located.

Question 25

DCS.XIX.5: Burns and corrosions (T20-T32)

Answer 25

Burns and corrosions of the same site that exhibit multiple degrees must be coded to the most severe degree of that site using codes in categories T20-T30 Burns and corrosions.

A code from categories T31.- or T32.- must be assigned in addition to a code from categories T20-T25 or T29.- when the total percentage of body surface involved in a burn or corrosion is documented.

When the site of the burn is not stated and only the total percentage of body surface involved is documented only a code from categories T31 or T32 Is required.

Question 26

DCS.XIX.6: Maltreatment syndromes (T74)

Answer 26

Codes in category T74.- Maltreatment syndromes classify non-accidental injuries (NAI)
and must be assigned using the following codes and sequencing:

T74.- Maltreatment syndromes
Code for the injury caused
Y07.- Other maltreatment

The responsible consultant must clearly state that an injury is a non-accidental injury before
a code from category T74.- can be assigned.

Question 27

What are the three ways you can code postprocedural complications?

Answer 27

Postprocedural complications and disorders.

Never assume that a condition is post procedural, it must clearly be documented in the medical record.

Postprocedural complications can be coded in three ways:

1. When the alphabetical index directs to a code in categories T80-T88 (using terms for the actual complication), apply the following codes and sequencing:

T80-T88
Y83-Y84

• Do not assign a code from Y83-Y84 when the code in range T80-T88 fully describes both the nature of the condition and the procedure that caused it.
• Do not assign codes Y83.8-.9 or Y84.8-.9 with codes in range T80-T88 because these codes do not add more information about the nature of the procedure.
• When multiple post procedural complications occur due to the same procedure only one code from Y83-Y84 is required sequenced after all the postprocedural complication codes.

2. When the alphabetical index directs to a code in a postprocedural disorder category in a body system chapter, not ending in .8 or .9, or where a specific standard indicates that the .8/.9 codes must be used, apply the following codes:

Code from postprocedural disorder category in a body system chapter
Y83-Y84

• Do not assign a code from Y83-Y84 when the code in range T80-T88 fully describes both the nature of the condition and the procedure that caused it.
• Do not assign codes Y83.8-.9 or Y84.8-.9 with codes in range T80-T88 because these codes do not add more information about the nature of the procedure.
• When multiple post procedural complications occur due to the same procedure only one code from Y83-Y84 is required sequenced after all the postprocedural complication codes.

3. When the alphabetical index does not direct to a code in categories T80-T88, or a code in a postprocedural disorder category in a body system chapter, or a postprocedural disorder category code with the 4th character .8 or .9, that is not a specific standard, apply the following:

Code from chapters I-XVIII classifying the specific condition
Y83-Y84
• A code from categories Y83-Y84 must always be assigned, including fourth characters .8 or .9, as this indicates that the condition was due to a procedure.
• Where multiple postprocedural conditions due to the same external cause are classified from chapters I-XVIII (not classified to one of the postprocedural disorder categories) the external cause code must be assigned multiple times, i.e. following each code from chapters I-XVIII

Question 28

How must post procedural infections be coded?

Answer 28

• Code from categories T80-T88 or a code from a postprocedural disorder body system category or a code from a body system chapter classifying the specific condition
• B95-B98
• U82.-,U83 or U84 (in the infective agent is confirmed to be resistant to antibiotic or antimicrobial drugs)
• Y83-Y84 (if required)

Question 29

DCS.XIX.8: Poisoning (T36-T65)

Answer 29

Where a reaction to a drug or medicine is not stated as being the result of improper use, it is assumed to be the result of proper use and therefore be coded as an adverse effect.

Poisonings must be coded as follows:
• Assign a code from Chapter XIX for the substance causing the poisoning from the table of drugs and chemical in section III of the alphabetical index.
• Assign an external cause code from Chapter XX for the circumstance of the poisoning (accidental, intentional, undetermined event) from the table of drugs in section III of the alphabetical index.
• Assign a code(s) for any manifestations if stated in the medical record.
o Manifestations classified to chapter XVIII must be coded in a secondary position following the external cause code.
o Manifestations outside of chapter XVIII must be coded in a secondary position after the external cause code, unless it is clear that the reaction or manifestation is the main condition treated.

When a drug has more than one component, each component must be coded separately and sequenced according to the order in which the components appear in the drug name.

Where the poisoning is confirmed to be more than one drug and each drug has been identified. Each drug must be coded separately. The responsible consultant must determine which drug is the most clinical dangerous.

Do not assign the same external cause code multiple times when coding multiple drugs or components. Assign each external cause code once after all the drugs/components it is associated with.

An adverse reaction due to a drug taken in combination with alcohol must be coded as a poisoning of both agents.

An adverse reaction due to a combination of taking a prescribed drug and a non-prescribed drug must be coded as a poisoning of both agents.

Question 30

DCS.XIX.9: Accidental awareness during general anaesthesia [AAGA]

Answer 30

When it is documented in the patient’s medical record, on the current admission, that the patient reported awareness during a procedure performed under general anaesthesia, the following codes must be assigned:

T88.5 Other complications of anaesthesia
Y48.- Drugs, medicaments and biological substances causing adverse
effects in therapeutic use: Anaesthetics and therapeutic gases

When it is specifically stated in the medical record that the AAGA was due to failure in dosage of anaesthetic, failure of effect of dosage of anaesthetic or an incorrect anaesthetic was given; assign external cause code Y63.6 Failure of dosage during surgical and
medical care: Nonadministration of necessary drug, medicament or biological substance instead of Y48.-.

If the awareness was reported during a procedure performed during pregnancy, labour, delivery or the puerperium using general anaesthesia, code O29.8 Other complications of anaesthesia during pregnancy, O74.8 Other complications of anaesthesia during
labour and delivery or O89.8 Other complications of anaesthesia during the puerperium must be assigned instead of code T88.5. See also DCS.XV.13:
Complications of anaesthesia during pregnancy, labour, delivery and the puerperium (O29, O74, O89).

When it is specifically stated in the medical record that the AAGA was due to equipment failure the following codes must be assigned:

R41.8 Other and unspecified symptoms and signs involving cognitive functions and awareness
Y70.- Anaesthesiology devices associated with adverse incidents

Question 31

DChS.XX.1: External causes

Answer 31

External cause codes in chapter XX classify outside factors as the cause of injury, poisoning and other adverse effects, the following must be assigned when using external cause codes:
• They must be assigned in addition to a code from chapter XIX or to a code from chapters I- XVIII when stated to be due to an external cause.
• They must be sequenced immediately following a code which describes the injury, poisoning or adverse effect from chapter XIX.
• When multiple injuries from chapter XIX or conditions from Chapter I-XVIII are due to the same external cause it is only necessary to record one external cause code from chapter XX following all codes that classify the injuries or conditions.
• When the external cause of an injury is not specified code X59.- must be assigned.
• Codes within range V01-Y36 must only be assigned on the first consultant episode in which the condition is recorded in the UK. Any subsequent episode where the same condition is being treated does not require the external cause code from V01-Y36.
• Codes in categories V40-Y98 must be assigned on every episode in which the condition is recorded. (except for Y83-Y84 which are not always coded)
• The ‘definitions of transport accidents’ and the ‘Classification and coding instructions for transport accidents’ at the beginning of Chapter XX give detailed definitions and instructions regarding the coding of transport accidents (V01-V99), including the order of preference when more than one kind of transport is involved. These must be referred to when assigning fourth character codes with these categories.
• A fourth character must be assigned with codes from categories W00-Y34 to identify where the injury, poisoning or adverse effect took place. The fourth characters can be found in the ‘Place of occurrence code’ section at the beginning of the chapter.
The exceptions are codes in categories Y06.- Neglect and abandonment and Y07.- Other maltreatment, see DCS.XIX.6: Maltreatment syndromes (T74).
• The correct fourth character subdivision for a place of occurrence of pub or nightclub
is .5 Trade and service area.

Question 32

DCS.XX.3: Conditions linked to travel (X51.9)

Answer 32

When conditions such as deep vein thrombosis (DVT) are linked to travel, the external cause code X51.9 Travel and motion must be assigned in addition. As it is impossible to define at which point on a journey a DVT occurred, the place of occurrence fourth character
.9 must be used.

Question 33

DCS.XX.4: Accidents (V01-X59) and intentional self-harm (X60-X84)

Answer 33

Intentional self-harm codes (X60-X84) are used to identify attempted suicides or purposely
self-inflicted poisoning or injury and must be assigned for any patient who has intended to harm themselves in any way. This includes any ‘cry for help’.

Where it is not clear whether an injury or overdose is an accidental or intentional self-harm attempt or an assault, the code that classifies the accidental external cause or accidental poisoning must be assigned (V01-X59).

Question 34

DCS.XX.5: Event of undetermined intent (Y10-Y34)

Answer 34

Event of undetermined intent codes (Y10-Y34) must only be used when undetermined intent is stated by a medical or legal authority, such as a coroner at an inquest. It must not be used when no information has been given about the circumstances of an event. If the
intent is not known, a code that classifies an accidental external cause must be assigned.

Question 35

DCS.XX.7: Drugs, medicaments and biological substances causing adverse effects in therapeutic use (Y40-Y59)

Answer 35

• Adverse effects results from the proper use of a substance. When in doubt assume it is proper.
• Coded as:
o Code for nature of adverse effect
o Code Y40-Y59 as indicated in the column adverse effect in therapeutic use in section 3, Alpha index.
• Multiple adverse effects resulting from a drug a code from Y40-Y59 is required for each adverse effect.
• Multiple drug/components identified each need a code from Y40-Y59
• Adverse reaction due to 2 or more prescribed drugs must be coded as an adverse reaction of both agents if they have been taken correctly.
• If an adverse effect is due to a prescription drug and it is not known if the drug was prescribed or not, code as an adverse effect.
• Adverse reaction due to a drug taken with alcohol must be coded as a poisoning of both agents.
• An adverse reaction occurring due to a prescribed and non-prescribed drug must be coded as poisoning of both agents.
• A poisoning code from Chapter XIX must never be used with an adverse effect code in Y40-Y59

Question 36

DCS.XX.8: Misadventure and adverse incidents during medical and surgical care
(Y60-Y82)

Answer 36

• Misadventure during a procedure Y60-Y69 in secondary position to code describing misadventure.
• Adverse incident out of the surgeon’s control during procedure Y70-Y82 in secondary position to code describing the adverse incident.
• Abnormal reaction after procedure assign a code from Y83-Y84

Question 37

DCS.XX.9: Evidence of alcohol involvement (Y90 and Y91)

Answer 37

Codes in categories Y90.- Evidence of alcohol involvement determined by blood
alcohol level and Y91.- Evidence of alcohol involvement determined by level of
intoxication must be assigned in a secondary position when evidence of alcohol
involvement, determined by blood alcohol level or by level of intoxication, is documented in
the medical record.

Question 38

DCS.XX.10: Hospital acquired conditions (Y95.X)

Answer 38

• Conditions that are hospital acquired add Y95.X
• Never assume must be stated.
• If transferred with hospital acquired condition still add Y95.X

Question 39

DCS.XXI.1: Persons encountering health services for examination and investigation (Z00–Z13)

Answer 39

• Z00-13 must only be used in primary in the absence of a diagnosis, or reason for admission. If found code this instead.
• Exceptions to this are Z02.- Z10.- must never be used in primary, and Z08/Z09.

Question 40

DCS.XXI.2: Follow-up examinations after treatment for a condition (Z08 and Z09)

Answer 40

•	Follow up examinations coded as follows:
o	No recurrence found during follow up:
	Z08.-/Z09.-
	Code to identify personal history.
o	Incidental finding during follow up (not treated):
	Z08.-/Z09.-
	Code to identify personal history.
	Code(s) for incidental finding(s)
o	Incidental finding during follow up (treated):
	Code(s) for incidental finding(s)
	Z08.-/Z09.-
	Code to identify personal history.
o	Recurrence found during follow up:
	Code for Recurrent condition
	Code(s) for incidental finding(s)

Question 41

DCS.XXI.3: Persons with potential health hazards related to communicable diseases
(Z20–Z29)

Answer 41

Codes from Z20-Z29 only used in primary if no diagnosis made.

Question 42

DCS.XXI.5: Persons encountering health services in circumstances related to reproduction and for specific procedures and health care (Z30–Z54)

Answer 42

Codes in categories Z30-Z54 must be used as follows:
Assign codes in categories Z30-Z54 in a primary diagnostic position only when there is no
diagnosis, complication, injury or symptom code from another chapter in ICD-10 to explain
the encounter.

The following codes are exceptions which must never be used in a primary position:
• Z30.0 General counselling and advice on contraception
• Z30.4 Surveillance of contraceptive drugs
• Z50.- Care involving use of rehabilitation procedures
• Z51.- Other medical care - see also DCS.XXI.9: Palliative Care (Z51.5, Z51.8)

Codes in categories Z30-Z54 must not be assigned in a secondary position to identify an intervention or procedure, when the procedure/intervention has been fully classified by the assignment of an OPCS-4 code following correct application of the OPCS-4 national
standards.

The exceptions to this standard are:
• Z33.X Pregnant state, incidental – see DCS.XV.33: pregnant state, incidental
(Z33.X)
• Z34.- Supervision of normal pregnancy – see DCS.XV.34: Supervision of
normal pregnancy (Z34)
• Z37.- Outcome of delivery - see DChS.XV.1: Outcome of delivery (Z37)
• Z38.- Liveborn infants according to place of birth - see DChS.XVI.1: Liveborn
infants according to place of birth (Z38)
• Z40.- Preventative surgery – see DCS.XXI.6: Preventative surgery (Z40)
• Z49.- Care involving dialysis - see DCS.XXI.8: Renal dialysis (Z49 and Z99.2)
• Z53.- Persons encountering health services for specific procedures, not
carried out – see DCS.XXI.11: Cancelled procedures and abandoned
procedures (Z53)
• Z54.- Convalescence – see DCS.XXI.12: Convalescence (Z54).

Question 43

DCS.XXI.6: Preventative surgery (Z40)

Answer 43

Patient admitted for preventative surgery due to a personal or family history must be coded as:

Z40 in primary
Z80-Z87 to identify personal or family history

Where preventative surgery is due to a current condition:

Code classifying current condition
Z40.- secondary position

Question 44

DCS.XXI.7: Trial without catheter (Z46.6)

Answer 44

o Successful TWOC coded to Z46.6

o Failed Twoc code to condition causing necessary catherization

Question 45

DCS.XXI.8: Renal dialysis (Z49 and Z99.2)

Answer 45

Z49.- never in primary, coded as follow:
o Admitted for renal dialysis Z49.- secondary to condition for dialysis
o Admitted for other treatment, but receives dialysis Z49.- not used.
Patients regularly receiving dialysis admitted for other reasons code Z99.2 in a secondary position.

Question 46

DCS.XXI.9: Palliative Care (Z51.5, Z51.8)

Answer 46

Palliative care coded to Z51.5 or Z51.8
Z51.5 – specialised palliative care
Z51.8 – not specified as specialised palliative care.

Question 47

DCS.XXI.10: Donors of organs and tissues (Z52)

Answer 47

Codes in category Z52.- Donors of organs and tissues must only be assigned for live donors of organs and tissues.

Question 48

DCS.XXI.11: Cancelled procedures and abandoned procedures (Z53)

Answer 48

Codes in Z53.- never in primary. For elective patients with cancelled procedures for any reason and no other procedure is carried out. Codes and sequencing:

o Code(s) classifying the condition(s) prompting the admission
o Z53.0
o Code describing reason for cancellation (if applicable i.e medical problem)

Cancellation due to lack of bed or theatre time must be coded to Z53.8

If cancelled due to condition resolving:
• Z03/Z04
• Z53.8
• Personal history code

If procedure has started and then abandoned do not code Z53.- code only reason for procedure and/or complication codes.

Question 49

DCS.XXI.12: Convalescence (Z54)

Answer 49

Codes in category Z54.- Convalescence must never be assigned in a primary position.

They must only be assigned in a secondary position when a patient has received convalescence in a dedicated convalescent unit.

Question 50

DCS.XXI.13: Persons with potential health hazards related to socioeconomic and psychosocial circumstances (Z55–Z65)

Answer 50

Codes in categories Z55-Z65 never in primary (except Z63.8)

Only assigned in secondary when circumstance influences patients’ current condition and adds further information or there is a national standard that instructs otherwise.

Question 51

DCS.XXI.14: Passive smoking (Z58.7)

Answer 51

If passive smoking is documented within the medical record by the responsible consultant,
code Z58.7 Exposure to tobacco smoke must be assigned in a secondary position.

Question 52

DCS.XXI.15: Living alone (Z60.2)

Answer 52

Living alone Z60.2 must only be used when stated that living alone has extended their length of stay.

Must not be used on an episode where the patients dies.

Question 53

DCS.XXI.16: Persons encountering health services in other circumstances (Z70–Z76)

Answer 53

Codes in categories Z70–Z76 Persons encountering health services in other circumstances must only be assigned in a primary position when there is no diagnosis, complication, injury, symptom or abnormal finding code that could be used to explain the encounter instead.

The following categories/codes are exceptions to this block and must NEVER be
used in a primary position:
Z71.0 Person consulting on behalf of another person
Z72 Problems relating to lifestyle
Z73.2 Lack of relaxation and leisure
Z73.4 Inadequate social skills, not elsewhere classified
Z73.5 Social role conflict, not elsewhere classified
Z73.6 Limitation of activities due to disability
Z74 Problems related to care-provider dependency, see DCS.XXI.18:
Problems related to care-provider dependency (Z74)
Z75 Problems related to medical facilities and other health care (except
Z75.5 Holiday relief care, see DCS.XXI.20: Holiday relief care (Z75.5))
Z76.0 Issue of repeat prescription
Z76.3 Healthy person accompanying sick person
Z76.4 Other boarder in health care facility

Question 54

DCS.XXI.17: Acopia (Z73.9)

Answer 54

Code Z73.9 Problem related to life-management difficulty, unspecified must be assigned for patients admitted to hospital because of an inability to cope.

Question 55

DCS.XXI.18: Problems related to care-provider dependency (Z74)

Answer 55

Codes in category Z74.- must only be assigned in a secondary position when a patient who is care dependant, is admitted for care because their carer is not available. The condition prompting why the person needs care must be recorded in the primary position.

Question 56

DCS.XXI.19: Persons awaiting admission to adequate facility elsewhere (Z75.1)

Answer 56

Z75.1 used when medical record states bed-blocking or medically fit for discharge but awaiting suitable accommodation elsewhere.

Question 57

DCS.XXI.20: Holiday relief care (Z75.5)

Answer 57

Patients admitted for care to allow their carers respite must be coded as follows:
• Z75.5 coded in primary position followed by chronic condition (if patient receives same level of care given by carer)
• If treatment is given for a different condition (i.e diagnosed whilst in hospital) this must be coded in primary followed by Z75.5. The patients chronic condition (reason for care) must be coded also.
• If the responsible consultant decides that the chronic condition needs additional treatment/ investigation above that the patient receives at home, the chronic condition must be coded in primary. Code Z75.5 is assigned in a secondary position.

Question 58

DCS.XXI.21: Persons with potential health hazards related to family and personal history and certain conditions influencing health status (Z80–Z99)

Answer 58

Codes in range Z80-Z99 must not be used in primary, except for Z85.6/Z85.7.
Used in secondary when the circumstance influences the patients current condition and to provide relevant additional information; with the exception of those problems listed on the list of co-morbidities which always must be coded.

Question 59

DCS.XXII.2: Resistance to antimicrobial and antineoplastic drugs (U82-U85)

Answer 59

Codes within categories U82 -U85 must:
• Never be used as primary diagnosis codes
• Only ever be used in a secondary position, sequenced directly following the code they enhance.
• Only be assigned when drug resistance is clearly documented.

Codes U82-U85 are used to identify antibiotic/antimicrobial resistance to which a causative agent is resistant. These codes must be assigned when the information is available, but the coder must never interpret laboratory test results in order to identify the resistance.

When an agent is resistant to two or more drugs at categories U82, U83 or U84 a code for each drug is required. The exceptions are when:

• An agent is resistant to two or more drugs classifiable to the same subcategory at U83.8 or U84.8.
• An agent is resistant to two or more drugs where the drugs are not specifically specified. (These cases should be referred back to the consultant)
If either of these exceptions applies, code u83.7 or U84.7 must be assigned.

Category U85.X must only be used to identify resistance, non-responsiveness and
refractive properties of a neoplasm or other condition to antineoplastic drugs.