ICD-10 General Coding Standards Flashcards
What is the primary diagnosis definition?
The primary diagnosis definition must always be applied when assigning ICD-10 codes on
the coded clinical record:
i) The first diagnosis field(s) of the coded clinical record (the primary diagnosis)
will contain the main condition treated or investigated during the relevant
episode of healthcare.
ii) Where a definitive diagnosis has not been made by the responsible clinician
the main symptom, abnormal findings, or problem should be recorded in the
first diagnosis field of the coded clinical record.
All other relevant diagnoses must be coded in addition to the primary diagnosis.
In DGCS.1: Primary diagnosis what is meant by ‘Specificity’
Where the diagnosis recorded as the main condition describes a condition in general
terms, and a term that provides more precise information about the site or nature of the
condition is recorded elsewhere, reselect the latter as the main condition.
Describe DGCS.2: Absence of definitive diagnosis statement
It is not always possible for the responsible consultant to provide a definitive (confirmed)
diagnosis in the medical record for a consultant episode but they may be treating or
investigating the patient’s condition based on a ‘presumed’ or ‘probable’ diagnosis.
If in any doubt and when the diagnosis information is ambiguous seek the advice of the
responsible consultant for clarification. If it is not possible to get advice from the
responsible consultant code as follows:
• Code the diagnosis recorded as being treated or investigated. (Terms that might be
recorded in the medical record are ‘working diagnosis’ ‘treat as’, ‘presumed’ or
‘probable’).
• If the responsible consultant records a differential diagnosis whilst working to
determine which one of several diseases may be producing the symptoms and in
the absence of any further information the main symptoms must be coded in line
with DGCS.1: Primary diagnosis (Terms that might be recorded in the medical
record are ‘likely’ or ‘likelihood’).
Should the absence of a diagnosis relate to documentation or recurring recording issues
the coding manager should refer through local information and clinical governance routes.
Where applicable the outcome should be documented as local practice in the local policies
and procedure manual for reference and audit purposes.
What is a Co-morbidity?
For the purposes of coding, co-morbidity is defined as:
• Any condition which co-exists in conjunction with another disease that is
currently being treated at the time of admission or develops subsequently,
and
• affects the management of the patient’s current consultant episode.
Describe the coding of Co-morbidities in multiple consultant episodes
Where there are multiple consultant episodes within one hospital provider spell, it is
possible that the patient’s co-morbidities will only be documented on the first consultant
episode in the medical record and not repeated for each subsequent consultant episode
within the hospital provider spell. Where this is the case the coder may code the
comorbidities recorded on the first consultant episode on each subsequent consultant
episode within that hospital provider spell and any other co-morbidities that develop during
the current hospital provider spell. However, as it is possible that some co-morbidities may
resolve during a hospital provider spell, care must be taken, and any uncertainty about the
presence of a comorbidity should be clarified with the responsible consultant.
Describe in detail the section of DGCS.3: Co-morbidities referring to ‘Co-morbidities always coded’
There are a number of medical conditions and other factors influencing health that must
always be coded for each consultant episode when they co-exist in conjunction with
another disease that is currently being treated at the time of admission (or develop
subsequently). This is regardless of specialty. These have been agreed by the Clinical Comorbidities
Working Group as co-morbidities that are clinically relevant - as they always
affect the management of the patient’s current consultant episode.
See Coding Clinic Ref 88: Coding of co-morbidities for the list of co-morbidities that
must always be coded when documented in the patient’s medical record and other
standards specifically related to coding co-morbidities.
The list does not replace the fundamental clinical coding principles. The four step coding
process must still be applied to ensure correct code assignment when translating medical
information into ICD-10 codes.
When other conditions, not contained within the co-morbidity list, have been
identified in the medical record by the responsible consultant as being relevant to
the consultant episode, then these conditions must also be coded.
Any uncertainty as to whether a documented condition is a current condition must be
clarified with the responsible consultant.
When can coders use diagnostic test results?
DGCS.4: Using diagnostic test results
As diagnostic procedures and associated technology advance clinical coders have access
to a wide range of information, including diagnostic test results and reports. Such
documents form part of the patient medical record and can be used by the coder to enable
assignment of the correct codes for a patient, but the following must be applied:
• Test results must not be interpreted by the coder to arrive at a diagnosis, this
is the role of the responsible consultant
• If a definitive diagnosis is documented on a test result report by the responsible
consultant (or designated representative - e.g. a microbiologist or haematologist), it
would be correct to assign codes for this diagnosis, as it is the responsible
consultant that has interpreted the results to arrive at a definitive diagnosis
Any uncertainty must always be referred back to the responsible consultant.
Give an example of test results which may be used by the coder, but must never be interpreted by
the coder.
Any from:
• Results that give ratios and measurements, such as blood pressure readings, BMI
(See also DCS.IV.3: Obesity (E66)), troponin levels, INR levels etc
• Histopathology reports will describe the microscopic features of a tissue sample and
will usually give a full description of the reported condition
• Microbiology reports provide details of organisms present and drug resistance. The organisms identified in the report may not necessarily be viewed by the
consultant/doctor as harmful to the patient. Clinical coders should take care not to
‘over-report’ pathology and microbiology results by attempting to record every organism
• Haematology reports involve the measurement of the various components of blood physiology and the clotting process
• Radiology results may identify a more specific diagnosis; for example, osteoarthritis
rather than pain in hip.
Complete the following sentences:
A Dagger codes denotes ………
An Asterisk code denotes ………
A Dagger codes denotes the underlying generalised disease also referred to as
aetiology
An Asterisk code denotes the manifestation of that disease in a particular organ
or site which is a clinical problem in its own right
What must be applied when assigning dagger (†) and asterisk (*) codes?
• They must always be used in combination and sequenced directly after each other
• The code that reflects the main condition treated or investigated during the consultant episode must be sequenced in the primary position (see DGCS.1:
Primary diagnosis)
• In instances where the responsible consultant has not specified, or is unable to confirm, which condition is the main condition treated, the dagger code must be
assigned before the associated asterisk code
• Where a dagger and asterisk combination is assigned, and neither condition is the
main condition treated, the dagger code must be sequenced before the asterisk code.
• Multiple asterisk codes with one dagger code must not be assigned, each asterisk
code must have its own dagger code, even where this means repeating dagger
codes
• A link must be made by the responsible consultant in the medical record to indicate that the manifestation (asterisk code) is caused by the underlying condition (dagger code); if they are not linked each diagnosis must be coded separately without the dagger and asterisk linkage.
• Codes designated as a dagger code, either at category or code level, must always
be used as a dagger code and must never be used alone, in the absence of an asterisk code. Codes not designated as a dagger or asterisk code may be paired
with an asterisk code to form a dagger asterisk combination. Dagger codes appear in the following forms in the Tabular List:
o When the associated asterisk code(s) is listed at the end of the code description of a dagger marked code the dagger code must be used with the listed asterisk
code(s)
o When the associated asterisk code is not listed in the code description of a dagger marked code but is listed as an inclusion underneath the dagger code the dagger code can be used with these inclusion terms or another asterisk marked code to form a dagger asterisk combination
o When a code is not marked as a dagger code but any of its inclusion terms are marked with a dagger then the code becomes a dagger code when used in
combination with the asterisk code listed in brackets in the inclusion.
• Codes designated as an asterisk code, either at category or code level, must always be used as an asterisk code in a dagger asterisk combination. They must never be used alone, in the absence of a dagger code. Asterisk codes appear in the following forms in the Tabular List:
o When the associated dagger code(s) is listed at the end of the asterisk code description the asterisk code must be used with the listed dagger code(s)
o When the associated dagger code is not listed in the asterisk code description but is listed as an inclusion underneath the asterisk code the asterisk code can
be used with these inclusion terms or a non-asterisk code to form a dagger asterisk combination
o When the associated dagger code is not listed in the asterisk code description or as an inclusion underneath the asterisk code the asterisk code can be used with
a non-asterisk code to form a dagger asterisk combination.
Briefly describe the three ways that infections are coded.
- If only the infectious agent/organism is documented and no site is specified, the infection is coded to the specified organism only, using a code from Chapter I Certain infectious and parasitic diseases.
- If only the site of the infection is documented and no infectious agent/organism is stated, code the site of the infection.
- If both the site of the infection and the agent/organism causing it are documented, a code(s) must be assigned which identifies both the site and organism.
How must ‘Syndromes’ be coded?
Syndromes must be coded as follows:
• Search the Alphabetical Index under the general term of ‘Syndrome’ or under the syndrome name, or both
• If the syndrome cannot be found in the Alphabetical Index, the coder must clarify with the responsible consultant whether the syndrome is congenital or acquired in order to determine the most appropriate code(s). Determining if it is of chromosomal
origin or not will assist in code assignment, as not all congenital anomalies are of chromosomal origin.
o Congenital
If it is of chromosomal origin assign a code from categories Q90-Q99 Chromosomal abnormalities, not elsewhere classified in Chapter XVII
If it is not of chromosomal origin assign a code from categories Q00-Q89 from Chapter XVII, depending on the body system it affects
o Acquired
Assign a code from a body system chapter, depending on the body system it
affects
- If, after the syndrome has been clinically diagnosed the patient is treated for one or more manifestations of that syndrome, the manifestation(s) being treated must be coded, with the appropriate code for the syndrome itself entered last
- If there is no indication of any presenting or treated manifestations, then only a code for the syndrome itself can be assigned. In most cases there will be presenting manifestations, but unless these are detailed in the patient’s medical record, the coder is unable to assign ICD-10 codes for them.
All of this information will enable the syndrome to be coded, at the very least, to the correct
chapter ‘catch all’ category and, ideally, to a more specific code within that chapter.
What does a ‘sequela’ code denote?
That a current condition or disease has been caused by a previously occurring disease or injury which has been treated, and is no longer present.
Describe the sequencing rules concerning sequela codes
Sequelae codes must only ever be used in a secondary position directly after the code for the current condition or disease. They must never be used on their own.
The codes for the original condition or injury that are classified by the sequelae code are listed at block, category or code level.
How are ‘acute on chronic’ conditions coded?
Where separate codes are available, codes for both the acute and chronic condition must be assigned. The acute condition must be sequenced first unless the chronic condition is the main condition treated or investigated in line with the Primary Diagnosis Definition.
