Key Learning Points Flashcards
How is ECT coded?
Each individual treatment within a course must be recorded seperately.
- 1st administration within a course = A83.8 Other specified electroconvulsove therapy in primary
- If a number of courses are administered during the same episode, each A83.8 must be assigned before assigning A83.9
- Subsequent administrations in the same course of therapy must be coded as A83.9 Unspecified electroconvulsive therapy (even if in a subsequent spell)
When is a site code required when coding procedures on cranial nerves?
When the specific cranial nerve is listed as an inclusion at the code.
Example: A32.2 Decompression of oculomotor nerve (iii)
Includes: Decompression of trochlear nerve (iv)
Decompression of abducens nerve (vi)
Why must care be taken when coding neurostimulators?
There are different categories depending on where they are positioned.
According to PChSC1, which code must be assigned in addition to show that a procedure is a MIGS (Minimally invasive glaucoma surgery) procedure?
Y76.9 Unspecified minimal access to other body cavity.
If mediastinal lymph nodes are biopsied/sampled during an EBUS-TBNA what type of code should be added?
A Chapter T code as operations on lymph nodes are classified to Chapter T and are not included at E63.- Diagnostic examination of mediastinum.
When must ventilation support (E85) be coded?
Codes within this category (E85) must always be assigned when ventilation support is performed in either an inpatient or outpatient setting.
This is an exception to PCSE4 which states codes E85-E98 must only be used in an outpatient setting or when admitted solely for the purpose of the procedure/intervention.
How must a gastroscopy be coded when described as ‘failed intubation’ ?
If the patient is unable to tolerate the scope and failed intubation is documented, the procedure must not be coded unless the point of abandonment is beyond the mouth.
When banding of haemorrhoids is carried out in conjunction with an endoscopic procedure, how should this be coded?
Both the code for the Rubber band ligation of haemorrhoids (H52.4) and the endoscopic procedure must be assigned.
If a procedure performed on a blood vessel of the liver does not have a specific code in Chapter J (Other abdominal organs - principally digestive) but one exists in Chapter L (Arteries and Veins), how should this be coded?
The Chapter L code must be assigned.
How should a failed or abandoned ERPC be coded?
Must still be coded as J43.9 Unspecified diagnostic endoscopic retrograde examination of bile duct and pancreatic duct.
This is an exception to the coding standard for failed procedures (PGCS3)
When ERCP is performed at the same time as a cholecystectomy, how should this be sequenced?
ERCP must be coded in a secondary position to the cholecystectomy.
According to PChSK1 how should percutaneous transluminal operations be coded when no specific 4th character procedure code exists to classify the procedure at a percutaneous transluminal category?
- Open procedure code
- Y79.- Aprroach to organ through artery or Y76.8 Other specified minimal access to other body cavity (if through vein)
- Y53.- Approach to organ under image control or Y68.- Other approach to organ under image control
- Z site code (if applicable)
If more than one percutaneous transuminal procedure has been performed, a code from Y79/Y76.8 must be assigned after each procedure code
Which codes must not be assigned in addition to codes from Chapter K?
Z94.- Laterality of operation
When angiocardiography (ventriculography) of the heart (K63.1-K63.3) is performed during the same radiology/theatre visit as coronary arteriography (K63.4-K63.6), what must be coded?
Both procedures must be recorded.
Why must a code from K65 Catheterisation of heart not be assigned in addition to codes in category K63 Contrast radiology of heart?
Because catheterisation is implicit within these codes.
Which type of procedures on blood vessels are excluded from Chapter L (Arteries and Veins)?
Procedures carried out on coronary blood vessels which are classified to Chapter K (Heart) instead.
When should codes L65-L72 not be used ?
When an intervention is classifiable within a named artery category from L01-L63.
When must codes from L71 Therapeutic transluminal operations on other artery (principle) and L66 Other therapeutic transluminal operations on artery (extended) be used?
Must be used to code interventions not classifiable at 4th character level within named artery categories.
What subsidiary code is also required when coding procedures classified to L71 Therapeutic transluminal operations on other artery (principle) and L66 Other therapeutic transluminal operations on artery (extended)?
A site code from Chapter Z as the categories L66 and L71 are not site specific.
If a procedure cannot be classified at a specific fourth-character within L66 and L71, what must be used?
The .8 and .9 subcategories at named artery categories.
What code range must the coder use when an artery or its branches is not specified at the category or code description or at the category inclusion?
L65-L72 with the addition of a site code from Chapter Z where available.
When an artery is listed as an inclusion term at a code in Chapter L, what must be assigned in addition?
A site code from Chapter Z.
What must be coded when angioplasty/venoplasty and insertion of stent are performed at the same time where individual codes for each are available?
Only the code for the stent/stent graft insertion is required because angioplasty/venoplasty is implicit within the stent/stent graft insertion code.
What do the codes from categories L76, L89 or O20 indicate? (used in addition to Chapter L codes for insertion or stent/stent grafts)
The type and number of stents/stent grafts.
How must the removal of bypass grafts be coded according to PChSL4: Removal of bypass grafts?
Coded to the original operation bypass category with the fourth character .8 plus code Y26.4 Removal of other repair material from organ NOC, unless there is a specific fourth character code that classifies the removal.
When is the only time code L97.6 Insertion of vascular closure device can be assigned?
When the patient returns to theatre for closure of a bleeding/leaking operative puncture wound.
*Must not be used when a vascular closure device is applied as part of a main procedure to close and seal the arteries at the end of the procedure. *
What does Appendix 1 in the National Clinical Coding Standards OPCS-4 provide?
A guidance table on coding procedures performed for pelvis organ prolapse and stress urinary incontinence to assist coders for procedures that are not easily reached using the Alphabetical Index.
When must urethral catheterisation and the subsequent removal not be coded?
Must not be coded when:
* insertion is performed routinely as part of, or following, a procedure
* insertion is performed to keep the patient comfortable during admission (e.g. elderly immobile long stay patient)
When must catheterisation of the bladder be coded?
If the patient is catheterised for urinary retention.
If the catheter is inserted routinely, but following removal the patient cannot void urine, this indicates the patient is in urinary retention. The reinsertion and subsequent removal should be coded in this instance.
How must a failed TWOC be coded/sequenced?
-
M47.3 Removal of urethral catheter from bladder
+ - M47.9 Unspecified urethral catheterisation of bladder
Which other type of code must be assigned to tape removal codes in categories M53 and M57, and why?
Approach codes from Chapter Y (even when the method is stated in the category or code description).
According to PCSP1: Refashioning of episiotomy scar, how should this be coded?
With the addition of a code from Chapter S.
- P13.8 Other specified other operations on female perineum
- S60.4 Reashioning of scar NEC
When would a code from category Q58 Delivery of terminated fetus be assigned?
When it is documented that the responsible consultant has ‘delivered’ a medically terminated fetus that is either liveborn or showing no signs of life.
When a procedure has been performed for a pregnancy with abortive outcome what subsidiary code must also be assigned?
Y95.- Gestational age
Which procedures are excluded from Chapter R Female genital tract associated with pregnancy, childbirth and puerperium?
Procedures associated with pregnancy with an abortive outcome (classified to Chapter Q instead).
In which position must a delivery code be assigned?
Must always be assigned in a primary procedural position.
How must different types of delivery be coded when coding multiple deliveries?
- Each different type of delivery must be recorded with the most serious sequenced first
- If all methods are identical, only one code is required.
What is the difference between R17 Elective caesarean delivery and R18 Other caesarean delivery?
- R17 - when the patient is not in labour
- R18 - when the patient is in labour (and for all emergency c-sections)
When can the code R24.9 All normal delivery be assigned?
Only when no other delivery codes from R17-R24 apply. (i.e. only for normal delivery when no other instrumentation used)
If one type of delivery method is used and changed to another type, how should this be coded?
Only the method used to successfully deliver the baby must be recorded.
When would the repair of an episiotomy be coded?
Only when the episiotomy has extended to a perineal tear.
Why are codes from categories Y53 Approach to organ under image control and Y68 Other approach to organ under image control not required in addition to codes R36-R43 for obstetric scans?
Because they are always carried out using ultrasound.
When must Anti-D be coded?
Every time it is given (using X30.1)
What does the note at the beginning of Chapter S (Skin) state?
That codes in Chapter S should not be used as primary codes for skin of the listed sites:
* Nipple and Areola
* Eyebrow
* Lip
* Canthus
* Eyelid
* External ear
* Perianal region
* External nose
* Scrotum
* Male perineum
* Penis (including: Prepuce)
* Vulva
* Female perineum
* Umbilicus
When can codes from Chapter S be used to enhance codes from another body system chapter?
- When it provides further information about the procedure that is not specified in the primary body system code
In which position must codes from Chapter S be used when used with body system chapter codes?
In a secondary position, directly after the body system code it is enhancing.
What are the codes and sequencing that must be followed for local skin flap procedures?
- Body system flap code (if available)
- Flap code from Chapter S (if adds further info)
- Z site code identifying site/organ being reconstructed/repaired (if not within body system code)
- Z94.- Laterality (if applicable)
What are the codes and sequencing that must be followed for other skin flap procedures (not local skin flaps)?
- Body system flap code (if available)
- Flap code from Chapter S (if adds further info)
- Z site code identifying site/organ being reconstructed/repaired (if not within body system code)
- Z94.- Laterality (if applicable)
- Chapter Y code(s) identifying type of flap harvested and site of harvest (if not within body system code)
- Z site code identifying site of harvest (if not within Y harvest code)
- Z94.- Laterality (if applicable)
If the same type of phototherapy has been administered more than once during a consultant episode, how should this be coded?
- Assign the relevant code from S12.- only once
If the different types of phototherapy have been administered during a consultant episode, how should this be coded?
A code for each different type of phototherapy should be assigned once only.
What sequencing must be followed when coding skin autografts?
- Body system code (if available or if site is excluded from Chapter S)
- Graft code from Chapter S (if adds further info)
- Z site code identifying site/organ being grafted (if not already within body system code)
- Z94.- Laterality (if applicable)
- Chapter Y code identiying type of tissue harvested and site of harvest
- Z site code identifying site of harvest (if not already within Chapter Y code)
- Z94.- Laterality (if applicable)
What sequencing must be followed when coding other types of skin graft (not autografts)?
- Body system code (if available or if site is excluded from Chapter S)
- Graft code from Chapter S (if adds further info)
- Z site code identifying site/organ being grafted (if not already within body system code)
- Z94.- Laterality (if applicable) **
Harvest codes must not be added to skin grafts that are not autografts.
When must debridement of skin be coded?
Debridement must always be coded whenever it is stated that skin debridement has been performed
When debridement and washout have been performed at the same time, how should this be coded?
Only the debridement should be coded. There is no requirement to code the washout, as it is implicit within the debridement code.
What are the sequencing rules when skin debridement and skin graft have been performed?
The skin graft must be selected as the primary code as this is the main procedure performed.
When can code T91.1 Biopsy of sentinel lymph node NEC be used?
Must only be used when the exact site of the sentinel lymph node is unknown.
What are the exceptions to PCSU1: Diagnostic imaging procedures, which states codes in the range of U01-U21 and U34-U37 are only for use in an outpatient setting or if the patient has been admitted solely for the purpose of the diagnostic imaging? i.e which imaging procedures must be coded for inpatient and outpatient episodes?
- **MRI
- CT
- U19.1 Implantation of electrocardiography loop recorder
- U19.7 Removal of electrocardiography loop recorder
- U20.1 Transthoracic echocardiography (TTE)
- U20.2 Transoesophageal echocardiography (TOE)
- U20.3 Intravascular echocardiography
- U20.4 Epicardial echocardiography**
Which codes must not be assigned in addition to body system imaging codes?
- Y97.- Radiology with contrast
- Y98.- Radiology procedures
When coding ultrasound and contrast fluoroscopy what is the element that defines which code is selected from category Y98 Radiology procedures?
The time duration and not the number of body areas defines which code is selected from category Y98.-
What are the 9 ‘body areas’ that are referred to in the codes in category Y98 Radiology procedures?
- Head
- Neck (incl. cervical spine)
- Thorax (incl. thoracic spine)
- Abdomen (incl. lumbar spine)
- Pelvic region (incl. all organs in genitourinary system, sacral spine and groin)
- Right leg
- Left leg
- Right arm
- Left arm
When can codes for nuclear medicine imaging (U01-U21 and U34-U37) be assigned? And what are the exceptions to this?
Only for use in an outpatient setting or if a patient is admitted solely for the purpose of a nuclear medicine imaging procedure.
Exceptions:
* Positron Emission Tomography (PET)
* Single photon emission computed tomography (SPECT)
* Positron emission tomography with computed tomography (PET/CT)
* Single photon emission computed tomography with computed tomography (SPECT/CT)
^must always be coded on inpatient and outpatient episodes.
When can codes U50-U54 (Rehabilitation) be used?
Only when a patient is either:
* admitted to a rehab unit solely for the purpose of rehabilitation
or
* is transferred to a rehab specialty either within the same trust or a different trust
What does ‘level of spine’ mean?
A ‘level of spine’ means either a vertebra, a disc, or a motion segment.
In what position must V55 Levels of spine be sequenced?
Directly after a code from V22-V70 to indicate the number of levels operated on.
Examples of operations on vertebrae
- Vertebral excision
- Decompression of fractured vertebrae
- Reduction and fixation of fractured vertebrae
- Biopsy of vertebrae
Examples of operations on intervertebral discs
- Disc excision
- Disc replacement
- Foraminoplasty
- Coblation to disc
- Discography
Examples of operations on motion segments
- Decompression of vertebra-disc-vertebra sections
- Interspinous process spacer insertions
- Facet joint injections
What does PChSV2: Discectomy for decompression state?
When discectomy is performed in order to decompress, only the code for the spinal decompression operation is necessary, as long as the following criteria are met:
* decompression and discectomy must have been performed on the same disc or group of vertebrae or motion segment
* the responsible consultant must have stated that discectomy was performed in order to result in decompression
When is it necessary to assign an additional code for spinal decompression performed with spinal fusion and instrumentation?
Only necessary to assign an additional code for the spinal decompression when the code description for the fusion/instrumentation procedure does not state both ‘fusion’ and ‘decompression’.
How should bone grafts with spinal fusion and instrumentation be coded?
Bone grafts with spinal fusion and instrumentation should not be coded as it is an integral part of the procedure.
If an autograft is used, a code for Harvest of bone (Y66) should be assigned to identify where the bone was harvested from.
What type of fixation must ‘K-wires’ be coded as?
Rigid fixation
When must K-wires not be coded in addition?
When used to augment anchorage of cerclage wires or in skeletal traction.
For procedures performed arthroscopically when can code W84.8 Other specified therapeutic endoscopic operation on other joint structure be assigned?
Only when:
* there is no specific 4th character endoscopic (arthroscopic) code that classifies the procedure
* There is no specific 4th character open code that classfies the procedure
* There is no .8 Other specified code in any other endoscopic or open category that describes the organ or structure on which the procedure is performed
How should procedures using multiple types of fixation be coded?
Only the main part of the device that is holding the fracture together must be coded.
When it is not clear which device is the main part holding the fracture together, advice must be sought from the responsible consultant.
What is the difference between an open and closed reduction?
Open = includes an open surgical operation for reducing and ummobilising the fracture.
Closed = consists of manual manipulation of the fracture (usually performed in an operating theatre with anaesthesia)
What are two types of fixation?
Internal and External
What are two types of internal fixation?
Intramedullary and extramedullary
What is external fixation of a bone?
Involves a fixation device outside of the bone. Includes braces, plates and fixators such as ilizarov
What is intramedullary fixation?
Where the main part of the fixation device passes longitudinally, inside the length of the medullary canal, found in long bones.
What is the criteria for assigning a code for a secondary reduction (W23 or O17)?
- Secondary reduction/remanipulation must only be coded when the patient undergoes further reduction or remanipulation on the same fracture/fracture dislocation site.
- May be the same or different from the original procedure i.e open reduction followed by open reduction or closed reduction followed by subsequent open reduction.
Secondary reductions may be performed in a different health facility to the one that the primary reduction was performed in (may have been in A&E - still needs to be coded as a remanipulation)
What is the purpose of codes in Chapter Y?
To enhance codes from body system chapters where this adds further information about the intervention/procedure that isn’t availble in the body system code.
In what position must Chapter Y codes be assigned?
Always in a secondary position, following the body system code they enhance.
When coding procedures where mesh has been inserted what should be coded in addition when the type of mesh is known?
- Y28.1 Insertion of synthetic mesh into organ NOC
- Y28.2 Insertion of biological mesh into organ NOC
-
Y28.3 Insertion of composite mesh into organ NOC
should be coded in addition to show the type of mesh used.
When coding procedures where mesh has been inserted but the type of mesh is not known, how should this be coded?
With the addition of
Y28.4 Insertion of mesh into organ NOC
When coding procedures where mesh has been inserted, when should codes from category Y28.- not be assigned in addition?
- When coding procedures where the code description contains ‘mesh’ or ‘tape’ Y28.1, Y28.2, Y28.3 should not be added unless the type of mesh is known and it adds further info to the body system code. Y28.4 Insertion of mesh into organ NOC must not be assigned in these instances as it adds no further info.
- When a sling is inserted and the code description contains ‘sling’ Y28.1, Y28.2, Y28.3 should not be added unless the sling is made of mesh and the type of mesh is known. Y28.4 Insertion of mesh into organ NOC must not be assigned where the sling is made of mesh but the type of mesh is not known in these instances.
When should approach to organ codes (Y45-Y52 and Y74-Y77) be assigned?
When the method of approach is not incorporated within the body system code description.
In which position must codes from approach to organ categories Y45-Y52 and Y74-Y77 be sequenced?
Directly after the body system code to identify the method of approach.
Site and laterality should be assigned after the approach codes.
Where a number of procedures have taken place using different methods of approach, how are the codes from Y45–Y52 and Y74-Y77 applied?
The approach codes must be assigned after each body system code.
In what circumstances should a code from Y53 Approach to organ under image control NOT be assigned?
- If image control is used before, during or after a procedure as a method of checking the anatomical position, or the position of a prosthesis/fixator after insertion, or to confirm a procedure is complete
- If the code for the procedure states the type of image control used
- If the type of image control used is implicit in the procedure i.e. the procedure is always carried out using a specific form of image control (maternity scans)
When should approach to organ under image control codes be used? (Y53, Y68 and Y78)
When a procedure is performed with image control and the code that classifies the procedure does not state the type of image control used.
Where a code from categories Y95 and Y53 or Y68 are both required, what sequencing must be applied?
Y53 or Y68 before Y95
In what position must codes from Y95.- Gestational age be assigned?
In a subsidiary position to the code describing the procedure related to the pregnancy.
When should codes from Chapter Z be used?
Must be used to enhance codes from Chapters A-X where this adds further info about the site and laterality of intervention.
In what position should codes from Chapter Z be sequenced?
Must only be used in a secondary position following a code from Chapter A-X.
When must Chapter Z site codes be used?
Must always be assigned when this adds further info about the site the procedure was performed on.
Is not required when it does not provide any additional info (e.g. when the site is already specified in the code description)
When must a Chapter Z laterality code be assigned?
Whenever laterality is documented and is not already implicit in the code description.
What is the exception to PCSZ2: Laterality of operation ?
Chapter K (Heart) - Z94 Laterality codes must not be assigned in addition to procedures from Chapter K.
What is meant by a minor amputation?
Any amputation of finger, hand, toe or foot.
What is meant by a major amputation?
Amputations that involve the arm or leg.
When should code X12.1 Reamputation at higher level be assigned?
- Only when a further amputation is performed on the same arm or leg as the original amputation i.e a further major amputation, (regardless of the bone of arm or leg that was orginally amputated.)
If an amputation of arm/leg is performed after a previous amputation of fingers/hands/toes/foot, this must be coded as a new amputation.
When should IV infusions and IV injections be coded?
Only when the patient is admitted solely for administration of the IV infusion/injection.
When should blood transfusions be coded? (X33)
Only if the patient is admitted solely for the purpose of a blood transfusion.
Must not be coded when given during surgery.
What is the exception to PCSX4: Blood transfusions?
- Intraoperative blood salvage and transfusion (X33.7 & Z36.4)
- Bone marrow transplantation and peripheral blood stem cell transplantation (X33.4-X33.6)
When intraoperative blood salvage and reinfusion have been performed during a procedure, how should this be coded?
- Code for the salvage (X36.4)
- Code for the transfusion (X33.7)
^must be assigned following the code(s) classifying the procedure.
When intraoperative blood salvage has been performed and not reinfused during the procedure, how should this be coded?
- Code for the salvage only (X36.4)
^following the procedure code
When salvaged blood has been reinfused after a procedure, how should this be coded?
- Code for the transfusion only (X33.7)
When can codes X35.1 Intravenous induction of labour be used?
NEVER
Codes in Chapter R must be used to code induction of labour.
When must a code from category X40 Compensation for renal failure be assigned?
- Every time an intervention classified to this category is performed.
- Any procedure performed in order to carry out a procedure from X40 (e.g insertion of dialysis catheter) must also be coded, with X40 sequenced after these procedures.
When should codes from X44 Administration of a vaccine be assigned?
Only if the patient is admitted solely for the purpose of vaccination.
When can donation of organs be coded? (X45)
Only if the patient donating is alive.
Not coded for donation of organs from ‘brain dead’ or ‘deceased’ patients.
What must the coder remeber about the assignment of radiotherapy preparation codes?
Preparation codes must:
- be used for inpatient and outpatient activity
- only be assigned once, per prescription, to cover all planning for each prescription
- be assigned on the first attendance/episode for delivery of radiotherapy
- be sequenced before the delivery codes
What is the exception to only assigning radiotherapy preparation codes once?
- When the original prescription needs adjusting so is therefore stopped and a new prescription is created.
How must radiotherapy preparation be coded?
-
X67.- Preparation for external beam radiotherapy or X68.- Preparation for brachytherapy
+ - Y92.- Support for preparation for radiotherapy (if used)
What does Y92.1 Technical support for preparation for radiotherapy typically include the manufacture of?
Immobilisation devices such as:
* Impression and shell fitting
* Lead cut-outs
* Mouth bites
* Beam shaping devices
How should radiotherapy be coded depending on the setting (i.e outpatient or inpatient)?
- Outpatient/day case - coded every time a fraction is given
- Inpatient - only coded once per hospital provider spell, regardless of number of fractions
When coding radiotherapy and there is a body system code available, how should this be coded?
The body system code should be assigned as the primary code - followed by the same sequence of codes for any other radiotherapy delivery
Which chapters contain body system radiotherapy codes?
- A (Nervous system)
- B (Endocrine system and Breast)
- C (Eye)
- J (Other abdominal organs)
- M (Urinary)
- P (Lower Female Genital Tract)
- Q (Upper Female Genital Tract)
- T ( Soft Tissue)
Which conditions must codes in categories X72-X73 be assigned for the treatment of? (Delivery of chemotherapy)
Must only be assigned for systemic anti-cancer therapy for the treatment of malignant or in-situ neoplasms.
If a drug that appears on the chemotherapy regimens list is used for the treatment of non-neoplastic/non-malignant diseases, how should this be coded?
X72-X73 should not be used.
Code to the method of andministration.
Codes from elsewhere from OPCS should be assigned where appropriate e.g infusion/injection codes.
What must a coder consider when assigning chemotherapy codes to the first day or subsequent day of a cycle?
Chemotherapy is coded differently depending on whether it is the first day or subsequent day of a cycle, regardless of attendance type.
How should delivery of chemotherapy be coded?
- For first day or attendance of any cycle = X72 or X73
- For subsequent days or attendances for the same cycle = X72.4
- Where a combination of regimens have been prescribed, a delivery code for each regimen must be assigned, even if this means assigning the same delivery code more than once.
If a chemotherapy regimen labelled as an adult regimen is prescribed for a paediatric patient, how should this be coded?
The code for the adult regimen must be assigned.
If a chemotherapy regimen labelled as an paediatric regimen is prescribed for an adult patient, how should this be coded?
The code for the paediatric regimen must be assigned.
Where an adult clinical trial consists of a listed regimen with added trial drug(s), how should this be coded?
Only the existing regimen is coded, the additional trial component(s) must not be coded.
Should paediatric clinical trial drugs be coded using X72-X73?
Yes - paediatric regimens are an exception as they do include cancer research trials and additionally specify the component drugs in the regimen.
What is meant by a regimen?
A regimen describes in full the name, drugs, doses, route and time of delivery of a specified ‘systemic anti-cancer therapy’ (SACT)
What must be assigned when chemotherapy is administered intrathecally, intravesically or intracavitarily?
A body system chapter code that classifies the route of administration must be sequenced before the relevant chemotherapy delivery code.
What is ‘Intravesical administration’?
Into the bladder
What is ‘Intrathecal administration’?
Into the cerebrospinal fluid (CSF)
What is ‘Intracavitary administration’?
Into a body cavity
What must be coded when a regimen includes both oral and parenteral administration?
The parenteral administration will determine the delivery code.
When can X73.1 Delivery of exclusively oral chemotherapy for neoplasm be assigned?
Must only be assigned when all of the drugs in a regimen are delivered orally.
Exception: if one or more of the components is delivered intrathecally. In this case, X73.1 must still be assigned, along with the body system code for method of delivery and the delivery code for the intrathecal component.
What must be coded when coding chemo-radiotherapy?
Both the radiotherapy and chemotherapy.
What sequencing must be followed when coding chemo-radiation?
There are no sequencing rules.
Which high-cost drugs are the exception that must always be coded on discharges?
- X83.3 Fibrinolytic drugs Band 1 - when Alteplase is given for treatment if acute stroke
- X90.4 Intravenous nutrition Band 1 - must be assigned once on every episode where a patient received parenteral nutrition (regardless of the number of days this is given)
- X89.2 Monoclonal antibodies Band 2 - when neutralising monoclonal antibodies are administered for the treatment of COVID-19.
If Alteplase has been administered for a condition that is not an acute stroke, how must this be coded?
According to the method of administration (i.e. infusion/injection)
What does PCSX30 instruct the coder about the number of times other chemotherapy drugs classified to category X74 must be coded?
That they must only be coded once per Hospital Provider Spell, usually on the first consultant episode in which the drug was administered.
