OPCS - Coding standards

Question 1

PCSA3: Neurostimulators (A09, A33, A48 and A70)

Answer 1

When a neurostimulator is permanently implanted under the skin:
• Code classifying the implantation of neurostimulator
• Chapter Z site code, where this adds more information
• Z94.- (if applicable)
When electrode leads are implanted temporarily to test effectiveness, and the generator is not implanted:
• Code classifying the implantation of electrodes
• Y70.5 temporary operations
• Chapter Z site code, where this adds more information
• Z94.- (if applicable)

Question 2

What do you need to remember when coding ECT?

Answer 2

• For the first administration within a course of therapy assign code A83.8
Other specified electroconvulsive therapy in the primary position
• Where a number of courses have been administered during the same consultant episode, all instances of A83.8 must be assigned before assigning A83.9
• For subsequent administrations in the same course of therapy (whether in the same consultant episode within a hospital provider spell or a subsequent hospital provider spell) code A83.9 Unspecified electroconvulsive therapy must be assigned.

Question 3

PCSD3: Combined approach tympanoplasty (D14.4)

Answer 3

A code for the graft material used must not be assigned in addition to code D14.4
Combined approach tympanoplasty as the graft is implicit within the code.

Question 4

PCSE1: Laryngopharyngectomy (E19 and E29)

Answer 4

When coding laryngopharyngectomy the following codes and sequencing must be used:

E19.- Pharyngectomy
E29.- Excision of larynx

The fourth character codes assigned will be dependent upon whether the excisions are
total, partial or unspecified.

Question 5

PCSE4: Non operations on lower respiratory tract (E85–E98) and ventilation support (E85)

Answer 5

Codes in categories E85–E98 must only be used for outpatient coding, or if the patient is admitted solely for the purpose of a procedure/intervention.

The exception to this standard is category E85 Ventilation support. Codes within this category must always be assigned when ventilation support is performed in either an inpatient or outpatient setting.

Question 6

PCSE5: Invasive ventilation with tracheostomy (E85.1)

Answer 6

When a tracheostomy is performed for invasive ventilation the following codes and sequencing must be applied:
E85.1 Invasive ventilation
E42.3 Temporary tracheostomy

Question 7

How must a gastroscopy be coded when described as ‘failed intubation’, i.e. when the scope only enters the mouth and the patient is unable to tolerate?

Answer 7

When a patient is admitted for a gastrointestinal tract endoscopy and the patient is unable to tolerate the scope and statements such as ‘failed intubation’ is documented in the medical record; the procedure must not be coded.

Question 8

G20.1 and G46.2 classify endoscopic coagulation of bleeding lesion of either oesophagus or upper gastrointestinal tract; when would these codes be assigned?

Answer 8

Answer = When coagulation of bleeding lesion(s) is performed using haemostatic spray as a therapeutic procedure. These codes must not be used to classify coagulation as a means of haemostasis at the end of a procedure.

Question 9

What does new standard PCSG6: Endoscopic insertion of nasogastric or nasojejunal feeding tube (G47.5 and G67.5) tell us?

Answer 9

Answer= The endoscopic insertion of an NG or NJ tube must be coded using the appropriate code with the addition of code Y76.3 Endoscopic approach to
other body cavity.

Question 10

What must be coded when banding of haemorrhoids is carried out in conjunction with an endoscopic procedure?

Answer 10

When banding of haemorrhoids is carried out in conjunction with an endoscopic procedure,
both H52.4 Rubber band ligation of haemorrhoid and the OPCS-4 endoscopic procedure code must be assigned.

Question 11

What must a coder be mindful of when coding a colonoscopy that does not progress beyond the sigmoid colon?

Answer 11

The exclusion at categories H20-H22 indicates that when a colonoscopy does not progress past the sigmoid colon a code from H23-H25 must be assigned.

Question 12

How must a failed or abandoned ERCP be coded?

Answer 12

Answer = A failed or abandoned ERCP, (i.e. an ERCP with incomplete insertion of the endoscope, or complete insertion of the endoscope but the ampulla cannot be cannulated) must be coded to J43.9 Unspecified diagnostic endoscopic retrograde examination of bile duct and
pancreatic duct.

Question 13

What is the sequencing of cholecystectomy and ERCP when performed together?

Answer 13

Answer = When endoscopic retrograde cholangiopancreatography (ERCP) is performed at the same time as cholecystectomy, the ERCP
must be coded in a secondary position.

Question 14

What sequencing must be followed when a coronary artery procedure involves the insertion of a combination of stents?

Answer 14

When a combination of drug eluting and metal or plastic stents have been inserted during a coronary artery procedure the following codes and sequencing must be used:
• body system chapter code describing the insertion of the drug eluting stent
• a code from category Y14 Placement of stent in organ NOC to classify the
insertion of the other types of coronary stent(s)
• a code from category Y53. Approach to organ under image control or Y68.
Other approach to organ under image control to classify the method of image control used.

Question 15

What is coded when an angiocardiography of the heart is carried out during the same radiology/theatre visit as a coronary arteriography?

Answer 15

When an angiocardiography of the heart (codes K63.1 K63.3) is performed with a coronary arteriography (codes K63.4 K63.6) during the same
radiology/theatre visit, both procedures must be recorded.

A code from category Y53. Approach to organ under image control or Y68. Other approach to organ
under image control must also be assigned in a secondary position in order to classify the method of image control used.

Question 16

Why must a code from category K65 Catheterisation of heart not be assigned in addition to codes in category K63 Contrast radiology of heart?

Answer 16

Because catheterisation is implicit within these codes.

Question 17

When must the codes within principal category L71 Therapeutic transluminal operations on other artery and extended category L66 Other therapeutic transluminal operations on artery be used?

Answer 17

They must be used to code interventions that are not classifiable at fourth character level within named artery categories (L01 L63).

Question 18

What subsidiary code is also required when coding procedures classified to these two categories and why?

Answer 18

A site code from Chapter Z must also be assigned as the categories L66 and L71 are not site specific.

Question 19

If a procedure cannot be classified at a specific fourth character within L66 and L71, what must be used?

Answer 19

The .8 and .9 subcategories at named artery categories, e.g. L63.8, L63.9 etc. must be used instead.

Question 20

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?

Answer 20

Answer = Where the artery is not specifically referred to within the code description or inclusion, a code from categories L65 L72 must be used instead with the addition of a site code from Chapter Z where available.

Question 21

If the artery or its branch are listed as an inclusion what subsidiary code must the coder ensure is also assigned?

Answer 21

A site code from Chapter Z

Question 22

What must be coded when an angioplasty/

venoplasty and insertion of stent are performed at the same time?

Answer 22

When angioplasty/ venoplasty and insertion of stent or stent graft are performed at the same time and individual codes are available for the angioplasty/ venoplasty and for the stent/stent graft insertion, only the code for the stent/stent graft insertion is required, because the angioplasty/ venoplasty is implicit within the stent/stent graft insertion code.

Question 23

PChSL4: Removal of bypass grafts

Answer 23

The removal of bypass grafts must be 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 removal of the bypass graft.

Question 24

PCSL1: Anastomosis without a site specific code (L16-L28 and L48-L63)

Answer 24

Anastomotic sites that are not specifically indicated at the fourth-character level within categories L16-L28 and L48-L63 must be assigned to the .8 within the relevant category.

Question 25

What do coders need to bear in mind when coding aortic aneurysm repairs?

Answer 25

Whether the repair was carried out as an emergency or as an elective procedure.

Question 26

How is a change of ureteric stent coded in OPCS 4.9?

Answer 26

Answer = A ureteric stent is coded according to method used to change the stent e.g. cystoscopically.

Question 27

PCSM1: Percutaneous drainage of kidney (M13.2)

Answer 27

Code M13.2 Percutaneous drainage of kidney includes the insertion of a nephrostomy tube for drainage. The insertion of the nephrostomy tube must not be coded in addition.

Question 28

When extracorporeal shockwave lithotripsy of calculus of ureter is performed via cystoscopy and a stent is inserted, what must be coded, and why?

Answer 28

Only the code M31.1 Extracorporeal shockwave lithotripsy of calculus of ureter is required as the cystoscopy and the insertion of a stent are integral parts of the procedure. A code from Y53 Approach to organ under image control or Y68 Other approach to organ under image control must be assigned in addition. If the stent is left in situ following the lithotripsy in order to facilitate the passage of fragments of the calculus, then the stent insertion would require coding in addition.

Question 29

PCSM6: Catheterisation of the bladder (M47)

Answer 29

``` Urethral catheterisation (M47.9 Unspecified urethral catheterisation of bladder) must not be coded when; • catheter insertion is performed routinely as part of, or following, a procedure • catheter insertion is performed to keep the patient comfortable during admission, for example in an elderly immobile long stay patient. ``` Neither must subsequent removal of the catheter be coded in these instances. If a patient is catheterised for urinary retention the insertion of the urethral catheter and its subsequent removal would not be considered a routine part of care and both the insertion and removal of the catheter must be coded. If a urethral catheter is inserted routinely, but following removal the patient is unable to void urine, this indicates that the patient is in urinary retention. The reinsertion of the urethral catheter, and its subsequent removal following reinsertion, would not be considered a routine part of care and both the reinsertion and subsequent removal of the catheter must be coded.

Question 30

How must a failed TWOC be sequenced?

Answer 30

When a patient is admitted for removal of an indwelling urinary catheter or trial without catheter (TWOC), and on removal the patient is unable to void resulting in the catheter being reinserted, this must be coded using the following codes and sequencing: M47.3 Removal of urethral catheter from bladder M47.9 Unspecified urethral catheterisation of bladder

Question 31

PCSP1: Refashioning of episiotomy scar (P13.8 and S60.4)

Answer 31

Refashioning of an episiotomy scar is coded using the following codes and sequencing: P13.8 Other specified other operations on female perineum S60.4 Refashioning of scar NEC

Question 32

PCSP3: Episiotomy to facilitate delivery of terminated fetus and subsequent repair (P14.9, P13.2, P25.5)

Answer 32

Where an episiotomy (P14.9) is carried out to facilitate delivery of a terminated fetus, this must be sequenced in a secondary position to the delivery code (Q58 Delivery of terminated fetus). The subsequent repair of an episiotomy is included within code P14.9 Unspecified incision of introitus of vagina and therefore must not be coded in addition. The exception is where the episiotomy has extended to a perineal or vaginal tear. In these cases, P13.2 Female perineorrhaphy or P25.5 Suture of vagina must be assigned in addition, to classify the repair of the tear.

Question 33

When a procedure has been performed for a pregnancy with abortive outcome what subsidiary code must also be assigned?

Answer 33

Y95 Gestational age.

Question 34

How must an intrauterine coil procedure and hysteroscopy be coded when performed during the same theatre visit?

Answer 34

Where an intrauterine coil procedure (insertion, replacement or removal) is performed during the same theatre visit as a diagnostic or therapeutic hysteroscopy, the hysteroscopy code must be sequenced before the intrauterine coil code.

Question 35

When would a code from category Q58 be assigned?

Answer 35

When it is documented in the medical records that the responsible consultant has delivered a medically terminated fetus that is either liveborn or showing no signs of life.

Question 36

PChSR1: Coding deliveries (R17-R25)

Answer 36

All deliveries (except for deliveries following a termination of a pregnancy), regardless of the number of weeks must be coded as follows: * A code from categories R17-R25 must be assigned in the primary position. * Code R24.9 must only be used for a normal vertex delivery, when no other code in categories R17-R25 describing the delivery applies. * If on type of delivery method is used and subsequently changed to another type, only the method used to successfully deliver the baby must be recorded. When coding caesarean sections: * Assign a code from R17 for caesarean sections performed when the patient is not in labour. * Assign a code from R18 for a caesarean section performed when the patient is in labour (and for all emergency caesarean sections) When coding multiple deliveries * Each different type of delivery must be coded with the most serious sequenced first * Where all delivery methods are identical only one code is required.

Question 37

PCSR5: Episiotomy to facilitate delivery and subsequent repair (R27.1, R32)

Answer 37

Where an episiotomy (R27.1) is carried out to facilitate delivery, this must be sequenced ina secondary position to the delivery code. The subsequent repair of an episiotomy is included within code R27.1 Episiotomy to facilitate delivery and therefore it must not be coded in addition. The exception is where the episiotomy has extended to a perineal tear. In these cases, a code from category R32 Repair of obstetric laceration must be assigned in addition, to classify the repair of the perineal tear.

Question 38

PCSR6: Gentle cord traction for removal of retained placenta

Answer 38

Gentle cord traction performed to remove a retained placenta forms part of the management of ‘normal’ delivery and cannot be classified using OPCS-4 codes.

Question 39

Looking at the standard PCSR7 how are obstetric scans classified to categories R36 R43 carried out?

Answer 39

Codes within categories R36–R43 must be used for day cases and inpatients when the patient has been admitted solely for the purpose of a procedure/intervention. When two or more obstetric scans classified within categories R37.- Non-routine obstetric scan for fetal observations and R38.- Other non-routine obstetric scan are performed during one scanning session, the following codes must be assigned: R37.2 Detailed structural scan Y95.- Gestational age Procedures classified to categories R36-R43 are always carried out using ultrasound therefore a code from category Y53 Approach to organ under image control or Y68 Other approach to organ under image control is not required to identify the method of image control.

Question 40

What does the note at the beginning of Chapter S indicate?

Answer 40

``` The Note at Chapter S states that these codes must not be used as primary codes for skin of: • The nipple • Eyebrow • Lip • Scrotum • Male perineum • Female perineum • Canthus • Eyelid • External ear • External nose • Perianal region • Penis • Vulva • Umbilicus • Abdominal wall ``` This is because they are uniquely named and are usually associated with another organ, such as the lip which is associated with the mouth, and form specific categories within other chapters. Or form a major part of the organ concerned for example the external ear is part of the ear, and as such is identified at a site inclusion term.

Question 41

PChSS1: Enhancing body system codes using codes from Chapter S

Answer 41

When using a code from Chapter S to enhance a code from another body system chapter the code from Chapter S must be assigned: * When it provides further information about the procedure that is not specified in the primary body system code. * In a secondary position, directly after the body system code it is enhancing.

Question 42

PCSS3: Coding skin grafts and harvests

Answer 42

Skin autograft (graft using material from the patient) * When a specific body system graft code is available or when the site of the graft is to the skin of the sites listed at the beginning of chapter S; assign the appropriate body system code. * Graft code from chapter S skin (if doing so adds further information) * Chapter Z site code identifying the specific site/organ being grafted (if this has not already been identified in the body system code) * Z94.- laterality of operation (if applicable) * Chapter Y code identifying the type of tissue harvested and the site of harvest. * Chapter Z site code identifying the site of the harvest (if this is not already identified in the harvest code) * Z94.- (if applicable) Other types of skin graft (skin grafts using material not harvested from patient, e.g. allograft and xenograft) * When a specific body system graft code is available or when the site of the graft is listed at the beginning of chapter S; assign the appropriate body system graft code. * Graft code from Chapter S and/or a code from Y27.- Graft to organ NOC (if doing so adds further information. * Chapter Z site code identifying the site of the graft (if this has not been identified by the body system code) * Z94.- laterality of operation (if applicable)

Question 43

Why are dermal substitutes used in combination with skin graft procedures, and where used, how are these coded?

Answer 43

They’re used in combination with skin grafts for deep defects and they must be coded in addition to the skin graft (and harvest) codes. They’re classified using code S53.7 Application of dermal substitute to skin as confirmed in the guidance associated

Question 44

When must debridement of skin be coded?

Answer 44

Answer = whenever it is stated within the patient’s medical record that skin debridement has been performed. When other procedures have taken place then the debridement must be coded in addition to these other procedures (the sequencing will depend on the main procedure performed). Where skin graft and skin debridement have been performed, the skin graft must be selected as the primary code as this is the main procedure performed.

Question 45

Looking at the code range T20 T27 what must the coder check before assigning a code?

Answer 45

Whether the hernia is primary or recurrent.

Question 46

When must the code T91.1 Biopsy of sentinel lymph node NEC be used?

Answer 46

It must only be used when the exact site of the sentinel lymph node is unknown.

Question 47

How is a sentinel node excision, biopsy or drainage reflected if T91.1 is not used?

Answer 47

Answer = By adding the site code O14.2 Sentinel lymph node to the lymph node procedure code from T86 T88.

Question 48

The majority of codes in the range U01 U21 are only for use in an outpatient setting; what imaging procedures are the exclusions to this in that they must always be coded?

Answer 48

* MRI magnetic resonance imaging * CT Computer tomography * Implantation of electrocardiography loop recorder * Removal of electrocardiography loop recorder * Transthoracic echocardiography * Transoesophageal echocardiography * Intravascular echocardiography * Epicardial echocardiography

Question 49

What fourth character codes from Y97 Radiology must not be used?

Answer 49

* Y97.2 Radiology with pre contrast as this classifies image(s) taken before contrast is given. * Y97.8 Other specified radiology with contrast and Y97.9 Unspecified radiology with contrast as the type of contrast would be coded using Y97.1 or Y97.3.

Question 50

When coding ultrasound and contrast fluoroscopy what is the element that defines which code is selected from category Y98 Radiology procedures?

Answer 50

It is the time duration and not the number of body areas that defines which code from category Y98 must be assigned. In the case of magnetic resonance imaging, computed tomography and plain x ray, it is the number of body areas scanned that defines which code must be assigned, irrespective of the time duration taken to perform these scans.

Question 51

What are the 9 ‘body areas’ that are referred to in the codes in category Y98 Radiology procedures?

Answer 51

* Head * Neck (including cervical spine) * Thorax (including thoracic spine) * Abdomen (including lumbar spine) * Pelvic region (including all organs in genitourinary system, sacral spine and groin) * Right leg * Left leg * Right arm * Left arm

Question 52

What is the default code that must be used when the area or duration of scan is not specified?

Answer 52

Y98.1 Radiology of one body area (or < 20 minutes)

Question 53

U01 U21 and U34 U37 include nuclear medicine imaging codes that are only for use in an outpatient setting, what are the exceptions?

Answer 53

* PET – positron emission tomography * PET/CT – positron emission tomography with computer tomography * SPECT – single proton emission computed tomography * SPECT/CT – single proton emission computed tomography with computed tomography

Question 54

Which subsidiary codes must be assigned | if radiopharmaceutical imaging substances are used during a nuclear medicine imaging procedure?

Answer 54

Y93 Gallium 67 imaging or Y94 Radiopharmaceutical imaging. Codes from categories Y97 Radiology with contrast or Y98 Radiology procedures must not be assigned in addition to nuclear medicine codes. .

Question 55

What does a level of spine mean?

Answer 55

A ‘level of spine’ means either a vertebra, a disc, or a motion segment.

Question 56

Name an example of a procedure carried out on vertebrae.

Answer 56

* Vertebral excision * Decompression of fractured vertebrae * Reduction and fixation of fractured vertebrae * Biopsy of vertebrae.

Question 57

Name an example of a procedure carried out on intervertebral discs.

Answer 57

* Disc excision * Disc replacement * Foraminoplasty * Coblation to disc * Discography.

Question 58

Name an example of a procedure carried out on motion segments.

Answer 58

* Decompression of vertebra disc vertebra sections * Interspinous process spacer insertions * Facet joint injections.

Question 59

In what position is V55 Levels of spine sequenced?

Answer 59

A code from category V55 Levels of spine must be assigned directly after a code from V22-V70 to indicate the number of levels operated on.

Question 60

What 4th character is assigned when the level of spine is not specified?

Answer 60

V55.9 Unspecified levels of spine.

Question 61

What criteria must be considered when coding discectomy for decompression?

Answer 61

When discectomy is performed in order to decompress, only the code that classifies the spinal decompression operation is necessary, as long as the following criteria are met: • The decompression and discectomy must have been performed on the same disc or group of vertebrae or motion segment and • The responsible consultant must have stated that discectomy was performed in order to result in decompression.

Question 62

When a spinal decompression has been performed with spinal fusion and instrumentation what codes must be assigned?

Answer 62

It is only necessary to assign an additional code for the spinal decompression if the code description (for the fusion/instrumentation procedure) does not state both ‘fusion’ and ‘decompression’.

Question 63

What must the coder remember about bone grafts performed at the same time as spinal fusion and instrumentation?

Answer 63

A bone graft (synthetic or allograft) is an integral part of the spinal fusion and instrumentation procedure. Therefore it is not necessary to assign an additional OPCS 4 code for the bone graft when it is performed together with spinal fusion and instrumentation. However, in instances where an autograft has been used during the fusion and instrumentation procedure, it is necessary to assign an additional OPCS 4 code from category Y66 Harvest of bone to identify the location where the bone was harvested from. bone to identify the location where the bone was harvested from.

Question 64

PChSW1: K-wire fixation

Answer 64

K-wire fixation must always be coded as rigid fixation. When K-wires are used to augment anchorage of cerclage wires or in skeletal traction, the use of K-wires must not be coded in addition.

Question 65

In what circumstances is it acceptable to assign the code W84.8 Other specified therapeutic endoscopic operations on other joint structure?

Answer 65

For procedures performed arthroscopically, code W84.8 Other specified therapeutic endoscopic operations on other joint structure must only be assigned when: • There is no specific 4th character endoscopic (arthroscopic) code that classifies the procedure * There is no specific 4th character open code that classifies 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

Question 66

What is the difference between an open and closed reduction?

Answer 66

• Open reduction includes an open surgical operation for reducing and immobilising the fracture. Complete fracture immobilisation is commonly carried out by combining reduction procedures with various methods of fixation. • Closed reduction consists of manual manipulation of the fracture and is usually performed in an operating theatre with the use of anaesthesia.

Question 67

What are the two type of fixations?

Answer 67

* Internal fixation includes inserting screws, plates, pins, wires and nails into the bone to hold the fracture in place. Intramedullary and extramedullary fixation are both forms of internal fixation. * External fixation involves a fixation device outside of the bone. It includes braces, plates, and fixators such as Ilizarov

Question 68

What is the criteria for assigning a code for a secondary reduction (W23 or O17)?

Answer 68

Secondary reduction and remanipulation of fracture / fracture dislocation codes must only be assigned when the patient undergoes further reduction or remanipulation on the same fracture / fracture dislocation site. The secondary reduction/ remanipulation procedure may be the same or differ from the original procedure. These may be: • The same, for example - primary open reduction followed by further open reduction or • Different, for example - primary closed reduction followed by subsequent open reduction, or reduction without fixation followed by secondary reduction with fixation.

Question 69

PCSX26: Reamputation (X12.1)

Answer 69

* X12.1 reamputation at a higher level must only be assigned when a further amputation has been performed on the same arm or leg as the original amputation. i.e. where there has been a previous amputation above the level of hand or foot. This is regardless of the bone of the arm or leg that was originally amputated. * Where amputation involving the arm or leg is performed after a previous amputation of the hand, fingers, foot or toes, this must be coded as a new amputation of the arm or leg. * A further amputation of the hand or foot must be coded using a code from category X08,X10,X11 Amputations are clinically categorised as either minor or major. A minor amputation is any amputation of the finger, hand, toe, or foot. Major amputations are those which involve the arm or leg. X12.1 Reamputation at higher level describes a further major amputation, it does not include: * a major amputation following a minor amputation * a subsequent minor amputation

Question 70

PCSX9: Compensation for renal failure (X40)

Answer 70

``` A code from category X40 Compensation for renal failure must be assigned every time an intervention classified to this category is performed. Any procedure(s) performed in order to carry out a procedure classifiable to category X40, such as insertion of dialysis catheters, central venous catheters, arteriovenous shunts, etc. must also be coded, with the code from X40 being sequenced after these other procedures. ```

Question 71

PCSX11: Donation of organ (X45)

Answer 71

The donation of organs must only to be coded, using a code from category X45 Donation of organ, if the patient donating the organs is alive . The removal of organs for donation from ‘brain dead’ or ’deceased’ patients must not be coded.

Question 72

PCSX15: Evaluation of cardioverter defibrillator (X50.5)

Answer 72

Code X50.5 Evaluation of cardioverter defibrillator must not be assigned when evaluation/testing is performed during the insertion of the cardioverter defibrillator.

Question 73

PCSX17: Anaesthetic without surgery (X59)

Answer 73

Codes in category X59 Anaesthetic without surgery must only be used to classify patients who receive a general or spinal anaesthetic, but subsequently do not undergo any procedure or intervention.

Question 74

What must a coder remember about the assignment of radiotherapy preparation codes?

Answer 74

Preparation codes must: • Be used for both 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.

Question 75

How must radiotherapy preparation be coded?

Answer 75

X67. Preparation for external beam radiotherapy or X68 Preparation for brachytherapy and Y92. Support for preparation for radiotherapy (if used).

Question 76

When must X65.9 Unspecified radiotherapy delivery be assigned?

Answer 76

It must only be used when the method of radiotherapy delivery is not classifiable to any of the other fourth characters within the category.

Question 77

What code must not be used with X65.9 Unspecified radiotherapy delivery?

Answer 77

Y91 External beam radiotherapy or its extended category Other external beam radiotherapy.

Question 78

Explain how radiotherapy is coded depending on setting.

Answer 78

* For outpatients and day cases, radiotherapy delivery must be coded every time a fraction is given * For inpatients, radiotherapy delivery must only be coded once per hospital provider spell, regardless of the number of fractions.

Question 79

What must a coder consider when assigning chemotherapy codes in different settings, i.e. inpatient, day case and outpatient?

Answer 79

First day or attendance of any cycle of a chemotherapy regimen (including when a cycle of the same regimen is repeated) Inpatient: • The procurement code (X70, X71). Only the first day of a new cycle is coded when chemotherapy is delivered as an inpatient. Outpatient and daycases • The procurement code (X70, X71) and • The corresponding delivery code (X72, X73) Subsequent days or attendances for the same cycle (including subsequent attendances for a repeated cycle) Inpatient: • no OPCS 4 codes are assigned. Subsequent delivery of the same cycle is not coded when given as an inpatient. Outpatient and daycases : • The delivery code X72.4 Delivery of subsequent element of cycle of chemotherapy for neoplasm.

Question 80

What must be assigned when chemotherapy is administered intrathecally (into the cerebrospinal fluid in the spinal cord), intravesically (into the bladder) or intracavitarily (into a body Answer = A body system chapter code that

Answer 80

A body system chapter code that classifies the route of administration must be sequenced before the relevant procurement / delivery codes in categories X70 X72 Intravesical administration of chemotherapy: M49.4 Introduction of therapeutic substance into bladder X70-X72 Procurement / delivery codes for the chemotherapy regimen administered Intrathecal administration of chemotherapy: A54.2 Injection of therapeutic substance into cerebrospinal fluid X70-X72 Procurement / delivery codes for the chemotherapy regimen administered Intracavitary administration of chemotherapy: Body system chapter code classifying introduction/injection of therapeutic or cytotoxic substance into a body cavity X70-X72 Procurement / delivery codes for the chemotherapy regimen administered

Question 81

What is meant by parenteral administration?

Answer 81

Via a route other than the mouth or rectum, i.e. via infusion, injection or implantation.

Question 82

What must be coded when a regimen includes both oral and parenteral administration?

Answer 82

The parenteral administration will determine the | delivery code.

Question 83

What codes must be assigned for electrochemotherapy ?

Answer 83

X70-X72 Procurement / delivery codes for the chemotherapy regimen administered Body system chapter code Y12.3 Electrochemotherapy to lesion of organ NOC Chapter Z site code(s) Z94.- Laterality of organ

Question 84

How must chemotherapy drugs used for the treatment of non neoplastic/non malignant conditions be coded?

Answer 84

These must be coded elsewhere e.g. X35.2 Intravenous chemotherapy, X29.2 Continuous intravenous infusion of therapeutic substance NEC. These chemotherapy drugs would be coded to the correct method of administration.

Question 85

How are high cost drugs coded in OPCS 4.9 (2020)?

Answer 85

There is no national requirement to collect high cost drug data on discharges from 1 st April 2020.

Question 86

Which high cost drugs are the exception that must always be coded on discharges from 1 st April 2020?

Answer 86

X83.3 Alteplase when it is given for treatment of acute stroke (PCSX25: Administration of thrombolytic/fibrinolytic drugs and alteplase) and X90.4 must be coded on every episode where a patient receives parenteral nutrition, regardless of the number of days it’s given.

Question 87

If Alteplase has been administered for a condition that is not an acute stroke, how must this be coded?

Answer 87

For a condition other than acute stroke, Alteplase must be coded according to the method of administration.

Question 88

What type of procedure code must precede Y10.2 Electrocauterisation of organ NOC or Y17.1 Electrocauterisation of lesion of organ NOC?

Answer 88

A code that classifies a cauterisation procedure. Where a cauterisation code does not exist, a code for destruction must be used.

Question 89

Code Y39.4 Lipofilling injection into organ NOC is to be used as a supplementary code for lipofilling on any area other than where?

Answer 89

Breast

Question 90

In which position must a code from the approach to organ categories Y45-Y52 and Y74-Y76 be sequenced?

Answer 90

A code from categories Y45-Y52 and Y74-Y76 must be assigned directly after the body system code to identify the method of approach. Any site and laterality codes must be assigned after the approach code.

Question 91

In which position must a code from approach to organ categories Y53, Y68 and Y78 be sequenced?

Answer 91

A code from categories Y53, Y68 and Y78 must be sequenced after the intervention, i.e. all codes that describe the intervention itself, and before the site and laterality codes.

Question 92

Where a number of procedures have taken place using different methods of approach, how are the codes from Y45 Y52 and Y74 Y76 applied?

Answer 92

They must be assigned after each body system code.

Question 93

Where a number of different types of image control have been used together a code for each type of image control must be assigned. What is the exception to this standard?

Answer 93

The exception to this is fluoroscopy when used with an | image intensifier, where it is only necessary to assign code Y53.4 Approach to organ under fluoroscopic control.

Question 94

In what circumstances should a code from Y53 Approach to organ under image control NOT be assigned?

Answer 94

If image control has been 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, a code to classify the image control must not be assigned.

Question 95

Where a code from categories Y95 and Y53 or Y68 are both required what sequencing must be applied?

Answer 95

The code from category Y53 or Y68 must be sequenced before the code from Y95.

Question 96

PCSY10: Anaesthetic (Y80-Y84)

Answer 96

When radiotherapy is delivered under general anaesthetic, a code from category Y80 General anaesthetic must be assigned in addition to the radiotherapy codes.

Question 97

When must site codes be used?

Answer 97

Site codes from Chapter Z must always be assigned when this adds further information about the site the procedure was performed on.

Question 98

What must a coder consider if a site is listed as an inclusion at a body system chapter category/code, e.g. A34.2 Exploration of oculomotor nerve (iii)?

Answer 98

Whether a site code can be added to identify the site listed in the includes note, i.e. A34.2 includes trochlear and abducens nerve.

Question 99

When must a laterality code be assigned?

Answer 99

When laterality is documented in the medical record, and is not already implicit in the code description, it must be coded. Where it is necessary to assign more than one code to describe all the steps which took place during one procedure on the same anatomical site; the laterality code must only be assigned following all of the codes that are required to describe the procedure on the anatomical site