OPCS - Coding standards Flashcards
PCSA3: Neurostimulators (A09, A33, A48 and A70)
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)
What do you need to remember when coding ECT?
• 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.
PCSD3: Combined approach tympanoplasty (D14.4)
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.
PCSE1: Laryngopharyngectomy (E19 and E29)
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.
PCSE4: Non operations on lower respiratory tract (E85–E98) and ventilation support (E85)
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.
PCSE5: Invasive ventilation with tracheostomy (E85.1)
When a tracheostomy is performed for invasive ventilation the following codes and sequencing must be applied:
E85.1 Invasive ventilation
E42.3 Temporary tracheostomy
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?
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.
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 = 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.
What does new standard PCSG6: Endoscopic insertion of nasogastric or nasojejunal feeding tube (G47.5 and G67.5) tell us?
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.
What must be coded when banding of haemorrhoids is carried out in conjunction with an endoscopic procedure?
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.
What must a coder be mindful of when coding a colonoscopy that does not progress beyond the sigmoid colon?
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.
How must a failed or abandoned ERCP be coded?
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.
What is the sequencing of cholecystectomy and ERCP when performed together?
Answer = When endoscopic retrograde cholangiopancreatography (ERCP) is performed at the same time as cholecystectomy, the ERCP
must be coded in a secondary position.
What sequencing must be followed when a coronary artery procedure involves the insertion of a combination of stents?
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.
What is coded when an angiocardiography of the heart is carried out during the same radiology/theatre visit as a coronary arteriography?
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.
Why must a code from category 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.
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?
They must be used to code interventions that are not classifiable at fourth character level within named artery categories (L01 L63).
What subsidiary code is also required when coding procedures classified to these two categories and why?
A site code from Chapter Z must also be assigned 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, e.g. L63.8, L63.9 etc. must be used instead.
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 = 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.
If the artery or its branch are listed as an inclusion what subsidiary code must the coder ensure is also assigned?
A site code from Chapter Z
What must be coded when an angioplasty/
venoplasty and insertion of stent are performed at the same time?
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.
PChSL4: Removal of bypass grafts
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.
PCSL1: Anastomosis without a site specific code (L16-L28 and L48-L63)
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.
What do coders need to bear in mind when coding aortic aneurysm repairs?
Whether the repair was carried out as an emergency or as an elective procedure.
How is a change of ureteric stent coded in OPCS 4.9?
Answer = A ureteric stent is coded according to method used to change the stent e.g. cystoscopically.
PCSM1: Percutaneous drainage of kidney (M13.2)
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.
When extracorporeal shockwave lithotripsy of calculus of ureter is performed via cystoscopy and a stent is inserted, what must be coded, and why?
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.
PCSM6: Catheterisation of the bladder (M47)
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.
How must a failed TWOC be sequenced?
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
PCSP1: Refashioning of episiotomy scar (P13.8 and S60.4)
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
PCSP3: Episiotomy to facilitate delivery of terminated fetus and subsequent repair (P14.9, P13.2, P25.5)
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.
When a procedure has been performed for a pregnancy with abortive outcome what subsidiary code must also be assigned?
Y95 Gestational age.
How must an intrauterine coil procedure and hysteroscopy be coded when performed during the same theatre visit?
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.
When would a code from category Q58 be assigned?
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.
PChSR1: Coding deliveries (R17-R25)
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.
PCSR5: Episiotomy to facilitate delivery and subsequent repair (R27.1, R32)
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.
PCSR6: Gentle cord traction for removal of retained placenta
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.
Looking at the standard PCSR7 how are obstetric scans classified to categories R36 R43 carried out?
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.
What does the note at the beginning of Chapter S indicate?
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.
PChSS1: Enhancing body system codes using codes from Chapter S
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.
PCSS3: Coding skin grafts and harvests
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)
Why are dermal substitutes used in combination with skin graft procedures, and where used, how are these coded?
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
When must debridement of skin be coded?
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.
Looking at the code range T20 T27 what must the coder check before assigning a code?
Whether the hernia is primary or recurrent.
When must the code T91.1 Biopsy of sentinel lymph node NEC be used?
It must only be used when the exact site of the sentinel lymph node is unknown.
How is a sentinel node excision, biopsy or drainage reflected if T91.1 is not used?
Answer = By adding the site code O14.2 Sentinel lymph node to the lymph node procedure code from T86 T88.
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?
- 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
What fourth character codes from Y97 Radiology must not be used?
- 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.
When coding ultrasound and contrast fluoroscopy what is the element that defines which code is selected from category Y98 Radiology procedures?
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.
What are the 9 ‘body areas’ that are referred to in the codes in category Y98 Radiology procedures?
- 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
What is the default code that must be used when the area or duration of scan is not specified?
Y98.1 Radiology of one body area (or < 20 minutes)
U01 U21 and U34 U37 include nuclear medicine imaging codes that are only for use in an outpatient setting, what are the exceptions?
- 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
Which subsidiary codes must be assigned
if radiopharmaceutical imaging substances are used during a nuclear medicine imaging procedure?
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.
.
What does a level of spine mean?
A ‘level of spine’ means either a vertebra, a disc, or a motion segment.
Name an example of a procedure carried out on vertebrae.
- Vertebral excision
- Decompression of fractured vertebrae
- Reduction and fixation of fractured vertebrae
- Biopsy of vertebrae.
Name an example of a procedure carried out on intervertebral discs.
- Disc excision
- Disc replacement
- Foraminoplasty
- Coblation to disc
- Discography.
Name an example of a procedure carried out on motion segments.
- Decompression of vertebra disc vertebra sections
- Interspinous process spacer insertions
- Facet joint injections.
In what position is V55 Levels of spine sequenced?
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.
What 4th character is assigned when the level of spine is not specified?
V55.9 Unspecified levels of spine.
What criteria must be considered when coding discectomy for decompression?
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.
When a spinal decompression has been performed with spinal fusion and instrumentation what codes must be assigned?
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’.
What must the coder remember about bone grafts performed at the same time as spinal fusion and instrumentation?
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.
PChSW1: K-wire fixation
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.
In what circumstances is it acceptable to assign the code W84.8 Other specified therapeutic endoscopic operations on other joint structure?
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
What is the difference between an open and closed reduction?
• 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.
What are the two type of fixations?
- 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
What is the criteria for assigning a code for a secondary reduction (W23 or O17)?
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.
PCSX26: Reamputation (X12.1)
- 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
PCSX9: Compensation for renal failure (X40)
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.
PCSX11: Donation of organ (X45)
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.
PCSX15: Evaluation of cardioverter defibrillator (X50.5)
Code X50.5 Evaluation of cardioverter defibrillator must not be assigned when evaluation/testing is performed during the insertion of the cardioverter defibrillator.
PCSX17: Anaesthetic without surgery (X59)
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.
What must a coder remember about the assignment of radiotherapy preparation codes?
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.
How must radiotherapy preparation be coded?
X67. Preparation for external beam radiotherapy or X68 Preparation for brachytherapy and Y92.
Support for preparation for radiotherapy (if used).
When must X65.9 Unspecified radiotherapy delivery be assigned?
It must only be used when the method of radiotherapy delivery is not classifiable to any of the other fourth characters within the category.
What code must not be used with X65.9 Unspecified radiotherapy delivery?
Y91 External beam radiotherapy or its extended category Other external beam radiotherapy.
Explain how radiotherapy is coded depending on setting.
- 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.
What must a coder consider when assigning chemotherapy codes in different settings, i.e. inpatient, day case and outpatient?
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.
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
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
What is meant by parenteral administration?
Via a route other than the mouth or rectum, i.e. via infusion, injection or implantation.
What must be coded when a regimen includes both oral and parenteral administration?
The parenteral administration will determine the
delivery code.
What codes must be assigned for electrochemotherapy ?
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
How must chemotherapy drugs used for the treatment of non neoplastic/non malignant conditions be coded?
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.
How are high cost drugs coded in OPCS 4.9 (2020)?
There is no national requirement to collect high cost drug data on discharges from 1 st April 2020.
Which high cost drugs are the exception that must always be coded on discharges from 1 st April 2020?
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.
If Alteplase has been administered for a condition that is not an acute stroke, how must this be coded?
For a condition other than acute stroke, Alteplase must be coded according to the method of administration.
What type of procedure code must precede Y10.2
Electrocauterisation of organ NOC or Y17.1 Electrocauterisation of lesion of organ
NOC?
A code that classifies a cauterisation procedure. Where a cauterisation code does not exist, a code for destruction must be used.
Code Y39.4 Lipofilling injection into organ NOC is to be used as a supplementary code for lipofilling on any area other than where?
Breast
In which position must a code from the approach to organ categories Y45-Y52 and Y74-Y76 be sequenced?
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.
In which position must a code from approach to organ categories Y53, Y68 and Y78 be sequenced?
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.
Where a number of procedures have taken place using different methods of approach, how are the codes from Y45 Y52 and Y74 Y76 applied?
They must be assigned after each body system code.
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?
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.
In what circumstances should a code from Y53 Approach to organ under image control NOT be assigned?
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.
Where a code from categories Y95 and Y53 or Y68 are both required what sequencing must be applied?
The code from category Y53 or Y68 must be sequenced before the code from Y95.
PCSY10: Anaesthetic (Y80-Y84)
When radiotherapy is delivered under general anaesthetic, a code from category Y80 General anaesthetic must be assigned in addition to the radiotherapy codes.
When must site codes be used?
Site codes from Chapter Z must always be assigned when this adds further information about the
site the procedure was performed on.
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)?
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.
When must a laterality code be assigned?
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
