How should poisoning/adverse effect due to combination drugs be coded? For example, Mersyndol, which is a combination of 3 drugs; codeine, paracetamol and doxylamine succinate.

If a combination drug is documented as the cause of a poisoning/adverse effect - and no individual component is identified as being responsible for the poisoning/adverse effect, assign a code for each of the components.

If a combination drug is documented as the cause of a poisoning/adverse effect - and one of the components is identified as causing the poisoning/adverse effect, assign a code for that drug only. Code(s) for the other components of the combination drug are not required.

See also ACS 1901 Poisoning and ACS 1902 Adverse effects.

a. Headache due to anaesthesia

How do you code headache due to anaesthesia (other than spinal and epidural anaesthesia)?

To code headache due to anaesthetic drugs or anaesthesia in ICD-10-AM Sixth Edition, follow the guidelines in ACS 1904 Procedural complications and ACS 1902 Adverse effects, Drugs.

For headache due to anaesthetic drugs, follow the index pathway:

Headache

- drug induced NEC G44.4

and assign G44.4 Drug-induced headache, not elsewhere classified with an external cause code to identify the drug.

If the headache is specified as due to anaesthesia, but not specifically the anaesthetic drugs, follow the index pathway:

Complications
- anaesthesia, anaesthetic NEC (see also Anaesthesia, complication or reaction NEC) T88.5

and assign T88.5 Other complications of anaesthesia with R51 Headache as an additional diagnosis to complete the clinical picture.

b. Leaking gastrostomy tube

What is the correct code assignment for leaking gastrostomy tube?

To assign a code for leaking gastrostomy tube follow the guidelines in ACS 1904 Procedural complications:

Therefore, the correct code to assign is T85.5 Mechanical complication of gastrointestinal prosthetic devices, implants and grafts by following the index pathway:

Leak, leakage

- device, implant or graft
- - gastrointestinal (bile duct) (oesophagus) T85.5

with Y83.3 Surgical operation with formation of external stoma and Y92.22 Health service area.

c. Postprocedural bile leak

What is the correct code assignment for postprocedural bile leak?

When postprocedural/anastomotic bile leakage is documented but trauma or mechanical complication (conditions listed in T82.0) due to gastrointestinal implant is not specified, assign K91.8 Other postprocedural disorders of the digestive system, not elsewhere classified, following the index pathway:

Complication
- digestive
- - postprocedural
- - - specified NEC K91.8

K83.8 Other specified diseases of biliary tract may be assigned as an additional code to specify the site of the postprocedural/anastomotic bile leak.

Where there is documentation that the postprocedural/anastomotic bile leak is due to trauma or mechanical complication (conditions listed in T82.0), assign the appropriate codes from Chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes (S00-T98) as per the guidelines in ACS 1904 Procedural complications. For example, for a postprocedural/anastomotic bile leak due to:

• operative trauma - assign T81.2 Accidental puncture and laceration during a procedure, not elsewhere classified with the appropriate injury code (S code) to identify the site of the trauma.
• mechanical complication (conditions listed in T82.0) due to a gastrointestinal implant - assign T85.5 Mechanical complication of gastrointestinal prosthetic devices, implants and grafts.

In addition, assign external cause of injury and place of occurrence codes as appropriate

What is the correct code to assign for a DIEP flap for breast reconstruction?

The correct code to assign for a DIEP flap for breast reconstruction is 45530-00 [1756] Reconstruction of breast using myocutaneous flap. Even though a DIEP flap does not use myocutaneous tissue, myocutaneous is a nonessential modifier in the Alphabetic Index, despite being specified in the code title.

The NCCH will review the code title of 45530-00 [1756] for a future edition of ACHI.

What is the correct procedure code to assign for duodenoscope assisted cholangiopancreatoscopy?

Duodenoscope assisted cholangiopancreatoscopy (DACP) allows direct visualisation of the biliary and pancreatic ducts. It is beneficial in circumstances where direct ductal visualisation is helpful in clarifying a diagnosis or providing targeted treatment that is not possible with conventional fluoroscopic imaging.

The procedure was first described in the mid-1970s when endoscopic retrograde cholangiopancreatoscopy (ERCP) was in its infancy. The procedure involves a small calibre cholangiopancreatoscope (daughter scope or baby scope) being passed through the accessory channel of the duodenoscope and is used to cannulate the ampulla of Vater and obtain images of the bile duct and then the pancreatic duct.

The technique, however, was not widely accepted due to expensive and inadequate instruments which suffered frequent breakage, poor optics, etc.

However, in recent years technological improvements have overcome the inadequate equipment of the past and DACP may expand management options for pancreaticobiliary disorders in the future.

The correct code assignment for DACP is:

30442-00 [957] Choledochoscopy

and

30473-00 [1005] Panendoscopy to duodenum

What is the correct principal diagnosis selection for a day stay urology admission where 'elevated PSA' alone is documented as the principal diagnosis on the discharge summary and as the indication on the operation report but where the histopathology report received after discharge indicates adenocarcinoma?

Prostate specific antigen (PSA) is a protein that is secreted into ejaculate which helps to nourish the sperm. Normally, only tiny amounts enter the bloodstream. However, cancer cells and other conditions can interfere with proper functioning and cause large amounts to enter the blood. It is currently the most widely used method to screen for prostate cancer.

It is acknowledged that elevated PSA is also an indicator of other conditions such as benign prostatic hyperplasia (BPH), urinary tract infections and prostatitis. For the scenario cited, where histopathology has confirmed a diagnosis of adenoacarcinoma, this should be assigned as the principal diagnosis. The adenoacarcinoma should be coded as a finding that adds specificity to the diagnosis of 'elevated PSA' as per the guidelines in ACS 0010 General abstraction guidelines,test results.

Clinical advice has confirmed that R79.8 Other specified abnormal findings of blood chemistry is the correct code to assign for elevated PSA.

Should an additional code for suture of wound be assigned with 30023-01 [1566] Excisional debridement of soft tissue involving bone or cartilage as it does not contain an includes note for suture of wound as in 30023-00 [1566] Excisional debridement of soft tissue

30023-00 [1566] Excisional debridement of soft tissue has the following note:

'Includes: suture of wound'

This has led some coders to assume that as there is no similar note at 30023-01 [1566] Excisional debridement of soft tissue involving bone or cartilage, that any suture of the wound should be assigned as an additional code for this procedure as it does not contain the same includes note.

However, in these circumstances the guidelines in ACS 0016 General Procedure Guidelines - Procedure Components apply and it is unnecessary to assign an additional code for suture of wound performed with excisional debridement. It is a component of the procedure.

The 'includes' note at 30023-00 [1566] will be reviewed for a future edition of ACHI.

What is the correct external cause code to assign for fall causing injury (other than drowning/submersion injury) while water skiing?

The correct external cause code to assign for fall from water skis causing injury (other than drowning/submersion injury) is W02.2 Fall involving water ski following the index pathway:

Fall, falling (accidental)
- involving
- - conveyance, pedestrian
- - - not in collision with pedestrian
- - - - ski(s)
- - - - - water W02.2

Water ski accidents may be classified as a pedestrian conveyance or water craft accident depending on the circumstances of the accident. However, clinical advice from the National Injury Surveillance Unit (NISU) confirmed that W02.2 Fall involving water ski describes this accident more specifically than the residual code V94.7 Other and unspecified water transport accidents, water skis and should, therefore, be assigned in this instance.

Should a code from Chapter 15 Pregnancy, Childbirth and the Puerperium be assigned in addition to a code for human immunodeficiency virus [HIV] disease (B20-B24) for HIV complicating pregnancy, delivery or the puerperium?

There is no index entry specifically for HIV complicating pregnancy and there is an exclusion note for 'human immunodeficiency virus [HIV] disease (B20-B24)' at O98 Maternal infectious and parasitic diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium. Therefore, it is unnecessary to assign a code from Chapter 15 Pregnancy, Childbirth and the Puerperium in addition to a code from B20-B24 for HIV complicating pregnancy, childbirth or the puerperium.

Z33 Pregnant state, incidental may be assigned as an additional code for episodes of care where a patient is admitted for HIV and is pregnant as per the advice in ACS 1521Conditions complicating pregnancy, Incidental pregnant state.

Please clarify ACS 1808 Incontinence below in relation to the following:

1808 INCONTINENCE

Incontinence is clinically significant when the incontinence:

• is not clinically considered to be physiologically normal,
• is not clinically considered to be developmentally normal, or
• is persistent in a patient with significant disability or mental retardation.

Urinary and faecal incontinence codes (R32 Unspecified urinary incontinence, R15 Faecal incontinence) should be assigned only when the incontinence is persistent prior to admission, is present at discharge or persists for at least seven days.

a. Should coders use the information in the first paragraph of the ACS to determine if the incontinence is 'clinically significant' before following the classification advice in the second paragraph or is this paragraph for information only?

b. When following the classification advice in the second paragraph, would a code for incontinence be assigned for any patient, with any length of stay (including same day) admitted for any condition who was incontinent once only, providing it was on their day of discharge. That is, would you assign an additional code for incontinence for a same day admission of an elderly patient where voluminous incontinence is noted but is not the principal reason for admission?

c. Does this ACS cover all types of urinary incontinence or only those classifiable to R32 Unspecified urinary incontinence

R32 Unspecified urinary incontinence and R15 Faecal incontinence should be assigned if they meet the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.

Additionally, advice in ACS 1808 Incontinence should be followed. Therefore, in answer to part (a) of this query, the first paragraph is for information only.

In answer to part (b), coders should apply the advice in the second paragraph where the intent is to code 'persistent' faecal and/or urinary incontinence. So, for a same day episode of care, the advice to assign a code for incontinence present at discharge should only be followed where the documentation confirms that incontinence is a persistent problem.

Lastly, in answer to part (c), the advice in ACS 1808 is for urinary incontinence classifiable to R32 Unspecified urinary incontinence, only. It does not apply to other types of urinary incontinence e.g. overflow, stress incontinence etc.

What is the correct code assignment for intercostal neuralgia?

The current index entries under Neuralgia and Neuritis do not include a subterm for intercostal. This may lead coders to assign G58.8 Other specified mononeuropathies. However, the index entry for Neuropathy has a subterm for intercostal, which assigns G58.0 Intercostal neuropathy, which is the correct code assignment for intercostal neuralgia.

Indexing improvements to this area of ICD-10-AM have been made for Seventh Edition.

Please clarify the advice under In vitro fertilisation (IVF) in ACS 1437 Infertility concerning the assignment of an additional code from N97 Female infertility.

The intent of the advice in the above paragraph is that female patients admitted specifically for 'IVF' with documented 'infertility' should have Z31.2 In vitro fertilisation assigned as the principal diagnosis. A code classifiable to N97 Female infertility should be assigned as an additional code to specify the type of infertility, including N97.9 Female infertility, unspecified for female infertility NOS. It is not necessary to assign a code from category N97 if the reason for the IVF is not specified or it is performed for another reason.

Ischaemic fingers due to occlusion of blood vessel secondary to injecting crushed benzodiazepine tablets into the ulnar artery.

What is the correct code assignment for the above scenario?

The correct codes to assign for this scenario are:

T42.4 Poisoning by antiepileptic, sedative-hypnotic and antiparkinsonism drugs, Benzodiazepines

I77.8 Other specified disorders of arteries and arterioles

and the appropriate external cause of injury codes.

Assign a more specific code if the type of blood vessel occlusion is specified e.g. I74.2 Embolism and thrombosis of arteries of upper extremities for thrombosis of ulnar artery.

What is the correct code to assign for a neonate suffering withdrawal due to maternal use of prescribed pain medication during pregnancy?

The correct code to assign for the neonate in this scenario is P96.1 Neonatal withdrawal symptoms from maternal use of drugs of addiction following the index pathway:

Reaction
- drug NEC
- - withdrawal
- - - newborn P96.1

The assignment of this code is not affected by whether or not the mother is drug dependent.

What is the correct code assignment for parafoveal telangiectasia treated by Avastin® injection into retinal blood vessels?

Parafoveal or perifoveal telangiectasia, also known as macular telangiectasis, is a peculiar retinal vascular disorder that affects the central portion of the macula.

Dilated retinal capillaries occur around the temporal aspect of the foveal area, eventually encircling it completely causing progressive loss of vision.

The correct code to assign for parafoveal telangiectasia is H35.0 Background retinopathy and retinal vascular changes following the pathway:

Disease, diseased
- retina, retinal
- - vascular lesion H35.0

or

Lesion
- retina, retinal
- - vascular H35.0

Avastin®(Bevacizumab) works by blocking a substance known as vascular endothelial growth factor (VEGF). Blocking or inhibiting VEGF helps prevent further growth of blood vessels. Initially, the drug was approved for the treatment of metastatic colorectal cancer to block blood vessels that the cancer needs to continue growing.

More recently ophthalmologists have injected Avastin® into the posterior chamber of the eye to treat age related macular degeneration and other eye conditions that cause loss of vision due to abnormal growth of blood vessels in the back of the eye, such as parafoveal telangiectasia. The drug was used because research indicated that VEGF is one of the causes for the growth of the abnormal vessels that cause these conditions.

The correct code to assign for Avastin® injection into abnormal retinal blood vessels is 42740-03 [209] Administration of therapeutic agent into posterior chamber following the index pathway:

Injection
- posterior chamber (by paracentesis) (eye) (therapeutic agent) 42740-03 [209]

The NCCH will consider improvements to the index for this condition and procedure for a future edition of ICD-10-AM/ACHI.

What is the correct code to assign for periductal mastitis?

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), used in the United States, assigns periductal mastitis to mammary duct ectasia while ICD-10-AM makes no such link.

A literature review reveals that periductal mastitis has been confused with and called duct ectasia. However, duct ectasia is almost certainly a separate condition affecting an older age group and characterised by subareolar duct dilatation and less pronounced and less active periductal inflammation. Current evidence suggests that smoking is an important factor in the aetiology of periductal mastitis but not in duct ectasia.

Therefore, the correct code to assign for periductal mastitis is N61 Inflammatory disorders of breast following the index pathway:

Mastitis (acute) (infective) (nonpuerperal) (subacute) N61

ACS 1901 Poisoning states that 'In addition to the code for poisoning, an additional code should be assigned to indicate any significant manifestation (e.g. coma, arrhythmia).'

In a scenario where a patient is transferred to an Intensive Care Unit (sedated/ventilated) from another hospital following carbon monoxide poisoning/benzodiazepine overdose and it is noted that an arrhythmia was treated at the scene, can this ACS be applied (i.e. can a code for the arrhythmia be assigned) at the receiving hospital where the condition is no longer present?

ACS 1901 Poisoning intends to provide guidance on the sequencing of code assignment for poisoning episodes of care. It highlights that in addition to a code from the poisoning chapter an additional code may be assigned for any 'significant manifestations.' It was not intended to expand the interpretation of 'significant manifestations.'

Coders should follow the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses to determine if a code for a manifestation of poisoning should be assigned.

What is the correct code assignment for pyelonephritis with renal calculus and hydronephrosis?

The correct code assignment for pyelonephritis with calculus and hydronephrosis is N13.2 Hydronephrosis with renal and ureteral calculus obstruction following the pathway:

Pyelonephritis
- with calculus
- - - with hydronephrosis N13.2

If the condition is documented with an infection, N13.6 Pyonephrosis may also be assigned with an additional code (B95-B97) to identify any infectious agent, to complete the clinical picture. See also ACS 0027 Multiple coding and ACS 0033 Conventions used in the tabular list of diseases.

Can you clarify ACS 1331 Soft tissue injuries, particularly in relation to contusions which are classified as superficial injuries rather than soft tissue injuries?

Soft tissue injuries include damage to muscles, ligaments and tendons. They usually fall into one of the following:

• contusions (bruises)
• sprains
• strains

A contusion is an injury to soft tissue often produced by a blunt force such as a kick, fall or blow.

A sprain is an injury to a ligament and is often caused by a wrench or twist.

While a strain is an injury to a muscle or tendon and is often caused by overuse, force or stretching.

ACS 1331 Soft tissue injuries advises that where a more specific injury is documented (e.g. contusion, sprain or strain), these should be coded rather than following the index pathway 'Injury, site.'

Where soft tissue injury is the only description documented for an injury, assign a code by following the index pathway 'Injury, site.'

ICD-10-AM, as per ICD-10, classifies 'contusion' as a superficial injury, however, this does not alter the classification advice above.

The NCCH will review ACS 1331 Soft tissue injuries for a future edition of the ACS.

ASGE, Technology Status Evaluation Report Gastrointestinal Endoscopy Vol 50, NO. 6, 1999, Duodenoscope-Assisted Cholangiopancreatoscopy. Accessed 1 December 2008. http://louisville.edu/medschool/medicine/gastro/media/ASGE%20Manual/content/7/7-08.pdf

Avastin®(Bevacizumab) Intravitreal Injection, 2003 The Eye Hospital, Launceston, Tasmania. Accessed 13 May 2009. http://www.eyehospital.com.au/brochures/avastin_intravitreal_injection.pdf

Bowers, K, The Alfred Hospital, Inflammatory Diseases of the Breast. Accessed 12 May 2009. http://www.surgeons.org/AM/presentations/KBowers_050219.pdf

Dixon, J.M, ABC of Breast Diseases: Breast Infection, BMJ 1994;309:946-949 (8 October). Accessed 12 May 2009. http://www.bmj.com/cgi/content/full/309/6959/946

Thompson, C.C, Kelsey.P.B., Current Opinion in Gastroenterology, 19(5):487-491, 2003, Duodenoscope-assisted Cholangiopancreatoscopy: A Review of Clinical Applications. Accessed 1 December 2008. http://www.medscape.com/viewarticle/460478

MedGadget, Spyglass™Direct Visualization System to Cure ERCP Addiction. Accessed 1 February 2009. http://medgadget.com/archives/2007/05/spyglass_direct_visualization_system_makes_ercps.html

VirtualMedicalCentre.com, PSA (Prostate Specific Antigen) Testing. Accessed 20 March 2009. http://www.virtualcancercentre.com/healthinvestigations.asp?sid=67

Vitreous-Retina-Macula Consultants of New York, Idiopathic perifoveal telangiectasia. Accessed 3 March 2009. http://www.vrmny.com/pe/ipt.html

Note: The following advice on diabetes mellitus also applies to impaired glucose regulation (IGR)

During the 2008 Sixth Edition Coding Workshops, the NCCH emphasised that diabetes mellitus must meet ACS 0002 Additional diagnoses to be coded. The education highlighted that routine BSLs do not fall under the ACS 0002 criteria for 'increased clinical care and/or monitoring' and therefore can not be used by coders to determine when to code diabetes mellitus and any associated conditions.

It is acknowledged that there may be some variation in the way that diabetes mellitus is coded in Sixth Edition, mainly due to how the index deals with diabetes and its associated conditions. Coders should continue to code diabetes as they have been and follow the advice published as a 10-AM Commandment in Coding Matters, Volume 15, No.1, June 2008 Diabetes mellitus and blood sugar levels. The NCCH in conjunction with the Coding Standards Advisory Committee (CSAC) recognises that there will be instances throughout the life of Sixth Edition where coding advice on diabetes will be sought. It is therefore recommended that coding queries related to diabetes mellitus be dealt with at the state level during Sixth Edition.

What is the correct intervention code to assign for apophysiodesis of the femur?

The correct code to assign for apophysiodesis of the femur is 48500-00 [1491] Epiphysiodesis of femur. Clinical advice confirms that an apophysiodesis is the same as an epiphysiodesis of the femur, except that it is performed at the proximal end of the femur rather than the distal end, which is more common. Clinical advice also indicated that:

"Technically a growth point that leads to a muscle attachment is an apophysis whereas a growth plate to a joint is an epiphysis." Courtenay, Brett (personal communication, Orthopaedic Clinician).

When should Z49.0 Preparatory care for dialysis be assigned for an admission for creation of an arteriovenous fistula and when should a complication code from category T82 Complications of cardiac and vascular prosthetic devices, implants and grafts be assigned?

Z49.0 Preparatory care for dialysis should be assigned for those admissions where the intention is for creation of a new fistula in preparation to commence dialysis treatment. Where the reason for creation of a new fistula is due to a complication relating to an existing fistula (even when the new fistula is being created at a different site), then assign the appropriate complication code from category T82 Complications of cardiac and vascular prosthetic devices, implants and grafts with external cause codes Y84.1 Kidney dialysis and Y92.22 Health service area.

What is the correct external cause code assignment for complications related to renal dialysis?

Ureteral stents are an integral part of urological practice. Stents can migrate, fragment or be forgotten and a portion of these will become calcified. Treatment to render a patient stent-free in these circumstances includes ureteroscopy, percutaneous nephroscopy, cystoscopic electrohydraulic lithotripsy, extracorporeal shock wave lithotripsy, open cysto-litholapaxy and simple nephrectomy - or a combination of the above.

The correct code to assign for endoscopic lithotripsy of an encrusted ureteric stent is 36809-00 [1074] Endoscopic fragmentation of ureteric calculus. Calcified encrustation is considered calculous material, therefore, the correct pathway is Destruction, calculus, ureter. Assign also a code for removal of ureteric stent as appropriate

What is the correct code to assign for non traumatic excoriation of skin of breast?

Non traumatic excoriation of skin of breast is also known as intertrigo.

Intertrigo is inflammation of skinfolds caused by skin-on-skin friction or chafing of warm, moist skin in areas such as the inner thighs and genitalia, the armpits, under the breasts, under abdominal folds, behind the ears and the web spaces between the fingers and toes.

The condition is particularly common in obese patients who are exposed to high heat and humidity, but it can occur in anyone.

The correct code to assign for non traumatic excoriation of skin of breast is L30.4 Erythema intertrigo.

What is the correct code to assign for failure to progress in labour?

Failure to progress in labour is a description rather than a diagnostic term, therefore a code for the underlying condition resulting in failure to progress should be assigned. Underlying causes may include cephalopelvic disproportion, malpresentation, inefficient uterine action, (primary uterine inertia or secondary uterine inertia), cervical dystocia, maternal exhaustion etc.

In the absence of documentation of an underlying cause for failure to progress, clinical advice indicates that the correct code to assign is O62.9 Abnormalities of forces of labour, unspecified.

For a diabetic patient with glaucoma NOS is it appropriate to assign E1-.39 * Diabetes mellitus with other specified ophthalmic complication and H40.9 Glaucoma, unspecified?

There is no index entry for 'Diabetes, with glaucoma' in ICD-10-AM, therefore E1-.39 * Diabetes mellitus with other specified ophthalmic complication should not be assigned in this scenario.

Should E1-.34 * Diabetes mellitus with other retinopathy be assigned in addition to H35.3 Degeneration of macula and posterior pole in a patient with macular degeneration and diabetes mellitus?

There is no index entry for 'Diabetes, with macular degeneration' in ICD-10-AM. Clinical advice indicates that there is no cause and effect relationship between macular degeneration and diabetes mellitus and it is therefore, inappropriate to assign E1-.34 * Diabetes mellitus with other retinopathy in the above scenario. These conditions should be coded separately unless the clinician clearly documents a link such as diabetic maculopathy.

What is the correct code to assign for sympathetic storm following traumatic brain injury?

Sympathetic storming occurs in 15% to 33% of patients with severe traumatic brain injury who are comatose. It is an exaggerated stress response marked by agitation or restlessness and can be associated with fever, posturing, tachycardia, hypertension and diaphoresis. It is thought to be caused by an increase in activity of the sympathetic nervous system created by a disassociation or loss of balance between the sympathetic and parasympathetic nervous systems.

In addition to coding out the traumatic brain injury the NCCH advises that sympathetic storm should be classified to G90.8 Other disorders of autonomic nervous system by following the pathway(s):

Disorder
- autonomic nervous system
-- specified NEC G90.8
or

Imbalance
- autonomic G90.8
or

Imbalance
- sympathetic G90.8

Assign also codes for manifestations of the sympathetic storm, as appropriate, if they meet the criteria in ACS 0002 Additional diagnoses.

What is the correct code to assign for unspecified gastroenteritis complicating pregnancy?

The correct code assignment for unspecified gastroenteritis complicating pregnancy is 098.8 Other maternal infectious and parasitic diseases complicating pregnancy, childbirth and the puerperium and A09.9 Gastroenteritis and colitis of unspecified origin.

Cauni, V, Geaviete, P, Georgescu, D, Mircliulescu, V. and Persu, C, Urology, Vol 68, Supplement 1, Novemeber 2006, Page 208, V-03.05 Endoscopic treatment in calcified ureteral stents. Accessed 26 August 2008. http://www.sciencedirect.com/science

DermIS, Dermatology Information System, Intertrigo. Accessed 1 February 2009. http://dermis.multimedica.de/dermisroot/en/12933/diagnose.htm

Janniger, C.K, Schwartz R.A, Szepietowski, J.C and Reich, A. American Family Physician, Sept 1, 2005, Intertrigo and Common Secondary Skin Infections. Accessed 1 February 2009. http://www.aafp.org/afp/20050901/833.html

Lemke, D.M, Critical Care Nurse Vol 27, No. 1, February 2007, Sympathetic Storming After Severe Traumatic Brain Injury. Accessed 9 December 2008. http://ccn.aacnjournals.org

Lemke, D.M, Journal of Neuroscience Nursing, 36 (1):4-9, 2004, Riding Out the Storm: Sympathetic Storming after Traumatic Brain Injury. Accessed 9 December 2008. http://www.medscape.com/viewarticle/469858

Monga, M, Klein, E, Castaneda-Zuniga, W.R, and Thomas, R, The Journal of Urology, Volume 153, issue 6, June 1995, Pages 1817-1819, The Forgotten Indwelling Ureteral Stent: A Urological Dilemma. Accessed 26 August 2008. http://www.sciencedirect.com/science

Where intubation for an anaesthetic is indicated by terms such as LM3, PM3, LMA4 or laryngeal, but ventilation was spontaneous (i.e. not controlled) should it be coded as a general anaesthetic or sedation?

Where documentation is unclear as to the type of anaesthetic being administered follow the guidelines in ACS 0031 Anaesthesia. For classification purposes in ACHI and the ACS 'general anesthesia' is indicated by the use of an artificial airway, such as an endotracheal tube, laryngeal mask or Guedel airway (see ACS 0031 Anaesthesia, point 2, Sedation).

What is the correct code assignment for patients admitted prior and post surgery for anticoagulation therapy when the surgery is performed at another hospital?

The correct code assignment for a patient admitted for anticoagulant stabilisation prior to surgery to be performed at another hospital is:

Z51.4 Preparatory care for subsequent treatment, not elsewhere classified

Z92.1 Personal history of long term (current) use of anticoagulants

See also ACS 2103 Admission for convalescence/aftercare.

NB: If there is a contractual arrangement existing between the two hospitals in the scenario cited then the guidelines within ACS 0029 Coding of contracted procedures should also be followed.

What is the correct code to assign for CSLD?

Clinical advice indicates that 'CSLD is often called bronchiectasis.' Research further specified 'The term CSLD is used to describe a diagnosis where there are clinical symptoms of bronchiectasis without High Resolution Computed Tomography (HRCT) evidence of bronchiectasis. The dominant symptom of CSLD is the presence of excessively prolonged moist cough. Other than the lack of HRCT features, the symptoms of CSLD is otherwise identical to that of bronchiectasis.' Chang et.al (2008).

Therefore, the correct code to assign for this condition is J47 Bronchiectasis

How do you code Epstein-Barr Virus (EBV) hepatitis?

The Epstein-Barr virus, also called Human herpesvirus 4 (HHV-4), is a virus of the herpes family (which includes Herpes simplex virus) and is one of the most common viruses in humans. Most people become infected with EBV, which is often asymptomatic but commonly causes the clinical syndrome known as infectious mononucleosis or glandular fever.

Epstein-Barr virus infections can also be associated with hepatocellular hepatitis. The frequency of this association varies with age. It is estimated to be in 10% of young adults and 30% in the elderly where it presents itself as an anicteric viral hepatitis.

The correct codes to assign for EBV hepatitis are:

B17.8 Other specified acute viral hepatitis

B27.0 Gammaherpesviral mononucleosis

by following the index pathways:

Hepatitis

- viral, virus

-- specified type (with or without coma) NEC B17.8

and

Epstein-Barr virus (gammaherpesviral mononucleosis) B27.0

It is incorrect to classify EBV infections to category B00 Herpesviral [herpes simplex] infections. Although Epstein-Barr virus is a herpesviral infection, it is not a Herpes simplex infection and the excludes note for gammaherpesviral mononucleosis in B00 directs coders to B27.0 Gammaherpesviral mononucleosis, where mononucleosis due to Epstein-Barr virus is classified.

When should a code for difficult intubation be assigned?

Difficult intubation is poorly defined in literature. It is sometimes described as repeated attempts at intubation, the use of bougie or other intubation aid.

The American Society of Anesthesiologists in their article entitled Practice Guidelines for Management of the Difficult Airway, Anesthesiology, V98, No 5, May 2003 state:

'A standard definition of the difficult airway cannot be identified in available literature. For these Guidelines, a difficult airway is defined as the clinical situation in which a conventionally trained anesthesiologist experiences difficulty with face mask ventilation of the upper airway, difficulty with tracheal intubation, or both.'

The following codes

T88.4 Failed or difficult intubation

Y84.8 Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure

Y92.22 Health service area

should only be assigned when the 'failed' or 'difficult' intubation meets the criteria in ACS 0002 Additional diagnoses. However, these codes should not be routinely assigned when 'difficult intubation' is documented.

What is the correct code to assign for laser ablation of the lower ureter?

Laser treatment is increasingly being used for a variety of urological procedures, including ablation of ureteric anastomotic and congenital strictures.

The correct code to assign for laser ablation of the lower ureter is 90358-00 [1088] Other procedures on ureter. Assign also the appropriate codes for endoscopy or stent insertion if performed.

What are the correct codes to assign for pelvic peritonitis secondary to pelvic inflammatory disease due to gonorrhoea?

Pelvic inflammatory disease is a broad term encompassing a variety of upper genital tract infections such as salpingitis, salpingo-oophoritis, endometritis, tubo-ovarian inflammatory masses, and pelvic or diffuse peritonitis.

PID usually results from ascending infection from the cervix and is a common and serious complication of some sexually transmitted infections especially chlamydia and gonorrhoea. PID can damage the fallopian tubes and tissues in and near the uterus and ovaries. Untreated PID can lead to serious complications, including infertility, ectopic pregnancy, abscess formation and chronic pelvic pain.

The correct code assignment for pelvic peritonitis secondary to pelvic inflammatory disease due to gonorrhoea is:

A54.2† Gonococcal pelviperitonitis and other gonococcal genitourinary infections

N74.3* Female gonococcal pelvic inflammatory disease

by following the index pathway:

Gonorrhoea

- pelvis(acute)(chronic)

-- female pelvic inflammatory disease A54.2† N74.3*

What is the correct procedure code to assign for sling procedure for male stress incontinence?

Urinary incontinence is a significant problem in men who undergo prostate surgery. Persistent, long term incontinence (usually stress incontinence) in patients following radical prostatectomy is difficult to treat. There are a number of male sling procedures which use various techniques, including bone anchors, to support the bulbar urethra and help to achieve effective dynamic urethral resistance.

Following clinical advice the correct code to assign for male sling procedure is 37044-00 [1109] Retropubic procedure for stress incontinence, male.

What is the correct code assignment for patients admitted for donor apheresis?

There are two types of patients admitted for donor apheresis. One type of donor is a patient with a known disease, such as a malignancy, admitted to donate their own cells for therapeutic reinfusion at a later date (autologous donation). In this scenario assign a code for the condition to be treated by the donated cells.

The other type of donor is a healthy donor, admitted to donate cells for infusion into another person (allogeneic donation). In this scenario, assign as the principal diagnosis Z51.81 Apheresis.

For patients admitted for therapeutic apheresis (eg plasmapheresis, leukapheresis etc.) assign as the principal diagnosis a code for the condition requiring treatment. It is unnecessary to also assign Z51.81 Apheresis as this information is specified by the procedure code.

See ACS 0301 Stem cell procurement and transplantation.

What are the correct codes to assign for plasmapheresis for ABO incompatible kidney transplant recipient?

Plasmapheresis in this scenario is one component of an immunosuppressant protocol for a patient who is to receive an ABO incompatible kidney transplant. Immune suppression reduces a normal immune response to prevent rejection of transplanted organs or cells.

The correct code to assign for same day prophylactic plasmapheresis for a patient who is to receive a kidney from an incompatible blood group donor is Z29.1 Prophylactic immunotherapy

Do not assign Z51.81 Apheresis as per the index entry 'Admission, plasmapheresis' as this is the code for a patient admitted for allogeneic donor apheresis (that is, a healthy donor admitted to donate cells for transplant into another person).

See also ACS 0301 Stem cell procurement and transplantation.

What is the correct code to assign for ventilator associated pneumonia?

Ventilator associated pneumonia (VAP) is a hospital acquired bacterial pneumonia in patients who are on mechanical ventilatory support through an endotracheal tube or tracheostomy tube for at least 48 hours. Pneumonia occurs as a result of microbial invasion of the normally sterile lower respiratory tract, often where there is a defect in host defenses and/or a virulent or overwhelming invasion of organisms.

Contaminates may also enter the patient's lungs from condensation on the intubation drainage tubing or because intubation itself bypasses the natural barrier between oropharynx and trachea. Bronchoscopy, tracheal suctioning, manual ventilation, the supine position of the patient and the use of paralytic agents may also play a role in the development of bacterial pneumonia in these patients.

VAP complicates the course of up to 47% of intubated patients and may have a mortality rate as high as 50%.

Following the guidelines in ACS 1904 Procedural complications the correct code to assign for ventilator associated pneumonia (VAP) is J95.8 Other postprocedural respiratory disorders following the pathway:

Pneumonia

- postprocedural J95.8

Assign also an additional code for the type of pneumonia from the choices listed under the lead term Pneumonia, plus the following external cause codes:

Y84.8 Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure, Other medical procedures

Y92.22 Health service area

ASERNIPS, Kidney transplantation using incompatible blood group donors, February 2008. Accessed 11 November 2008: http://www.surgeons.org/AM/Template.cfm?Section=ASERNIP_S_NET_S_Database&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=17&ContentID=4938

ASERNIPS, ProACT? Therapy for male stress urinary incontinence, October 2007. Accessed 10 November 2008: http://www.horizonscanning.gov.au/internet/horizon/publishing.nsf/Content/asernip-s-net-s-summaries-2007

Berry, Angela, CNC, Intensive Care Unit, Westmead Hospital, Sydney West Area Health Service, Ventilator Associated Pneumonia (VAP). Accessed 24 July 2008. http://intensivecare.hsnet.nsw.gov.au/five/doc/icuconnect/hospital%20contributions/2006/november_VAP_westmead.pdf

Chang et.al, Chronic Wet Cough: Protracted Bronchitis, Chronic Suppurative Lung Disease and Bronchiectasis, Pediatric Pulmonology 43:519-531. Accessed 23 October 2008 http://www.interscience.wiley.com

Friedman, N Deborah, Russo Philip L. Richards, Michael J, Surveillance for ventilator-associated pneumonia: the challenges and pitfalls, A report from the VOCNISS Coordinating Centre, Victoria, Australia, Vol.10 Issue 4, December 2005. Accessed 24 July 2008. http://www.publish.csiro.au/?act=view_file&file_id=HI05122.pdf

Hubner and Schlarp 2005, Treatment of incontinence after prostatectomy using a new minimally invasive device: adjustable continence therapy, BJU International, Vol 96, Issue 4 (p 587 - 594). Accessed 10 November 2008: http://www3.interscience.wiley.com/cgi-bin/fulltext/118670052/PDFSTART

Lawee, David, Mild Infectious Mononucleosis presenting with transient mixed liver disease, The College of Family Physicians of Canada. Accessed 29 July 2008 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1949255

Patient UK, Pelvic Inflammatory Disease (PID). Accessed 24 July 2008 http://www.patient.co.uk/showdoc/40000099

St. Vincent's Clinic, Dr Raji Kooner, Treatment Options, Laser Surgery. Accessed 11 November2008: http://www.roboticprostatesurgery.com.au/to_lasersurgery.html

Virology Down Under, Epstein-Barr Virus. Accessed 24 July 2008. http://www.uq.edu.au/vdu/VDUEBV.htm

Virtual Medical Centre.com, Pelvic Inflammatory Disease. Accessed 24 July 2008. http://www.virtualendocrinecentre.com/diseases.asp?did=791

This is the second of a two part series on FAQs which were asked at the ICD-10-AM/ACHI/ACS Sixth Edition education workshops held during April - June 2008.

Part 1 was published in the September Edition of Coding Matters refer Volume 15 No.2.

The title of this ACS has changed from ‘Prematurity and low birth weight’ to ‘Low birth weight and gestational age’ and the prematurity section in this standard has been deleted.

Previous advice in ACS 1618 included the following:

However, if the infant is > 28 days old and ≥ 2500g on admission, assign Z51.88 Other specified medical care as the principal diagnosis and a code from P07 as an additional diagnosis.

This advice has been amended and incorporated into ACS 1605 where the following excerpt is significant.

Codes from ICD-10-AM Chapter 16 Certain conditions originating in the perinatal period:

• will still apply for infants > 28 days who are still in the birth episode and
• will still apply for infants > 28 days who are discharged and subsequently readmitted with a condition documented as originating in the perinatal period.

These changes allow coders to assign the codes for prematurity for babies who are transferred for ‘fattening up’ post premature birth.

Version 6.0 AR-DRGs due for release later this year will allow appropriate grouping of these cases. However, the current and previous versions of AR-DRGs will assign these patients to error DRG 963Z Neonatal diagnosis not consistent with age/weight.

Coders should contact their respective health departments to discuss funding implications of this change to the Australian Coding Standard.

What are the correct codes to assign for calculi of the VUJ and PUJ?
There are no index entries for calculi of the VUJ or PUJ. Therefore, codes should be assigned based on the higher anatomical site. The correct code to assign for a calculus of the vesicoureteric junction is N20.1 Calculus of ureter and the correct code to assign for a calculus of the pelvoureteric junction is N20.0 Calculus of kidney.

Should a separate code be assigned for the insertion of a capsular/intracapsular tension ring during cataract surgery?

It is estimated by the World Health Organization (WHO) that 12 to 15 million people go blind from cataracts and 8 million cataract operations are carried out world-wide each year. Such operations involve surgical removal of the opacified lens and substitution with an artificial intraocular lens.

Capsular/intracapsular tension rings are sometimes used to provide stabilisation of the capsular bag and the intraocular lens both during and after surgery and to prevent capsular bag shrinkage. They may also be used for patients with loose or broken zonules (ligaments that suspend the lens), which may have been weakened or broken due to trauma or disease.

Capsular/intracapsular tension rings are in use in Australian health care but they are not used in every cataract repair. There is still debate as to whether these rings prevent the occurrence of capsular bag shrinkage and whether they are appropriate for use in children.

As capsular/intracapsular tension rings are a component procedure of some cataract operations it is unnecessary to assign a separate code for their insertion as per the guidelines in ACS 0016 General Procedure Guidelines — Procedure components.

Do you need to assign procedure codes for insertion of central venous and arterial lines when inserted under general anaesthetic during coronary artery bypass grafting?

Insertion of central venous and arterial lines are considered routine for patients undergoing coronary artery bypass grafting. Therefore, it is unnecessary to assign codes for them. However, if they are inserted as a stand alone procedure under an anaesthetic (except local) they should be coded as per the guidelines in ACS 0042 Procedures normally not coded, point b, which states:

“The listed procedures should be coded if anaesthesia (except local) is required for the procedure (see ACS 0031 Anaesthesia).”

ACS 0042 Procedures normally not coded will be reviewed in conjunction with ACS 0909 Coronary artery bypass grafts for a future edition of the ACS.

Note: This advice should also be applied when central venous and arterial lines are performed as a component of any type of surgery.

Coding of dental procedures is a very specialised area that requires an understanding of dental terminology and anatomy. This article is part one of a two part article written to assist coders to understand common procedures and terms used in dental services.

In ACHI, Sixth Edition dental intervention codes are based on The Australian Schedule of Dental Services (Eighth Edition) published by the Australian Dental Association incorporated.

 

Tooth Anatomy

Knowledge of the anatomy of teeth is important in the understanding of both the disease processes and interventions required for the treatment of dental diseases (see Figure 1).

Figure 1 - Tooth Anatomy

Definitions

Enamel - the tough, shiny, white outer surface of the tooth.

Dentin - the hard but porous tissue located under both the enamel and cementum of the tooth. Dentin is harder than bone.

Cementum - the layer of tough, yellowish, bone-like tissue that covers the root of a tooth. It helps hold the tooth in the socket. The cementum contains the periodontal membrane.

Crown - the visible part of a tooth.

Tooth root - the portion of the tooth that lies beneath the gum line and is embedded in bone. The tooth root serves as an anchor to hold the tooth in position.

Pulp - the soft inner structure of a tooth consisting of nerve and blood vessels.

Gingiva - the gum.

Deciduous teeth - the primary or baby teeth; the first set of teeth that are later replaced by permanent teeth.

Exfoliation - the process by which the deciduous teeth fall out to make way for the eruption of permanent teeth.

Eruption - the process by which the teeth break through the gums.

Figure 2 - Types of Teeth

Incisors - the four front teeth in the lower and upper jaw are called incisors. The central pair in the lower and upper jaw are called central incisors and the teeth on either side of the central incisors are called lateral incisors. These teeth are broad and flat with a narrow edge that is used for cutting or snipping off pieces of food.

Canines - the four canine teeth are situated next to the lateral incisors on the lower and upper jaw. They are also referred to as eyeteeth or cuspids. Canines are the longest and most stable teeth in the mouth. They are used to rip and tear food and have a single long root.

Premolars - next to each of the canine teeth are two premolars, also referred to as bicuspids. These teeth are a cross between canines and molars. Like the canine teeth, premolars have sharp points for ripping; however, they also have a broad surface, like molars, for chewing and grinding.

Molars - these are the last three teeth on both sides of the mouth, in the upper and lower jaw. They are numbered first, second or third molar according to their location.

The third molars are also referred to as wisdom teeth. Wisdom teeth are the last teeth in the mouth and are the last teeth to erupt. Molars are the largest teeth in the mouth. They have a broad surface that is used for crushing, grinding and chewing food.

 

Dental notation

Tooth numbering systems are used by dentists to associate information to a specific tooth. These notation systems are used in medical records and operation reports to help to identify which specific tooth is being treated. Two common tooth numbering systems used in Australia are the Federation Dentaire Internationale (FDI) Two Digit Notification method and the Palmer notification method.

FDI Two Digit Notification Method

This notification method is a combination of two numbers. The first number indicates the tooth's location (upper left or right, lower left or right) and the second number indicates the specific tooth (see Table 1).

 

Palmer notification method

Permanent teeth
In this method, the teeth are also divided into quadrants and are numbered from 1 to 8 in the same manner as the FDI notification method. The method of identifying the specific quadrant however is different. Each quadrant is identified by an shaped symbol. The number of the tooth then sits inside the shaped symbol. The refers to teeth in the upper right quadrant, the refers to teeth in the upper left quadrant. The lower quadrants are identified by the upside down shaped symbols. The refers to the lower right quadrant and the refers to the lower left quadrant (see Figure 4 and Example 1).

Deciduous teeth

The Palmer notification method has a different method of numbering deciduous teeth. The teeth are identified by the letters A to E. The teeth are assigned a letter starting at the central incisor (A) and working toward the 3rd molar (E). The system for the identification of the tooth's position is exactly the same as for permanent teeth (see Figure 5 and Example 2)

 

Position of teeth

Anterior - are the teeth in front of the mouth, e.g. central incisors, lateral incisors and cuspids.

Posterior - are the teeth at the back of the mouth including molars and bicuspids.

 

Tooth Surfaces

There are five possible tooth surfaces that can be restored - buccal, distal, lingual, mesial, and occlusal/incisal (see Figure 7).

Buccal - is the surface of the tooth that faces toward the cheek.

Distal - is the proximal surface that is orientated away from the midline of the dental arch. It is the opposite of mesial.

Lingual - is the tooth surface next to the tongue.

Mesial - is the proximal surface that is closest to the midline of the dental arch.

Occlusal - is the surface of the tooth that has contact with the opposing tooth.

Incisal - is the surface of the tooth that has contact with the opposing anterior teeth. It refers to the cutting edge of an incisor or canine tooth.

Dental arch - is the curved structure that is formed by the teeth in their normal position.

 

Dental restorations

Dental restorations or fillings are used to restore function and integrity to the structure of teeth. The most common causes for the loss of tooth structure are dental caries or tooth trauma.

Dental restorations are classified into two types, direct and indirect (see Table 3).

Direct restorations are performed by placing the restorative material directly onto the tooth. These types of restorations are usually performed in one visit and examples include dental amalgam, glass ionomers, resin ionomers and resin composite fillings.

Indirect restorations involve materials that have been fabricated outside the mouth. Examples include: inlays, onlays, veneers, crowns and bridges.

 

Types of tooth impaction

This is the second of a two-part series to provide guidance on the coding of dental procedures. It provides advice on the classification of dental procedures and tables listing the types of interventions that may be performed.

In ACHI, Sixth Edition dental intervention codes are based on The Australian Schedule of Dental Services and Glossary (8th Edition) published by the Australian Dental Association Incorporated (see reference details below).

 

NCCH published tables in Coding Matters Vol 7, No 3 containing commonly performed dental procedures with definitions. The following tables are an update of the previously published information.

+ Preventative

 

+ Periodontic Interventions

 

+ Oral Surgery

 

+ Endodontics

 

+ Restorative Types

 

+ Prosthodontics

 

+ Orthodontics

 

+ General Dental Services

 

The ICD-10-AM Third Edition Education Program Frequently Asked Questions (FAQs) — part 2 — contained the following advice:

‘Diabetes should be coded when it meets the criteria in ACS 0002 Additional diagnoses. The taking of BSLs is one indication that diabetes mellitus meets the criteria of ACS 0002.’

This advice was also published on the NCCH Queries Database.

ACS 0002 Additional diagnoses has been revised for the ACS Sixth Edition. During the revision process, the issue of diabetes and BSLs was discussed by the NCCH and the Coding Standards Advisory Committee (CSAC). Both the NCCH and CSAC subsequently supported the advice that diabetes should only be coded when it meets the criteria in ACS 0002. Revision to ACS 0002 advises:

“The national morbidity data collection is not intended to describe the current disease status of the inpatient population but rather, the conditions that are significant in terms of treatment required, investigations needed and resources used in each episode of care.

For coding purposes, additional diagnoses should be interpreted as conditions that affect patient management in terms of requiring any of the following:

• commencement, alteration or adjustment of therapeutic treatment
• diagnostic procedures
• increased clinical care and/or monitoring.”

The above criteria should be applied to each individual case in order to determine the appropriateness of assigning codes for diabetes mellitus. Coders should not automatically assign diabetes codes when BSLs are documented in the clinical record. BSLs are routinely recorded for many diabetic patients and should therefore not be assumed to indicate increased clinical care or monitoring.

As this advice may lead to a change in coding practice for some coders it is effective from the implementation of ICD-10-AM Sixth Edition, July 2008.

What is the correct code to assign for diarrhoea due to Clostridium difficile?

Clostridium difficile is the most common cause of infectious hospital-acquired diarrhoea in developed countries. Although in most cases it causes a relatively mild illness, occasionally, and particularly in elderly patients, it may result in serious illness and even death. The bacterium produces two toxins which are responsible for the diarrhoea and which damage the cells lining the bowel. However, not all strains of C. difficile produce toxin; these strains are unlikely to cause disease and patients colonised by them remain healthy.

Almost all patients who develop C. difficile diarrhoea are taking, or have recently been given, antibiotic therapy. Diarrhoea is the most common symptom but abdominal pain and fever may also occur. In the majority of patients, the illness is mild and full recovery is usual, although elderly patients may become seriously ill with dehydration as a consequence of the diarrhoea. Occasionally patients may develop a severe form of the disease called pseudomembranous colitis, which is characterised by significant damage to the large bowel.

The current index pathway directs coders to assign A04.8 Other specified bacterial intestinal infections. However, clinical advice received by the NCCH indicates that the correct code to assign is A04.7 Enterocolitis due to Clostridium difficile.

The indexing of this condition will be reviewed for a future edition of ICD-10-AM.

This advice highlights a change to current coding practice and is effective from the implementation of ICD-10-AM Sixth Edition, July 2008.

What is the correct code to assign for dropped lens/nucleus?

Clinical advice regarding dropped lens/nucleus indicated the following:

“There are two types of lenses that can drop; the human crystalline lens (which can become cataractous) and an intraocular lens.

The most common cause of ‘dropped’ cataractous lens is when (usually) part of the lens is dropped during cataract surgery, typically the nucleus of the lens. This occurs either because of a hole being torn in the capsule of the lens or because the attachments of the lens to the ciliary body via the zonular fibres are weak and disrupted by the trauma of the surgery.

Intraocular lenses can be dropped at the time of surgery, usually where the capsule is torn. They can also dislodge later in the post-operative course, depending largely on how they have been fixated. Typically, lenses placed in the so called ciliary sulcus are dislodged. Late dislodgement can occur when the capsular bag dislodges from the ciliary body. The alignment of the intraocular lens can also change in the longer term because of particular patterns of fibrosis in the capsular bag.”

When lens fragments/nucleus are dropped into the vitreous cavity after a capsular breach, assign:

T81.2 Accidental puncture and laceration during a procedure, not elsewhere classified

S05.8 Other injuries of eye and orbit

Y60.0 Unintentional cut, puncture, perforation or haemorrhage during surgical and medical care, During surgical operation

Y92.22 Health service area

Where there is a later displacement of the lens, without documentation of a capsular breach, assign:

T85.2 Mechanical complication of intraocular lens

Y83.1 Surgical operation and other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure, Surgical operation with implant of artificial internal device

Y92.22 Health service area

Patient admitted with gallstone ileus. What is the correct code to assign for jejunotomy (open procedure) with removal of calculus and cholecystotomy?

The following codes should be assigned for the abovementioned procedures:

30375-03 [893] Enterotomy of small intestine

30375-26 [963] Cholecystotomy

The NCCH and CSAC have agreed that malnutrition may be coded when it is documented by a dietitian in the clinical record. This decision is supported in the Introduction to the Australian Coding Standards (ACS) as follows:

“The term ‘clinician’ is used throughout the document and refers to the treating medical officer but may refer to other clinicians such as midwives, nurses and allied health professionals. In order to assign a code associated with a particular clinician’s documentation, the documented information must be appropriate to the clinician’s discipline.”

Dietitians meet the definition of a clinician in the ACS and diagnosis and treatment of malnutrition is appropriate to their profession.

Malnutrition must meet the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses to be coded.

Is it necessary to assign a code for Seprafilm® inserted during a procedure?
To reduce the occurrence of adhesions following surgery, surgeons can use adhesion barriers to separate tissue and organs while the body heals. Seprafilm® is a type of adhesion barrier composed of chemically modified sugars, some of which occur naturally in the human body. It is a clear film that sticks to the tissues to which it is applied and is slowly absorbed into the body over a period of seven days. It is placed at sites of tissue injury during surgery (commonly abdominal and pelvic surgery) to help prevent the formation of adhesions between tissues and organs.

The insertion of Seprafilm® is a prophylactic measure which is completely absorbed into the body and does not require removal. It is unnecessary to assign a code for this procedure.

What is the correct code to assign for slow coronary flow/slow flow syndrome?
The concept of slow coronary flow was first diagnosed in 1972. The coronary slow flow phenomenon is an angiographic finding characterised by delayed distal vessel opacification in the absence of significant epicardial coronary disease. It typically presents as persistent chest pain or angina pectoris and can significantly impair quality of life.

Clinical advice indicates that this is not a new syndrome but is more frequently identified now due to an increase in the number of angiograms performed. The correct code to assign for slow coronary flow syndrome is I20.8 Other forms of angina pectoris.

Vascular access devices
ACHI defines a vascular access device (VAD) as an implanted venous catheter with a reservoir attached. The subcutaneous reservoir is designed to accept multiple punctures from special types of needles (e.g. Huber or Gripper needles) and may be accessed to withdraw fluid or to infuse substances. A Port-A-Cath is a type of VAD used in Australian facilities.

Classification
Where patients are admitted for adjustment, management, fitting or removal of a vascular access device, assign:

Z45.2 Adjustment and management of vascular access device

ACHI codes for insertion, revision and removal of VADs are in block [766] Vascular access device

Vascular/venous catheters
In ACHI, central venous catheters that don‘t have subcutaneous reservoirs (Hickman‘s, PICC lines) are classified as vascular/venous catheters and not as vascular access devices.

Classification
Where patients are admitted for adjustment, management, fitting or removal of vascular/venous catheters (without reservoirs), assign:

Z45.8 Adjustment and management of other implanted devices

ACHI codes for insertion and removal of vascular/venous catheters (Hickman‘s, PICCs and CVCs) are in block [738] Venous catheterisation.

Drug delivery devices
A drug delivery device is a piece of equipment used to administer pharmacological substances.

An ambulatory, external infusion pump is a type of drug delivery device that is attached to a vascular access device to infuse substances over long periods. The pump is computerised to allow the administration of a prescribed dose and rate of medication over a defined time period. External drug delivery devices may also be attached to venous catheters (without reservoirs) — for example, a Hickman‘s Drug delivery devicess line - or other, nonvascular catheters for administration of pharmacological agents via other routes — for example, for the subcutaneous administration of insulin (via an insulin pump).

ACHI also contains codes for implantable drug delivery devices, such as the implantable spinal infusion device or pump. These devices administer drug therapy for pain control directly into the intrathecal space. A catheter is inserted into the spinal canal and attached to a pump implanted in the abdomen or chest wall.

Classification
Where patients are admitted for adjustment, management, fitting or removal of a drug delivery device, (except for loading of a drug delivery device for same-day admission of chemotherapy to treat a neoplasm — see examples 7 and 8) assign:

Z45.1 Adjustment and management of drug delivery device

ACHI codes for insertion, replacement or removal of an implantable spinal infusion device or pump are:

39127-00 [39] Insertion of implantable spinal infusion device or pump

39126-00 [56] Revision of implantable spinal infusion device or pump

39133-02 [40] Removal of implantable spinal infusion device or pump

ASERNIP-S, Australian Safety and Efficacy Register of New Interventional Procedures - Surgical, Rapid Review, Intracapsular Tension Ring, September 2001, The Royal Australasian College of Surgeons. Accessed 12 May 2008. http://www.surgeons.org/AM/Template.cfm?Section=Home&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=4853

Association of Medical Microbiologists, Facts about Clostridium difficle infection. Accessed 26 October 2007. http://www.amm.co.uk/files/factsabout/fa_cdiff.htm

Beltrame JF, Limaye SB, Horowitz JD, The Coronary Slow Flow Phenomenon - A New Coronary Microvascular Disorder, Cardiology, International Journal of Cardiovascular Medicine, Surgery, Pathology and Pharmacology, Vol. 97, No. 4, 2002, pages 197-202. Accessed 12 May 2008.

Chee S-P, Cataract and Refractive Surgery Today, PAL of a Dropped Nucleus. Accessed 15 February 2008. http://www.crstodayeurope.com/Issues/0307/f6_chee.html

Riley TV, Epidemic Clostridium difficile, eMJA, The Medical Journal of Australia, Vol. 185, No. 3, 2006, pages 133-134. Accessed 12 November 2007. http://www.mja.com.au/public/issues/185_03_070806/ril10472_fm.html

Fazio VW, Cohen Z, Fleshman JW et.al., Reduction in Adhesive Small-Bowel Obstruction by Seprafilm® Adhesion Barrier After Intestinal Resection, (Dis Colon Rectum 2005 49 (1): 1-11), Presentation at Prince of Wales Hospital Journal Club by Dr Anita Jacombs BST. Accessed 12 May 2008. http://www.sesiahs.health.nsw.gov.au/powh/General%20Surgery/Journal%20Club/POWH%20Journal%20Club.ppt

Genzyme Australasia, Seprafilm®. Accessed 12 May 2008. http://www.genzyme.com.au/prod/sepraf/au_p_hcp_bio-seprafilm.asp

Intermedex, Ultrasonic Phacoemulsification Handpieces. Accessed 15 February, 2008. http://www.intermedex.com/phaco.html

Li J-J, Wu Y-J, Qin X-W, Should slow coronary flow be considered as a coronary syndrome? Medical Hypotheses, Vol. 66, No. 5, 2006, pages 953-956, ScienceDirect, Health Science Journals. Accessed 12 May 2008.

Visitech, Visitech Eye Hospital, Dropped Lens. Accessed 6 February 2008. http://www.visitech.org/case-dropped-lens.html