ICD-10-AM T Code Survey Guidlines

NCCH is now working on the development of ICD-10-AM seventh edition and would like your help in making improvements to the complication code section T80 ? T88.Complications of surgical and medical care not elsewhere classified Analysis of the national morbidity data indicates that the following codes are heavily used in Australian hospitals, but because these codes indicate ?other? complications we are unclear what conditions or circumstances are being assigned to these codes:

Code

Description

Count

T781

Other adverse food reactions, not elsewhere classified

837

T808

Other complications following infusion, transfusion and therapeutic injection

1560

T818

Other complications of procedures, not elsewhere classified

8593

T828

Other complications of cardiac and vascular prosthetic devices, implants and grafts

8150

T838

Other complications of genitourinary prosthetic devices, implants and grafts

2177

T848

Other complications of internal orthopaedic prosthetic devices, implants and grafts

4202

T8581

Other complications due to nervous system device, implant or graft

676

T8588

Other complications of internal prosthetic device, implant or graft, NEC

2870

T876

Other and unspecified complications of amputation stump

734

T885

Other complications of anaesthesia

1151

T888

Other specified complications of surgical and medical care, not elsewhere classified

701

 

If we can collect some data about why coders use these codes, we may be able to include some of these conditions in a revised classification in ICD-10-AM seventh edition (to be implemented in 2010) which will in turn provide greater clarity about complications in health care in the morbidity data collection.

We are asking for coders to contribute either via hardcopy or by entering responses on our website. Firstly, you will need to register your intent to participate with us and nominate whether you will contribute on the website or by hardcopy.

We?d like coders to tell us what condition/s you were coding when assigning one of the above codes. We are interested in receiving the words or phrases you found in the medical record which directly influenced your decision to use these codes. We do not want you to submit any patient information ? just the clinical words.

The information we will require is on the form inserted into this edition of Coding Matters. The website will be similar and can be viewed here when you register.

The survey will run from December 07 through to 31 October 2008.

General guidelines
When you register with us, we would like to get a contact number from you in case we need to clarify anything with you but we do not intend to contact you about this survey unless absolutely necessary.

It IS NOT necessary to indicate the case ID, in fact, please don?t ? just list the codes regardless of whether they are from one patient record or multiple records.

 If you find that you use a code for the same condition in many records, then say that in the comment so that you don?t have to repeat the same information each time you use that code.

This isn?t a rigorous investigation of each occurrence or the frequency of use of a particular code, but rather getting your feedback on how you use the codes. So while we aren?t expecting you to keep repeating the same information, we would like you to tell us when the information in the record is different for a particular code.

We would also like to know something about the following external cause codes when you use them in conjunction with the study T codes:

Y70-Y82 Medical devices associated with misadventures in diagnostic and therapeutic
use
Y83-Y84 Surgical and 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.

See an example of reporting these codes below.

The more information we have about the various types of conditions that a code is used for, and the different ways that condition or circumstances might be expressed, the better we will be at determining how best to build in all the possible index entries for a code.

So we anticipate that after a while, you may find that you have no new information arising from the records for a particular code/s - then stop reporting on that code/s.

Hardcopy participation
To register your participation, photocopy the form, and send completed forms to Kerry by fax (02 9351 9603) or by mail. A copy of the form will be available on the website also.

Website participation
Register and add your latest information at your convenience. We will make visible other submissions so participants can see what others are contributing. This is an anonymous process as only your registration number will be visible on your submissions.

If you decide to stop participating in the survey please let our contact person know.

Contact person at NCCH: Kerry Innes, 02 9351 9461, k.innes@usyd.edu.au. Please call if you have any queries.