Download April 2015 Coding Queries

Queries discussed by
WA Clinical Coding Advisory Group
Meeting on 1st April 2015
Attendees: Deb Yagmich, Brooke Holroyd, Rosi Katich, Elise Groenewold, Bill Pyper, Sharon Linton, Silvana Rossi, Brian
Stanley, Jennifer Vardy, Anita Jacoby.
Apologies: Dragana Losic, Wilhelmina Blocher, Tonia Brockman, Liz Gecan, Dimity Mutton.
Query no.
Query Description
Decision
1
Alcohol or drug withdrawal
scale
Recommendation: Patients who have been drinking alcohol or taking drugs prior to their admission are often placed on
an alcohol or drug withdrawal chart during their inpatient admission. The purpose of this chart is to monitor the patient for
withdrawal. During this process of monitoring patients may be given medications, such as diazepam, to prevent
withdrawal.
Should alcohol or drug
withdrawal be coded if a
patient is placed on an alcohol
or drug withdrawal scale
during their admission?
The presence of an alcohol or drug withdrawal chart or scale in a patient’s medical record does not meet the criteria for
assignment of a code for withdrawal. Withdrawal is a clearly defined physical state and must be clearly documented by the
clinician. It must also meet the criteria in ACS 0002 Additional diagnoses in that it requires:
 commencement, alteration or adjustment of therapeutic treatment
 diagnostic procedures
 increased clinical care and/or monitoring.
Medication such as diazepam may be given prophylactically, to prevent withdrawal, and should not be seen as evidence
of withdrawal being present. Coders should query with the clinician if medication was administered, as this may be an
indication that the patient was in withdrawal.
If the coder is unable to verify that withdrawal was present and no other use disorder (such as dependence) was present,
a code for harmful use (fourth character of ‘1’) may be assigned for documentation of ‘abuse’ or ‘use disorder’ to prevent
loss of vital alcohol/drug information, as per the instruction in ACS 0503 Drug, alcohol and tobacco use disorders.
Decision: Alcohol or drug withdrawal must be clearly documented by the clinician and must meet the criteria in
ACS 0002 Additional diagnoses to be coded. If withdrawal is not documented, the coder may assign a code for
harmful use for documentation of ‘abuse’ or ‘use disorder’.
[WA Clinical Coding Advisory Group Decision Date: 01/04/2015]
1
continued
Query no.
Query Description
Decision
2
Diagnosis for same-day
removal of cervical suture
Recommendation: A cervical suture, also known as cervical cerclage, McDonald suture, Shirodkar suture or cervical
stitch, is a treatment for cervical incompetence or insufficiency during pregnancy. When the cervix is incompetent, it
dilates too early in the pregnancy and increases the risk of a late miscarriage or preterm birth. To prevent this, a suture is
inserted into and around the cervix early in pregnancy (between 12 and 14 weeks). Generally, the suture is removed
towards the end of the pregnancy to allow for vaginal delivery. Some types of sutures are permanent and the patient must
deliver by caesarean section.
What is the correct principal
diagnosis code to assign when
a patient is admitted as a
same-day case for removal of
a cervical suture, originally
inserted for cervical
incompetence?
Removal of the cervical suture is a component of the continuing treatment for cervical incompetence and therefore should
be assigned a principal diagnosis code of O34.3 Maternal care for cervical incompetence.
Decision: The principal diagnosis for same-day removal of cervical suture for cervical incompetence should be
O34.3 Maternal care for cervical incompetence.
[WA Clinical Coding Advisory Group Decision Date: 01/04/2015]
3
Os acromiale
What is the correct code to
assign for os acromiale?
Recommendation: The acromion is the bony roof of the shoulder. The bone has three separate cartilage growth centres,
and in the process of development, the acromion transforms from four separate bones into one single bone. In certain
people, one of the three growth centres does not become bone. This condition is called os acromiale. The remaining
cartilage growth centre allows for a small degree of motion of the acromion. This motion may have the ability to pinch the
group of tendons responsible for function of the shoulder and upper arm (rotator cuff), or may pinch a fluid-filled sac that
reduces the friction between the acromion and the rotator cuff (subacromial bursa). This condition may or may not cause
rotator cuff inflammation and shoulder pain.
Clinical advice is that os acromiale is a disorder of bone development and therefore should be coded to M89.21 Other
disorders of bone development and growth, shoulder region.
Use of this code for a patient over 19 years will trigger an age edit, which can be responded to as ‘correct’.
Decision: Os acromiale should be coded to M89.21 Other disorders of bone development and growth, shoulder
region.
[WA Clinical Coding Advisory Group Decision Date: 01/04/2015]
4
Hypertension in APSGN
Which code should be
assigned for hypertension in
children who are admitted for
acute post-streptococcal
Recommendation: Acute post-streptococcal glomerulonephritis (APSGN) is an inflammatory disease of the kidneys
which occurs 2 to 3 weeks after skin or throat infection with group A streptococcus. Not all types of streptococcus cause
kidney problems, only those caused by nephritogenic strains. The streptococcal infection causes the glomeruli of the
kidneys to become inflamed by an immunologic process. The exact mechanism remains to be determined. APSGN can
cause haematuria, hypertension, oedema, oliguria and proteinuria. It most commonly affects children but can occur at any
age.
2
continued
Query no.
Query Description
Decision
glomerulonephritis?
Treatment of APSGN focuses on relieving the symptoms. Antibiotics may be given to destroy any streptococcal bacteria
that remain in the body. Blood pressure and diuretic medications may be needed to control oedema and high blood
pressure.
Even though hypertension is a symptom of APSGN, if it is treated as a condition in its own right (i.e. by the administration
of antihypertensive medication), it should be coded.
If hypertension is documented as due to APSGN, it should be coded to I15.1 Hypertension secondary to other kidney
disorders. The clinician may be queried if documentation is unclear.
Decision: Hypertension due to APSGN should be coded to I15.1 Hypertension secondary to other kidney
disorders, if it meets the criteria for coding in ACS 0002 Additional diagnoses. If documentation is unclear, the
coder may seek clinical advice.
[WA Clinical Coding Advisory Group Decision Date: 01/04/2015]
5
Cellulitis/abscess due to
self-injecting
In light of the March 2015
Coding Rule ‘Cellulitis of an
infected blister’, should T79.3
Post traumatic wound
infection, NEC also be
assigned with the cellulitis
code in the January 2010
CCWA query?
Recommendation: The CCWA query in January 2010 recommended:
Query: What is the correct external cause code for cellulitis of thigh due to self-injecting steroids?
Decision: The correct external cause code is W46 Contact with hypodermic needle
Recommendation: Assign codes:
L03.11 Cellulitis of lower limb
S70.9 Superficial injury of hip and thigh, unspecified
W46 Contact with hypodermic needle
Y92.9 Place of occurrence at or in unspecified place of occurrence
U73.9 Injury or poisoning occurring while engaged in unspecified activity
If there is no cellulitis or abscess documented code T79.3 Post traumatic wound infection, not elsewhere
classified is required to show that the site is infected.
S70.9 Superficial injury of hip and thigh, unspecified
T79.3 Post traumatic wound infection, not elsewhere classified
W46 Contact with hypodermic needle
Y92.9 Place of occurrence at or in unspecified place of occurrence
U73.9 Injury or poisoning occurring while engaged in unspecified activity
ACCD Coding Rule March 2015 ‘Cellulitis of an infected blister’ states that T79.3 Post traumatic wound infection, NEC
should be assigned with a cellulitis code when coding cellulitis of a superficial injury as instructed in ACS 1916 Superficial
3
continued
Query no.
Query Description
Decision
injuries.
To be in line with national advice, we recommend assigning T79.3 Post traumatic wound infection, NEC in addition to the
cellulitis code in the first example of the above query.
Decision: CCWA decision ‘Cellulitis/abscess due to self-injecting’ is still current, however we recommend also
assigning T79.3 Post traumatic wound infection, NEC in addition to the cellulitis code in the first example of the
query.
[WA Clinical Coding Advisory Group Decision Date: 01/04/2015]
WA advice replaced by ACCD advice
1
Cellulitis of an infected
blister
Q: Patient admitted for cellulitis of an infected blister of the index finger. Swabs taken of the blister grew Staphylococcus
aureus which clinical documentation confirmed as the source of the infection. Should a code for cellulitis be assigned as
well as T79.3 Post traumatic wound infection, not elsewhere classified, as per ACS 1916 Superficial injuries?
A:
ACS 1916 Superficial injuries instructs that T79.3 Post traumatic wound infection, not elsewhere classified and a code for
the associated infectious agent should be assigned as additional codes if a superficial injury is infected. The instruction in
the specialty standard should be followed despite T79.3 being an NEC code. However it does not preclude the
assignment of a more specific code for the infection, such as cellulitis in the scenario cited. For example:
Patient admitted for cellulitis of an infected blister of the index finger. Documentation in the clinical record confirms an
associated infection with Staphylococcus aureus.
The following codes would be assigned (and sequenced following the principles in ACS 0001 Principal diagnosis):
L03.01 Cellulitis of finger
S60.82 Blister of wrist and hand
T79.3 Post traumatic wound infection, not elsewhere classified
B95.6 Staphylococcus aureus as the cause of diseases classified to other chapters
and appropriate external cause of injury codes.
ACS 1916 Superficial injuries has been identified for review for a future edition.
[Coding Rules, March 2015]
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continued
Query no.
Query Description
Decision
2
Skin rollering
Q: What is the correct procedure code to assign for skin rollering?
A: Skin rollering is also known as skin needling or percutaneous collagen induction therapy. A dermaroller with tiny
stainless steel acupuncture needles causes multiple tiny pinpoint puncture wounds to the dermis. This dermal damage
induces the production of new collagen and elastin, resulting in smooth skin, soft lines and reduction of stretch mark and
scars through the skin’s natural wound healing process. Skin rollering creates damage to the dermis but without the
removal of the healthy epidermis, which happens with other resurfacing techniques.
As there is no specific ACHI code for skin rollering procedure, assign:
90676-00 [1660] Other procedures on skin and subcutaneous tissue following the index pathway:
Procedure
- skin (subcutaneous tissue) NEC 90676-00 [1660]
[Coding Rules, March 2015]
3
VAC dressings
Q: Should VAC dressings be coded?
A:
Vacuum assisted wound closure (VAC) is a type of wound dressing which uses negative pressure to promote wound
healing. The wound is covered with open cell foam or gauze dressing that moulds to the wound bed. A drainage tube is
attached, the wound is then sealed and vacuum or negative pressure is applied via a pump. The suction pressure
removes or ‘debrides’ loose tissue and has been shown to reduce swelling, aid wound closure and promote formulation of
granulation tissue.
VAC dressings are classified in ACHI as a nonexcisional debridement and therefore assign the following code as
appropriate when performed:
90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue
or
90686-00 [1627] Nonexcisional debridement of burn.
As VAC dressings are classified to nonexcisional debridement, ACS 0042 Procedures not normally coded, point 7 –
Dressings, does not apply.
This will be clarified in ACS 0042 Procedures not normally code, point 7 – Dressings in a future edition.
[Coding Rules, March 2015]
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continued
Query no.
Query Description
Decision
4
Laceration with debridement
Q:
Is it necessary to assign a code for suturing of skin in addition to a code for (excisional) debridement?
A:
When excisional debridement is performed, it is not necessary to assign an additional code for suturing of a wound at the
same site of the debridement. The suturing of the wound is a component of the procedure, as per the guidelines in ACS
0016 General Procedure Guidelines/Procedure components.
Improvements to ACHI Alphabetic Index will be considered for a future edition.
5
High metal ions and
metallosis due to THR
[Coding Rules, March 2015]
Q:
How do you code metallosis due to metal-on-metal joint prostheses (for example, total hip replacements)?
A:
Metallosis may occur due to the adverse effects of metal debris from metallic joint prostheses, particularly following total
hip replacement.
The acetabular cup and implant head in metal-on-metal implants are composed of cobalt-chromium alloys. Continuous
movement of the hip joint results in micro-particles of metal being released into the soft tissues; these micro-particles may
result in necrosis surrounding the implant or corrode and release metal ions into the systemic circulation resulting in
elevated serum levels of chromium and cobalt. Metal poisoning occurs when toxic levels of these metals accumulate,
leading to implant failure, tissue and bone necrosis, and organ damage.
Metallosis may result in localised or systemic effects, such as:
- tissue or bone necrosis or pseudotumour formation adjacent to the prosthesis
- cardiomyopathy or heart failure
- visual impairment, that may lead to blindness
- skin rashes
- nervous system dysfunction (cognitive impairment, memory loss, depression)
- thyroid dysfunction
Patients may describe joint pain, a metallic taste, headaches, anorexia and weight loss.
A revision procedure is required to replace the metal-on-metal implant with a nonmetallic implant (for example, ceramic
and polyethylene).
6
continued
Query no.
Query Description
Decision
As the metallosis is due to a breakdown of the prosthesis it is classified as a mechanical complication of the device.
Therefore, where there is documented evidence of metallosis due to a joint prosthesis, assign:
T84.0 Mechanical complication of internal joint prosthesis
Y83.1 Surgical operation with implant of artificial internal device
Y92.22 Heath service area
Where documentation specifies that the patient has excessively high serum levels of cobalt or chromium, assign as an
additional diagnosis:
R79.0 Abnormal level of blood mineral
As per the guidelines in ACS 1904 Procedural complications: An additional code from Chapters 1 to 19 should be
assigned where it provides further specificity.
Additional codes for any specific manifestations should be assigned based on documentation in the clinical record and the
criteria for code assignment in ACS 0002 Additional diagnoses.
[Coding Rules, March 2015]
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