Download December 2014 Coding Queries (PDF 290KB)

Queries discussed by
WA Clinical Coding Advisory Group
Meeting on 5th December 2014
Attendees: Deborah Yagmich, Elise Groenewold, Rosi Katich, Brooke Holroyd, Dragana Losic, Anita Jacoby, Joan Knights,
Sharon Linton, Silvana Rossi, Brian Stanley, Wilhelmina Blocher.
Apologies: Bill Pyper, Jodi Griffin, Justine Baggen, Evans Obaga.
Query no.
Query Description
Decision
1
Parkinson’s Disease with
neurogenic orthostatic
(postural) hypotension
Recommendation: CCWA 6 Ed. (Jan 2010) decision gives the following advice:
Is the CCWA decision from
January 2010 ‘Parkinson’s
disease and postural
hypotension’ still current?
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Q: Is it correct to code G90.3 Multi-system degeneration for a Parkinson’s patient with postural hypotension?
A: Pathway “Parkinsonism, with, orthostatic hypotension” = G90.3. Without a documented causal link, the ICD-10AM classification “with” does not equate to a cause and effect relationship unless there is an ACS stating
otherwise (e.g. 0401 DM and IH and 1008 COPD). Coders must ensure documentation of a link/association
between Parkinson’s and postural hypotension before assigning G90.3. Postural hypotension can be caused by
adverse effects of medication – if documented this would preclude use of G90.3. Assign G90.3 if a cause and
effect relationship is documented between Parkinson’s and postural hypotension. G20 does not need to be
assigned as an ADx. If no link and both qualify to be coded, assign G20 and I95.1
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The essential modifier ‘neurogenic’ was added to index entries for G90.3 in 7 edition:
 Hypotension; neurogenic, orthostatic
 Hypotension; orthostatic, neurogenic
 Parkinsonism; with; neurogenic orthostatic hypotension
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Addition of neurogenic as an essential modifier to G90.3 supports the original CCWA 6 Ed. advice.
Parkinson’s disease is a central nervous system disorder. Neurogenic orthostatic (postural) hypotension is a peripheral,
autonomic nervous system disorder and; occurs in patients with neurologic diseases, such as Parkinson’s disease.
Parkinson’s disease with neurogenic orthostatic hypotension = Multi-system degeneration.
There must be a documented link, association or cause and effect relationship between Parkinson’s disease and
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continued
Query no.
Query Description
Decision
orthostatic hypotension to assign G90.3 i.e. the orthostatic hypotension must be documented as neurogenic in origin.
Examples of a documented link:
 A Parkinson’s patient with documentation of ‘neurogenic orthostatic hypotension’
 ‘Parkinson’s with orthostatic hypotension’ documented in the patient notes
 Documentation of: ‘Parkinson’s:
1.1 dementia
1.2 orthostatic hypotension’
Orthostatic hypotension can also be caused by adverse effects of medication. Documentation of drug-induced, orthostatic
hypotension in a Parkinson’s patient would preclude assignment of G90.3 (See Drug induced postural hypotension,
CCWA, May 2011). If there is documentation of Parkinson’s and orthostatic hypotension, not clearly stated as neurogenic
in origin and both qualify to be coded, assign G20 Parkinson’s disease and I95.1 Orthostatic hypotension.
Decision: CCWA January 2010 decision ‘Parkinson’s Disease and postural hypotension’ has been retired. Assign
G90.3 Multi-system degeneration for documentation of Parkinson’s with orthostatic hypotension that is
neurogenic in origin or Parkinson’s with a documented link to orthostatic hypotension. If there is documentation
of Parkinson’s and orthostatic hypotension, not clearly stated as neurogenic in origin; and both qualify to be
coded, obtain clarification from the treating clinician on the origin of the orthostatic hypotension. If no link exists,
assign G20 Parkinson’s disease and I95.1 Orthostatic hypotension.
[WA Clinical Coding Advisory Group Decision Date: 05/12/2014]
2
Lavage of peritoneal cavity
If lavage of peritoneal cavity is
performed with another intraabdominal procedure, should
30396-00 [989] Debridement
and lavage of peritoneal cavity
be coded as an additional
procedure or is lavage a
procedural component?
Examples of documentation
include:
Recommendation: 30396-00 [989] Debridement and lavage of peritoneal cavity should not be routinely assigned for
documentation of lavage, washout or irrigation of the peritoneal or pelvic cavity performed during intra-abdominal surgery.
The lavage may be a routine procedural component, inherent in the intra-abdominal surgery; or it may be a significant
procedure, over and above that which is considered to be routine.
Coders should be guided by the documentation in each case, ACS 0016 General procedure guidelines, and ACS 0042
Procedures normally not coded, to determine if it is appropriate to assign 30396-00 [989] Debridement and lavage of
peritoneal cavity in addition to other intra-abdominal procedures.
Once it has been determined that the procedure should be coded, lavage, washout or irrigation of peritoneal or pelvic
cavity should be assigned 30396-00 [989] Debridement and lavage of peritoneal cavity, following the pathway “Lavage,
peritoneal cavity” or “Irrigation, peritoneal cavity.”
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continued
Query no.
Query Description
Decision
‘Laparoscopic washout of
peritoneal cavity’
If lavage, washout or irrigation of peritoneal or pelvic cavity qualifies for coding and is performed at laparoscopy, assign an
additional code to capture the laparoscopic procedure as per ACS 0023 Laparoscopic, arthroscopic, endoscopic surgery;
and “Laparoscopic procedures (that can only be assigned to an open code), performed with another laparoscopic
procedure,” CCWA, July 2009.
‘Laparoscopic appendicectomy
with washout of peritoneal
cavity’
‘Laparoscopic ovarian
cystectomy with washout of
pelvic cavity’
Decision: For lavage, washout or irrigation of peritoneal or pelvic cavity, assign 30396-00 [989] Debridement and
lavage of peritoneal cavity.
Coders should be guided by the documentation in each case, ACS 0016 General procedure guidelines and ACS
0042 Procedures normally not coded, to determine if it is appropriate to assign 30396-00 [989] Debridement and
lavage of peritoneal cavity in addition to other intra-abdominal procedures.
[WA Clinical Coding Advisory Group Decision Date: 05/12/2014]
3
Cerebral Palsy patients
admitted for Botox
What is the principal diagnosis
for cerebral palsy (CP) patients
admitted for Botox injections?
Recommendation: CP patients receive Botox (Botulinum toxin type A) injections for temporary relief of
symptoms/manifestations such as excessive drooling or muscle spasticity. Botox only provides temporary relief, so repeat
injections are necessary. The most common form of CP is spastic cerebral palsy.
Excessive drooling (sialorrhoea)
Botox injected into salivary glands reduces salivary secretions to alleviate excessive drooling.
For CP patients admitted for Botox for excessive drooling, follow ACS 0001 Principal diagnosis, ‘Problems and underlying
conditions,’ point 2 and assign the problem (excessive drooling) as the principal diagnosis, followed by the underlying
condition (CP) as an additional diagnosis:
PDx K11.7 Disturbances of salivary secretion
ADx G80.x Cerebral palsy
Muscle spasticity
Spasticity is the dominant component of spastic CP but it can also occur in dyskinetic, ataxic, and mixed CP. Botox
injected into spastic muscles (e.g. elbow/biceps, ankle/gastrocnemius) acts as a muscle relaxing agent. Once spasticity is
reduced the patient undergoes mobilisation therapy to improve movement at the associated joint.
Recent research has shown that the use of Botox to treat spasm aids in the brain developing new motor control pathways.
This research indicates that the patient will eventually have a permanent reduction in the severity of their CP above that
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continued
Query no.
Query Description
Decision
due to the temporary relief of spasm by Botox. This is significant as CP was once considered a static encephalopathy
which did not improve.
For CP patients admitted for Botox for muscle spasticity, assign a code from G80.x Cerebral palsy as the principal
diagnosis, following the index pathway:
Palsy
- cerebral
The “See also condition” instruction at “Spasm(s), spastic, spasticity” in the index makes it incorrect to assign R25.5
Cramp and spasm as the principal diagnosis in an effort to satisfy the instructions of ACS 0001, ‘Problems and underlying
conditions.’
Note that if the spasticity has developed into a documented spastic deformity such as talipes, this condition should be
assigned as the principal diagnosis, with CP as an additional diagnosis, following ACS 0001 Principal diagnosis –
problems and underlying conditions.
Muscle contracture
Botox is not a treatment for muscle contracture. A muscle contracture is a permanent shortening of a muscle, occurring as
a complication of prolonged muscle spasticity, as seen in patients with CP. Prolonged muscle spasticity can result in
atrophy/fibrosis of a muscle/tendon with contracture of the associated muscle/joint. Contractures are treated with
progressive casting or surgery. Botox injected into spastic muscles may prevent the future development of muscle
contracture.
Where there is no diagnosis given or where CP alone is documented as the principal diagnosis in episodes for Botox, the
clinician should be queried as to: 1) which specific symptom/manifestation of CP is being treated by Botox; and 2) the
specific type of CP if not documented.
Decision: The April 2014 WACCAG advice for “Botox in cerebral palsy” will be retired.
This query will be forwarded on to the ACCD for clarification. In the interim, coders should follow the advice
below.
For cerebral palsy patients admitted for Botox injections for excessive drooling, follow ACS 0001 Principal
diagnosis and assign K11.7 Disturbances of salivary secretion as the principal diagnosis, followed by G80.x
Cerebral palsy as an additional diagnosis.
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continued
Query no.
Query Description
Decision
For cerebral palsy patients admitted for Botox for muscle spasticity, assign a code from G80.x Cerebral palsy as
the principal diagnosis.
Where there is no diagnosis given or where CP alone is documented as the principal diagnosis in episodes for
Botox, the clinician should be queried as to: 1) which specific symptom/manifestation of CP is being treated by
Botox; and 2) the specific type of CP if not documented.
4
Rapid Endovascular Balloon
Occlusion of the Aorta
(REBOA)
What is the correct code to
assign for Rapid Endovascular
Balloon Occlusion of the Aorta
(REBOA)? This is a new
procedure that is starting to be
performed in some hospitals.
[WA Clinical Coding Advisory Group Decision Date: 05/12/2014]
Recommendation: Rapid endovascular balloon occlusion of the aorta (REBOA) is a resuscitative measure performed for
end-stage shock from blunt and penetrating injury in non-compressible areas of the body (e.g. chest, abdomen, pelvis).
The aim is to prevent extreme blood loss and shock and associated mortality whilst the source of bleeding is identified and
surgically addressed. Traditionally, an open procedure would be necessary for these cases, for example a thoracotomy
with clamping for thoracic aortic trauma. REBOA involves a less invasive approach by obtaining arterial access through
the common femoral artery, passing a vascular sheath, floating a balloon catheter to the appropriate section of the aorta
and inflating the balloon to occlude blood flow.
There is currently no Index entry in ACHI for REBOA. The most appropriate code for this procedure is a code from Block
768, depending on the site of the occlusion. The most likely codes are:
 35321-04 [768] Transcatheter embolisation of blood vessels, chest
 35321-05 [768] Transcatheter embolisation of blood vessels, abdomen
 35321-06 [768] Transcatheter embolisation of blood vessels, pelvis.
These codes can be assigned by following the Index pathway:
Arrest (of)
- haemorrhage
- - artery
- - - via surgical peripheral catheterisation – see Embolisation, blood vessel, transcatheter, by site
Decision: Rapid Endovascular Balloon Occlusion of the Aorta (REBOA) should be assigned a code from Block
768 Transcatheter embolisation of blood vessels. A public submission will be made to the ACCD for a specific
Index entry for REBOA.
[WA Clinical Coding Advisory Group Decision Date: 05/12/2014]
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continued
Query no.
Query Description
Decision
5
Tribal circumcision
What is the correct external
cause code for a complication
of male tribal circumcision?
Recommendation: Usually, the type of instrument used to perform the tribal circumcision will not be documented. In
these cases it is appropriate to assign W45.9 Foreign body or object entering through skin by following the Index pathway:
Contact
- with
- - sharp object (cutting or piercing instrument) NEC W45.9
In the event that the type of instrument is documented, a more specific code may be assigned.
Please note that this decision replaces an earlier CCWA decision from June 2010 as the Alphabetical Index was updated
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in 8 edition.
Decision: The correct external cause code for complication of male tribal circumcision is W45.9 Foreign body or
object entering through skin.
6
Prescribed drug induced
psychosis
What is the correct code to
assign for drug induced
psychosis, when the drug is
prescribed and taken
therapeutically? Is it
appropriate to assign a code
from F11-F19? This patient
was admitted with L-Dopa
induced psychosis.
[WA Clinical Coding Advisory Group Decision Date: 05/12/2014]
Recommendation: The block notes at F10-F19 state that “This block contains a wide variety of disorders that differ in
severity and clinical form but that are all attributable to the use of one or more psychoactive substances, which may or
may not have been medically prescribed.”
Therefore, these codes may be assigned for drug induced psychosis occurring during therapeutic use. The index pathway
for L-Dopa induced psychosis is:
Psychosis
- drug induced – code to F11-F19 with fourth character .5
L-Dopa does not fit into any of the categories F11-F18, therefore F19.5 Mental and behavioural disorders due to multiple
drug use and use of psychoactive substances, psychotic disorder should be assigned. External cause codes for adverse
effect in therapeutic use should also be assigned: Y46.7 Antiparkinsonism drugs causing adverse effects in therapeutic
use, Y92.22 Health service area, U73.8 Injury or poisoning occurring while engaged in other specified activity.
Decision: A code from F11-F19 with a fourth character of .5 should be assigned for drug induced psychosis
occurring during therapeutic use. External cause codes for adverse effect in therapeutic use should also be
assigned.
[WA Clinical Coding Advisory Group Decision Date: 05/12/2014]
6
continued
Query no.
Query Description
1
Endovenous thermal
ablation of varicose veins
Decision
WA Advice replaced by ACCD advice
Q: What is the correct procedure code to assign for endovenous radiofrequency ablation (RFA)
or endovenous laser therapy (EVLT) for the treatment of varicose veins?
A: Endovenous thermal ablation is a new, minimally invasive endovenous technique for the treatment of varicose veins.
There are two types of endovenous thermal ablation that are in use: Endovenous radiofrequency ablation (RFA) and
endovenous laser therapy (EVLT). In contrast to the traditional ligation or stripping, RFA is designed to ablate the
incompetent veins through a percutaneously inserted catheter using imaging guidance. Through the catheter tip,
radiofrequency energy or laser energy is delivered to the wall of an incompetent vein, resulting in irreversible occlusion of
the vein.
Currently ACHI does not provide a specific code for EVLT or RFA for the treatment of varicose veins. Therefore assign an
appropriate site code from block [727] Interruption of sapheno-femoral or sapheno-popliteal junction varicose veins to
classify endovenous thermal ablation of varicose veins. An additional code will be created for this procedure for Ninth
Edition.
[NCCH Coding Rules March 2014]
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