Coding Education Newsletter Issue 9, January 2014 Coding queries & audit Inside this issue discussion cases Coding queries The January 2014 coding queries and audit discussion Audit discussion cases cases are now available to view on our website: ACCD http://www.clinicalcoding.health.wa.gov.au/news/ HIMAA Certification Currency Coding queries 1. Causal link in same day endoscopy coding WA Cancer Registry 2. Infra-orbital bruise La Trobe University online short courses 3. Palacos bone cement Coding tip – Conditions Audit discussion cases complicating pregnancy 1. Post-partum complications following caesarean twin Back to basics – Sequelae delivery Coder spotlight – Jo Fitzgerald 2. Cancelled elective procedure from WACHS – Wheatbelt 3. Debridement of plantar wound Santa’s story winning entry Contacts Coding Education Team website www.clinicalcoding.health.wa.gov.au Editorial queries: [email protected] 1 Australian Consortium La Trobe University for Classification coding courses Development (ACCD) Enrolments are currently open for the following La Trobe University online short Several publications have recently been courses: released and are available to all CLIP users: Clinical Coding Auditing course 2014 (applications close Friday April 4, Errata 2, December 2013 2014) December 2013 Coding Rules Comprehensive Clinical Coding (equivalent of former 10-AM Refresher Short Course 2014 Commandments and Q & A) (application close Monday February FAQs from eighth edition education 17, 2014). – Part 2 For further information, including the Code-it! ACCD Newsletter application form, visit: http://www.latrobe.edu.au/courses/health- information-management/short-courses HIMAA Certification Currency Clinical coder Certification 8th edition Currency applications open on 1 February and close 28 February 2014. The application form will be available on 1 February. http://himaa2.org.au/education/?q=node/16 2 WA Cancer Registry A reminder for clinical coders that coding queries relating to neoplasms or histopathology reports should be directed via the normal coding query process, rather than direct to Dr Tim Threlfall at the WA Cancer Registry. In answering our queries, our team will liaise with WA Cancer Registry staff whenever necessary. 2 “Discussed with patient need to control Coding tip: Conditions diabetes to prevent complications like complicating pregnancy IUGR” ACS 1521 Conditions complicating “Aim for discharge home in 2-3 days. pregnancy directs coders that a condition Patient not keen to stay in hospital – should be classified as a pregnancy related reinforced that it is necessary for fetal complication in the following situations: wellbeing”. If the condition complicates The above documentation indicates pregnancy; or obstetric care, therefore pregnancy is not considered ‘incidental’. The following If the condition is aggravated by the diagnosis codes would be assigned: pregnancy; or O24.12 Pre-existing diabetes mellitus, If the condition is the main reason for Type 2, in pregnancy, insulin obstetric care. treated E11.65 Type 2 diabetes mellitus with It can be difficult for coders to determine if poor control any of the above criteria are met, particularly when there is scant or poor documentation. For non-obstetric conditions, the coder Back to basics: should check the documentation carefully to Sequelae determine whether any obstetric observation or care is given. Some There are three types of sequelae in the examples include CTG monitoring; ICD-10-AM classification: ultrasound; being seen by a midwife or Sequelae of disease (ACS 0008) obstetrician etc. If any obstetric observation or care is given, the condition should be Sequelae of injuries, poisoning, toxic coded as a pregnancy related complication effects and other external causes (with the appropriate ‘O’ code). (ACS 1912) ‘Incidental pregnant state’ means the care Sequelae of procedural received is essentially indistinguishable complications (ACS 1904) when compared with a non-pregnant patient with the same condition. The fact There is no time limit for sequelae i.e. it that the patient is pregnant is noted, but may be apparent almost immediately, or does not affect the admission in any way, may occur months or years later. and there is nil obstetric care or observation. Sequelae of disease A sequela of a disease is a current Example condition directly caused by a previous 8/40 pregnant patient admitted from condition. antenatal clinic for BSL monitoring, diabetic As the previously occurring condition is no education and commencement of insulin longer current, an acute code for the due to poorly controlled Type 2 diabetes condition is not assigned. Rather, an mellitus. The patient is not seen by a appropriate sequelae code is used. midwife or obstetrician. No CTG or ultrasound. However the doctor documents the following: 3 Sequelae of disease (continued) Example Organic personality disorder (current condition) Two codes are required and are sequenced resulting from brain injury (previous injury) from MVA as follows: 3 years ago. 1. The residual condition (current F07.0 Organic personality disorder condition) T90.5 Sequelae of intracranial injury Y85.0 Sequelae of motor-vehicle 2. The cause of the sequela (previous accident condition no longer receiving acute Y92.49 Unspecified public highway, treatment) using the appropriate street or road U73.9 Injury or poisoning occurring while sequela code. engaged in unspecified activity Example Bilateral neural deafness (current condition) resulting from previous measles infection (previous Sequelae of a procedural condition). complication H90.3 Sensorineural hearing loss, bilateral A sequela of a complication is a B94.8 Sequelae of other specified infectious and current condition that is the result of parasitic diseases a previously occurring procedural complication or misadventure. Sequelae of injuries, poisoning, Two codes are required and are sequenced toxic effects and other external as follows: causes 1. The residual condition (current A sequela of an injury is a current condition) condition directly caused by a previous 2. T98.3 Sequelae of complications of injury, poisoning, toxic effect or other surgical and medical care, NEC external cause. Example As the underlying cause is no longer current, an acute code for injury, poisoning, Ureterovaginal fistula (current condition) resulting toxic effect or other external cause is not from previous ureteral injury (previous assigned. Rather, the appropriate sequelae misadventure) during laparoscopic hysterectomy. code is assigned from the code range T90 N82.1 Other female urinary-genital tract fistulae – T98. T98.3 Sequelae of complications of surgical and medical care, NEC Three codes are required and sequenced as follows: Sequelae often occur as a late effect, and therefore some coders incorrectly think if a 1. The residual condition (current procedural complication occurs a long time condition) after a procedure, it is considered a 2. The cause of the sequela (previous sequelae. Time is not the factor that defines injury, poisoning etc.) using a code sequelae – it is the presence of a current from T90 - T98. condition caused by a previous condition. For example, displacement of a 3. The external cause of the injury, hip prosthesis two years after the original poisoning etc. using a code from Y85 surgery is not classified as a sequela - Y89, plus place of occurrence and because the displacement is not caused by activity codes. a previous condition. This is instead classified as a procedural complication. 4 sessions to enhance my knowledge and Coder spotlight understanding. I recently had a diabetes training session with the DoH Coding This issue we interviewed Jo Education Team and have signed up for the Fitzgerald from the WA Country HIMAA Intermediate Challenge Exam Health Service - Wheatbelt… coming up in March. How long have you been coding? What casemix/specialties do you find 5 years most challenging in your current role? At which hospital did you commence For me the most challenging are Diabetes your coding career? and Orthopaedics. I commenced my traineeship at Northam Hospital, and am now coding for 14 hospital Describe the coding service at your sites in the Wheatbelt. hospital The Wheatbelt has 24 hospital sites and 20 What made you decide to become a Residential Aged Care Facilities. Currently clinical coder? there are two coders – myself based at In the early 90’s I heard about Morbidity Northam Hospital, and Thea Smith based at Officers and asked what they did. When I Narrogin Hospital. Amy Collins is the was told about the job, I liked the sound of it Manager of Corporate and Health as it sounded very interesting, especially if I Information and is based in Wheatbelt could no longer nurse. Regional Office in Northam (separate to the hospital). Both Thea and I have introductory What do you like most about clinical Certificates and are looking to complete the coding? Intermediate Certificate this year. We liaise I enjoy the challenge of finding codes and with each other and other coders interesting diagnoses. throughout the WA Country Health Service. We have also worked with Amy to organise What do you like least about clinical training sessions with the DoH and coding coding? sessions in the Metro area to further improve our knowledge and skills in Clinical and clerical staff can lack casemix that is not common to the understanding about the importance of Wheatbelt, or that with which we struggle. clinical documentation, data integrity