DRG Workshop 18 – 22 November 2013 Belgrade.

Classifications and coding Tuesday, November 19th, 2013

Introduction and overview to clinical classification and coding

What is clinical coding? Translation of narrative text into codes Understanding of clinical information Understanding of classification system Ability to allocate appropriate code(s) Atrial fibrillation = I48

Classification & Nomenclature Statistical classification: Brings together diseases that are similar and groups them under one category or code Limited number of categories Nomenclature: Has a separate listing for every condition and therefore a separate code for every disease Very extensive and detailed

Good clinical coder Knowledge of: Medical terminology Medical science Disease processes Investigations, treatments and interventions Content and structure of clinical record Understanding of classification system Understanding of coding rules and standards

Why code? Provision of database of coded information Used for: Clinical management Clinical research Identifying disease trends Monitoring quality of care

Why code? Used for cont.: Funding & financial management Review resource consumption Workforce & facilities planning Setting benchmarks Comparisons

Accurate coding Need for accurate coding: Ensures information is reliable to use Necessary for accurate DRG allocation

Abstraction of information from the clinical record ↓ Assignment of ICD-10 and ACHI codes Assignment of DRG

Calculating an AR-DRG: Data Items Required Sex ICD-10 and ACHI Codes Principal diagnosis Additional diagnoses, such as complications and comorbidities Procedure/s Length Of Stay Or Admission and Separation Dates Same-day Status Mode of separation (discharge status) Includes died, transferred Newborn admission weight For age 28 days or less, plus older if less than 2500 grams

If it’s not written, it didn’t happen! The production of quality clinical data is a collaborative effort Channels of communication between clinicians and clinical coders should be open and frequently used Quality documentation supports quality coding which results in appropriate DRG allocation

Good clinical documentation The most appropriate DRG can only be assigned to an episode of patient care when relevant clinical information is accurately documented in the clinical record

Good clinical documentation cont. Need clear and complete documentation Important for clinical specialties to understand what information can impact on DRG assignment

Dementia – impact on DRG assignment Age 69 years Gender Male Diagnosis Cognitive impairment Principal diagnosis R41.8 Other and unspecified symptoms and signs involving cognitive functions and awareness MDC 23 Factors influencing health status and other contacts with health services DRG Z61A Signs and symptoms AR-DRG cost weight 0.67 ALOS 2.71 days Reimbursement $2,617

Dementia – impact on DRG assignment cont. Diagnosis Mild cognitive disorder Principal diagnosis F06.7 Mild cognitive disorder MDC 01 Diseases and disorders of the nervous system DRG B64B Delirium without catastrophic complication and/or comorbidity AR-DRG cost weight 1.40 ALOS 6.03 days Reimbursement $5,452

Dementia – impact on DRG assignment cont. Diagnosis Cognitive change due to dementia Principal diagnosis F03 Unspecified dementia MDC 01 Diseases and disorders of the nervous system DRG B63Z Dementia and other chronic disturbances of cerebral function AR-DRG cost weight 2.70 ALOS 12.82 days Reimbursement $10,562

Coding process Abstraction of information Be aware of potential documentation issues Unclear Incomplete Missing Conflicting

Coding process Abstraction of information cont. Review the whole clinical record Look at Discharge information forms Progress notes Investigation results Operation reports Specialist notes

If you cannot analyse and abstract you cannot code Coding process Abstraction of information cont. Apply medical terminology and medical science knowledge Apply coding rules Apply coding standards If you cannot analyse and abstract you cannot code

Coding process Methodology (used in Australian) Read the front sheet Read the discharge summary/letter Compare Dx on front sheet & Discharge summary Read history and physical examination Identify any interventions to be coded Review entire record

Example Patient presented with rapid onset of dyspnoea and chest pain. A chest X-ray revealed a spontaneous pneumothorax.

Coding process Allocating codes Methodology Identify the statement to be coded & refer to the appropriate Alphabetic index Locate the lead term Follow any notes under the lead term Read all nonessential and essential modifiers

Coding process Allocating codes cont. Methodology cont. Follow any cross-references Refer to the Tabular list to verify code Read and follow any coding notes Check ACS ▼ Assign the code

Accurate inpatient coding Correct identification of Diagnoses and Procedures Assignment of correct ICD-10 and ACHI codes Correct sequence of Pdx

Causes of errors Failure to review the entire clinical record Failure to abstract the relevant information Coding not validated by content of record Selection of the incorrect ICD-10 or ACHI codes Sequencing errors Transposition errors Poor documentation

A three volume clinical classification comprising: The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) A three volume clinical classification comprising: Tabular List (Volume 1) Alphanumeric listing of diseases Instruction Manual (Volume 2 Introduction, instructions and guidelines for Vol 1 & 2 Alphabetical Index (Volume 3) Comprehensive alphabetical index of diseases and conditions found in the Tabular List

ICD-10 – Volume 1 ICD-10 is a variable-axis classification epidemic diseases constitutional or general diseases local diseases arranged by site developmental diseases injuries 3 main elements to the structure 3 volumes 22 chapters alphanumeric codes

ICD-10 – Volume 1 Tabular List – Volume 1 22 broad groupings of diseases and injuries called chapters, I-XXII (roman numerals) Within the chapters, codes are divided up into blocks of 3 character categories (usually by site or type of disease)

Structure of the ICD-10 code In ICD-10 the 4 character code consists of J45.9 First character A to Z Lastly Another digit Followed by 2 digits Then a point

Special groups The following six chapters are special groups of diseases and conditions which are not included in the chapters organised by anatomical site infections cancer pregnancy newborns congenital conditions injuries These 6 chapters have priority, have precedence over anatomical site chapters

Inclusion Terms May be listed under block and code titles – additional examples and synonyms of the diagnoses and diagnostic terms that are classified there They do not include every possible diagnosis or term – as a guide only Not always in the alphabetic index

Exclusion Terms Found at chapter, block, category or code title level Important warnings to coders that if the condition being coded is listed in the exclusion terms it may not be coded under that code

Punctuation [ ] Square brackets – used to enclose synonyms, abbreviations, alternative words ( ) Parentheses are used in the normal way to enclose additional information or examples of codes May be used to enclose nonessential modifiers – the presence or absence of these terms in the diagnosis has no effect on the selection of the code : Colons – a term in an inclusion or exclusion list followed by a colon means that the term is incomplete { } Braces – link a series of terms, each of which is modified by the term to the right of the brace

Annotations * Asterisk symbol † Dagger symbol denotes a code describing the aetiology or underlying cause of a disease, should always be sequenced with the appropriate manifestation code * Asterisk symbol denotes a code describing the manifestation of a disease and should always be assigned with the appropriate aetiology code

Words and abbreviations NEC Not elsewhere classified Used in code and category titles to warn the coder that there may be another, better or more specific code in the classification If there is more precise information about the condition, then look for a more specific code NOS Not otherwise specified This means ‘unspecified’ Codes that contain terms followed by NOS can be used when there is not enough information to assign a more specific code

Words and abbreviations cont. ‘AND’ in code titles In the tabular list of diseases, ‘and’ means ‘and/or’ This code title means that under H21.3 you can code diagnoses of ‘cyst of iris’ OR ‘cyst of ciliary body’ OR ‘cyst of anterior chamber’ OR a combination of the three The use of ‘and’ to mean ‘and/or’ only occurs in the Tabular List (Vol 1)

Other and unspecified codes There is not always a separate heading for each disease Most of the codes have 4 characters – a letter, 2 numbers, a decimal point and then another number The 4th characters of ‘8’ & ‘9’ are residual codes: .8 = other .9 = unspecified You must be directed to ‘other’ and ‘unspecified’ codes by the index

Aetiology and manifestation Known as dagger asterisk system For certain conditions, it is important to identify both the aetiology (underlying disease) and the manifestation (resulting condition) Provides further information for morbidity coding Dagger = aetiology G30.0† Alzheimer’s disease with early onset F00.0* Dementia in Alzheimer’s disease with early onset Asterisk = manifestation

Alphabetical Index – Volume 2 Lists diagnostic terms and their corresponding code numbers from the tabular list Contains many more terms than those appearing in the tabular list Three sections: Alphabetic index of diseases and nature of injury External causes of injury Table of drugs and chemicals

Conventions Lead terms Essential modifiers Nonessential modifiers main term, first place to look in index, usually the name of a disease or condition, not a site Essential modifiers found under the lead term (subterms), with a hyphen in front. May be essential modifiers under subterms, down to five indents Nonessential modifiers May be found after a lead term or subterm, in parentheses ( ). Have no effect on code selection

Conventions cont. Lead term Nonessential modifiers Sequenced in alphabetic order Essential modifier

Coding rules, guidelines and standards ICD-10 Volume 2, Instruction Manual provides a basic description of the ICD contains rules and guidelines for the use of the classification for coding of mortality and morbidity data contains guidelines for the presentation and interpretation of data

Coding rules, guidelines and standards cont. Australian Coding Standards Provide rules, guidelines advice Assume coder has basic training Assist with consistency in use and application of ICD-10-AM and ACHI

Australian Classification of Health Interventions – ACHI Self-contained classification based on a fee schedule (MBS) Numeric codes – five digits with a two digit extension

Development of ACHI No companion intervention classification with ICD-10 Need for an intervention classification to accompany ICD-10-AM The Medicare Benefits Schedule (MBS): a fee schedule formed the basis of ACHI

Development of ACHI cont. Features Meaningful terminology Staged procedures Devices 38430-00 [565] Thoracoplasty, staged, first stage 38430-01 [565] Thoracoplasty, staged, second or subsequent stage 35309-08 [754] Open transluminal balloon angioplasty with stenting, single stent 35309-09 [754] Open transluminal balloon angioplasty with stenting, multiple stents

Development of ACHI cont. Features Laterality Codes for procedures commonly performed together 33524-00 [700] Renal endarterectomy, unilateral 33527-00 [700] Renal endarterectomy, bilateral 30532-01 [864] Oesophagogastric myotomy, abdominal approach, with closure of diaphragmatic hiatus 49562-02 [1511] Arthroscopic removal of loose body of knee with chondroplasty and multiple drilling or implant

ACHI Structure Chapters follow the ICD-10 structure as closely as possible Anatomical site rather than surgical

ACHI Structure cont. Multi-axial structure Exceptions primary axis – site secondary axis – procedure type tertiary axis – specific site, procedure or technique used Exceptions dental, obstetrics, radiation oncology, imaging and miscellaneous procedures

ACHI Structure cont. Primary axis –site Order is ‘superior’ to ‘inferior’ or head to toe approach Orthopaedics  head  sternum and ribs  spine  shoulder  upper arm

ACHI Structure cont. Secondary axis – intervention least invasive most invasive Examination Application, insertion, removal Incision Destruction Excision Reduction (in musculoskeletal chapter only) Repair Reconstruction Revision Re-operation Other procedures

Example Concepts classified first by site (nose) then by intervention: Examination 41653-00 Examination of nasal cavity and/or postnasal space 41764-00 Nasendoscopy Type of procedure Application, insertion, removal 41907-00 Insertion of nasal septal button Incision 41659-00 Removal of intranasal foreign body 41683-00 Division of nasal adhesions

ACHI Structure cont. Numbering system and blocks Code numbers not in numerical order Block numbers are in numerical order

ACHI Structure cont. Block numbers (1 - 2016) assist users in finding a specific code provide the means of easily aggregating certain types of procedures for data analysis purposes

ACHI Structure cont. Diagnostic terms generally not included in ACHI descriptions Exceptions- when the diagnosis is integral to the procedure being performed 32132-00 [941] Sclerotherapy of haemorrhoids Injection of haemorrhoids

Code structure No intrinsic meaning in this extension When only one concept within an MBS item the extension is 00 36561-00 [1047] Closed biopsy of kidney

Code structure cont. The first five characters represent the MBS item number: 42773 Detached retina, diathermy or cryotherapy for 42773-00 Repair of retinal detachment by diathermy 42773-01 Repair of retinal detachment by cryotherapy The last two characters are allocated for each new procedural concept derived from the MBS item description

Example MBS item number ACHI extension 16520-00 Elective classical caesarean section 16520-01 Emergency classical caesarean section 16520-02 Elective lower segment caesarean section 16520-03 Emergency lower segment caesarean section ACHI extension

Appendices in ACHI Appendix A: Mapping table Lists all MBS item numbers that have not been used in the classification and their maps Appendix B: ACHI code list Complete numerical listing of all ACHI codes and the corresponding block number

Conventions in the Tabular List Certain words, symbols and punctuation marks special meaning provide guidance in code selection Refer to: Tabular list - Conventions used in the tabular list of interventions ACS 0040 - Conventions used in the tabular list of interventions

Conventions in the Tabular List cont. Most are the same as those used for diseases New or different: Includes notes refers to inherent procedural components or equipment further defines the site and/or in code titles – ‘and’ means and, ‘or’ means or 59900-00 [607] Left ventriculography 59900-01 [607] Right ventriculography 59900-02 [607] Left and right ventriculography

Structure of ACHI Index Alphabetical according to main terms type of procedure actual name of procedure eponyms Alphabetical sequencing for subterms Exceptions The following subterms come first under a main term as with by without for

Structure of ACHI Index cont.

Conventions in the Alphabetic Index Alphabetic index in the section Conventions used in the tabular list of interventions ACS 0041 Conventions used in the alphabetic list of interventions

Conventions cont. Same as those used for diseases: essential and nonessential modifiers NEC – not elsewhere classified ‘see’ and ‘see also’ Unique to interventions See block - you must go to the Tabular List and look at the codes in the block Omit code – instruction in index next to procedures that are an operative approach

General standards for interventions ACS 0016 General procedure guidelines ACS 0042 Procedures normally not coded ACS 0031 Anaesthesia ACS 0020 Bilateral/Multiple procedures ACS 0019 Procedures not completed or interrupted

General standards for interventions cont. ACS 0023 Laparoscopic/ arthroscopic/ endoscopic surgery ACS 0032 Allied health interventions ACS 0038 Procedures distinguished on the basis of size, time, number of lesions or sites ASC 0047 Adhesions

ACS 0016 General procedure guidelines A procedure is defined as a clinical intervention represented by a code A clinical interventions is surgical in nature carries a procedural risk carries an anaesthetic risk requires specialised training special facilities or equipment only available in an acute care setting A procedure is defined as a clinical intervention represented by a code A clinical interventions Is surgical in nature carries a procedural risk carries an anaesthetic risk requires specialised training special facilities or equipment only available in an acute care setting NEXT SLIDE.

ACS 0016 General procedure guidelines cont. Ordering of intervention codes Procedure performed for treatment of the principal diagnosis Procedure performed for treatment of an additional diagnosis Diagnostic/exploratory procedure related to the principal diagnosis Diagnostic/exploratory procedure related to an additional diagnosis for the episode of care

ACS 0016 General procedure guidelines cont. Do not code clinical interventions that are routine in the treatment expected or inherent parts of treatment Refer to ACS 0042

ACS 0042 Procedures normally not coded Usually routine in nature Performed for most patients Can occur multiple times Resources often reflected in Dx

ACS 0042 Procedures normally not coded cont. Important “Note” at beginning of list A specialty ACS may override ACS 0042 If performed under GA – must code Code if procedure is the principle reason for admission Become familiar with this list

ACS 0019 Procedure not completed or interrupted If a procedure is started but is interrupted or not completed, code as far as it went: if only an incision was made, code an incision of the site if the surgeon entered a body cavity or space, code an exploration of the site ACHI has some codes for ‘failed procedures’

ACS 0023 Laparoscopic/arthroscopic/ endoscopic surgery A procedure maybe endoscopically performed or via a traditional incision ACHI has codes which differentiate between these If no endoscopic code available assign a code for the specific procedure a code for the endoscopy

ACS 0047 Adhesions If division of adhesions performed, even if part of another procedure code the diagnosis of adhesions and code the division of adhesions

ACS 0020 Bilateral/multiple procedures Bilateral procedures Definition Bilateral procedures are those which involve the same organ/structure on different sides of the body at the same operative episode

ACS 0020 Bilateral/multiple procedures cont. Bilateral procedures Classification guidelines Procedures with a bilateral code e.g. bilateral knee replacement Code once Inherently bilateral procedures e.g. tonsillectomy home.hawaii.rr.com/dochazenfield/images/Norma

ACS 0020 Bilateral/multiple procedures cont. Bilateral procedures cont. Classification guidelines cont. Procedures with no code option for bilateral e.g. bilateral fracture wrists Code twice http://www.matthews.co.nz/images/cataracts.jpg home.hawaii.rr.com/dochazenfield/images/Norma

ACS 0020 Bilateral/multiple procedures cont. Definition ACHI generally refers to organs, diseases and sites using the singular tense. This is done for consistency and ease of updating. For example, the code title intranasal removal of polyp from maxillary antrum includes where one, or more than one, polyp is removed. Thus polyp can be interpreted as polyp or polyps. Other examples include wart(s), skin tag(s), biopsy/biopsies, lesion(s).

ACS 0020 Bilateral/multiple procedures cont. Classification guidelines The same procedure repeated during the episode of care at different visits to theatre Code as many times as performed The same procedure repeated during a visit to theatre involving one entry point/approach and similar/same lesions Assign one code

ACS 0020 Bilateral/multiple procedures cont. Classification guidelines cont. The same procedure repeated during a visit to theatre involving one entry point/approach and different lesions The same procedure repeated during a visit to theatre involving more than one entry point/approach and more than one non-bilateral site Assign a code for each procedure

ACS 0020 Bilateral/multiple procedures cont. Classification guidelines cont. Skin or subcutaneous lesion removal Assign code for excision of multiple lesions by site Excision of lesions from eyelid (1) and nose (1) and neck (2). Codes: 31230-00 [1620] Excision of lesion(s) of skin and subcutaneous tissue of eyelid 31230-01 [1620] Excision of lesion(s) of skin and subcutaneous tissue of nose 31235-01 [1620] Excision of lesion(s) of skin and subcutaneous tissue of neck

ACS 0038 Procedures distinguished on the basis of size, time or number of lesions or sites Where there is no documentation of size, duration or number follow the index default code If there is no default, assign a code for the smallest size the least duration the least number of lesions The least number of sites

ACS 0032 Allied health interventions Refer to Block 1916 General allied health interventions For inpatient coding assign a code from block [1916] to identify allied health interventions only one code per professional group for each admission

Line Coding Wedge resection of the toenail for ingrown nail Male admitted for drainage of pilonidal cyst Transurethral prostatectomy for benign prostatic hypertrophy

Line Coding cont. Unilateral, partial thyroidectomy for thyrotoxicosis Excision of wart from tip of nose (skin) Patient with mature senile cataract for intracapsular removal and insertion of intraocular lens

Anaesthesia

ACS 0031 Anaesthesia Anaesthesia partial or complete loss of sensation use of drugs to induce anaesthesia Assign an anaesthetic code for each ‘visit to theatre’ If more than one anaesthetic given, code according to hierarchy in ACS

ACS 0031 Anaesthesia cont. Cerebral anaesthesia – block [1910] general anaesthesia (GA) – assign when artificial an airway is used sedation – assign when no artificial airway is used Conduction anaesthesia – block [1909] neuraxial block – epidural, spinal, caudal regional block – based on the general anatomical area of the field of anaesthesia infiltration of local anaesthesia – not coded

ACS 0031 Anaesthesia cont. Anaesthesia in labour 92507-xx [1333] Neuraxial block during labour and delivery procedure Assigned for neuraxial block for pain relief in labour and then continued for anaesthesia during a delivery procedure.

ACS 0031 Anaesthesia cont. American Society of Anesthesiologists (ASA) score Two character extension 1st character = the score that is documented by the anaesthetist on the anaesthetic/operation form (1-9) 2nd character = modifier of ‘E’ for emergency cases (0, 9) must be documented before assigning ‘0’ if not documented assign ‘9’

ACS 0031 Anaesthesia cont. Guidelines for coding anaesthesia only one code from either [1909] or [1910] is to be assigned for each visit to theatre if more than one code in a block use hierarchy sequence the anaesthesia code following the procedure code(s) it relates to assign a code from [1912] Postprocedural analgesia when a neuraxial or regional block is continued after the procedure procedures not normally coded ARE coded if they are performed under anaesthesia

Ventilatory support

Ventilatory support ACHI codes for CVS are found in block [569] and NIV in block [570] Block [569] Ventilatory support: 13882-00 ≤ 24 hours 13882-01 > 24 and < 96 hours 13882-02 ≥ 96 hours Block [570] Noninvasive ventilatory support: 92209-00 ≤ 24 hours 92209-01 > 24 and < 96 hours 92209-02 ≥ 96 hours

Ventilatory support cont. The classification of CVS and NIV is based on the number of hours i.e. ≤ 24 hours, > 24 and < 96 hours or ≥ 96 hours. All cases of CVS and NIV should be coded.

Ventilatory support cont. ACS 1006 Ventilatory support Definition Noninvasive ventilation Continuous ventilatory support (NIV) (CVS) 98

Ventilatory support cont. ACS 1006 Ventilatory support cont. Definition of CVS 99

Ventilatory support cont. ACS 1006 Ventilatory support cont. Definition noninvasive ventilation NIV includes: Bi-level positive airway pressure BiPAP Continuous positive airway pressure CPAP Intermittent positive pressure breathing IPPB etc. 100

Ventilatory support cont. ACS 1006 Ventilatory support cont. Guidelines for coding ventilatory support: When both CVS and NIV are used for treatment, code each separately refer block [569] and [570] Subsequent periods of the same type of ventilation are added together Calculated as completed cumulative hours 101

Ventilatory support cont. ACS 1006 Ventilatory support cont. Cumulative hours (all hours ventilatory support are added together), so only one code for duration is needed based on the type of ventilatory support 35 year old man admitted in acute respiratory distress, intubated and ventilated in ICU for 46 hours Look up: Management (for the duration) ACHI codes: 13882-01 [569] Management of continuous ventilatory support, > 24 and < 96 hours 102

Ventilatory support cont. ACS 1006 Ventilatory support cont. Guidelines for coding CVS cont.: Do not code methods of weaning (eg CPAP, IMV) separately. Weaning is included in calculating the length of time that a patient is on ventilatory support. Do not code ventilation when patient brings in their own ventilatory support devices Ventilation provided during surgery is associated with anaesthesia and if provided for ≤ 24 hrs, do not code 103

Ventilatory support cont. ACS 1006 Ventilatory support cont. Guidelines for coding CVS cont. Code a tracheostomy if it was performed with CVS from Block [536] Do not code any method of intubation (e.g. ETT) for ventilatory support Do not code any noninvasive airway (e.g. mask, nasal prong) 104

Ventilatory support cont. ACS 1006 Ventilatory support cont. Calculating the duration of CVS – for the purposes of coding, CVS starts when: the patient is intubated anywhere in your hospital, or CVS is started through the patient’s tracheostomy, or at the time of admission for those patients who have been admitted already intubated and ventilated 105

Ventilatory support cont. ACS 1006 Ventilatory support cont. For the purposes of coding, CVS ends when: the patient is extubated, or the CVS is ceased after any period of weaning, or CVS via the tracheostomy is stopped, or the patient is discharged, transferred from your hospital or the patient dies, or when a change of episode occurs 106

Ventilatory support cont. ACS 1006 Ventilatory support cont. Transferred patients: Intubated and ventilated Assign a code for the appropriate hours of CVS at both the transferring and receiving hospitals Intubated (without ventilation) Transferring hospital assigns a code for the intubation/tracheostomy if performed Receiving hospital assigns a code for the management of the intubation 107

Pharmacotherapy

Pharmacotherapy Terminology PHARMACOTHERAPY defined as ‘the treatment of a condition by means of drugs’

Pharmacotherapy cont. Terminology cont. ‘administration’ or ‘administration of agent’ is the preferred terminology not ‘injection/infusion/instillation’. Exception for blocks 32–37 (epidural/spinal/caudal) for coding of pain management

Pharmacotherapy cont. [1920] Pharmacotherapy Use of codes Codes made up of 5 digit core = route of administration 2 digit extension = drug type Use of codes must follow coding conventions and only assign drug administration codes from Block [1920] Pharmacotherapy when meets appropriate coding standards or conventions.

Pharmacotherapy cont. Multiple drugs given at same administration Code the individual drugs administered Assign the extension that indicates the main intent of the pharmacotherapy If the main intent of the pharmacotherapy is unknown, assign code highest in the hierarchy (i.e. the lowest number)

Pharmacotherapy cont. Multiple administration of the same drug When a patient receives multiple administrations of the same drug by the same route, within one episode of care, assign the pharmacotherapy code once only.

Pharmacotherapy cont. Vascular access devices Drug delivery devices An implanted venous catheter with a reservoir attached Drug delivery devices A device (e.g. ambulatory, external infusion pump) attached to a vascular access device 114

Pharmacotherapy cont. Vascular access device – Port-A-Cath 115

Pharmacotherapy cont. Huber needle 116

Pharmacotherapy cont. Block 766 Vascular access device Includes codes for: 34528-02 [766] Insertion of vascular access device 34530-06 [766] Revision of vascular access device 34530-05 [766] Removal of vascular access device

Pharmacotherapy cont. Loading of a drug delivery device can be found at Block 1920 for example: Maintenance codes at Block 1922

Pharmacotherapy cont. Same-day admission for ‘management’ only of vascular access/drug delivery device assign as PDx: or Z45.1 Adjustment and management of infusion pump Z45.2 Adjustment and management of vascular access device 119

Anaesthesia 1 A 76 year old man was referred by his local doctor for treatment of a tension pneumothorax. He also suffers from COAD which further unbalanced the tension pneumothorax. A chest tube was inserted under a sedation (ASA 2) to drain the pneumothorax. A follow-up x-ray showed significant reduction in the size of the pneumothorax.

Anaesthesia 2 25 year old Darko presented with acute abdominal pain for the past 24 hours. He stated that he felt nauseous, had vomited twice and did not feel like eating. A physical examination confirmed a diagnosis of acute appendicitis and he was taken to theatre for an emergency appendicectomy (GA 2E). At laparotomy the appendix was seen to be ruptured and there was evidence of peritonitis. The appendix was removed and a peritoneal lavage was performed. continued next slide...... 122 122

Anaesthesia 2 cont. continued... The following day the patient was still unwell with fever, chills, shaking and tachycardia. His white cell count was elevated and blood was taken for culture. Microbiology results confirmed Staphylococcus aureus septicaemia. He was transferred to ICU and treated with IV antibiotics and fluids. He improved over the next few days and was transferred back to the ward for discharge at the end of the week. 123 123

Anaesthesia 3 This 48 yo male was admitted for renal transplant. He has chronic renal failure, end-stage. He has been maintained on haemodialysis for a number of years, however his condition deteriorated significantly and he was placed on the transplant waiting list. He underwent a renal transplant under combined GA and regional block (ASA 3). He was started on a triple immuno-suppression regimen. He was discharged and is for follow-up in the renal clinic in one week. 124 124

Ventilation 1 Patient is on ventilatory support for 2 hours prior to surgery, has the surgery for 5 hours and is ventilated for a further 12 hours after surgery. 125 125

Ventilation 2 Patient is ventilated for 12 hours prior to surgery, has the surgery (3 hours) and is ventilated for a further 6 hours after surgery. The following day the patient is again ventilated for 3 hours prior to surgery, has the surgery (10 hours) and is ventilated for another 12 hours. Two days later the patient goes into respiratory failure and is ventilated for 48 hours. 126 126

Ventilation 3 Patient is intubated and ventilated for surgery (2 hours) and extubated in recovery. Two days later the patient goes into respiratory failure and is ventilated for 24 hours. 127 127

Ventilation 4 Patient with chronic emphysema is placed on CPAP for 24 hours. This is reduced to 12 hours off during the day and 12 hours on at night for the next 3 days. 128 128

Ventilation 5 Patient goes into respiratory failure and is intubated and ventilated for 24 hours. They are weaned via CPAP for a further 2 hours and extubated successfully. The following day due to poor respiratory effort they are given CPAP for another 12 hours. 129 129

Ventilation 6 A female patient presented with a history of chronic maxillary sinusitis. She complained of experiencing continuous postnasal drip, recurrent rhinitis and often severe pain. A bilateral Caldwell-Luc operation was performed under GA (ASA 1). Postoperatively she suffered a respiratory arrest in recovery and was intubated and ventilated. She was transferred to the intensive care unit (ICU) and extubated after 34 hours.

Pharmacotherapy 1 Patient with Crohn’s disease admitted same day for treatment with IV infusion infliximab via a PICC line. 131 131

Pharmacotherapy 2 Same-day admission for removal of spinal infusion device under sedation (ASA 1). 132 132

Pharmacotherapy 3 Patient with carcinoma of the pancreas admitted for chemotherapy via infusion pump. Chemotherapy cassette changed and infusion pump set for 7 days at a dose of 200mg per 24hrs. Patient discharged home on same day. 133 133

Specialty coding and Coding support Wednesday, November 20th, 2013

Cardiovascular

Cardiovascular Coronary artery bypass grafts (CABGs) are performed to improve blood flow to the heart muscle For correct code assignment, need to know: the number of coronary arteries grafted the type of material used 136

Cardiovascular cont. Coronary artery bypass grafts (CABGs) cont. also need to code cardiopulmonary bypass (CPB) if performed e.g. 137

Cardiovascular cont. ACS 0909 Coronary artery bypass grafts Provides detailed medical science information Classification guidelines List of routine procedures performed with CABGs that are NOT coded e.g. cardioplegia, hypothermia, pacing wires Reoperation CABGs

Cardiovascular cont. Pacemakers and defibrillators ACS 0936 Cardiac pacemakers and implanted defibrillators Terminology Pacemaker leads are now referred to as electrodes Assign codes for both pacemaker device and electrodes

Cardiovascular cont. Pacemakers Single and dual chamber Biventricular/triple chamber Implantable cardioverter defibrillators (ICDs) Combined ICD and Pacemaker device

Cardiovascular cont. ACHI codes One set of electrode codes for use with pacemakers and ICDs Combined pacemaker/defibrillator concept in the defibrillator code

Cardiovascular cont. ACHI codes cont. Blocks 650 and 653 are for insertion of cardiac pacemaker/defibrillator generator Insertion of electrodes can be found in Blocks 647–649 Codes in Blocks 654, 655 and 656 for ‘adjustment’ and ‘replacement’ pacemaker or defibrillator electrodes and cardiac pacemaker or defibrillator generator

Cardiovascular cont. ACS 0936 Cardiac pacemakers and implanted defibrillators Definitions Implantable cardiac defibrillator functions For placement of an electrode into the atrium or ventricle Single, dual and triple chamber pacemakers and defibrillators

Cardiovascular cont. ACS 0936 Cardiac pacemakers and implanted defibrillators cont. Classification guidelines Assign code for insertion: Pacemaker device 38353-00 [650] Insertion of cardiac pacemaker generator Defibrillator device 38393-00 [653] Insertion of cardiac defibrillator generator Code also insertion of electrodes: Pacemaker or defibrillator electrode(s) from Blocks 648 or 649

Cardiovascular cont. ACS 0936 Cardiac pacemakers and implanted defibrillators cont. Classification guidelines cont. EXAMPLE 1: Transvenous insertion of a permanent defibrillator electrode into the right ventricle and a permanent pacemaker electrode into the right atrium. Assign: 38390-02 [648] Insertion of permanent transvenous electrode into other heart chamber(s) for cardiac defibrillator and 38350-00 [648] Insertion of permanent transvenous electrode into other heart chamber(s) for cardiac pacemaker

Cardiovascular cont. ACS 0936 Cardiac pacemakers and implanted defibrillators cont. Classification guidelines cont. ‘Testing’, ‘Reprogramming’, ‘Replacement’, ‘End-of-(battery) life’ and ‘Complications…’ include guidelines for pacemakers and defibrillators Guidelines for ‘Removal’ and ‘Adjustment’ of permanent pacemaker or defibrillator

Pacemakers and defibrillators – Points to remember Cardiovascular cont. Pacemakers and defibrillators – Points to remember do not code routine testing of pacemaker at time of insertion for replacement, assign a code for the replacement of the generator and/or any electrodes elective admission (diagnosis code) for replacement of pacemaker/defibrillator (‘end of life’) is Z45.0 Adjustment and management of cardiac device with the appropriate procedure codes Z95.0 Presence of cardiac device should be assigned for all other surgical cases not related to the management of the pacemaker

Cardiovascular cont. Heart Valves Heart Valve repair 4 valves Aortic Mitral Tricuspid Pulmonary Heart Valve repair Annuloplasty Valvuloplasty

Cardiovascular cont. Heart Valve replacement Removal and replacement Types of replacements: Bioprosthetic, Mechanical, Biological

Cardiovascular cont. Anatomical section in ACHI for each valve Blocks for repair and replacement Aortic valve – [622] & [623] Mitral valve – [626] – [628] Tricuspid valve – [632] – [634] Pulmonary valve – [637]

Cardiovascular cont. Cardiac catheterisation and coronary angiography Blocks for these procedures are: [667] Cardiac catheterisaton Codes split on laterality [668] Coronary angiography Codes split on with/out heart catheterisation and laterality [607] Examination procedures on left ventricle

Cardiovascular cont. ACS 0933 Cardiac catheterisation and coronary angiography Definition Classification guidelines Default codes when no documentation of which side of heart: Patients < 10 years old – left and right (assign 38206-00 [667] Right and left heart catheterisation) Patients > 10 years old – left (assign 38203-00 [667] Left heart catheterisation

Cardiovascular cont. Blocks for angioplasty procedures [670] Transluminal coronary angioplasty [671] Transluminal coronary angioplasty with stenting Codes split on Open/closed procedure Number of arteries Number of stents

Obstetrics

Obstetrics DRG grouping defaults for: O10 - O46, O98, O99 - antepartum O60 - O75, O80–O82 - delivery O15.2, O71, O72, O85–O92 - postpartum Z37.0 Single live birth – changes default to delivery Z39.0 Care and examination immediately after delivery – changes default to postpartum

Obstetrics cont. Special chapter of ICD-10 take precedence over system chapters Organised according to progress of a pregnancy – antenatal, delivery, postnatal Contains codes that describe all obstetric conditions in the mother (from conception to 42 days after delivery) 156

Obstetrics cont. Other maternal disorders predominantly related to pregnancy (O20–O29) Contains categories and codes for common conditions in pregnancy Block 020–029 is not very extensive and only contains specific codes for common complications No general codes in this block 157

Obstetrics cont. Other maternal disorders predominantly related to pregnancy (O20–O29) continued O24 Diabetes mellitus in pregnancy and O25 Malnutrition in pregnancy are also used for the same condition if it arises in delivery and the puerperium There are different codes for: pre-existing diabetes mellitus gestational diabetes 158

Obstetrics cont. Analgesia and anaesthesia during labour and delivery Patient may have Analgesic – to relieve pain Anaesthetic – for partial or complete loss of sensation A Neuraxial block for pain relief (epidural) may be continued for anaesthesia (for caesarean, repair of obstetric tear etc). Codes in block [1333] used for the above see next slide for an example… 159

Obstetrics cont. 160

Obstetrics cont. Analgesia and anaesthesia during labour and delivery cont. If neuraxial block for caesarean only (no pain relief prior) then code from block [1909] is assigned 161

Obstetrics cont. ACS 1513 Induction Causing labour to start artificially Surgical – artificial rupture of membranes (ARM) Medical – infusion of drug (oxytocin) Need to code the procedure of induction and (if documented) a diagnosis code for the reason for the induction Codes are found in Block 1334 Medical or surgical induction of labour 162

Obstetrics cont. ACS 1513 Induction cont. Augmentation is the increasing of uterine contractions after labour has begun spontaneously Different procedure codes for augmentation found in Block 1335 Medical or surgical augmentation of labour Do not mix induction and augmentation procedure codes Cannot assign codes from both Blocks 1334 and 1335 on the same episode 163

Obstetrics cont. Outcome of delivery Every delivery episode for gestation > 20 weeks must have a code for outcome of delivery (Z37-) Indicates number of babies and whether liveborn or stillborn Z37.- indicates that the delivery took place during this admission 164

Perinatal ACS 1615 Specific interventions for the sick neonate Interventions to be coded for neonates (not normally coded for other patients) Enteral infusion Oxygen therapy Parenteral fluid therapy Parenteral antibiotics/anti-infectives Phototherapy – code only if administered for > 12hrs 165

Perinatal cont. ACS 1615 Specific interventions for the sick neonate cont. Respiratory support in the neonate Ventilation as a means of resuscitation at birth should not be coded Code as per the guidelines in ACS 1006 Ventilatory support with the following points: Continuous ventilatory support (CVS) should be coded in neonates regardless of the duration (except if initiated during surgery and not exceeding 24 hours) NIV should always be coded e.g. CPAP based on hours of duration 166

Skin Procedures

Debridement & Dressings Debridement procedures, Index look up Debridement, burn Debridement, skin Codes located in different blocks Block 1627 Debridement of burn Block 1628 Other debridement of skin and subcutaneous tissue

Debridement & Dressings cont. Dressings of burns are separate from other dressings of other wounds, Index look up Dressing, burn Dressing, by type Codes located in different blocks Block 16 Dressing of burn Block 1601 Dressing of other wound

Debridement & Dressings cont. ACS 1203 Debridement Excisional Burns Skin & subcutaneous tissue Nonexcisional Burns (<10% or > 10%) Skin and subcutaneous tissue with or without bone or cartilage involvement Default to excisional

Debridement & Dressings cont. If multiple dressings and debridements performed in same operative episode – code only once If both debridement and dressing performed in same operative episode of same site – code only debridement ACS 0042 Procedures normally not coded Dressings only coded if performed under anaesthetic

VAC Dressings Vacuum assisted wound closure (VAC® dressing)

VAC Dressings cont. Wound dressing but is a nonexcisional debridement Correct code assignment 90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue OR 90686-00 [1627] Nonexcisional debridement of burn

Wound repairs ACS 1217 Repair of wound of skin and subcutaneous tissue Definitions for: Superficial wound repair Deep wound repair Do not code suturing of skin and subcutaneous tissue in the repair of soft tissue structures in deep tissue wounds

Wound repairs cont. Block 1635 Repair of wound of skin and subcutaneous tissue Codes based on: Site – face or neck / other Superficial / involving soft tissue If specific structure of soft tissue is documented code to repair of specified structure

Grafts and flaps Grafts and flaps are the transplantation of healthy tissue Maybe used on different tissue not just skin Grafts do not have own blood supply Used to treat Burns Injuries Areas of extensive skin loss Defects

Skin grafts Terminology found in ACHI Autograft uses skin from the patient’s own body Allograft uses skin from another human being Xenograft uses skin from a nonhuman species Synthetic and cultured skin

Skin grafts cont. More terms Split thickness Full thickness Composite Simple graft Complicated graft Small graft Large graft

Skin grafts cont. Skin grafts Follow the index: Graft (repair) - skin (autogenous) (free) (mucous membrane) - - then site or graft type Separate codes for skin grafts for burns Graft (repair) - skin (autogenous) (free) (mucous membrane) - - for burn - - - then site or graft type

Skin grafts cont. Blocks 1640 to 1650 Type of graft Burn Description of area Site

Skin grafts cont. Codes Type of graft Size of graft Site of graft Burn site % of area grafted

Flaps Has its own blood supply Types Single tissue flaps: Skin, fascia, muscle, bone, viscera Composite flaps: Fasciocutaneous Myocutaneous Osteofasciocutaneous

Flaps cont. Local flap – donor site next to recipient site Advancement Rotation Transposition Interpolation Distant flap – donor site is different body site Pedicel flap Free flap

Flaps cont. Follow the index: Flap (repair) - then site or flap type No separate codes for burns

Flaps cont. Blocks 1651-1654 Blocks 1671-1674 Type of skin flap Size of flap Complicity Blocks 1671-1674 Type of flap

Flaps cont. Blocks notes

Flaps cont. Codes Examples Type of flap Site of flap Size of flap Stage of procedure Examples 45221-01 Direct distant skin 45206-00 Local skin flap of eyelid 45221-01 Direct distant skin 45227-00 Indirect distant skin flap, formation of tubed pedicle

Cardiovascular 1 A patient was admitted with coronary artery disease in 3 arteries. He underwent surgery and the Theatre Sister entered the following procedures in the theatre log. Which interventions would you code? continued next slide..... 189 189

Cardiovascular 1 cont. Procedure Yes No Insertion of endotracheal tube Infusion of GA Cardioplegia Cardiopulmonary bypass Sternotomy Procurement of saphenous vein from (L) leg Suture of saphenous vein to coronary artery CABG x 3 Temporary pacing wires Insertion of wire to sternum Suture of thoracic wound 190 190

Cardiovascular 2 This male patient with a history of ongoing chest pain, was admitted to hospital for a left heart catheterisation and coronary angiogram. He also smokes a pack of cigarettes a day. A left cardiac catheterisation with coronary angiography was performed under local anaesthetic. The results showed severe coronary artery disease of 2 arteries. The Cardiothoracic surgeon decided that a double bypass was needed and the patient is to be readmitted in two weeks for surgery. 191 191

Cardiovascular 3 This patient with coronary artery disease (CAD) was admitted for surgery. PTCA (Percutaneous transluminal coronary angioplasty) was performed under sedation where a single stent was placed in one coronary artery (LAD).

Cardiovascular 4 Patient admitted with severe lower back pain. The Consultant performed a spiral arteriography under GA (ASA 1) which revealed occlusion of the vertebral artery. The Consultant then proceeded to a percutaneous transluminal balloon laser angioplasty with insertion of a single stent. Patient was discharged 2 days later.

Cardiovascular 5 Admission: 21/4/xx Discharge: 24/4/xx Sex: M Age: 63 M.O.: Dr Gongolo Dx: Sick sinus syndrome / bradycardia Presenting condition: Patient with a history of sick sinus syndrome presents for insertion of a permanent pacemaker Other Conditions: Hypertension Gout Peripheral vascular disease continued next slide......

Cardiovascular 5 cont. Procedures: 22/4/xx continued... Procedures: 22/4/xx Insertion of VVI permanent pacemaker and ventricular pacing lead (right subclavian vein approach) under a general anaesthetic (ASA 2). Post op complication: Acute gout (L) ankle treated with medication. Follow-up appointment: Patient was discharged home and will be followed up in 6/52 in rooms.

Cardiovascular 6 This patient with severe mitral valve incompetence underwent mitral valve replacement with a bioprosthesis under a GA (ASA 2) and with Cardiopulmonary bypass. Recovery went well and she was discharged home.

Cardiovascular 7 This fifty-eight year old female presented to the Emergency department after experiencing pressing and squeezing pain, under her breast bone following a brisk walk after her evening meal. A previous cardiac catheterisation had confirmed CAD. She was stabilised and taken to theatre where she was ventilated and placed on a cardiopulmonary bypass machine. continued next slide......

Cardiovascular 7 cont. continued... Coronary artery bypass grafts using left internal mammary graft to LAD, saphenous vein graft to PDA, RDA and marginal circumflex artery was then performed under GA (ASA 3. She was successfully taken off bypass following surgery and returned to the ward and extubated after 12 hours. Her post operative recovery was excellent and she was discharged home to be followed-up in the Cardiac Clinic  

Obstetrics 1 30 year old lady admitted for ‘trial of scar’ due to a previous LSCS. She was admitted in labour, membranes having ruptured at 8:00. Syntocinon was commenced and an epidural was inserted for pain relief. As the baby showed signs of heart decelerations, the epidural was topped up and a mid-forceps delivery of a healthy female infant was performed. Episiotomy was repaired. 199 199

Obstetrics 2 37/40 pregnant female was admitted to the maternity ward with increased blood sugar levels. She has been a Type 2 diabetic for the last 5 years. During her pregnancy she required insulin to maintain her sugar levels. She was assessed by both the obstetric and endocrinology teams with regards to the increasing risk of her diabetes to the baby. The decision was made to perform a lower segment caesarean section under epidural. A healthy live female infant was delivered by LSCS 2 days after admission. 200 200

Obstetrics 3 Patient admitted at 40 weeks for induction of labour due to breech presentation. Induction of labour was via ARM and IV Syntocin. Epidural was given for pain relief during labour. Labour progressed to a successful assisted breech delivery of a live male infant. Third degree obstetric laceration was repaired using local anaesthetic. 201 201

Perinatal 1 Premature baby (1350grams), born at 31 completed weeks gestation, with an Apgar score of 3 at 1 minute, subsequently developed pneumothorax, respiratory distress syndrome and physiological jaundice of prematurity and was admitted to special care nursery (SCN). Interventions included IV antibiotics for 5 days, CPAP and oxygen therapy for 48 hours and phototherapy for 3 days.

Skin procedures 1 Patient admitted for excision of a squamous cell carcinoma of his left ear (pinna). Under general anaesthetic (ASA 2) the patient underwent an excision of the SCC with a full thickness skin graft. Donor site was the left side of the neck.

Skin procedures 2 Patient was admitted complaining of a 4 month problem relating to her left eyelid which wasn’t meeting when she closed her eyes. Physical examination was normal apart from her eye problem which was diagnosed as a left ectropion. She went to theatre where under GA (ASA 1) a wedge excision with repair of the ectropion of her left lower eyelid was performed with a split skin graft

Skin procedures 3 A 2 year old boy was admitted following a burn injury to his right arm after he pulled a cup of hot tea off the kitchen table at home. He had second degree burns to his right forearm (BSA 4%) and some minor first degree burns to his hand (BSA 1%) . He was taken to theatre and under a GA the burns of his chest and forearm were debrided. Skin was excised from his right thigh and a split skin graft was applied to his right forearm. Dressings were applied to his hand.

Coding Queries Coding advice Auditing

Coding query mechanism Two-way process Avenue to resolve coding problems Provide feedback on problem areas

What is a coding query? Answer to problem areas in coding: New condition – no code New procedure – no code Limited medical science knowledge Incomplete understanding of classification system ‘Alone’ coder

Coding advice Crucial to the coding process Helps maintain accurate and consistent data Reduces variations in decisions Provides support to coders

Who provides the answers? Sound knowledge of: Medical science Medical terminology Coding and classification system Coding conventions Coding standards/guidelines

Query process Written NOT verbal Allows for consistent responses Storage of responses No misunderstanding No misinterpretations Does not allow for dissemination

Query process cont. Set guidelines Document the process Submission of query Response to query

Steps in query process Coder responsibility Review the classification Reference texts, web Seek advice locally Send off for advice

Steps in query process cont. Submission of the query Email Fax Web submission Query form Detailed information Enquirer Query

Example

Example - Electronic

Steps in query process cont. Reviewing the query Review the classification Check the query database Check other classifications Reference texts, websites Seek clinician advice

Steps in query process cont. Reviewing the query cont. Seek international advice Circulate & discuss Prepare a response Publish the query Submit feedback to the authors

Query database Storage Easy reference

Example

Publishing Q&As Up-dates coder workforce Consistent solutions to problems Coder education

Publishing Q&As Methods Coding magazines Websites

Example - Australia The 10-AM Commandments

Example - Australia

Example - Ireland

Development and use of internal audit programs

Assessing coding quality Auditing Round table Output editing Focused study of LOS outliers

Quality activity plan Scope of the program Objectives of the quality activities Methods by which these are achieved Individuals responsible for conducting activities Reporting structure

Quality activity plan cont. Discussion of results and action Confidentiality statement Method and frequency of evaluating the effectiveness of the program Evidence of improvement and refinement of the program over time

Sample Selection Period of audit Audit sample Random sample representative of morbidity database only some records will have errors Target sample defined by coding manager or auditor e.g. specialty, edit /error DRGs

Sampling method - Random Generate a listing of MRNs of all patients separated during the audit period. Sample size 5% recommended Minimum of 46

Round table method Group of coders code the same records and discuss the codes assigned Aims to create coding consistency Allows discussion of different answers

Round table method cont. Non-threatening, educational Majority answer will not always be correct Group may be coders from: one hospital across hospitals in an area across hospitals with a particular specialty

Focused study of LOS outliers Excessive numbers of length of stay outliers may indicate the presence of errors in coded data Review high LOS outliers in non-CC DRGs

Review reports for ‘face value’ accuracy Output editing Review reports for ‘face value’ accuracy Transposition Sudden increase or decrease in no. of cases Missing codes Mismatched codes Consistently erroneous coding patterns Consistent disregard for coding rules Use of obsolete codes

Quality activities schedule Audit Tool twice a year (random) as required (targeted) ‘Face value’ identification monthly Round table quarterly or monthly Focused study of LOS outliers monthly

Any questions?