Transcript DRG Workshop - r f z o . r s

DRG Workshop
18 – 22 November 2013
Belgrade.
DRG Workshop
Belgrade, 18-22.November 2013.
Classifications and coding
Tuesday, November 19th, 2013
DRG Workshop
Belgrade, 18-22.November 2013.
Introduction and overview
to clinical classification and
coding
DRG Workshop
Belgrade, 18-22.November 2013.
What is clinical coding?
• Translation of narrative text into codes
Atrial fibrillation = I48
• Understanding of clinical information
• Understanding of classification system
• Ability to allocate appropriate
code(s)
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Classification & Nomenclature
Statistical classification:
Nomenclature:
•Brings together diseases that are
similar and groups them under one
category or code
•Has a separate listing for every
condition and therefore a separate
code for every disease
•Limited number of categories
•Very extensive and detailed
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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
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Why code?
• Provision of database of coded information
• Used for:
– Clinical management
– Clinical research
– Identifying disease trends
– Monitoring quality of care
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Why code?
• Used for cont.:
– Funding & financial management
– Review resource consumption
– Workforce & facilities planning
– Setting benchmarks
– Comparisons
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Accurate coding
• Need for accurate coding:
– Ensures information is reliable to use
– Necessary for accurate DRG allocation
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Abstraction of information from the
clinical record
↓
Assignment of ICD-10 and ACHI codes
↓
Assignment of DRG
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Calculating an AR-DRG:
Data Items Required
Sex
ICD-10 and ACHI Codes
- Principal diagnosis
Length Of Stay
- Additional diagnoses, such as
complications and comorbidities
Or
Admission and Separation Dates
- Procedure/s
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
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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
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Belgrade, 18-22.November 2013.
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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
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Good clinical documentation cont.
• Need clear and complete documentation
• Important for clinical specialties to understand
what information can impact on DRG
assignment
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Dementia – impact on DRG assignment
Age
Gender
Diagnosis
Principal diagnosis
MDC
DRG
AR-DRG cost weight
ALOS
Reimbursement
69 years
Male
Cognitive impairment
R41.8 Other and unspecified
symptoms and signs involving cognitive
functions and awareness
23 Factors influencing health status
and other contacts with health services
Z61A Signs and symptoms
0.67
2.71 days
$2,617
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Dementia – impact on DRG assignment cont.
Diagnosis
Principal diagnosis
MDC 01
DRG
AR-DRG cost weight
ALOS
Reimbursement
Mild cognitive disorder
F06.7 Mild cognitive disorder
Diseases and disorders of the nervous
system
B64B Delirium without catastrophic
complication and/or comorbidity
1.40
6.03 days
$5,452
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Dementia – impact on DRG assignment cont.
Diagnosis
Principal diagnosis
MDC
DRG
AR-DRG cost weight
ALOS
Reimbursement
Cognitive change due to dementia
F03 Unspecified dementia
01 Diseases and disorders of the
nervous system
B63Z Dementia and other
chronic disturbances of cerebral
function
2.70
12.82 days
$10,562
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Coding process
Abstraction of information
• Be aware of potential documentation issues
– Unclear
– Incomplete
– Missing
– Conflicting
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Coding process
Abstraction of information cont.
• Review the whole clinical record
• Look at
– Discharge information forms
– Progress notes
– Investigation results
– Operation reports
– Specialist notes
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Coding process
Abstraction of information cont.
• Apply medical terminology and medical
science knowledge
If you cannot analyse and abstract you
cannot code
• Apply coding rules
• Apply coding standards
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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
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Example
Patient presented with rapid onset of
dyspnoea and chest pain. A chest Xray revealed a spontaneous
pneumothorax.
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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
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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
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Accurate inpatient coding
• Correct identification of Diagnoses and
Procedures
• Assignment of correct ICD-10 and ACHI codes
• Correct sequence of Pdx
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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
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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 DRG
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Tabular List
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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
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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)
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Structure of the ICD-10 code
– In ICD-10 the 4 character code consists of
J45.9
First
character
A to Z
Followed by
2 digits
Lastly
Another
digit
Then
a point
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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
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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
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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
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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
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Annotations
† 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
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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
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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
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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
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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
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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
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Conventions
• Lead terms
– 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
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Conventions cont.
Lead term
Nonessential modifiers
Sequenced in
alphabetic
order
Essential modifier
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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
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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
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Australian Classification of Health
Interventions – ACHI
• Self-contained classification based on a fee schedule
(MBS)
• Numeric codes – five digits with a two digit extension
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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
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Development of ACHI cont.
• Features
− Meaningful terminology
− Staged procedures
38430-00 [565] Thoracoplasty, staged, first stage
38430-01 [565] Thoracoplasty, staged, second or
subsequent stage
− Devices
35309-08 [754] Open transluminal balloon angioplasty
with stenting, single stent
35309-09 [754] Open transluminal balloon angioplasty
with stenting, multiple stents
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Development of ACHI cont.
• Features
− Laterality
33524-00 [700] Renal endarterectomy, unilateral
33527-00 [700] Renal endarterectomy, bilateral
− Codes for procedures commonly performed
together
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
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ACHI Structure
• Chapters follow the ICD-10 structure as closely
as possible
• Anatomical site rather than surgical
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ACHI Structure cont.
• Multi-axial structure
− primary axis – site
− secondary axis – procedure type
− tertiary axis – specific site, procedure or technique
used
• Exceptions
− dental, obstetrics, radiation oncology, imaging and
miscellaneous procedures
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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
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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
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Example
Concepts classified first by site (nose) then by
intervention:
Type of
procedure
Examination
41653-00
Examination of nasal cavity and/or
postnasal space
41764-00
Nasendoscopy
Application, insertion, removal
41907-00 Insertion of nasal septal button
Incision
41659-00 Removal of intranasal foreign body
41683-00 Division of nasal adhesions
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ACHI Structure cont.
• Numbering system and blocks
− Code numbers not in numerical order
− Block numbers are in numerical order
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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
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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
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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
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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
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Example
MBS item number
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
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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
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Conventions in the Tabular List
• Conventions
− 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
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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
right ventriculography
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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
o
o
o
as
by
for
o
o
with
without
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Structure of ACHI Index cont.
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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
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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
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General standards for
interventions
ACS 0016
ACS 0042
ACS 0031
ACS 0020
ACS 0019
General procedure guidelines
Procedures normally not coded
Anaesthesia
Bilateral/Multiple procedures
Procedures not completed or
interrupted
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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
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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
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ACS 0016 General procedure
guidelines cont.
Ordering of intervention codes
1. Procedure performed for treatment of the
principal diagnosis
2. Procedure performed for treatment of an
additional diagnosis
3. Diagnostic/exploratory procedure related to the
principal diagnosis
4. Diagnostic/exploratory procedure related to an
additional diagnosis for the episode of care
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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
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ACS 0042 Procedures normally not
coded
•
•
•
•
Usually routine in nature
Performed for most patients
Can occur multiple times
Resources often reflected in Dx
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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
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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’
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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
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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
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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
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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
Code once
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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
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ACS 0020 Bilateral/multiple
procedures cont.
• Multiple procedures
− 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).
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ACS 0020 Bilateral/multiple
procedures cont.
• Multiple procedures
− 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
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ACS 0020 Bilateral/multiple
procedures cont.
• 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
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ACS 0020 Bilateral/multiple
procedures cont.
• 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
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subcutaneous
of neck
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2013.
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 ofDRGsites
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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
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Line Coding
a) Wedge resection of the toenail for ingrown
nail
b) Male admitted for drainage of pilonidal cyst
c) Transurethral prostatectomy for benign
prostatic hypertrophy
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Line Coding cont.
d) Unilateral, partial thyroidectomy for
thyrotoxicosis
e) Excision of wart from tip of nose (skin)
f) Patient with mature senile cataract for
intracapsular removal and insertion of
intraocular lens
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Anaesthesia
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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
DRG Workshop
Belgrade, 18-22.November 2013.
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
DRG Workshop
Belgrade, 18-22.November 2013.
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.
DRG Workshop
Belgrade, 18-22.November 2013.
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’
DRG Workshop
Belgrade, 18-22.November 2013.
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
DRG Workshop
Belgrade, 18-22.November 2013.
Ventilatory support
DRG Workshop
Belgrade, 18-22.November 2013.
Ventilatory support
• ACHI codes for CVS are found in block [569] and
NIV in block [570]
– Block [569] Ventilatory support:
13882-00
13882-01
13882-02
≤ 24 hours
> 24 and < 96 hours
≥ 96 hours
– Block [570] Noninvasive ventilatory support:
92209-00
92209-01
92209-02
≤ 24 hours
> 24 and < 96 hours
≥ 96 hours
DRG Workshop
Belgrade, 18-22.November 2013.
96
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.
DRG Workshop
Belgrade, 18-22.November 2013.
97
Ventilatory support cont.
• ACS 1006 Ventilatory support
– Definition
Noninvasive ventilation
(NIV)
Continuous ventilatory support
(CVS)
DRG Workshop
Belgrade, 18-22.November 2013.
Ventilatory support cont.
• ACS 1006 Ventilatory support cont.
– Definition of CVS
DRG Workshop
Belgrade, 18-22.November 2013.
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.
DRG Workshop
Belgrade, 18-22.November 2013.
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
DRG Workshop
Belgrade, 18-22.November 2013.
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
ACHI codes:
13882-01 [569] Management of continuous ventilatory support,
> 24 and < 96 hours
Look up:
Management (for the duration)
DRG Workshop
Belgrade, 18-22.November 2013.
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
DRG Workshop
Belgrade, 18-22.November 2013.
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)
DRG Workshop
Belgrade, 18-22.November 2013.
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
DRG Workshop
Belgrade, 18-22.November 2013.
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
DRG Workshop
Belgrade, 18-22.November 2013.
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
DRG Workshop
Belgrade, 18-22.November 2013.
Pharmacotherapy
DRG Workshop
Belgrade, 18-22.November 2013.
Pharmacotherapy
• Terminology
– PHARMACOTHERAPY
• defined as ‘the treatment of a condition by means of
drugs’
DRG Workshop
Belgrade, 18-22.November 2013.
109
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
DRG Workshop
Belgrade, 18-22.November 2013.
110
Pharmacotherapy cont.
• [1920] Pharmacotherapy
– 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.
DRG Workshop
Belgrade, 18-22.November 2013.
111
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)
DRG Workshop
Belgrade, 18-22.November 2013.
112
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.
DRG Workshop
Belgrade, 18-22.November 2013.
113
Pharmacotherapy cont.
• Vascular access 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
DRG Workshop
Belgrade, 18-22.November 2013.
Pharmacotherapy cont.
• Vascular access device – Port-A-Cath
DRG Workshop
Belgrade, 18-22.November 2013.
Pharmacotherapy cont.
• Huber needle
DRG Workshop
Belgrade, 18-22.November 2013.
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
DRG Workshop
Belgrade, 18-22.November 2013.
117
Pharmacotherapy cont.
• Loading of a drug delivery device can be found
at Block 1920 for example:
• Maintenance codes at Block 1922
DRG Workshop
Belgrade, 18-22.November 2013.
118
Pharmacotherapy cont.
• Same-day admission for ‘management’ only
of vascular access/drug delivery device
assign as PDx:
Z45.1 Adjustment and management of infusion pump
or
Z45.2 Adjustment and management of vascular
access device
DRG Workshop
Belgrade, 18-22.November 2013.
DRG Workshop
Belgrade, 18-22.November 2013.
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.
DRG Workshop
Belgrade, 18-22.November 2013.
121
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......
DRG Workshop
Belgrade, 18-22.November 2013.
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.
DRG Workshop
Belgrade, 18-22.November 2013.
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.
DRG Workshop
Belgrade, 18-22.November 2013.
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.
DRG Workshop
Belgrade, 18-22.November 2013.
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.
DRG Workshop
Belgrade, 18-22.November 2013.
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.
DRG Workshop
Belgrade, 18-22.November 2013.
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.
DRG Workshop
Belgrade, 18-22.November 2013.
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.
DRG Workshop
Belgrade, 18-22.November 2013.
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 CaldwellLuc 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.
DRG Workshop
Belgrade, 18-22.November 2013.
130
Pharmacotherapy 1
Patient with Crohn’s disease admitted same day
for treatment with IV infusion infliximab via a
PICC line.
DRG Workshop
Belgrade, 18-22.November 2013.
131
Pharmacotherapy 2
Same-day admission for removal of spinal
infusion device under sedation (ASA 1).
DRG Workshop
Belgrade, 18-22.November 2013.
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.
DRG Workshop
Belgrade, 18-22.November 2013.
133
Specialty coding and Coding
support
Wednesday, November 20th,
2013
DRG Workshop
Belgrade, 18-22.November 2013.
Cardiovascular
DRG Workshop
Belgrade, 18-22.November 2013.
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
DRG Workshop
Belgrade, 18-22.November 2013.
Cardiovascular cont.
• Coronary artery bypass grafts (CABGs) cont.
– also need to code cardiopulmonary bypass (CPB) if
performed e.g.
DRG Workshop
Belgrade, 18-22.November 2013.
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
DRG Workshop
Belgrade, 18-22.November 2013.
138
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
DRG Workshop
Belgrade, 18-22.November 2013.
139
Cardiovascular cont.
• Pacemakers
– Single and dual chamber
– Biventricular/triple chamber
– Implantable cardioverter defibrillators (ICDs)
– Combined ICD and Pacemaker device
DRG Workshop
Belgrade, 18-22.November 2013.
140
Cardiovascular cont.
• ACHI codes
– One set of electrode codes for use with
pacemakers and ICDs
– Combined pacemaker/defibrillator concept in the
defibrillator code
DRG Workshop
Belgrade, 18-22.November 2013.
141
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
DRG Workshop
Belgrade, 18-22.November 2013.
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
DRG Workshop
Belgrade, 18-22.November 2013.
143
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
DRG Workshop
Belgrade, 18-22.November 2013.
144
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
DRG Workshop
Belgrade, 18-22.November 2013.
145
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
DRG Workshop
Belgrade, 18-22.November 2013.
146
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
DRG Workshop
Belgrade, 18-22.November 2013.
Cardiovascular cont.
• Heart Valves
• Heart Valve repair
– 4 valves
•
•
•
•
– Annuloplasty
– Valvuloplasty
Aortic
Mitral
Tricuspid
Pulmonary
DRG Workshop
Belgrade, 18-22.November 2013.
148
Cardiovascular cont.
• Heart Valve replacement
– Removal and replacement
– Types of replacements:
• Bioprosthetic, Mechanical, Biological
DRG Workshop
Belgrade, 18-22.November 2013.
149
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]
DRG Workshop
Belgrade, 18-22.November 2013.
150
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
• Codes split on laterality
DRG Workshop
Belgrade, 18-22.November 2013.
151
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
DRG Workshop
Belgrade, 18-22.November 2013.
152
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
DRG Workshop
Belgrade, 18-22.November 2013.
153
Obstetrics
DRG Workshop
Belgrade, 18-22.November 2013.
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
DRG Workshop
Belgrade, 18-22.November 2013.
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)
DRG Workshop
Belgrade, 18-22.November 2013.
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
DRG Workshop
Belgrade, 18-22.November 2013.
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
DRG Workshop
Belgrade, 18-22.November 2013.
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…
DRG Workshop
Belgrade, 18-22.November 2013.
Obstetrics cont.
DRG Workshop
Belgrade, 18-22.November 2013.
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
DRG Workshop
Belgrade, 18-22.November 2013.
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
DRG Workshop
Belgrade, 18-22.November 2013.
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
DRG Workshop
Belgrade, 18-22.November 2013.
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
DRG Workshop
Belgrade, 18-22.November 2013.
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
DRG Workshop
Belgrade, 18-22.November 2013.
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
DRG Workshop
Belgrade, 18-22.November 2013.
Skin Procedures
DRG Workshop
Belgrade, 18-22.November 2013.
167
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
DRG Workshop
Belgrade, 18-22.November 2013.
168
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
DRG Workshop
Belgrade, 18-22.November 2013.
169
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
DRG Workshop
Belgrade, 18-22.November 2013.
170
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
DRG Workshop
Belgrade, 18-22.November 2013.
171
VAC Dressings
• Vacuum assisted wound closure (VAC®
dressing)
DRG Workshop
Belgrade, 18-22.November 2013.
172
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
DRG Workshop
Belgrade, 18-22.November 2013.
173
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
DRG Workshop
Belgrade, 18-22.November 2013.
174
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
DRG Workshop
Belgrade, 18-22.November 2013.
175
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
DRG Workshop
Belgrade, 18-22.November 2013.
176
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
DRG Workshop
Belgrade, 18-22.November 2013.
177
Skin grafts cont.
• More terms
– Split thickness
– Full thickness
– Composite
– Simple graft
– Complicated graft
– Small graft
– Large graft
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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
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Skin grafts cont.
• Blocks 1640 to 1650
• Type of graft
• Burn
• Description of area
• Site
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Skin grafts cont.
– Codes
• Type of graft
• Size of graft
• Site of graft
• Burn site
• % of area grafted
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Flaps
• Has its own blood supply
• Types
– Single tissue flaps:
• Skin, fascia, muscle, bone, viscera
– Composite flaps:
• Fasciocutaneous
• Myocutaneous
• Osteofasciocutaneous
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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
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Flaps cont.
• Follow the index:
Flap (repair)
- then site or flap type
– No separate codes for burns
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Flaps cont.
• Blocks 1651-1654
– Type of skin flap
– Size of flap
– Complicity
• Blocks 1671-1674
– Type of flap
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Flaps cont.
• Blocks notes
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Flaps cont.
• Codes
–
–
–
–
• Examples
Type of flap
Site of flap
Size of flap
Stage of procedure
45221-01 Direct distant skin
45227-00 Indirect distant skin flap, formation of tubed pedicle
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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.....
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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
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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.
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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).
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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.
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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
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Cardiovascular 5 cont.
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.
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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.
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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......
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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
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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 midforceps delivery of a healthy female infant was
performed. Episiotomy was repaired.
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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.
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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.
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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.
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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.
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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
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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.
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Coding Queries
Coding advice
Auditing
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Coding query mechanism
• Two-way process
– Avenue to resolve coding problems
– Provide feedback on problem areas
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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
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Coding advice
• Crucial to the coding process
• Helps maintain accurate and consistent
data
• Reduces variations in decisions
• Provides support to coders
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Who provides the answers?
• Sound knowledge of:
– Medical science
– Medical terminology
– Coding and classification system
– Coding conventions
– Coding standards/guidelines
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Query process
• Written NOT verbal
– Allows for consistent responses
– Storage of responses
– No misunderstanding
– No misinterpretations
– Does not allow for dissemination
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Query process cont.
• Set guidelines
• Document the process
– Submission of query
– Response to query
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Steps in query process
1. Coder responsibility
– Review the classification
– Reference texts, web
– Seek advice locally
– Send off for advice
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Steps in query process cont.
2. Submission of the query
– Email
– Fax
– Web submission
3.Query form
– Detailed information
• Enquirer
• Query
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Example
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Example - Electronic
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Steps in query process cont.
4. Reviewing the query
– Review the classification
– Check the query database
– Check other classifications
– Reference texts, websites
– Seek clinician advice
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Steps in query process cont.
4. Reviewing the query cont.
– Seek international advice
– Circulate & discuss
– Prepare a response
– Publish the query
– Submit feedback to the authors
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Query database
• Storage
• Easy reference
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Example
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Publishing Q&As
• Up-dates coder workforce
• Consistent solutions to problems
• Coder education
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Publishing Q&As
• Methods
– Coding magazines
– Websites
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Example - Australia
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Example - Australia
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Example - Ireland
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Development and use
of internal audit programs
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Assessing coding quality
•
•
•
•
Auditing
Round table
Output editing
Focused study of LOS outliers
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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
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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
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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
• only some records will have errors
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Sampling method - Random
• Generate a listing of MRNs of all patients
separated during the audit period.
• Sample size
– 5% recommended
– Minimum of 46
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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
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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
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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
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Output editing
Review reports for ‘face value’ accuracy
• Transposition
• Sudden increase or
decrease in no. of cases
• Consistently erroneous
coding patterns
• Missing codes
• Consistent disregard for
coding rules
• Mismatched codes
• Use of obsolete codes
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Quality activities schedule
• Audit Tool
• Round table
– twice a year (random)
– as required (targeted)
• ‘Face value’
identification
– quarterly or monthly
• Focused study of LOS
outliers
– monthly
– monthly
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Any questions?
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