CODING GUIDELINES No. 5

CODING GUIDELINES No. 5 January, 2000 Please note that the Coding Advisory Service Telephone Number is 0131-552-7325 The number is manned Tuesday to Thursday from 09.00 to 17.00 hrs. N.B. All the following guidelines will take effect from 1 st April, 2000 Coding Guidelines - ICD10 Geriatric Falls/ Off legs/ Off feet If there is no further information available, the above terms should be coded in the following way:- Geriatric Falls - code R54.X Senility/Old age [no external chapter code required] Off legs/off feet -code R26.8 Other and unspecified abnormalities of gait and mobility Unsteadiness on feet NOS If it is an emergency admission, Admission Type would be 36 - Patient non-injury. However, if there is an injury, the injury and external cause should be coded first. Example - bruised hip due to (geriatric) falls at home: Codes S70.0 - Contusion of hip W19.0 - Unspecified fall at home If the patient is prone to falls, the code R54.X - Senility/Old age may be added. In this case the Admission Type for an emergency admission would be 33 - Patient Injury - Home Accident. Definition of Perinatal Period From 1 st April 2000 the following definitions will apply:- For morbidity coding the Perinatal Period applies to disorders manifesting or originating in the first 7 days of life (i.e. ends at 7 completed days after birth) Neonatal Period commences at birth and ends 28 completed days after birth. Please notice that this will be an amendment to the ICD10 Training Manual, Chapter XVI page 1 National Services Scotland 2010 1

ICD10 index amendments The following ICD10 index errors have been noted:-. a) p 457 Presentation, fetal - face (mother) O32.3 - - causing obstructed labor O64.2 - - to pubes O32.8 (amended from O32.3) b) Table of drugs and chemicals p 695 Meningococcal vaccine adverse effect amend to Y58.9 (from Y59.8) Please amend your ICD10 Index. Coding Guidelines - OPCS4 Re-amputations There has been some confusion around the correct use of the OPCS-4 codes for reamputation. The following two examples are used to illustrate their correct use. 1. A patient is admitted and has an amputation of the right foot through the ankle, and then a few days later goes back to theatre for a right below knee amputation. Code - first amputation X10.1 Amputation of foot through ankle second amputation X09.5 Amputation of leg below knee 2. Patient has amputation 8 inches below the knee, taken back to theatre later and reamputated to 4 inches below the knee. [re-amputation takes place through the same bone] Code - first amputation X09.5 Amputation of leg below the knee second amputation X12.1 Re-amputation at a higher level Z78.9 Bone of lower leg nec Code X12.1 - Reamputation at a higher level should only be used when the re-amputation would take the coder to the same code as the original amputation. When using X12.1, a Z code should also be added to identify the specific site of the amputation. Plasmapheresis Plasmapheresis is the taking out or withdrawal of contaminated plasma and should be coded:- X36.8 Other specified blood withdrawal If plasma is re-inserted then this should be coded:- X34.2 Transfusion of plasma Where both procedures occur in the same episode, use both codes. National Services Scotland 2010 2

Tension-free Vaginal Tape Procedure A new procedure for the treatment of stress incontinence in women is now being carried out, using a tension-free vaginal tape. The tape is put into position as a support for the urethra (bladder outlet). In order to perform this procedure, the clinician makes an incision in the vagina to insert the tape, which is like a thread or ribbon, with a needle at each end. The tape is introduced with the curved rounded needles through the vaginal incision and around the bladder neck, on each side. Two small incisions are made in the abdomen suprapubically, purely as a mechanism for getting the needles out and to allow the tape to travel through, and eventually anchor into, the pelvic tissues. The tape is adjusted to effectively support the urethra and the excess tape material is trimmed off. The bit of tape left in-situ grips into the pelvic tissues without the need to suture it. Both the abdominal and the vaginal cuts are then closed with absorbable sutures. From 01/04/00, the correct OPCS4 code to reflect this procedure is: M53.8 Other specified vaginal operations to support outlet of female bladder. This code replaces any interim codes previously given out. MMR Vaccine The default code for MMR Injection is X37.4 - Intramuscular immunotherapy However if it is stated that MMR was given subcutaneously then code to X38.5 - Subcutaneous immunotherapy Pain Relief Code List In SMR Update No 4, January 1998, a list of additional procedures for SMR00 Short List was published which included a list of procedures for Pain Control. The following list of amendments to that list has been agreed by the Clinical Coding Review Group: Intravenous regional sympathetic block - A81.8 + Y38.8 (amend from A73.5 + Z12.7) LA stellate ganglion block - A81.8 + Y82.1 (amend from A73.5 + Z12.7) LA/diagnostic lumbar sympathetic block - A81.8 +Y82.1(amend from A73.5 + Z12.7) Acupuncture - A70.8 + Y33.1 (amend from S53.3 + Y33.1) The new codes should be used from 01/04/00. Note also that the codes given in this list have been carefully considered to give the best information possible and should be used wherever these procedures have been performed whether on a SMR00 or SMR01. It is suggested that you keep a copy of the list with your Coding Guidelines. If you do not have the original list, please contact your Clinical Coding Co-ordinator. Dupuytren s Release It has been agreed by the Clinical Coding Review Group that if no further information is available for the term Dupuytren s Release - Default code - T52.1 - Palmar fasciectomy National Services Scotland 2010 3

Shoulder Surgery The following code list has been agreed by the Scottish Register of Shoulder Arthroplasty Group. OPERATION/PROCEDURE Shoulder Hemiarthroplasty primary cemented primary uncemented primary nec revision (includes conversions) cemented revision (includes conversions) uncemented revision (includes conversions) nec OPCS4 CODES W49.1 + laterality W50.1 + laterality W51.1 + laterality W49.3 + laterality W50.3 + laterality W51.3 + laterality Total Shoulder Replacements primary cemented W52.1 Z81.3 primary uncemented W53.1 Z81.3 primary nec W54.1 Z81.3 revision (includes conversions) cemented W52.3 Z81.3 revision (includes conversions) uncemented W53.3 Z81.3 revision (includes conversions) nec W54.3 Z81.3 Acromioplasty Sub acromial decompression - (open) W81.8 Z68.2 (endoscopic) W84.8 Z68.2 Other Shoulder Procedures Rotator cuff repair - (open) T79.1 + laterality (endoscopic) T79.1 Y52.8 Joint stabilisation (open only) Gleno humeral W77.- Z81.3 Acromial clavicular W77.- Z81.2 Excision of acromial clavicular joint (open only) W08.5 Z81.2 Index error The following index error has been noted in the Eponym section of OPCS4 W74.2 Jones (KG) Reconstruction Ant. Cruciate Ligament (Z84.6) (amended from W74.3) Please amend your OPCS4 index National Services Scotland 2010 4

Reversal of Hartmanns Hartmann s procedure is coded to:- H33.5 - Rectosigmoidectomy and closure of rectal stump and exteriorisation of bowel with an appropriate secondary code of G74.-, H14.- or H15.-. If a Reversal of Hartmann s is carried out, the notes should be checked for the exact procedure performed. However, in the absence of further information, the default code for Reversal of Hartmann s is:- H15.4 - Closure of colostomy Y16.2 - Anastomosis of organ noc (England only) Z29.1 - Rectum In Scotland, since only 2 codes may be recorded the default will be H15.4 and Z29.1. For National Clinical Coding Qualification examination questions, use H15.4, Y16.2 and Z29.1. Subcutaneous injections Since the introduction of OPCS4 coders have had great difficulty in allocating a code for subcutaneous injections. This has resulted in inconsistencies in recording with some coders coding to: S52 - Introduction of therapeutic substance into subcutaneous tissue and others to X38 - Subcutaneous injection. It has been agreed by the UK Coding Review Panel that as from 1/4/2000 - we should delete the codes S52.2 and S52.4 from our OPCS4 Tabular List. Add at beginning of category S52 - Excludes: subcutaneous injections (X38) Add brackets to the term local action [non-essential modifiers] at X38.1.2.3 and.6. These codes will then be suitable for either local or systemic action. ALPHABETICAL INDEX Delete S52- Injection subcutaneous tissue therapeutic Add X38.- Injection subcutaneous tissue therapeutic General Information National Clinical Coding Qualification Due to the fact that IHRIM administer both the NCCQ and the IHRIM Certificate, the Clinical Coding exam, currently scheduled for May, is being brought forward to April. This allows the administrators more time between the two sets of exams. All future coding exams will now be scheduled for April and October, and the dates for this year are Friday 28 th April and Monday 30 th October. The closing dates for registration are 28 th February and 31 st August, respectively. Anyone interested in sitting the examination can contact SCCC in the first instance for further information and a registration form. The fee for the examination is 70. National Services Scotland 2010 5

DQA News What have the Quality Assessment and Accreditation Team been up to? I notice it has been a while since I last updated you as to what the team have been up to, so I thought it was time I did. General news Firstly, we have changed our name to the Data Quality Assurance (DQA) Team. This was done to help avoid confusion between us and the Data Accreditation Team, particularly as both teams come under the SMR and Standards Unit in ISD. As from January 2000 we will be losing the services of Walter Lawder, one of our longer serving team members. Walter has taken up a 3 month secondment working with the Administration Team in ISD before taking early retirement in March. Replacing Walter will not be easy, and we all wish him well in his new post and retirement. Trust wide projects carried out over the last year or so SMR04 - this project has taken most of the year to complete the assessments undertaken for 22 trusts. All preliminary and final reports (except 1) have been issued to trusts. As this was the first time SMR04 data has been assessed reports were tailored more to the identification of problem areas and the provision of feedback on good coding practices rather than simply providing accuracy rates. An all trust report will be produced and this will form the basis for setting up an internal ISD group to review the completion of SMR04. Findings from this group will be circulated to the Service for comment. Investigation of anomalies resulting from Coppish - this project has been running on and off alongside the SMR04 and other smaller projects. The project involves comparing SMR00 and SMR01 data against ISD(S)1 and investigating significant differences. The first round of comparisons have been issued to trusts and comments received. Trust reconfiguration has delayed the second round of comparisons and plans are in place to circulate these early next year. At the same time we plan to carry out face to face interviews to complete a questionnaire primarily looking at the collection of ISD(S)1 data. The intention is to make a series of recommendations to improve the accuracy and completeness of both SMR and ISD(S)1 returns. Trust wide projects planned for next year SOCRATES - Cancer registration data - plans are being put in place for an assessment of cancer registration data. The sample will be around 3,000-3,500 records and will include all the new data items added since the introduction of the new data set in January 1997. A small pilot assessment has taken place to test our procedures and methodology. So watch out we will be calling upon you soon! SMR01 - this project is scheduled for late summer beginning of autumn and is likely to cover discharges in the year 2000! We will be in touch in due course. Chris Jones, Data Quality Manager National Services Scotland 2010 6

Coding guidelines - Cumulative Summary (January 2000) ICD10 Coding Guidelines Abortion codes in SMR02 Feb 97 Abortion coding Jan 99 Acute on Chronic Conditions Jan 99 Administration of abortifacient drug Apr 98 Alcohol-related conditions May 96 Ante-partum haemorrhage Jan 98 Arterial disease Feb 97 Burns classified according to percentage of body area Sep 99 Cancelled procedure, condition resolved Nov 96 Cancer patients admitted for chemotherapy May 97 Clicking hip Nov 96 COAD Sep 99 Coding HIV disease Feb 97 Coding HIV disease in ICD10 Nov 96 Coding poisonings with the drug Ecstasy Nov 96 Co-morbidities on SMR01 coding Jun 99 Compound drugs Sep 99 Conditions caused by an infectious agent Nov 96 Conditions in pregnancy May 96 Convalescence on SMR01 Feb 97 Dagger and asterisk coding May 96 Drugs and alcohol poisoning May 97 E Coli 0157 Feb 97 External cause codes May 97 Geriatric Falls/ Off Legs/ Off feet Jan 00 Head Injuries Jun 99 Helicobacter infection Nov 96 Helicobacter positive May 97 Helicobacter pylori infection May 96 ICD10 index changes Feb 97/Jan 98/Jan 00 Injury with tendon involvement Nov 96 Last position coding - ICD10 Sep 99 Left Ventricular Dysfunction Jan 99 Lewy Body Dementia/Syndrome/Disease Jan 99 Malignant pleural effusion Nov 96 Meconium staining Sept 97 MRSA (Methicillin resistant staphylococcus aureus) May 96 Multi-organ failure Nov 96 Multiple rehabilitation procedures Feb 97 National Services Scotland 2010 7

ICD10 Coding Guidelines (continued) Observation codes (Z03.- and Z04.-) when to use them May 97 Obstructive jaundice Apr 98 Old myocardial infarction Jan 98 Patient who takes overdose transferred to psychiatric hospital May 97 Perinatal Period - revised definition Jan 00 Pfeiffer s disease/ syndrome Jun 99 Poisoning - intentional self-harm or accidental? May 96 Postnatal administration of Anti D May 97 Post procedural disorders May 96 Presumptive diagnoses Jan 98 Prophylactic mastectomy Jun 99 Prosthetic device at the end of its natural life May 97 Rhabdomyolysis Sept 97 Recurrent tonsillitis Feb 97 Removal of grommets May 97 Sequelae codes Feb 97 Site of musculoskeletal involvement Apr 98 Spontaneous Rupture of Membranes Nov 96 Toxic Confusional State Jan 99 Termination of pregnancy using Mifepristone (RU486) May 97 Unconfirmed conditions May 96 Uncontrolled Diabetes Jan 99 Use of codes Y90 - Y98 Nov 96 Viagra - adverse effect Sep 99 Coding guidelines - Cumulative Summary (January 2000) OPCS4 Coding Guidelines Acromioplasty Jan 00 Anti D Sept 97 Amendment to coding update - Laparoscopic hydrotubation Feb 97 - LLETZ/Loop diathermy of cervix Nov 96 - Pharyngolaryngectomy Nov 96 Brushings for Cytology Sept 97 Cadaver coding Sept 97 Cervical Studies Jun 99 CLO test for helicobacter Nov 96 Cold coagulation to cervix Apr 98 Coloposcopy of Cervix Jan 99 Dacron mesh keratoprostheses Sep 99 Diagnostic Endoscopy where no biopsies taken Jun 99 National Services Scotland 2010 8

OPCS4 Coding Guidelines (continued) Excision of lesion of skin Apr 98 Endoscopic Balloon Ablation of Endometrium Jan 99 Dupuytren s Release Jan 00 Guidelines for coding failed minimum access procedures in OPCS4 Sept 98 Hartmann s Reversal Jan 00 HEAL - Hysteroscopic endometrial ablation - laser Apr 98 Hickman Line insertion Apr 98 Index error Jan 00 Injections and infusions Apr 98 Irrigation of peritoneal cavity Nov 96 Laparoscopic Hysterectomy Jan 99 Laparoscopic Hysterectomy/Laparoscopic Oophorectomy Jan 99 Laparotomy Sept 97 Microwave prostatectomy Apr 98 MMR Vaccine Jan 00 Multiple Endoscopic Biopsies Jan 99 Nerve blocks Sep 99 Pain Relief Codes Jan 00 Plasmapheresis Jan 00 Peripheral stem cell procedures Jun 99 Proctoscopy Jan 98 Re-amputations Jan 00 Recording non-operations Sept 97 Subcutaneous Injections Jan 00 Tension-free Vaginal Tape Procedure Jan 00 Tension band wiring of a fracture of the patella Jan 98 Termination of pregnancy using Mifepristone (RU486) pessary Apr 98 Therapeutic v diagnostic procedures Unicondylar/Unicompartmental knee joint replacement Apr 98 Unlikely pair codes Jun 99 NB: From Nov 96 to Sept 98 issues were entitled Coding Quarterly National Services Scotland 2010 9