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Records 11 to 20 of 1435
3185 - Absent red eye reflex - retired 30/6/2020
Could you please indicate what code should be assigned when a newborn is found to have an absent red eye reflex on examination and is referred to specialist eye services for further investigation?...
(March 2017)
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2134 - Accidental punctures and lacerations - retired 30/6/2013
Should accidental punctures & lacerations during procedures be coded when no action is taken?
Search Details:
We have checked NCCH query database, ICD coding newsletter & Coding Matters but have come up with no information regarding this subject....
(March 2007)
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1986 - Accidents and injuries during pregnancy - retired 30/6/2010
Scenario 1:
Obstetric patients present following motor vehicle accidents (MVAs), accidents in the home, workplace etc. They are seen by the O&G clinician, and CTG is performed to assess fetal wellbeing.
We code these episodes according to the 'Minor Trauma Coding Guidelines' (ICD Coding Newsletter - June 2001), as well as coding 'O99.8 Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium' as the principal diagnosis.
Tha...
(December 2004)
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3541 - Achilles tendon repair and debridement
This patient was admitted with an Achilles tendon rupture.
The title on the operation report is left tendoachilles repair.
In the body of the operation report it is documented that the tear was identified and debrided. It was then repaired with PDS suture using Krakow techinique with augment repair of tendon and paratendon with 2.0 vicryl.
VICC query #3073 Debridement with repair states: “VICC considers that a code for th...
(June 2020)
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2709 - ACS 0001 Principal diagnosis - two or more diagnoses that equally meet principal diagnosis definition
When a doctor lists several conditions as principal diagnosis my understanding of this standard has always been that we take into consideration the circumstances of the admission when choosing the principal diagnosis, as per example 1 in the standard (where I interpret all diagnoses as meeting criteria for coding). If, after viewing the notes, more than one diagnosis could equally be principal, as determined by admission circumstances, workup and therapy provided, we should refer to the clinici...
(June 2012)
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2989 - ACS 0001 Principal diagnosis problems and underlying conditions - retired 30/6/2020
ACS 0001 Principal Diagnosis, sub-heading Problems and underlying conditions, point 2, Coding the problem as the principal diagnosis.
Scenario: patient with previously diagnosed secondary neoplasm to bone, admitted for MANAGEMENT OF BONE PAIN.
We have coders and auditors developing material for students and would appreciate clarification. This has been discussed with more than 20 individuals and the response vary 50/50 between the answers provid...
(June 2015)
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2648 - ACS 0001 Principal diagnosis, problems with underlying conditions in the perinatal period
Please clarify the use of ACS 0001Principal diagnosis - Problems with underlying conditions, point two 'Coding the problem as the principal diagnosis' when applied to conditions originating in the perinatal period.
ACS 1605 Conditions originating in the perinatal period, second dot point 'Conditions originating in the perinatal period still apply for infants >28 days who are discharged and subsequently readmitted with a condition documented as originating in the perinata...
(December 2011)
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3635 - ACS 0002 – Documented plan for routine care
In ACS 0002 example 11 the patient was advised by a nurse to drink more fluids as slightly hypotensive. In this example, the hypotension was not a significant condition in the episode of care, as the patient was only advised to drink more fluids; therefore it does not meet the criteria in ACS 0002.
If, following clinical consultation, a doctor documents a plan which would be considered routine care such as ‘encourage oral fluids’ would the condition still be considered c...
(September 2020)
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2572 - ACS 0002 Additional diagnoses and ACS 0010 General abstraction guidelines - retired 30/6/2017
We have a case where hypokalaemia is recorded as an additional diagnosis on the discharge summary, blood tests show low potassium and the administration of slow k is documented on the drug chart. There is no documentation of hypokalaemia within the body of the medical record.
The standard 0010 General abstraction Guidelines infers that conditions need to be supported within the body of the medical record before the coder can assign a code for the condition.
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(December 2010)
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3646 - ACS 0002 Additional diagnoses and discharge medication
This patient was admitted with a traumatic subdural haematoma following a fall with headstrike. On the day of discharge U&Es were performed which showed potassium 3.1 mmol/L.
The discharge summary records the following:
# Hypokalaemia
– likely in the setting of poor oral intake whilst in hospital
- Prescribed Slow K and for GP to repeat U&Es in 3-4 days (slip given)
The discharge prescription confirms that the patient was ...
(September 2020)
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