Health data standards and systems

ACS 0112 Infection with drug resistant microorganisms instructs coders to assign a code from Z06.x Bacterial agents resistant to antibiotics when a clinician has documented the infection as being resistant to an antibiotic. At our hospital the pathology reports will often document that the infection is resistant to an antibiotic however the clinician will not have documented it in the record. Can we apply the same logic we do when coding the type of organism and assign a code from Z06.x when it is documented only on the pathology report. (ie patient has UTI and no organism is documented, however a urine result indicates E.Coli we can code it directly from the path report). Or must it be documented by a clinician in the record?

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NCCH #1703 advises to only code the Z06 code when it is documented by a clinican. This was to avoid use of Z06 when a 'R' was documented on the pathology reports. Our reports actually document 'resistant to penicillin' etc, not just the R. Is this more substantial documentation and allow for coding of Z06 from path results?

If there is documentation of infection in the clinical notes, then the organism recorded on the microbiology report can be coded. However the resistance to the organism should not be coded unless it is documented in the clinical notes as being a resistant organism, not just resistance to a drug (as per ACS 0112 Infection with drug resistant microorganisms).

This advice is consistent with NCCH advice published in Coding Matters Volume 9 Number 2 September 2002.