Health data standards and systems

I am seeking clarification of the requirement by DHS to fully code out all conditions that a patient has whilst he or she is receiving either Rehabilitation or GEM care. It has been brought to my attention that there is a large metropolitan network that apparently has instructed its coders to simply put in the appropriate “Z” code for rehab, and a principal diagnosis for GEM. It takes many hours each month for my staff to fully code all the complications, co morbidities and other interventions for these patients. It not used at all in for in house reporting.

The VICC advises that irrespective of Care Type conditions meeting additional diagnosis criteria in the episode of care must be coded. In addition, rehabilitation and GEM episodes must be coded in accordance with ACS 2104 Rehabilitation and 2108 Assessment and applicable Victorian additions to the ACS. This is mandated by the Victoria-Public hospitals and Mental Health Services Policy and Funding Guidelines 2006–07 - General Conditions of Funding, section 6.1 Supply of statistics and information which states:
“The hospital or SRHS will code patient episodes reported to the VAED in accordance with the current Australian Coding Standards and as amended from time to time, Victorian Additions to the Australian Coding Standards effective 1 July 2006 and ICD Coding Newsletters issued from time to time by the department”.