EmailACS 0010 General abstraction guidelines
Publication Date: December 2009
ICD 10 AM Edition: Sixth edition
Retired Date: 30/6/2015
Query Number: 2419
We are seeking clarification on the application of ACS 0010 General Abstraction Guidelines. In particular our query relates to coding from test results where there are findings with an unclear, or no associated condition documented.
Example three on page 9 of the Australian Coding Standards lists examples of where conditions would not be coded based on test results.
We have three scenarios listed below that we would like advice on how to code:
1. Patient admitted for elective laparoscopic cholecystectomy for gallstones, histopathology of gallbladder shows chronic cholecystitis, cholelithiasis and moderately differentiated adenocarcinoma. Should we assign codes for the adenocarcinoma?
2. Patient admitted for elective hysterectomy for menorrhagia, histopathology of uterus shows uterine carcinoma. Should we assign codes for the carcinoma?
3. Patient presents with bowel obstruction, day two colonoscopy performed, histology: adenocarcinoma, transverse colon. CT abdomen on day four shows liver metastases. Can we assign codes for the liver metastases?
Example three on page 9 of the Australian Coding Standards lists examples of where conditions would not be coded based on test results.
We have three scenarios listed below that we would like advice on how to code:
1. Patient admitted for elective laparoscopic cholecystectomy for gallstones, histopathology of gallbladder shows chronic cholecystitis, cholelithiasis and moderately differentiated adenocarcinoma. Should we assign codes for the adenocarcinoma?
2. Patient admitted for elective hysterectomy for menorrhagia, histopathology of uterus shows uterine carcinoma. Should we assign codes for the carcinoma?
3. Patient presents with bowel obstruction, day two colonoscopy performed, histology: adenocarcinoma, transverse colon. CT abdomen on day four shows liver metastases. Can we assign codes for the liver metastases?
Response
This query was originally published in the December 2008 VICC queries database release as follows:
The VICC notes the sentence in ACS 0002 Additional diagnoses which states that the purpose of the Admitted Patient Care National Minimum Data Set is to collect information about care provided to admitted patients in Australian hospitals. This means that only conditions that are relevant to the episode of care are coded, rather than all conditions a patient has. Additional findings need documentation of clinical significance to be able to be coded and this is supported by example three in ACS 0010 General abstraction guidelines.
Therefore in answer to your scenarios one and two, unless the clinician has documented the clinical significance of the test results, the findings would not be coded. In answer to your scenario three, if the clinician has confirmed that the adenocarcinoma has caused the bowel obstruction, the liver metastases would be coded in accordance with ACS 0236 Neoplasm coding and sequencing.
The response has been reviewed and the last paragraph has been updated as follows:
The VICC notes the sentence in ACS 0002 Additional diagnoses which states that the purpose of the Admitted Patient Care National Minimum Data Set is to collect information about care provided to admitted patients in Australian hospitals. This means that only conditions that are relevant to the episode of care are coded, rather than all conditions a patient has. Additional findings need documentation of clinical significance to be able to be coded and this is supported by example 3 in ACS 0010 General abstraction guidelines.
Therefore in answer to your scenarios, unless the clinician has documented the clinical significance of the test results, the findings would not be coded.
The VICC notes the sentence in ACS 0002 Additional diagnoses which states that the purpose of the Admitted Patient Care National Minimum Data Set is to collect information about care provided to admitted patients in Australian hospitals. This means that only conditions that are relevant to the episode of care are coded, rather than all conditions a patient has. Additional findings need documentation of clinical significance to be able to be coded and this is supported by example three in ACS 0010 General abstraction guidelines.
Therefore in answer to your scenarios one and two, unless the clinician has documented the clinical significance of the test results, the findings would not be coded. In answer to your scenario three, if the clinician has confirmed that the adenocarcinoma has caused the bowel obstruction, the liver metastases would be coded in accordance with ACS 0236 Neoplasm coding and sequencing.
The response has been reviewed and the last paragraph has been updated as follows:
The VICC notes the sentence in ACS 0002 Additional diagnoses which states that the purpose of the Admitted Patient Care National Minimum Data Set is to collect information about care provided to admitted patients in Australian hospitals. This means that only conditions that are relevant to the episode of care are coded, rather than all conditions a patient has. Additional findings need documentation of clinical significance to be able to be coded and this is supported by example 3 in ACS 0010 General abstraction guidelines.
Therefore in answer to your scenarios, unless the clinician has documented the clinical significance of the test results, the findings would not be coded.
