EmailACS 0002 Additional diagnoses and ACS 0010 General abstraction guidelines
Publication Date: December 2010
ICD 10 AM Edition: Seventh edition
Retired Date: 30/6/2017
Query Number: 2572
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.
The following is an excerpt from a previous HDSS bulletin:
“…the important point to remember is that in each case, the coder must decide whether or not the condition meets 0002. Note that documentation refers to written documentation,… the coder needs to see evidence that the test is performed for investigation of the particular condition…” Source- HDSS Bulletin Issue 13 Page 5 (unsure of date)
Can you please verify if the bulletin advice still applies? And, can you define what the term ‘supported’ means within the ACS 0010. Does this mean written documentation within 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.
The following is an excerpt from a previous HDSS bulletin:
“…the important point to remember is that in each case, the coder must decide whether or not the condition meets 0002. Note that documentation refers to written documentation,… the coder needs to see evidence that the test is performed for investigation of the particular condition…” Source- HDSS Bulletin Issue 13 Page 5 (unsure of date)
Can you please verify if the bulletin advice still applies? And, can you define what the term ‘supported’ means within the ACS 0010. Does this mean written documentation within the medical record?
Response
ACS 0010 General abstraction guidelines states that the clinical coder must verify information recorded on the front sheet and/or the discharge summary by reviewing pertinent documents in the body of the clinical record. VICC interprets the 'body' of the record as all information regarding the patient for an episode which includes test results and medication charts; ACS 0010 also includes test results in its discussion and examples.
Whilst hypokalemia may not be documented in the progress notes, there is evidence in the body of the record (test results and medication chart) that links to (supports) the diagnosis of hypokalaemia listed on the discharge summary. This evidence is used to determine if the hypokalaemia meets ACS 0002 Additional diagnoses. In this case because there was commencement of treatment, the hypokalaemia does meet ACS 0002 and is therefore coded.
Please note that the advice in HDSS Bulletin 13 has been superseded by further updates to ACS 0002 Additional diagnoses and ACS 0010 General abstraction guidelines.
Whilst hypokalemia may not be documented in the progress notes, there is evidence in the body of the record (test results and medication chart) that links to (supports) the diagnosis of hypokalaemia listed on the discharge summary. This evidence is used to determine if the hypokalaemia meets ACS 0002 Additional diagnoses. In this case because there was commencement of treatment, the hypokalaemia does meet ACS 0002 and is therefore coded.
Please note that the advice in HDSS Bulletin 13 has been superseded by further updates to ACS 0002 Additional diagnoses and ACS 0010 General abstraction guidelines.
