EmailDocumentation of down arrows after a result
Publication Date: March 2016
ICD 10 AM Edition: Eighth edition
Retired Date: 30/6/2020
Query Number: 2819
I wish to clarify if we are able to code anaemia in the following example, as we are currently receiving a lot of documentation with arrows after the result.
Patient has documentation in medical record of Hb (downward arrow) and was given PRBC. When reviewing their pathology for that day, we can see that their Hb was low. Are we able to code anaemia?
Patient has documentation in medical record of Hb (downward arrow) and was given PRBC. When reviewing their pathology for that day, we can see that their Hb was low. Are we able to code anaemia?
Response
This query was originally published in the 2013-14 September database release VICC queries database release as follows:
VICC advises that there is no published advice to indicate that the position of the arrow is important. If the arrow is positioned after the result, please follow the same advice as you would if the arrow were positioned before the result.
Coding Matters Volume 16 Number 2 advice titled Use of abbreviations and symbols should be followed and is reproduced below:
"Question:
When can coders use abbreviations and symbols documented in the clinical record to assign conditions, eg Hb or Hb 98 documented and transfusion given – can anaemia be assigned for (downward arrow) K or K2.9 documented and potassium supplements commenced – can hypokalaemia be assigned?
Clinicians sometimes use abbreviations and symbols to document conditions in the clinical record. Each case should be assessed on its own merits to determine if the documentation sufficiently describes a condition that meets the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses, in order to be coded.
When (downward arrow) Hb or (downward arrow) K is documented as the indication for an intervention such as a blood transfusion or commencement of medication, a code for the condition can be assigned if the test result or clinician confirms that the patient’s haemoglobin or potassium is below the normal range; as the criteria for code assignment in ACS 0001 or ACS 0002 has been met. See ACS 0010 General abstraction guidelines.
So, where (downward arrow)Hb is documented as the indication for a transfusion and the test results and/or clinician verifies the patient’s haemoglobin is below the normal range – follow the index pathway, Low, haemoglobin and assign D64.9 Anaemia, unspecified.
Where (downward arrow)K is documented as the indication for commencement of medication and the test results and/or clinician verifies the patient’s potassium is below the normal range, follow the index pathway Deficiency, potassium (K); Depletion, potassium; Hypokalaemia; or Hypopotassaemia and assign E87.6 Hypokalaemia.
However, if ICD-10-AM does not provide an index look up or there is uncertainty or ambiguity in relation to such abbreviated forms of documentation, they should be confirmed with the clinician prior to code assignment. Coders should not assign codes on the basis of test results alone."
March 2016 update: Whilst the VICC response is still current, the ACCD advice referenced in the response was updated in the September 2015 Coding Rules as follows:
"Q:
When can coders use abbreviations, symbols and test result values documented in the clinical record to assign conditions, eg (downward arrow)Hb or Hb 98 documented and transfusion given - can anaemia be assigned? (downward arrow)K or K2.9 documented and potassium supplements commenced - can hypokalaemia be assigned?
A:
Clinicians may document test result values as well as abbreviations and symbols in the clinical record as shorthand to indicate conditions such as anaemia, hypokalaemia, hypercalcaemia etc.
Where such shorthand is used to document/describe a condition, each instance must be assessed on its merits and where possible confirmed with a clinician to ensure that the documentation sufficiently describes a condition that is both supported by an appropriate index entry and meets the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.
Test result values, symbols and abbreviations are not to be used in isolation to inform code assignment and coders should therefore:
• clarify the significance of the documented shorthand (test result, values, abbreviations and symbols) with the clinician to inform code assignment
Where this is not possible assign a code for the condition represented in shorthand (as described above) only if:
• test results (pathology report) verify that a result is abnormal AND
• there is an appropriate ICD-10-AM index pathway AND
• it meets the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.
For example, where (downward arrow)Hb or a haemoglobin level (eg.Hb 98) is documented as the indication for a transfusion and the test results (pathology report) and/or the clinician verifies the patient's haemoglobin is below the normal range, follow the index pathway:
Low
- haemoglobin
to assign D64.9 Anaemia, unspecified.
Where (downward arrow) K or a potassium level (eg. K 2.9) is documented as the indication for commencement of medication and the test results and/or clinician verifies the patient's potassium is below the normal range, follow the index pathways:
Deficiency
- potassium (K)
Depletion
- potassium
Hypokalaemia
Hypopotassaemia
to assign E87.6 Hypokalaemia.
However, if ICD-10-AM does not provide an index look up or there is uncertainty or ambiguity in relation to such abbreviated forms of documentation, always confirm with the clinician prior to code assignment."
VICC advises that there is no published advice to indicate that the position of the arrow is important. If the arrow is positioned after the result, please follow the same advice as you would if the arrow were positioned before the result.
Coding Matters Volume 16 Number 2 advice titled Use of abbreviations and symbols should be followed and is reproduced below:
"Question:
When can coders use abbreviations and symbols documented in the clinical record to assign conditions, eg Hb or Hb 98 documented and transfusion given – can anaemia be assigned for (downward arrow) K or K2.9 documented and potassium supplements commenced – can hypokalaemia be assigned?
Clinicians sometimes use abbreviations and symbols to document conditions in the clinical record. Each case should be assessed on its own merits to determine if the documentation sufficiently describes a condition that meets the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses, in order to be coded.
When (downward arrow) Hb or (downward arrow) K is documented as the indication for an intervention such as a blood transfusion or commencement of medication, a code for the condition can be assigned if the test result or clinician confirms that the patient’s haemoglobin or potassium is below the normal range; as the criteria for code assignment in ACS 0001 or ACS 0002 has been met. See ACS 0010 General abstraction guidelines.
So, where (downward arrow)Hb is documented as the indication for a transfusion and the test results and/or clinician verifies the patient’s haemoglobin is below the normal range – follow the index pathway, Low, haemoglobin and assign D64.9 Anaemia, unspecified.
Where (downward arrow)K is documented as the indication for commencement of medication and the test results and/or clinician verifies the patient’s potassium is below the normal range, follow the index pathway Deficiency, potassium (K); Depletion, potassium; Hypokalaemia; or Hypopotassaemia and assign E87.6 Hypokalaemia.
However, if ICD-10-AM does not provide an index look up or there is uncertainty or ambiguity in relation to such abbreviated forms of documentation, they should be confirmed with the clinician prior to code assignment. Coders should not assign codes on the basis of test results alone."
March 2016 update: Whilst the VICC response is still current, the ACCD advice referenced in the response was updated in the September 2015 Coding Rules as follows:
"Q:
When can coders use abbreviations, symbols and test result values documented in the clinical record to assign conditions, eg (downward arrow)Hb or Hb 98 documented and transfusion given - can anaemia be assigned? (downward arrow)K or K2.9 documented and potassium supplements commenced - can hypokalaemia be assigned?
A:
Clinicians may document test result values as well as abbreviations and symbols in the clinical record as shorthand to indicate conditions such as anaemia, hypokalaemia, hypercalcaemia etc.
Where such shorthand is used to document/describe a condition, each instance must be assessed on its merits and where possible confirmed with a clinician to ensure that the documentation sufficiently describes a condition that is both supported by an appropriate index entry and meets the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.
Test result values, symbols and abbreviations are not to be used in isolation to inform code assignment and coders should therefore:
• clarify the significance of the documented shorthand (test result, values, abbreviations and symbols) with the clinician to inform code assignment
Where this is not possible assign a code for the condition represented in shorthand (as described above) only if:
• test results (pathology report) verify that a result is abnormal AND
• there is an appropriate ICD-10-AM index pathway AND
• it meets the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.
For example, where (downward arrow)Hb or a haemoglobin level (eg.Hb 98) is documented as the indication for a transfusion and the test results (pathology report) and/or the clinician verifies the patient's haemoglobin is below the normal range, follow the index pathway:
Low
- haemoglobin
to assign D64.9 Anaemia, unspecified.
Where (downward arrow) K or a potassium level (eg. K 2.9) is documented as the indication for commencement of medication and the test results and/or clinician verifies the patient's potassium is below the normal range, follow the index pathways:
Deficiency
- potassium (K)
Depletion
- potassium
Hypokalaemia
Hypopotassaemia
to assign E87.6 Hypokalaemia.
However, if ICD-10-AM does not provide an index look up or there is uncertainty or ambiguity in relation to such abbreviated forms of documentation, always confirm with the clinician prior to code assignment."
