Health data standards and systems

Scenario one:

Operation report - Bladder adherent to peritoneum. Careful division of adhesions.

Do the Index entries for Adhesions/Adhesive, bladder and gallbladder refer to adhesions within the bladder/gallbladder or when the bladder/gallbladder is adherent to other organs/tissue? There is no Index entry for Adhesions/bladder/internal (as there is for uterus), however perivesical adhesions (ie situated or occurring around the bladder) are Indexed to N32.8 Other specified disorders of bladder.

Should we assign codes for adhesions, bladder N32.8 AND adhesions, peritoneum/peritoneal K66.0?

Adhesions, adhesive (postinfective) K66.0
- bladder (sphincter) N32.8
- gallbladder K82.8
- peritoneum, peritoneal (male) K66.0
- perivesical N32.8
- uterus, uterine (periuterine) (to abdominal wall) (see also Adhesions/peritoneum/female pelvic) N73.6
- - internal N85.6

Can VICC also please clarify the intention of ACHI codes for division of adhesions?

In the scenario above, in addition to coding Division/adhesions/peritoneum, should we follow Index entry Division/adhesions/bladder even though the code description is 'division of intraluminal bladder adhesions' and there is no mention of entry into the bladder on the Operation Report and 'intraluminal' is a non-essential modifier in the Index?

Division (freeing)
- adhesions
- - bladder (intraluminal) (neck) 37008-06 [1095]
- - - endoscopic (transurethral) 36812-02 [1095]
- - peritoneum (open) 30378-00 [986]
- - - via laparoscopy 30393-00 [986]

37008-06 Division of intraluminal bladder adhesions
Excludes: transurethral division of intralumial adhesions (36812-02 [1095])

30378-00 Division of abdominal adhesions
Includes: insertion of long intestinal tube

Scenario two:

Division of inflammatory adhesions between appendix and bowel and appendix and abdominal wall.

Should we assign codes for adhesions, appendix K38.8 AND adhesions, bowel and abdominal wall K66.0?

VICC considers that the Index entries for Adhesions/Adhesive, bladder and gallbladder refer to adhesions within the bladder/gallbladder.

In scenario one, as the operation report states bladder adherent to peritoneum, the correct code to assign is K66.0 Peritoneal adhesions because there is no documentation of adhesions within the bladder. In regard to the ACHI code, the correct code to assign is 30378-00 [986] Division of abdominal adhesions.

VICC does not consider that 37008-06 [1095] Division of intraluminal bladder adhesions should be assigned in addition. In answer to the question regarding the term 'intraluminal' being in the code title, because intraluminal is a non-essential modifier in the Index, it does not matter if the term is in the code description.

In scenario two, as the adhesions are between bowel loops and the abdominal wall, K66.0 Peritoneal adhesions is the only code assigned.