EmailACS 0002 and Eleventh Edition Victorian Education
Publication Date: June 2020
Implementation Date: 1/07/2020
ICD 10 AM Edition: Eleventh Edition
Query Number: 3626
ACS 0002 states the following:
“Documentation of a consultation does not have to be a formal consultation report. Documentation of assessment of a condition in the progress notes or elsewhere (eg a care plan) is sufficient. Telephone or electronic consultation with clear documentation of the information exchange is also regarded as a clinical consultation.”
1. Can you please further clarify other forms of ‘Clinical Consultation’ as mentioned in ACS 0002? Are the following forms of documentation also regarded as ‘Clinical Consultation’?
a. Medications prescribed on the medication chart by doctor with documentation of the condition and treatment in the same nursing progress note. For example, a nurse documents stat dose of magnesium for Mg 0.65 in the progress notes, test results verify that Mg 0.65 is abnormal and the doctor has signed off on the magnesium order on the medication chart. “
b. Nursing documented “Doctor aware” in progress notes.
ACS 0002 also states the following:
For the purposes of classification, a clinical consultation refers to documentation provided by the:
• treating clinician/team who is primarily responsible for managing a patient's condition during the episode of care
• specialist who provides advice/opinion, to the referring clinician/team, regarding a patient's management
• nurses, midwives and allied health professionals who are engaged in a patient's management within their scope of practice.
2. Can you please further clarify if the following conditions documented by a Dietitian are within a Dietetics scope of practice?
a. Electrolyte imbalances. For example, a Dietitian documents in progress notes or Dietitian Assessment form Mg 0.65 or (down arrow)Mg0.65 with a plan to replace Magnesium in the same note and test results verify that Mg 0.65 is abnormal. Magnesium is signed off on the medication chart.
b. Dietitian documents Neutropenia with a plan for Neutropenic diet.
c. Dietitian documents Hypoalbuminaemia with a plan to replace Albumin.
“Documentation of a consultation does not have to be a formal consultation report. Documentation of assessment of a condition in the progress notes or elsewhere (eg a care plan) is sufficient. Telephone or electronic consultation with clear documentation of the information exchange is also regarded as a clinical consultation.”
1. Can you please further clarify other forms of ‘Clinical Consultation’ as mentioned in ACS 0002? Are the following forms of documentation also regarded as ‘Clinical Consultation’?
a. Medications prescribed on the medication chart by doctor with documentation of the condition and treatment in the same nursing progress note. For example, a nurse documents stat dose of magnesium for Mg 0.65 in the progress notes, test results verify that Mg 0.65 is abnormal and the doctor has signed off on the magnesium order on the medication chart. “
b. Nursing documented “Doctor aware” in progress notes.
ACS 0002 also states the following:
For the purposes of classification, a clinical consultation refers to documentation provided by the:
• treating clinician/team who is primarily responsible for managing a patient's condition during the episode of care
• specialist who provides advice/opinion, to the referring clinician/team, regarding a patient's management
• nurses, midwives and allied health professionals who are engaged in a patient's management within their scope of practice.
2. Can you please further clarify if the following conditions documented by a Dietitian are within a Dietetics scope of practice?
a. Electrolyte imbalances. For example, a Dietitian documents in progress notes or Dietitian Assessment form Mg 0.65 or (down arrow)Mg0.65 with a plan to replace Magnesium in the same note and test results verify that Mg 0.65 is abnormal. Magnesium is signed off on the medication chart.
b. Dietitian documents Neutropenia with a plan for Neutropenic diet.
c. Dietitian documents Hypoalbuminaemia with a plan to replace Albumin.
Response
For scenario 1a, VICC advises that medication prescribed on the medication chart by a doctor is considered clinical consultation, in response to the nurse’s documentation of “stat dose magnesium for abnormal mg of 0.65”.
As well as the clinical consultation, code assignment must be based on meeting one of the three criteria in ACS 0002 Additional diagnoses.
Therefore, in addition to the clinical consultation, the coding of hypomagnesaemia is based on the administration of therapeutic treatment as per dot point one of ACS 0002 Additional diagnoses. This is in accordance with example three of Eleventh Edition ICD-10-AM/ACHI/ACS Victorian education and ACE Coding Rule TN1035 Low magnesium, which instructs to follow the lead term Hypomagnesaemia to assign E83.4 Disorders of magnesium metabolism, for low magnesium without further specification.
For scenario 1b, VICC does not consider the nurse's documentation of 'doctor aware' alone is clear evidence of clinical consultation. Therefore the criteria in ACS 0002 Additional diagnoses is not met for the purpose of code assignment.
For the examples in scenario 2, VICC considers if a clinician has documented a condition, coders should trust that the clinician has documented appropriately to their scope of practice. See also VICC query #3290 titled VICC query #2752 Coding from nursing documentation.
As well as the clinical consultation, code assignment must be based on meeting one of the three criteria in ACS 0002 Additional diagnoses.
Therefore, in addition to the clinical consultation, the coding of hypomagnesaemia is based on the administration of therapeutic treatment as per dot point one of ACS 0002 Additional diagnoses. This is in accordance with example three of Eleventh Edition ICD-10-AM/ACHI/ACS Victorian education and ACE Coding Rule TN1035 Low magnesium, which instructs to follow the lead term Hypomagnesaemia to assign E83.4 Disorders of magnesium metabolism, for low magnesium without further specification.
For scenario 1b, VICC does not consider the nurse's documentation of 'doctor aware' alone is clear evidence of clinical consultation. Therefore the criteria in ACS 0002 Additional diagnoses is not met for the purpose of code assignment.
For the examples in scenario 2, VICC considers if a clinician has documented a condition, coders should trust that the clinician has documented appropriately to their scope of practice. See also VICC query #3290 titled VICC query #2752 Coding from nursing documentation.
