EmailACS 0010 Clinical documentation and general abstraction guidelines documented descriptions
Publication Date: September 2020
Implementation Date: 1/10/2020
ICD 10 AM Edition: Eleventh Edition
Query Number: 3627
ACS 0010 Clinical documentation and general abstraction guidelines states the following:
Do not use test result values, descriptions, medication charts, symbols and abbreviations in isolation to inform code assignment. For example:
• a documented description (eg low blood sugar level) does not necessarily mean that the patient has a particular condition (eg hypoglycaemia).
If the documentation does not sufficiently describe a disease/condition, clinical coders should clarify the significance of the documented shorthand (test result, values, abbreviations and symbols) with the clinician to inform accurate 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 appropriate ICD-10-AM indexing AND
• it meets the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.
1. While following the above guidelines in ACS 0010, can we code hypotension from the “documented description” in the following scenario?
Doctor documents “low BP” or “(down arrow) BP” with a plan to withhold their antihypertensive medications. Antihypertensive medications are withheld on the medication chart.
We have noted the following:
• There is no pathology report that can verify the BP result is abnormal
• There is an appropriate index for low, blood pressure (see also hypotension) I95.9
• ACS 0010 states “If the ICD-10-AM Alphabetic Index does not provide appropriate indexing, or there is uncertainty or ambiguity in relation to abbreviated forms or descriptions in the documentation, confirm with the clinician prior to code assignment.”
• ACS 0010 states “low blood sugar level” does not necessarily mean that the patient has hypoglycaemia
Do not use test result values, descriptions, medication charts, symbols and abbreviations in isolation to inform code assignment. For example:
• a documented description (eg low blood sugar level) does not necessarily mean that the patient has a particular condition (eg hypoglycaemia).
If the documentation does not sufficiently describe a disease/condition, clinical coders should clarify the significance of the documented shorthand (test result, values, abbreviations and symbols) with the clinician to inform accurate 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 appropriate ICD-10-AM indexing AND
• it meets the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses.
1. While following the above guidelines in ACS 0010, can we code hypotension from the “documented description” in the following scenario?
Doctor documents “low BP” or “(down arrow) BP” with a plan to withhold their antihypertensive medications. Antihypertensive medications are withheld on the medication chart.
We have noted the following:
• There is no pathology report that can verify the BP result is abnormal
• There is an appropriate index for low, blood pressure (see also hypotension) I95.9
• ACS 0010 states “If the ICD-10-AM Alphabetic Index does not provide appropriate indexing, or there is uncertainty or ambiguity in relation to abbreviated forms or descriptions in the documentation, confirm with the clinician prior to code assignment.”
• ACS 0010 states “low blood sugar level” does not necessarily mean that the patient has hypoglycaemia
Response
VICC notes that a blood pressure (BP) reading is a test result and therefore when there is documentation of “(down arrow) BP”, the following advice in ACS 0010 Clinical documentation and general abstraction guidelines under section Test results and medication charts should be applied:
'…assign a code for the condition represented in shorthand…only if:
• test results (pathology report) verify that a result is abnormal AND
• there is appropriate ICD-10-AM indexing AND
• it meets the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses'
For documentation of 'Low BP', for which the medication has been withheld, VICC considers the Index entry Low/ blood pressure (see also Hypotension) should be followed and the default code I95.9 Hypotension, unspecified assigned.
VICC acknowledges the sentence in ACS 0010 Clinical documentation and general abstraction guidelines section titled Test results and medication charts, which states 'Do not use test result values, descriptions, medication charts, symbols and abbreviations in isolation to inform code assignment' and considers that low blood sugar level has been provided as an example only in this section of the standard, where a documented description cannot be used in isolation to inform code assignment.
As with all documented descriptions, refer to ACS 0002 Additional diagnoses to ensure the condition meets criteria for coding. Therefore for documentation of low blood sugar levels, provided the criteria in ACS 0002 Additional diagnoses has been met, follow Index entry Sugar/blood/low to assign E16.2 Hypoglycaemia, unspecified.
'…assign a code for the condition represented in shorthand…only if:
• test results (pathology report) verify that a result is abnormal AND
• there is appropriate ICD-10-AM indexing AND
• it meets the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses'
For documentation of 'Low BP', for which the medication has been withheld, VICC considers the Index entry Low/ blood pressure (see also Hypotension) should be followed and the default code I95.9 Hypotension, unspecified assigned.
VICC acknowledges the sentence in ACS 0010 Clinical documentation and general abstraction guidelines section titled Test results and medication charts, which states 'Do not use test result values, descriptions, medication charts, symbols and abbreviations in isolation to inform code assignment' and considers that low blood sugar level has been provided as an example only in this section of the standard, where a documented description cannot be used in isolation to inform code assignment.
As with all documented descriptions, refer to ACS 0002 Additional diagnoses to ensure the condition meets criteria for coding. Therefore for documentation of low blood sugar levels, provided the criteria in ACS 0002 Additional diagnoses has been met, follow Index entry Sugar/blood/low to assign E16.2 Hypoglycaemia, unspecified.
