Health data standards and systems

This patient was admitted with a traumatic subdural haematoma following a fall with headstrike. On the day of discharge U&Es were performed which showed potassium 3.1 mmol/L.

The discharge summary records the following:
# Hypokalaemia
– likely in the setting of poor oral intake whilst in hospital
- Prescribed Slow K and for GP to repeat U&Es in 3-4 days (slip given)
The discharge prescription confirms that the patient was discharged with a course of Slow K.

We note the following in ACS 0002 Additional diagnoses:

However, where these findings or conditions are incidental to the episode of care and are only flagged for follow-up or referral post discharge they do not qualify for code assignment under ACS 0002 Additional diagnoses.

As per this instruction, the request for the GP to repeat U&Es does not qualify the hypokalaemia to be coded under ACS 0002 Additional diagnoses.

However, the patient was not only referred to the GP for follow up, they were also provided with the medication to treat the hypokalaemia.

Can the committee please advise whether hypokalaemia should be coded in this scenario?

Does the provision of discharge medication (or a discharge prescription) for a documented condition qualify the condition for code assignment under ACS 0002 Additional diagnoses?

VICC notes in the scenario cited, hypokalaemia is documented on the discharge summary. As per ACS 0010 Clinical documentation and general abstraction guidelines, 'before classifying any documented clinical concept the clinical coder must verify the information on the front sheet and or the discharge summary (or equivalent) by reviewing pertinent documents/data within the body of the current episode of care'.

If the hypokalaemia is verified, VICC considers the hypokalaemia meets ACS 0002 Additional diagnoses dot point three; Increased clinical care, as a clinical consultation was provided for the condition with documentation of a clinical assessment (provision of a discharge prescription) and a diagnosis (hypokalaemia) and a care plan for the condition (repeat U&Es and prescription of slow K).

VICC does not consider the section titled Incidental findings and conditions in ACS 0002 Additional diagnoses applicable in this scenario, as this section of the standard refers to findings or conditions that are only flagged for follow-up or referral post discharge.

Note: This query has been retired due to Twelfth Edition amendments to ACS 0002 Additional diagnoses. Please refer to VICC #3869 Plan for post-discharge management.