EmailACS 0051 findings on endoscopy
Publication Date: May 2023
Implementation Date: 1/06/2023
ICD 10 AM Edition: Twelfth Edition
Query Number: 3663
ACS 0051 Same-day endoscopy – diagnostic states to assign codes for all findings (these findings do not need to meet criteria in ACS 0002 Additional diagnoses).
However ACS 0010 Clinical documentation and general abstraction guidelines states “in the event that an investigation result varies from the clinical documentation, such as a clinical diagnosis of gastric ulcer with 'no evidence of ulcer' reported on histopathology, the case should be referred to the clinician. Although investigation results are critical in the classification process, there are some diseases which are not always confirmed on investigation.
For example, Crohn's disease is not always confirmed on biopsy.
It is important to seek clinical advice where necessary for:
- verification of diagnoses recorded on the front sheet and/or the discharge summary which are not supported in the health care record, and
- clarification of discrepancies between investigation results and clinical documentation.
Findings that provide more specificity about a diagnosis
Laboratory, x-ray, pathological and other diagnostic results should be coded where they clearly add specificity to already documented conditions that meet the criteria for a principal diagnosis (see ACS 0001 Principal diagnosis) or an additional diagnosis (see ACS 0002 Additional diagnoses).
Findings with an unclear, or no associated condition documented
Unless a clinician can indicate that a test result is significant and/or indicates the relationship between an unclear test result and a condition, such test results should not be coded."
Both ACS 0010 and ACS 0051 are General Standards so ICD-10-AM provides no guidance as to which takes preference.
Scenario:
Gastroscopy Report
Problem: Recurrent severe iron deficiency anaemia.
Oesophagus: Normal. Moderate hiatus hernia
Stomach: Normal. Biopsies taken.
Duodenum: Normal. Biopsies taken.
No cause for IDA.
Histopathology Report
Clinical Notes: IDA
Diagnosis: Chronic gastritis with intestinal metaplasia.
In this scenario the histopathological finding of chronic gastritis with intestinal metaplasia does not provide more specificity about a diagnosis and the clinician has not indicated that the result is significant or related to the condition of iron deficiency anaemia.
Is the advice in VICC #3038 Same day endoscopy flow chart VICC feature article (retired) which allows the coding of all findings, both clinical and histological, still applicable following changes to ACS 0010 for Eleventh Edition?
Can chronic gastritis be coded in this scenario?
Search Details
ACS 0051 Same-day endoscopy – diagnostic
ACS 0010 Clinical documentation and general abstraction guidelines
VICC #3038 Same day endoscopy flow chart VICC feature article (retired)
However ACS 0010 Clinical documentation and general abstraction guidelines states “in the event that an investigation result varies from the clinical documentation, such as a clinical diagnosis of gastric ulcer with 'no evidence of ulcer' reported on histopathology, the case should be referred to the clinician. Although investigation results are critical in the classification process, there are some diseases which are not always confirmed on investigation.
For example, Crohn's disease is not always confirmed on biopsy.
It is important to seek clinical advice where necessary for:
- verification of diagnoses recorded on the front sheet and/or the discharge summary which are not supported in the health care record, and
- clarification of discrepancies between investigation results and clinical documentation.
Findings that provide more specificity about a diagnosis
Laboratory, x-ray, pathological and other diagnostic results should be coded where they clearly add specificity to already documented conditions that meet the criteria for a principal diagnosis (see ACS 0001 Principal diagnosis) or an additional diagnosis (see ACS 0002 Additional diagnoses).
Findings with an unclear, or no associated condition documented
Unless a clinician can indicate that a test result is significant and/or indicates the relationship between an unclear test result and a condition, such test results should not be coded."
Both ACS 0010 and ACS 0051 are General Standards so ICD-10-AM provides no guidance as to which takes preference.
Scenario:
Gastroscopy Report
Problem: Recurrent severe iron deficiency anaemia.
Oesophagus: Normal. Moderate hiatus hernia
Stomach: Normal. Biopsies taken.
Duodenum: Normal. Biopsies taken.
No cause for IDA.
Histopathology Report
Clinical Notes: IDA
Diagnosis: Chronic gastritis with intestinal metaplasia.
In this scenario the histopathological finding of chronic gastritis with intestinal metaplasia does not provide more specificity about a diagnosis and the clinician has not indicated that the result is significant or related to the condition of iron deficiency anaemia.
Is the advice in VICC #3038 Same day endoscopy flow chart VICC feature article (retired) which allows the coding of all findings, both clinical and histological, still applicable following changes to ACS 0010 for Eleventh Edition?
Can chronic gastritis be coded in this scenario?
Search Details
ACS 0051 Same-day endoscopy – diagnostic
ACS 0010 Clinical documentation and general abstraction guidelines
VICC #3038 Same day endoscopy flow chart VICC feature article (retired)
Response
This query was received under Eleventh Edition coding and was referred to (at the time) IHPA who provided the following response in Twelfth Edition:
For Twelfth Edition, amendments were made to the Australian Coding Standards (ACS) to clarify the different types of ACS and make explicit the boundaries between the ACS, the appendices and other related information.
The ACS/Introduction/General and specialty standards states:
The first two chapters of the ACS, General standards for diseases and General standards for interventions, contain general descriptions and guidelines that apply to code assignment across all episodes of care.
…
Note that ACS are not mutually exclusive, and multiple standards may apply to an episode of care. Apply first the general standards for diseases and interventions (such as ACS 0001 Principal diagnosis, ACS 0002 Additional diagnoses, ACS 0010 Clinical documentation and general abstraction guidelines), then apply the guidelines in the specialty standards that may take precedence over the general standards.
ACS 0051 Same-day endoscopy – diagnostic specifically applies to same-day episodes of care for endoscopy of any body system, for diagnostic purposes.
ACS 0051 Same-day endoscopy – diagnostic/Classification/1. Symptom/condition documented as the indication for endoscopy states:
1.1 If a causal link is documented between the indication/symptom and any of the findings, that is, either the clinician documents the link, or the classification directs clinical coders to assume a link:
- assign as principal diagnosis a code for the finding identified as the cause of the indication and do not assign a code for the indication/symptom…
- assign codes for all other findings as additional diagnoses (Note: These findings do not need to meet the criteria in ACS 0002 Additional diagnoses).
…
1.2 If no causal link is documented between the indication/symptom and any of the findings:
- assign a code for the indication/symptom as the principal diagnosis
- assign codes for all findings as additional diagnoses.
ACS 0051 does not specify that ‘findings’ are limited to those included in the endoscopy report. Endoscopy findings may be reported at the time of the intervention or reported in a histology report if an excision or biopsy is performed.
Therefore, apply the above guidelines regardless of whether there is clinical documentation of a histological finding at the time of the endoscopy.
For multi-day episodes of care, apply the guidelines in ACS 0010 Clinical documentation and general abstraction guidelines/Test results and medication chart.
As this response is based on existing classification guidelines, it will not be published. [End of IHACPA response].
Further to the IHACPA response, VICC notes that this advice does not apply to multiday episodes or to any episode to which ACS 0051 Same-day endoscopy – diagnostic does not apply e.g. same day biopsy not via endoscopy. Therefore, for the scenario cited in the query, a code for the chronic gastritis is assigned.
Note: IHACPA advised VICC that this query would not be published. Therefore VICC has published the query in accordance with the committee’s business rules to publish queries referred to IHACPA that IHACPA does not publish. VICC notes the committee has also added further information to the IHACPA response. This information does not alter the IHACPA response.
For Twelfth Edition, amendments were made to the Australian Coding Standards (ACS) to clarify the different types of ACS and make explicit the boundaries between the ACS, the appendices and other related information.
The ACS/Introduction/General and specialty standards states:
The first two chapters of the ACS, General standards for diseases and General standards for interventions, contain general descriptions and guidelines that apply to code assignment across all episodes of care.
…
Note that ACS are not mutually exclusive, and multiple standards may apply to an episode of care. Apply first the general standards for diseases and interventions (such as ACS 0001 Principal diagnosis, ACS 0002 Additional diagnoses, ACS 0010 Clinical documentation and general abstraction guidelines), then apply the guidelines in the specialty standards that may take precedence over the general standards.
ACS 0051 Same-day endoscopy – diagnostic specifically applies to same-day episodes of care for endoscopy of any body system, for diagnostic purposes.
ACS 0051 Same-day endoscopy – diagnostic/Classification/1. Symptom/condition documented as the indication for endoscopy states:
1.1 If a causal link is documented between the indication/symptom and any of the findings, that is, either the clinician documents the link, or the classification directs clinical coders to assume a link:
- assign as principal diagnosis a code for the finding identified as the cause of the indication and do not assign a code for the indication/symptom…
- assign codes for all other findings as additional diagnoses (Note: These findings do not need to meet the criteria in ACS 0002 Additional diagnoses).
…
1.2 If no causal link is documented between the indication/symptom and any of the findings:
- assign a code for the indication/symptom as the principal diagnosis
- assign codes for all findings as additional diagnoses.
ACS 0051 does not specify that ‘findings’ are limited to those included in the endoscopy report. Endoscopy findings may be reported at the time of the intervention or reported in a histology report if an excision or biopsy is performed.
Therefore, apply the above guidelines regardless of whether there is clinical documentation of a histological finding at the time of the endoscopy.
For multi-day episodes of care, apply the guidelines in ACS 0010 Clinical documentation and general abstraction guidelines/Test results and medication chart.
As this response is based on existing classification guidelines, it will not be published. [End of IHACPA response].
Further to the IHACPA response, VICC notes that this advice does not apply to multiday episodes or to any episode to which ACS 0051 Same-day endoscopy – diagnostic does not apply e.g. same day biopsy not via endoscopy. Therefore, for the scenario cited in the query, a code for the chronic gastritis is assigned.
Note: IHACPA advised VICC that this query would not be published. Therefore VICC has published the query in accordance with the committee’s business rules to publish queries referred to IHACPA that IHACPA does not publish. VICC notes the committee has also added further information to the IHACPA response. This information does not alter the IHACPA response.
