EmailAdmission for insertion of port and chemotherapy multi day admissions
Publication Date: September 2021
Implementation Date: 1/10/2021
ICD 10 AM Edition: Eleventh Edition
Query Number: 3764
We often see patients admitted for a multi-day stay admission, with a port inserted first and then administration of chemotherapy for their malignant neoplasm. We are seeking advice regarding principal diagnosis selection for the following common scenarios:
Scenario 1 – Principal diagnosis on discharge summary is elective admission for port insertion with further documentation on discharge summary and progress notes for port insertion and chemotherapy for cancer.
Scenario 2 – no discharge summary available and therefore no principal diagnosis documented. Progress notes documentation for insertion of port and then chemotherapy to start next day for cancer treatment.
We are finding that there are differing views on how these scenarios should be coded.
For scenario 1, some state that ACS 0001 should be applied and that the admission for the port insertion is the reason for admission as documented on the discharge summary and therefore is the principal diagnosis. They then follow the Index pathway for Admission/insertion of device – see Fitting. Fitting/vascular access device (infusion port) (Port-A-Cath) (reservoir) to assign Z45.2 Adjustment and management of vascular access device. The Excludes note at Z45.2 that excludes that for pharmacotherapy for neoplasm (Z51.1) is not being followed because they say this only applies for same day (Z51.1) cases.
Others are disagreeing that the Excludes note at Z45.2 can be ignored as a convention and are then applying ACS 0044 Pharmacotherapy to assign the cancer as the Principal Diagnosis (following the logic in the Multi-day episodes of care for pharmacotherapy for neoplasm section and examples).
For Scenario 2 we are finding most coders would assign the cancer as the principal diagnosis as although the port insertion is documented first, the reason for admission is treatment of the cancer and the port is inserted first to enable the chemotherapy to be administered.
We have been unable to find current advice which clarifies the correct principal diagnosis selection in these scenarios. We have also noted the advice given in VICC #3439 Principal diagnosis selection for insertion of a continuous glucose monitoring (CGM) device. The response was “VICC advises that if the documented condition is unstable type 1 diabetes, it is correct to assign the unstable type 1 diabetes as the principal diagnosis for a same day admission for an insertion of a continuous glucose monitoring device. A code from the Z40 - Z54 range would only be assigned in the absence of a documented condition.”
Can the logic that a code from the Z40 - Z54 range would only be assigned in the absence of a documented condition be applied to other scenarios such as admission for port insertion and chemotherapy for malignant neoplasms?
There is also a note at categories Z40 – Z54 which states: Categories Z40–Z54 are intended for use to indicate a reason for care. They may be used for patients who have already been treated for a disease or injury, but who are receiving follow-up or prophylactic care, convalescent care, or care to consolidate the treatment, to deal with residual states, to ensure that the condition has not recurred, or to prevent recurrence.
Can VICC please clarify the application of the Excludes note at Z45.2 and provide advice on the correct principal diagnosis selection in these scenarios?
Search details:
ACS 0044 Pharmacotherapy
VICC Q3439 Principal diagnosis for a same day admission for an insertion of a continuous glucose monitoring device (CGM).
VICC Q2127 Coding of cancer with insertion/removal infusaport – Retired 30/6/2010
VICC Q2147 Insertion and removal of infusaport – Retired 30/6/2013
Coding Matters September 2008 Volume 15, Number 2 Retired 30/6/2019
Scenario 1 – Principal diagnosis on discharge summary is elective admission for port insertion with further documentation on discharge summary and progress notes for port insertion and chemotherapy for cancer.
Scenario 2 – no discharge summary available and therefore no principal diagnosis documented. Progress notes documentation for insertion of port and then chemotherapy to start next day for cancer treatment.
We are finding that there are differing views on how these scenarios should be coded.
For scenario 1, some state that ACS 0001 should be applied and that the admission for the port insertion is the reason for admission as documented on the discharge summary and therefore is the principal diagnosis. They then follow the Index pathway for Admission/insertion of device – see Fitting. Fitting/vascular access device (infusion port) (Port-A-Cath) (reservoir) to assign Z45.2 Adjustment and management of vascular access device. The Excludes note at Z45.2 that excludes that for pharmacotherapy for neoplasm (Z51.1) is not being followed because they say this only applies for same day (Z51.1) cases.
Others are disagreeing that the Excludes note at Z45.2 can be ignored as a convention and are then applying ACS 0044 Pharmacotherapy to assign the cancer as the Principal Diagnosis (following the logic in the Multi-day episodes of care for pharmacotherapy for neoplasm section and examples).
For Scenario 2 we are finding most coders would assign the cancer as the principal diagnosis as although the port insertion is documented first, the reason for admission is treatment of the cancer and the port is inserted first to enable the chemotherapy to be administered.
We have been unable to find current advice which clarifies the correct principal diagnosis selection in these scenarios. We have also noted the advice given in VICC #3439 Principal diagnosis selection for insertion of a continuous glucose monitoring (CGM) device. The response was “VICC advises that if the documented condition is unstable type 1 diabetes, it is correct to assign the unstable type 1 diabetes as the principal diagnosis for a same day admission for an insertion of a continuous glucose monitoring device. A code from the Z40 - Z54 range would only be assigned in the absence of a documented condition.”
Can the logic that a code from the Z40 - Z54 range would only be assigned in the absence of a documented condition be applied to other scenarios such as admission for port insertion and chemotherapy for malignant neoplasms?
There is also a note at categories Z40 – Z54 which states: Categories Z40–Z54 are intended for use to indicate a reason for care. They may be used for patients who have already been treated for a disease or injury, but who are receiving follow-up or prophylactic care, convalescent care, or care to consolidate the treatment, to deal with residual states, to ensure that the condition has not recurred, or to prevent recurrence.
Can VICC please clarify the application of the Excludes note at Z45.2 and provide advice on the correct principal diagnosis selection in these scenarios?
Search details:
ACS 0044 Pharmacotherapy
VICC Q3439 Principal diagnosis for a same day admission for an insertion of a continuous glucose monitoring device (CGM).
VICC Q2127 Coding of cancer with insertion/removal infusaport – Retired 30/6/2010
VICC Q2147 Insertion and removal of infusaport – Retired 30/6/2013
Coding Matters September 2008 Volume 15, Number 2 Retired 30/6/2019
Response
In accordance with ACS 0044 Pharmacotherapy, Classification section Multi-day episodes of care for pharmacotherapy for neoplasm, VICC advises for the scenarios cited the principal diagnosis is the neoplasm. Z45.2 Adjustment and management of vascular access device is not assigned.
Even though the Excludes note at Z45.2 excludes that for pharmacotherapy for neoplasm (Z51.1) may only apply for same day episodes, Z45.2 would still not be assigned because in the scenarios cited, the neoplasm was the condition chiefly responsible for occasioning the episode of care and is therefore the principal diagnosis. The insertion of the port is part of the management and treatment of the neoplasm.
This is supported by the note at category Z40-Z54 which states ‘Categories Z40–Z54 are intended for use to indicate a reason for care. They may be used for patients who have already been treated for a disease or injury, but who are receiving follow-up or prophylactic care, convalescent care, or care to consolidate the treatment, to deal with residual states, to ensure that the condition has not recurred, or to prevent recurrence.’
Therefore, Z45.2 Adjustment and management of vascular access device would only be assigned as principal diagnosis if the episode of care was for insertion of the port alone without commencement of treatment for the neoplasm.
Even though the Excludes note at Z45.2 excludes that for pharmacotherapy for neoplasm (Z51.1) may only apply for same day episodes, Z45.2 would still not be assigned because in the scenarios cited, the neoplasm was the condition chiefly responsible for occasioning the episode of care and is therefore the principal diagnosis. The insertion of the port is part of the management and treatment of the neoplasm.
This is supported by the note at category Z40-Z54 which states ‘Categories Z40–Z54 are intended for use to indicate a reason for care. They may be used for patients who have already been treated for a disease or injury, but who are receiving follow-up or prophylactic care, convalescent care, or care to consolidate the treatment, to deal with residual states, to ensure that the condition has not recurred, or to prevent recurrence.’
Therefore, Z45.2 Adjustment and management of vascular access device would only be assigned as principal diagnosis if the episode of care was for insertion of the port alone without commencement of treatment for the neoplasm.
