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Coding News from Clinical Coding Services
New Zealand Health Information Service (NZHIS)

Issue 1

Hi Everyone

Welcome to my first email update to inform you all about what has been happening with Clinical Coding at NZHIS over the last few months. This update will be a regular feature - it will be distributed every second month and 'Coder's Update' will be published annually.

Hospital Contacts :

I would like to thank those people who sent through their contact details. Our email system has now been updated and we have created a new email group 'DHB Clinical Coding Team Leaders and Clinical Coders' where information will be distributed. Please remember to inform Mary-Ellen Wetherspoon or myself if contact details change.

Heath Information Management Association of Australia (HIMAA):

HIMAA has informed me that New Zealand is the only country to whom they are prepared to provide ICD-10 3rd Edition Courses. This means the course information and application forms are no longer available on the HIMAA website. If anyone would like course information or forms they can request these from me at Tracy_Thompson@nzhis.govt.nz or Mary-Ellen at Mary-Ellen_Wetherspoon@nzhis.govt.nz. Remember New Zealand students get a 15% discount. HIMAA have confirmed their 2006 conference will be held in Auckland on the 25/26th September.

Health Information Association of New Zealand (HIANZ):

HIANZ will be holding just the one Study Day this year. It will be on the 28th July 2006 at Waikato Hospital, Hamilton. HIMAA will be participating in the coders' session, topics are yet to be confirmed and notification of topics will be sent out in due course. The HIANZ Conference this year will be held at Te Papa Wellington on the 23rd/24th November.

Hospital visits:

I am in the process of visiting hospitals and to date I have completed 7 visits. The purpose of these visits is to introduce myself to those of you who don't know me and to also gather information around coder education.

Over the next few months I will be in contact with those hospitals I have not visited to arrange a day.

Performance Indicators For Coding Quality - PICQ 2004:

NZHIS has purchased a National Licence to run PICQ across NMDS data. There are a few technical problems that need to be sorted out before we can progress. Palmerston North, Taranaki and Hutt Hospitals have kindly volunteered to be the pilot sites. After the trial we will be distributing regular reports to hospitals.

NZHIS Coders Regional Education Day:

The first Coders' Regional Education Day was held at Wellington Hospital on Wednesday 22nd February. Twenty five coders attended from Wellington, Hutt, Palmerston North, Masterton, Gisborne and Wanganui Hospitals.

The day consisted of the topics listed below:

• Diabetes in children using coding data extracted from NMDS - Sandy Dawson, NZHIS
• Data Quality, NMDS, PICQ, Casemix & DRGs - Tracy Thompson, NZHIS
• Mr Tripathi (Vascular Surgeon) talked in detail about carotid stenosis/occlusion, endarterectomy/stenting, varicose veins, stripping/avulsions/stabbing, bypass/in situ grafts, complications, endo procedures and endoluminal repairs
• Vascular case review - Marina Brovkovitch, Senior Coder Wellington Hospital
• Coding queries - Mary-Ellen Wetherspoon, NZHIS
• Quiz on topics that were covered over the day

The feedback received from the coders indicated they all enjoyed the day and found the learning experience valuable. Mr Tripathi's session was a definite highlight. I will now be planning other Regional Education Days to be held around the country, so will be in contact with DHBs shortly.

Accident Compensation Corporation (ACC):

Over the last few months I have been working with Angela Pidd (NZHIS), Rory Matthews (ACC), Frewyeni Kidane and Sha Sha Guo (Funding and Planning Directorate, Ministry of Health) reconciling 04/05 ACC data with NMDS coded data. This is part of the Public Health Acute Levy and there are over 6000 events that have been flagged by ACC and MoH as requiring investigation.

"NMDS coding plays a major part in identifying accident cases treated by hospitals and is used in calculating the amount ACC pays for public health acute treatment" (Reference: Accident Services - Who Pays? The Impact of the Injury Prevention, Rehabilitation, and Compensation ACT 2001 on District Health Boards, 3rd edition, July 2002).

I thought it would be useful to provide you with some feed back as we identified a number of areas that need improvement in the recording of hospital events for accident cases. I have provided detailed guidelines below in how to record different types of scenarios.

Administrative issues:

Hospitals are required to identify accident cases by using the following fields:

• Accident flag
• ACC claim number (M46/45, ACC45 or Accident Insurance Treatment Certificate AITC)
• Principal Health Service Purchaser code
• Admission type

PHS code of A0 (ACC direct purchase) MUST NOT be used for acute admissions.

If the Accident flag is set to 'Y' (for any principal health service purchaser code), then the ACC claim number field should not be blank.

ACC Acute = patient admitted as a result of an accident

Principal health service purchaser code would be 13 = base purchase.

Accident flag is to be set to 'Y' = yes and accident claim number field MUST be populated, it should not be blank.

Admission type would be AC = acute.

ACC Arranged = this is someone returning for treatment within 7 days of the decision being made by the specialist that an admission is necessary:

Principal health service purchaser code would be 13 = base purchase.

Accident flag is to be set to 'Y' = yes and accident claim number field MUST be populated, it should not be blank.

Admission type would be AA = arranged admission

ACC Non-Acute = Elective admission:

If the principal health service purchaser code is any of the codes that start with 'A' or '17' then the accident flag MUST be set to 'Y' = yes and if the accident flag is set to 'Y' then the ACC claim number field MUST be populated, it should not be blank.

Admission type MUST be WN = waitlist

ACC Non-Acute Inpatient Rehabilitation:

ACC directly purchase rehabilitation services for inpatient care after the acute event is completed.

Providers must have a contract arrangement with ACC to be able to provide Non-Acute Inpatient Rehabilitation for ACC claimants.

Patients who are admitted under the ACC Non-Acute Inpatient Rehabilitation Contract are patients who have been admitted acutely following an accident, (i.e. Fractured NOF) and then require ongoing inpatient rehabilitation. The patient will remain in the acute ward until they have been assessed and are ready to start full rehabilitation.

A0 – should also be used when a patient is "discharged (from acute event) and readmitted" into the ACC Non-Acute Rehabilitation Contract. These are special cases and should only be done as part of the documented process of changing a patient into ACC direct funding.

Principal health service purchaser code would be A0 = ACC direct purchase

The accident flag MUST be set to 'Y' =yes and if the accident flag is set to 'Y' then the ACC claim number field MUST be populated, it should not be blank.

Admission type MUST be AA = arranged admission

The Non-Acute Rehabilitation patients will have to be discharged from the acute phase and readmitted to rehabilitation with ACC principal health service purchaser code of A0 (ACC direct purchase ). The discharge type should be DW (discharge to other service within same facility) when discharging the patient from acute ward to the rehabilitation ward. In cases where ACC no longer fund the treatment the patient will be discharged with the discharge type code of DF (change of funder) and readmitted under the normal MoH principal health service purchaser code of 13 = base purchase.

In-Hospital Accidents:

Where a patient has sustained an injury as a result of an accident during their stay in hospital, an ACC45 form is to be completed by the hospital.

The accident flag is to be set to 'N' = no and an ACC45 claim number reported. In these cases the accident date must be either the date of admission or between the admission and discharge dates.

If a patient has an in-hospital accident and sustains an injury while admitted under ACC Non-Acute Rehabilitation or ACC Elective Surgery Contracts, and the injury is serious enough that treatment (operation) is required, the patient needs to be discharged (from rehabilitation or elective contract) with a discharge type of DF (change of funder) and readmitted (under surgical or medical care) for the acute in-hospital accident (follow ACC acute process above for readmitting).

If the primary reason for the patients admission to hospital is a result of an accident and the patient sustains another injury due to an accident in-hospital, then the in-hospital accident cannot be reported to the NMDS (National Minimum Dataset), as the NMDS has only 1 field available for reporting the accident flag and 1 field for the ACC claim number.

It may be possible for some hospitals to capture the in hospital accident within their own patient management system but not submit it to the NMDS. An ACC45 form is still to be completed by the hospital for the in-hospital accident. Any injuries sustained resulting from an in-hospital accident will be captured in the ICD-10 coding.

Coding issues:

Sequencing of principal and additional diagnoses:

Rehabilitation standard 2104 (page 273) states "The condition which led to the patient being in a rehabilitation facility should be assigned as an additional diagnosis" (examples page 274, ACS 2104).

Example:
Patient admitted to rehabilitation following surgery for a fracture NOF, patient also has a history of Parkinson's disease. Patient admitted under ACC Non-Acute Inpatient Rehabilitation Contract, PHS code A0, accident flag set to 'Y' and ACC claim number present. This event is ACC funded for rehabilitation for the injury.

Examples:
Sequenced incorrectly:
Rehabilitation Z50.X
Parkinson's disease G20
Fracture NOF S72.00
and external cause codes etc

Sequenced correctly:
Rehabilitation Z50.X
Fracture NOF S72.00
External cause codes
Parkinson's disease G20

There have also been rehabilitation events that do not have the rehabilitation code (Z50.X) sequenced as the principal diagnosis.

There are other events where the sequencing of codes does not appear to be correct. Depression and other mental health disorders have been assigned as principal diagnosis when the patient was admitted acutely due to overdose or other self inflicted injuries.

ACS 0530 Drug Overdose (page 112) states "When an admission is occasioned for treatment of a drug overdose and the patient subsequently receives treatment for an associated psychiatric condition in the same episode (event) of care, the overdose should be sequenced as the principal diagnosis".

Please remember to ensure acute and mental health conditions are sequenced and coded correctly.

Sequencing of external cause codes:

ACS 2001 External Cause Code Use and Sequencing (page 265) states "External cause codes should be sequenced directly after the diagnosis code(s) to which they relate". There are instances in the NMDS where there is an injury (reason for admission) and complication coded in the same event. The complication external cause codes have been sequenced before the accident external cause codes and vice versa.

Examples:

Sequenced incorrectly:
Fracture subcapital femur S72.03
Post op Haematoma T81.0
Complication internal device Y83.1
POO, hospital Y92.22
Fall from slipping W01.0
POO, home Y92.09
Activity, unspecified U73.9

Sequenced correctly:
Fracture subcapital femur S72.03
Fall from slipping W01.0
POO, home Y92.09
Activity, unspecified U73.9
Post op Haematoma T81.0
Complication internal device Y83.1
POO, hospital Y92.22

There are numerous events where the accident, place of occurrence and activity codes are incorrectly sequenced. The place of occurrence or activity has been sequenced above the accident, for example:

Sequenced incorrectly:
Activity, unspecified U73.9
POO, home Y92.09
Fall from slipping W01.0

Sequenced incorrectly:
POO, home Y92.09
Fall from slipping W01.0
Activity, unspecified U73.9

Sequenced correctly:
Fall from slipping W01.0
POO, home Y92.09
Activity, unspecified U73.9

The accident code MUST be sequenced before the place of occurrence or activity codes. There are no rules for sequencing place of occurrence or activity codes, but for national consistency please sequence the accident first, place of occurrence second and then activity code last. This is also consistent with code assignment/sequencing within 3M Codefinder.

Assignment of external cause codes to non-traumatic conditions:

The external cause standard states external cause codes "may also be used as additional codes with conditions classified in any other chapter but having an external cause". Please remember to assign external cause codes where the condition is a result of an external cause.

Example:

Low back pain due to a twisting injury at home while doing house work. X-rays are normal, no injury diagnosed, patient discharged home.

Principal diagnosis Low back pain M54.5
Accident Twisting injury X50
POO Home Y92.09
Activity House work U73.1

Code selection:

Ensure the correct code has been selected for assignment, non-traumatic versus traumatic codes. There have been several events where the patient has been admitted acutely, accident flag set to 'Y' and ACC45 claim number present and ACC claim form indicates injury but principal diagnosis reported to NMDS is a non-traumatic code.

Example:

Subdural haemorrhage (acute) (non-traumatic) 162.0 when should be: Traumatic subdural haemorrhage S06.5

Sequelae of Injuries etc:

Remember to assign sequelae codes when there is a residual condition present. Refer to ACS 1912 Sequelae of Injuries, Poisoning, Toxic Effects and Other External Causes

Accident dates:

There are inconsistencies between the accident dates reported to the NMDS and those on the ACC45 claim forms. Please ensure the accident dates assigned to the external cause codes are as accurate as possible.

Editing code descriptions:

In the NMDS data dictionary it states "free text should always be used for external cause codes". It goes on to say "agencies are encouraged to provide this information, particularly the description of the circumstances surrounding an injury, as it is used extensively in injury-prevention research". Please edit external cause code descriptions where possible.

Points to remember:

• Accurate assignment of principal diagnosis
• Sequence external cause codes correctly
• Assign external cause code where condition (non-traumatic) is as a result of an external cause
• Sequence additional diagnosis codes correctly
• Accurate assignment of accident dates
• Accurate code selection (traumatic codes (S00-T98) versus non-traumatic codes)
• Assign sequelae codes where appropriate
• Edit code descriptions especially external cause codes

For more information on some of the points highlighted above refer to:

NZHIS National Minimum Dataset Data Dictionary - www.nzhis.govt.nz
Accident Services - Who Pays? - www.acc.co.nz

NOTE: Where you think it is appropriate to forward any of this information onto other people within your DHB, please do so.

Diagnostic Related Group (DRG) Issues:

There are two issues under review at the moment in relation to DRG assignment.

Carotid stenosis with angioplasty:

When assigning any of the codes from section I65 Occlusion and stenosis of precerebral arteries, not resulting in cerebral infarction as principal diagnosis, and any procedure code from block [754] Transluminal balloon angioplasty the grouper assigns an error DRG.

Example:

Principal diagnosis I65.2 Occlusion and stenosis of carotid artery

Procedure code:
35309-07 [754] Percutaneous transluminal balloon angioplasty with stenting, multiple stents

DRG assigned with the above codes is 901Z Extensive OR Procedure Unrelated to Principal Diagnosis.

A thorough investigation has been carried out to assess where the problem lies in this situation. A solution to map the error DRG has been proposed as a work around at this time. There is no change in current coding practice.

Mental Health:

Currently, coders responsible for mental health patients have been advised to use Z03.2 Observation for suspected mental and behavioural disorders for patients who are seen by the service, but in which no diagnosis has been made. An issue regarding the DRG this code is grouped to was raised by a concerned clinician who asked NZHIS to consider the possible implications of prejudice that might be implied by this DRG and code assignment.

Where a mental health patient requires examination and is found to have no mental illness or other diagnosis, NZHIS advise coders to follow the standard ACS 0521 Admitted Patient without Sign of Mental Illness (page112) for the correct code assignment. NZHIS would like this to take effect from 18/04/06.

Voluntary patients:

Z00.4 General psychiatric examination NEC
Z71.1 Person with feared complaint in whom no diagnosis is made

Involuntary patients:

Z04.6 General psychiatric examination, requested by authority

New Zealand Coding Authority (NZCA):

The current term for NZCA is due to finish on the 30th June 2006. The team has worked hard to address and resolve coding issues for the sector and we would like to acknowledge and thank all members for their valuable contribution.

In order to best address issues surrounding future classification upgrades, and to further improve the service, NZHIS is proposing to make changes to the NZCA effective from 1 July 2006, which is the start of the new NZCA term.

The proposal is to reduce the size of the NZCA and to develop a new larger sub-group, the New Zealand Coding Committee (NZCC).

The NZCA would consist of approximately 5 members elected from the sector. The activities that the NZCA would be involved in would be high level classification and case mix issues, and work requiring direct communication with NCCH. Meetings would occur 4 times a year to coincide with CSAC meetings.

The proposed NZCC would provide a means by which a greater number of coders at all DHBs would be involved in the process of query resolution. A rep would be nominated from each DHB and it is envisaged that meetings will be held monthly via teleconference.

Most of you would be aware by now that the process of updating the NZCA website has been in progress for some months. Included in the upgrade is a new query webpage which will improve the level of efficiency with which queries are managed. The site is due to go live in June 2006 after thorough testing is completed.

Details of all the changes to the NZCA website and the NZCA/NZCC, and the draft terms of reference for these groups will be available sometime after Easter. This will give all of you plenty of time to review, evaluate and provide feedback on these new developments before June.

Auckland University of Technology (AUT) – Health Information Degree:

Despite our best efforts to move forward on this project, the Health Information Degree which was in the first stages of development in November last year will not proceed as planned for 2007. Mary-Ellen Wetherspoon is currently investigating alternative means of being able to provide this education option for New Zealand coders and other colleagues in the sector working with health information. At this stage the distance course available through Curtin University (Perth) should be considered for those that want to pursue this avenue in the short term. Website: www.curtin.edu.au/

Please forward this information onto the smaller/rural hospitals within your DHB. If you have any questions/comments regarding any of the information above please contact Mary-Ellen or myself.

Tracy Thompson
Senior Advisor - Coding Education
Clinical Coding Services
New Zealand Health Information Service
Corporate & Information Directorate
Ministry of Health
DDI: 04 460 4037
Mobile: 027 270 4491
Fax: 64-4-922-1897

http://www.nzhis.govt.nz
mailto:Tracy_Thompson@nzhis.govt.nz

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