Clinical coding secrets (12)

Clinical coding secrets (12)

By Dr.Sedeek El Hakeem (MBBS, TQM, cert.CII, IFCE)

Today I’ll present a new dose of Clinical coding secrets, I have been abstracted them from my reading Australian Coding Standards and practicing Australian clinical coding(ICD10AM,ACHI) at a private general hospital (150 beds) in KSA
HYPERTENSION
When coding combinations of hypertension, heart and kidney disorders, it is important to distinguish if, and how, they are related.


HYPERTENSION
• Hypertension may cause heart and/or kidney disease.
• Hypertension may be caused by other conditions, including some kidney disorders.
• Hypertension and heart and kidney disease may be unrelated although they are present at the same time.
==HYPERTENSIVE HEART DISEASE (I11)
Certain heart conditions: 

I50.- Heart failure 
I51.4 Myocarditis, unspecified 
I51.5 Myocardial degeneration 
I51.6 Cardiovascular disease, unspecified 
I51.7 Cardiomegaly
I51.8 Other ill-defined heart diseases 
I51.9 Heart disease, unspecified 

are classified to category I11 Hypertensive heart disease when a causal relationship is stated (eg 'due to hypertension' or 'hypertensive'). In such cases, assign only a code from category I11.

The same heart conditions with hypertension, but without a stated causal relationship, are coded separately. Sequence according to the circumstances of the episode of care.
== HYPERTENSIVE HEART AND KIDNEY DISEASE (I13)
Assign codes from combination category I13 Hypertensive heart and kidney disease, when both hypertensive heart disease (I11) and hypertensive kidney disease (I12) are present. The term 'hypertensive' by default indicates that there is a causal relationship.

(See also ACS 1438 Chronic kidney disease).
== SECONDARY HYPERTENSION (I15)
Assign these codes when hypertension is stated to be 'due to' or 'secondary to' another condition, such as renal artery stenosis (I15.0 Renovascular hypertension) or phaeochromocytoma (I15.2 Hypertension secondary to endocrine disorders).

Assign also a code from N18.- Chronic kidney disease where I15.0 Renovascular hypertension or I15.1 Hypertension secondary to other kidney disorders are assigned (see also ACS 1438 Chronic kidney disease).

Today I presented a new dose of Clinical coding secrets; I hope this dose will help you to sail safely in the sea of clinical coding as you know coding translates medical service into money 
Next time I’ll provide a new dose of Clinical coding secrets

For more information contact me on
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sedeeks2011@gmail.com
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Clinical coding secrets 1

Clinical coding secrets(part1)

by Dr Sedeek El Hakeem

These clinical coding standards have been written with the basic objective of satisfying sound coding convention according to ICD-10-AM and ACHI. Consideration of the various uses of inpatient data collections was secondary. Issues such as DRG allocation, research and planning aims were considered only after the requirement for accurate ICD-10-AM and ACHI coding was satisfied.

The clinical record should be the primary source for the coding of inpatient morbidity data. Accurate coding is possible only after access to consistent and complete clinical information. Without good documentation, coding guidelines are difficult, if not impossible, to apply. It is assumed that coding decisions are not made solely based on information provided on the clinical record front sheet (or a copy of same) but that analysis of the entire clinical record is performed before code assignment.

The responsibility for recording accurate diagnoses and procedures, in particular principal diagnosis, lies with the clinician, not the clinical coder.

The 'ICD' was first used to classify causes of mortality as recorded at the registration of death. Later, its scope was extended to include diagnoses in morbidity. It is important to note that although the ICD is primarily designed for the classification of diseases and injuries with a formal diagnosis, not every problem or reason for coming into contact with health services can be categorised in this way. Consequently, the ICD provides for a wide variety of signs, symptoms, abnormal findings, complaints and social circumstances that may stand in place of a diagnosis.

Next time I'll provide more Clinical coding secrets

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