Do the official ICD-10-CM guidelines take precedence over the coding directives within the code set that is index tabular when determining the principal diagnosis?

Publication Date: May 2021

Implementation Date: 1/06/2021

ICD 10 AM Edition: Eleventh Edition

Query Number: 3726

We often see documentation of plastic surgery for conditions that are not recognised by ICD-10-AM e.g. excess size breasts. ACS 1204 Plastic Surgery states that when the condition is not specified, or is a term not recognised by ICD-10-AM (e.g. ageing face), assign Z41.1 Other plastic surgery for unacceptable cosmetic appearance or Z42.- Follow-up care involving plastic surgery as the principal diagnosis, as appropriate. The Conventions used in the Tabular List of Diseases states that “when a clinician uses terminology that is not listed in the ICD-10-AM Alphabetic Index, seek clarification for alternative terms that are listed in ICD-10-AM. If no alternate description is provided, to utilise one of the following strategies” with Example 44 instructing to follow index pathway for Disease/site. ACS 0001 Principal diagnosis also states: “In determining principal diagnosis, the coding directives in the ICD-10-AM manuals take precedence over all other guidelines (see ICD-10-AM Tabular List: Conventions used in the ICD-10-AM Tabular List and ICD-10-AM Alphabetic Index: Conventions and general arrangement of the ICD-10-AM Alphabetic Index)”. 1. Can VICC please clarify, does the specialty standard ACS 1204 Plastic surgery override the instructions in the Conventions used in the Tabular List of Diseases and ACS 0001 Principal diagnosis? 2. Can we seek further documentation from the clinician of alternative terminology which best reflects the condition in these circumstances?

3. In the absence of further documentation, can we follow the Conventions used in the ICD-10-AM Tabular List (Example 44) to assign a code for disease of the specified site e.g. disease breast? Or does the instruction in ACS 1204 require that either Z41.1 / Z42.- be assigned?

Response

VICC notes the Introduction to the Australian Coding Standards which states: ‘The level of detail in the ACS reflects the assumption that users of the document will have had training in abstracting relevant information from health care records and in the use of ICD-10-AM and ACHI. It is assumed that clinical coders are aware of, and follow, ICD-10-AM and ACHI conventions in the first instance.’ VICC also notes the Guidance in the use of ICD-10-AM of the ICD-10-AM Diseases Tabular which states: ‘In order to classify accurately, it is essential to have a working knowledge of medical science and to understand the characteristics, terminology and conventions of ICD-10-AM. The ICD-10-AM Alphabetic Index contains many terms not included in the ICD-10-AM Tabular List, and clinical classification requires that the Alphabetic Index, the Tabular List and the Australian Coding Standards are all consulted before a code is assigned.’ Guidance in the use of ICD-10-AM in the ICD-10-AM Diseases Tabular Introduction lists the steps to follow when classifying diseases: 1. Identify in the current episode of admitted care, the clinical concept requiring classification (see also ACS 0001 Principal diagnosis and ACS 0002 Additional diagnoses). Avoid indiscriminate coding of irrelevant information, such as symptoms or signs characteristic of the diagnosis (see also General standards for diseases). Note: Certain symptoms represent important problems in medical care in their own right and may at times require code assignment (see also the Instructional note at the beginning of Chapter 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified). 2. Locate the lead term in the appropriate section of the ICD-10-AM Alphabetic Index. The lead term is usually a noun, but may be an adjective or eponym, identifying the pathological condition or injury. • Follow any Instructional note(s) that appear under the lead term • Note any terms enclosed in parentheses (i.e. nonessential modifiers; they do not affect code assignment), as well as any terms indented under the lead term (i.e. subterms; these essential modifiers may affect code assignment), until the clinical concept has been accounted for • Follow carefully any cross references (see and see also). Note: A code in the ICD-10-AM Alphabetic Index with a dash in the fourth or fifth position identifies that a fourth or fifth character is required for a valid code. The additional characters are located in the ICD-10-AM Tabular List. 3. Refer to the ICD-10-AM Tabular List to verify the suitability of the code selected: • Be guided by any Instructional notes (e.g. 'Inclusion' terms, 'Includes' and 'Excludes' notes, 'Code also', 'Use additional code') at the selected code, or at the chapter, block or category. 4. Refer to the Australian Coding Standards: • First, refer to the General standards for diseases • Refer to any specialty standards, as indicated by an ACS symbol in the ICD-10-AM Tabular List 5. Refer to national Coding Rules, as appropriate 6. Assign the code. Therefore, VICC advises the Australian Coding Standards and ICD-10-AM Coding Conventions should be used in conjunction with each other. In this instance ACS 1204 Plastic Surgery would be applied following the steps to classifying diseases in the Guidance in the use of ICD-10-AM in the ICD-10-AM Diseases Tabular Introduction as it is the next step after the conventions. For example, when the documented principal diagnosis is ‘’excess size breasts’’, in the absence of further documentation that allows a condition of the breast to be coded, VICC advises to assign Z41.1 Other plastic surgery for unacceptable cosmetic appearance or Z42.- Follow-up care involving plastic surgery following ACS 1204 Plastic surgery. When a documented condition is not indexed, Conventions used in the ICD-10-AM Tabular List example 44 cannot be applied to assign a code for disease of a specified site e.g. disease breast as referring to Australian Coding Standards is the next step in the Guidance in the use of ICD-10-AM.

VICC does however consider it is appropriate to seek further documentation from the clinician regarding alternative terminology which reflects the medical condition as per ACS 0010 Clinical documentation and general abstraction guidelines.