The advice provided in the Australian Coding Standards (ACS) and coding rules does not clarify several issues:nurse pushing patient

  • Is significance relevant to whether the condition is to be coded or is ACS 0001 and ACS 0002 all that is needed to indicate relevance to the episode?
  • What is the definition of persistence which is required to be met before this condition can be coded (assuming it meets ACS 0001 or ACS 0002)?
  • Is it reasonable to assume that a Trial of Void is undertaken to confirm continence?

It is assumed that the answers to each of these three questions must be YES if the code is to be allocated.

Reference Material and notes on standard or coding rules

ACS 1808 Incontinence:

1:  Significance is defined but the text does not indicate if significance is the requirement for inclusion in coding.

Incontinence is significant when:

      • Is not clinically considered to be physiologically normal
      • Is not clinically considered to be developmentally normal, or
      • Is persistent in a patient with significant disability or mental retardation “(significance in this context is not defined in the standard)

2:  Assign only when: 

2.1 the incontinence is persistent prior to admission,

2.2 Is present at discharge

2.3 Or persists for at least 7 (seven) days

Clarification of the standard

Incontinence must be significant to be coded?  (TN200 Published 15 June 2009 – Status Current)

Answer provided – references ACS 0001  and ACS 0002 – therefore, which of the following is correct?:

A:  Code if significant AND treated, investigated or monitored during the stay

Or

B:   What is persistence?

Some clarification is provided in TN200 – which indicates that the specification is present on admission, and present at discharge are intended to specify that the incontinence is persistent.  However persistent is not defined other than present at admission, present at discharge. 

  • no indication of whether both are required
  • no indication of the length of the problem to indicate persistence.  Does this require clinical documentation of the word persistent? Such documentation is not common.  Is there a number of days which make the condition persistent?

Example from a specific patient record

Though individual records are invaluable to assist evaluation and clarification of coding rules, the rules are designed for generic application and therefore need to be written in a manner which clarifies the situation for all cases.  

A disagreement between coders:

Coder A:  Do not assign R32 as 

  • no documentation to link the failed Trial of void with urinary incontinence

Coder B:  Apply clinical knowledge would require assigning urinary incontinence as the TOV failed and IDC inserted.  This meets 1801 as it is 

  • significant – not physiologically or developmentally normal
  • Persists – was present before admission and after admission
  • Meets ACS 0001/0002 – was treated during the stay

An extract of the key components of the example record is provided  (on the right).

What do you think? Please comment below…

Record:

Past History: obesity and mobility: She weighs 100kg and requires a hoist for transfers, she is currently able to transfer and walk with assistance.

She has failed two Trials of Void, and has a history of rectocele, cystocele and hysterectomy with plans to follow up with urologist and gynaecologist.

Postoperative course: Her pain did improve post-op, however progress with physiotherapy was very slow. She was seen by the Rehab team and long term rehabilitation was felt the appropriate plan of action.

Patient developed painful leg cramps which was felt likely due to her ongoing UTI. Vancomycin 1g BD was added to her regimen. She subsequently became pryrexic and this was treated symptomatically. She had attempted Trial of Void on the day before discharge which failed. She now has an indwelling catheter. She has resisted efforts to mobilise and has been noted to have very poor dietry intake.