But where does the data come from?

Andrew Wooding CCTQM ADHB But where does the data come from?

Who gets coded? Only inpatient events get coded “A healthcare encounter in which a person becomes resident in a healthcare facility. [H]ealthcare users who receive assessment and/or treatment for three hours or more, or who have a general anaesthetic are to be admitted. This also applies to healthcare users of Emergency Departments…

… When calculating the three hours, exclude time in a waiting room, exclude triage and use only the duration of assessment/treatment. If part of the assessment/treatment includes observation, then this time contributes to the three hours. ‘Assessment/treatment’ is clinical assessment, treatment, therapy, advice, diagnostic or investigatory procedures from a nurse or doctor or other health professional.”

From Documentation to Data

Documentation • Responsibility of clinician • Complete, Timely, Legible, Specific • If it’s not documented, it didn’t happen

Coding process • Abstraction • Read the record • Analyse the concepts • Assignment • Find the codes in the classification • Enter codes into system • Review • Does the codeset make sense?

ACS 0001 • The principal diagnosis is defined as: “The diagnosis established after study to be chiefly responsible for occasioning an episode of admitted patient care.”

ACS 0002 • An additional diagnosis is defined as: “A condition or complaint either coexisting with the principal diagnosis or arising during the episode of admitted patient care.”

ACS 0002 – Part 2 For coding purposes, ADx should be interpreted as conditions that affect patient management in terms of requiring any of the following: • Commencement, alteration or adjustment of therapeutic treatment; • Diagnostic procedures; • Increased clinical care and/or monitoring.

Case study Patient admitted with a headache • PDx: R51 Headache • AR-DRG B77Z – Headache • WIES: 0.4350 • Revenue: $2,024.63

Radiology result CT head shows SDH • PDx: I62.0 Subdural haemorrhage • AR-DRG B70C – Stroke w/o cat/sev CC • WIES: 0.9729 • Revenue: $4,930.89

OR procedure SDH drained • PDx: I62.0 Subdural haemorrhage • PProc: 39600-00 Drainage of ICH • AR-DRG B02C – Craniotomy w/o cat/sev CC • WIES: 3.9042 • Revenue: $19,787.15

Co-morbidity Physio attended for hemiplegia • PDx: I62.0 Subdural haemorrhage • ADx: G81.9 Hemiplegia • PProc: 39600-00 Drainage of ICH • AR-DRG B02B – Craniotomy w Sev CC • WIES: 6.4277 • Revenue: $32,567.22

Co-morbidity (lab result) Slow-K prescribed for low potassium • PDx: I62.0 Subdural haemorrhage • ADx: G81.9 Hemiplegia • E87.6 Hypokalaemia • PProc: 39600-00 Drainage of ICH • AR-DRG B02A – Craniotomy w Cat CC • WIES: 7.4713 • Revenue: $37,865.42

Case scenario • 86-year-old female slipped on the dance floor and fell at a night club she was attending to celebrate her great-granddaughter’s graduation. Admitted to hospital, X-ray showed sub-capital fracture of left neck of femur. Moore’s hemiarthroplasty was performed under epidural block (3E) because of her significant co-morbidities of COPD, CHF and emphysema.

And another • A 63-year-old woman was admitted for repair of aortic valve stenosis. Co-morbidities included Type 2 DM, hypercholesterolaemia and obesity. She had a mechanical AVR with CPB performed under GA.

Maybe a third? • Patient presented with a necrotic area on the left shin. He banged it on the coffee table 4 days previously. He was also found to be suffering from osteoarthritis in his L hip and diabetes with multiple complications. The foot ulcers were cleaned out and grafted along with the pretibial wound. His hypertension and CORD were well controlled without medications.

Falls from Supermarket trollies • “One of the leading cause of injuries in children under five is falls from supermarket trollies.” • “But how do you know?” W02.9 Fall involving other and unspecified pedestrian conveyance Fall: • involving powered scooter • while seated in, or climbing into or out of shopping trolley

But prior to 2008 W17 Other fall from one level to another Fall from or into: • cavity • dock • haystack • hole • pit • quarry • shaft • tank • well

Coding mantras • If it’s not documented, it didn’t happen • Just because you can, doesn’t mean you should • If at first you don’t succeed, cheat

Classification vs Nomenclature • ICD-10 is a statistical classification • SNoMed is a nomenclature I47.1 Supraventricular tachycardia Tachycardia (paroxysmal): • atrial • atrioventricular [AV]: • NOS • re-entrant (nodal) [AVNRT] [AVRT] • junctional • nodal

The good stuff • Single national MRN • HCU identifier • Popularly, the NHI number • Data back to 1948 • Code Descriptions • M, S, T, U, V, W, X, Y codes • “Other” codes • Further back in time, most codes

But where does the data come from?