Scribd
Upload
9 views

Module 2_Fundamental principles and conventions

The document outlines updates to the Australian Coding Standards (ACS), including the addition of a glossary to clarify terms and descriptions relevant to the Australian health system. It details amendments made to improve clarity and structure, including the creation of a new appendix for clinical documentation queries and the relocation of certain standards. Additionally, it addresses the review process for the ACS, including the removal of outdated codes and the introduction of new guidelines for coding conventions.

Uploaded by

smagi2343
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
9 views

Module 2_Fundamental principles and conventions

The document outlines updates to the Australian Coding Standards (ACS), including the addition of a glossary to clarify terms and descriptions relevant to the Australian health system. It details amendments made to improve clarity and structure, including the creation of a new appendix for clinical documentation queries and the relocation of certain standards. Additionally, it addresses the review process for the ACS, including the removal of outdated codes and the introduction of new guidelines for coding conventions.

Uploaded by

smagi2343
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 16

Module – 2 – Fundamental Principles and conventions

Lesson 1 of 6 - ACS Glossary

A Glossary has been added to the introductory content of the Australian Coding
Standards (ACS).

The Glossary describes terms or phrases used in the general ACS to assist in
their application.

The Glossary focuses on descriptions of certain classification terms, allowing


standards to focus on the classification guidelines.

Term – Terms are listed bold on the left


Description – Descriptions have been developed in the context of the Australian
health system. They are primarily sourced from national agencies such as the
Australian Institute of Health and Welfare (AIHW) and the Australian Commission
on Safety and Quality in Health Care (ACSQHC).
Description References – Description are supported by publications referenced
in parentheses.
Examples and contextual information – Glossary descriptions are followed by
examples or other contextual information.

Navigate and apply Glossary terms

Eight items are described in the Glossary:

 Admitted patient stay


 Care plan
 Clinical consultation
 Clinician
 Episode of care
 Health care record
 Routine care
 Scope of practice.
Note that where a term above is also described in a specialty standard, follow
the guidance in the specialty standard.

Lesson 2 of 6 - ACS Introduction and new appendices


Clarifying amendments

A number of amendments were made to the ACS to clarify the different types of
ACS and the boundaries between the ACS, the appendices and other related
information.

These include:

 the interaction between the appendices and the National


Coding Advice (Coding Rules)
 the distinction between general and specialty standards
 the purpose and scope of ACS examples
 actions relating to data quality.

Structure and content of the ACS Introduction


The advisory content within the ACS introduction has been amended and
placed under new subject headings.
New appendix
A new appendix has been created by separating the guidelines for formulating
clinical documentation queries from ACS 0010 Clinical documentation and
general abstraction guidelines. See education module: Clinical documentation
and general abstraction guidelines that details changes to this standard.
Appendix B should be used in conjunction with the Clinical Coding Practice
Framework to formulate clinical documentation queries to clinicians.

Access the Clinical Coding Practice Framework from the following


websites:

Health Information Management Association of Australia (HIMAA)


Clinical Coders’ Society of Australia (CCSA)
Independent Health and Aged care pricing Authority (IHACPA)
Lesson – 3 of 6 – Retired and Amended ACS
Review of ACS

The ACS are regularly reviewed and revised for currency and to determine their
ongoing necessity. Some standards have been removed in Twelfth Edition with
guidance instead incorporated within the Tabular Lists and/or Alphabetic Indices.

Consolidation of content and structure of the ACS has also been undertaken to
reduce ambiguity, and improve relevance and comprehensibility.
Relocation of content from the ACS to the Alphabetic Index and/or
Tabular List
Example
The guidelines from ACS 1437 Infertility and in vitro fertilisation (IVF) are now
contained in the ICD-10-AM Alphabetic Index and Tabular List.
For further details of specific ACS amendments see education modules related to
the relevant body system and / or the Reference to Changes for
ICD-10-AM/ACHI/ACS Twelfth Edition.

ACS title or content amendments


For certain ACS, content was relocated to other ACS and the ACS titles amended.

ACS 0049 Disease codes that must never be assigned


ACS 0049 Disease codes that must never be assigned has been amended.
1. Rationale – Rationale has been added to explain why a code may appear
in the list in ACS 0049 Disease codes that must never be assigned.

2. Outdated concepts in mental health – Certain codes reflecting outdated


concepts from category F65 Paraphilic disorders are inappropriate and
have been added to ACS0049 – Disease codes that must never be
assigned. Legacy terms have been retained in the ICD-10-AM Alphabetic
Index but concepts have been classified to a residual (unspecified) code.
See education module: Mental and behavioural disorders to see detail of
amendments to other outdated terminology.

3. Outdated Concept – R65.1 – Severe sepsis has been added to the list. For
details of amendments related to R65.1 see education module: Sepsis,
infectious diseases and resistance to antimicrobial drugs.

4. New ICD-10 Code – T76 Unspecified effects of external causes has been
created in Twelfth Edition to maintain alignment with the parent
classification (ICD-10). It has been added to ACS 0049 due to its non-
specific nature. See education module: Other ICD-20-AM for further
details.
Lesson – 4 of 6 – Conventions and other guidance

Conventions
The guidelines and examples in the conventions across all volumes of ICD-10-AM
and ACHI have been amended to improve consistency and clarity.
Amended conventions

The conventions contain new guidelines for the following:

 Glossary description/definition
 Code also
 Use additional codes
 Use additional external cause code
 Typeface (microorganisms)
 Residual (other and unspecified) codes
 Format (refer to education module: Other ACHI)
 Male and female codes.

A patient’s self-reported sex does not always correspond to their biological


characteristics due to conflicting biological characteristics that they are unaware
of (e.g. internal organ or chromosomal abnormality) or the patient’s preference
to respond with gender rather than sex.

For Twelfth Edition, subterms in the index and code titles use ‘male’ and ‘female’
to correspond to sex characteristics of a particular reproductive system which
include those that have been surgically created. Some examples include:

 ‘Male’: prostate, seminal vesicle, scrotum, tunica vaginalis, testis, vas


deferens, epididymis, spermatic cord and penis. Male is also applicable for
implants and surgically created anatomy – such as the anatomy resulting
from a phalloplasty.
 ‘Female’: ovary, fallopian tube, uterus, cervix, vagina, clitoris, vulva,
procedures associated with labour, delivery procedures and postpartum
procedures. Female is also applicable for implants and surgically created
anatomy – such as the anatomy resulting from a vaginoplasty.

Note: Clinical coders should not apply the patient’s reported sex in a patient
administration system, or other clinical systems, to assign codes that use ‘male’
or ‘female’.

Where required, accompanying amendments have been made within the


classification. Refer to the Reference to Changes for ICD-10-AM/ACHI/ACS
Twelfth Edition.
The ICD-10-AM and ACHI conventions need to be understood and followed by
those who partake in the clinical coding process and by those who use coded
data.

Guidance in the use of ICD-10-AM and ACHI


Guidance in the use of ICD-10-AM and Guidance in the use of ACHI are located at
the front of each Tabular List. The process and sequence of code assignment is
described; namely the location of terms in the Alphabetic Index, followed by
reference to the Tabular List, prior to referring to the ACS.

Lesson 5 of 6 – Quiz –

You might also like