Coding Rules Current as at 18-Oct-2016 08: 31

Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2895 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Coding from documentation in previous admissions

Q:

There is a Coding Rule relating to diabetes mellitus which states that the condition must be documented in the current admission in order to assign a code for the diabetes. Should that rule be applied to all conditions where there is a coding instruction in a specialty standard to ‘code where documented’?

A:

The Coding Rule Documentation of diabetes mellitus, published in June 2012, states that:

‘…previous admissions and correspondence can be used to inform assignment of diabetes mellitus codes. However, previous admissions and correspondence should not be used:

1. 
   to assign diabetes mellitus if it has not been documented in the current admission...’
   

This instruction is relevant for all specialty standards instructing that certain conditions must be coded when documented (HIV/AIDS, viral hepatitis and tobacco use), that is, the conditions must be documented within the episode of care in order to be assigned a code.