معايير الترميز الصحي الأسترالية (تقنيات الترميز )

Australian Coding Standards

The ICD-10-AM classification system has numerous coding standards that provide specific definitions and directives on correct coding techniques.  As part of the conditions of the Victorian casemix funding formula, the HIM, when allocating ICD-10-AM codes, must follow all the coding standards. Occasionally, these standards are enhanced or refined by the Victorian Department of Human Services to support the casemix funding formula.

There are over 280 ICD-10-AM coding standards.  The standards are broken into sections related to body systems with some other additional sections including pregnancy, symptoms and signs, abnormal clinical and laboratory findings, general standard for procedures and general standards for diseases. 

Some of the coding standards are:

• HIMs must not make diagnostic decisions when reviewing the medical record.  For example, they must not automatically assume that a patient is anaemic if a pathology result shows a haemoglobin level below the pathology reference range.  Instead the documentation within the medical record must specify that a patient is anaemic and treatment is initiated.
• Symptoms should not be coded as a principal diagnosis when a related definitive diagnosis has been established.
• When acute and chronic conditions exist concurrently, and are recorded as such within the medical record code both the acute and chronic condition.
• When two or more diagnosis equally meet the criteria for principal diagnosis the clinician should be asked to indicate which diagnosis best meets the principal diagnosis definition.  If no further information is available code the first mentioned diagnosis as the principal diagnosis.
• Tonsillitis, not specified as acute or chronic, should be coded to acute unless a tonsillectomy is performed, in which case the tonsillitis is coded as chronic.  Chronic = recurrent.
• Cardiac or cardiorespiratory arrest should be coded only if resuscitation intervention is undertaken, regardless of patient outcome.  Cardiac arrest should not be sequenced as the principal diagnosis.
• Appendicitis - even though no pathological evidence of appendicitis is recorded, a clinical diagnosis of appendicitis should be coded if documented.  If diagnosis of abdominal pain is recorded and no histopathological evidence of appendicitis, code the abdominal pain.  If diagnosis of abdominal pain and histopathological evidence of an appendiceal condition is documented code the appendiceal condition.
• Febrile convulsions should be assigned as the principal diagnosis in cases of febrile convulsions with no underlying cause documented.  Where an underlying cause is documented, the principal diagnosis conventions should be followed.

The coding standards clearly emphasize that

"the responsibility for recording accurate diagnosis and procedures, in particular, principal diagnosis, lies with the clinician, not the clinical coder."

"A joint effort between the clinician and clinical coder is essential to achieve complete and accurate documentation, code assignment and reporting of diagnoses and procedures."