Procedure Definition and Code Order
After all the diagnosis codes have been listed, the procedure codes and some non-operative procedures are recorded.
A procedure is defined as a clinical intervention that:
- is surgical in nature and/or
- carries a procedural risk and/or
- carries an anaesthetic risk and/or
- requires specialised training and/or
- requires special facilities or equipment only available in an acute care setting
The order for the recording of procedure is based on the following hierarchy;
- procedure performed for the treatment of the principal diagnosis
- procedure performed for the treatment of an additional diagnosis
- diagnostics/exploratory procedure related to the principal diagnosis
- diagnostic/exploratory procedure related to the additional diagnosis for the episode of care.
Examples of non-operative treatments that are coded include:
- Allied Health interventions
- Anaesthesia for a procedure
- Blood transfusion
- Biopsies such as bone marrow
- Cardiac catheterisation
- CPAP
- Cytotoxic drugs
- Dialysis
- Lumbar puncture
- Mechanical ventilation
- Phototherapy in newborns
- Radiological examinations
- In neonates the administration of electrolytes, anti-infectives, and antibiotics
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