ResiCAT_USER-GUIDE_ACT-edition_2014_92pp

ResiCAT User Manual

DEFINITIONS

7

C LASSIFICATION OF C ODING C HANGES – E RROR T YPE

7.1

Incorrect principal diagnosis This category is assigned if the selection of the principal diagnosis is incorrect. It is applied where the code itself is correct but has not been placed as the first (principal) diagnosis and would not be assigned where the condition selected as principal diagnosis is correct but the actual code is incorrect (e.g. diarrhoea is principal diagnosis but wrong code for diarrhoea has been selected). In the latter case, the discrepancy would be classified as 'Incorrect diagnosis code'.

Incorrect diagnosis code Used where the code selected for a diagnosis code is incorrect at any level.

Missing additional diagnosis code Used where a secondary diagnosis code is not recorded but is justified by the documentation and meets the Australian Coding Standard for an additional diagnosis. Unjustified diagnosis code (unnecessary or unsubstantiated) Used where a condition that has no bearing on the care or treatment of the patient during the episode of care has been coded or the use of a diagnosis code without sufficient information in the record to substantiate its use. This category includes codes where either the base condition or the 5 th digit level is not substantiated by clinical documentation. Incorrect procedure code Any occasion within an admission where the procedure code was incorrect at any level. Missing procedure code Used where a procedure code was not recorded but was justified by the documentation. Unjustified procedure code (unnecessary or unsubstantiated) Coding of a procedure that is not required to be coded or the use of a procedure code without sufficient information in the record to substantiate its use.

Other A discrepancy that does not fit into any of the categories above.

Version 1.4

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