Worked case: code a complex encounter

Two cases from WHO's own guide

Two cases, both from WHO's own guide. We work each one step by step: the main condition, the cause, then the other conditions.

Hip fracture, and hypothermia

Case one. The main condition is recorded as a hip fracture from a fall. The other condition is severe hypothermia, resulting from exposure to the cold weather.

• Hip fracture · NC72.2Z · Main condition · Fracture of neck of femur
• from a
• fall · PA6Z · Its cause · Fall, unspecified height
• . Severe
• hypothermia · NF02 · Other condition
• resulting from
• exposure to the cold weather · PB16 · Its cause · Exposure to cold weather
• .

Nature first, then the cause

Step one: the main condition. The practitioner identified the hip fracture, so it's the main condition, coded as fracture of neck of femur, unspecified. Step two: its cause, an unintentional fall from unspecified height, postcoordinated with the fracture. Step three: the cluster. The nature of the condition, a slash, then the external cause.

• NC72.2Z · Step 1: main condition
• PA6Z · Step 2: its cause

Each condition brings its cause

Now the other condition. Hypothermia, with its own external cause, the exposure to cold weather, postcoordinated with it. It forms its own cluster, separate from the fracture.

• NF02 · Other condition
• PB16 · Its cause

Two clusters

The answer: a main condition cluster for the fracture and its fall, and an other condition cluster for the hypothermia and its cause. Each condition keeps its own cause.

When not to link

Case two. The main condition is rheumatoid arthritis. The other conditions are hypertension, type 2 diabetes mellitus and cataract. The cataract was not documented as a diabetic cataract.

• Main condition · FA20.Z · Rheumatoid arthritis, serology unspecified.
• Other conditions · Three · Hypertension, type 2 diabetes mellitus and cataract.

Separate codes, no cluster

The answer: each condition is coded separately. The cataract must not be linked to the diabetes, because it was not documented as a diabetic cataract, so there's no combination that indicates clustering.

• Main · FA20.Z · Rheumatoid arthritis.
• Other · BA00.Z · Hypertension.
• Other · 5A11 · Type 2 diabetes mellitus.
• Other · 9B10.Z · Cataract.

Check yourself

Pause and think. A right cataract and type 2 diabetes mellitus are both documented, with no documented causal link. How should they be coded? The answer: Separately: the cataract with its laterality, and the diabetes as another condition. Where a causal relationship is not documented or cannot be inferred, the two stem codes cannot be part of the same cluster.

• One cluster linking the cataract to the diabetes
• Separately: the cataract with its laterality, and the diabetes as another condition
• Only the diabetes
• Only the cataract

Keep these in mind

The main condition is the reason for admission. Nature first, then the external cause. Each condition brings its own cause. And link only what is documented as linked.

• Main condition: the reason for admission
• Nature first, then the external cause
• Each condition brings its own cause
• Link only what is documented as linked