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Kidney Care
A guide to recording
activity within renal units
for national reporting
FIRST EDITION | JUNE 2011
Better Kidney Care for All
Reader Page
Title
A guide to recording activity within renal units for
national reporting
Authors
Hugh Cairns - Expert Working Group, NHS Information Centre
Julie Renfrew - NHS Kidney Care
Beverley Matthews - NHS Kidney Care
James Medcalf - KQIP
Jill Cockrill - NHS Information Centre
Lynn Bracewell - Connecting for Health
Publication Date
June 2011
Target Audience
Clinicians, coders, and information system managers working
with renal units.
Circulation List
NHS Trust CEOs, Directors of Finance, Clinical Coders,
Connecting for Health leads, renal IT advocates,
commissioners and information leads in specialised
commissioning, PCTs and emerging pathfinder consortia,
clinical directors in kidney services, specialist registrars in
kidney services.
Description/purpose
This document has been written to support accurate clinical
coding in renal services, rather than as a precise guide. It
contains an introduction to clinical coding and its importance,
gives detailed examples of how renal activity should be
recorded, and contains useful reference materials and links to
further sources.
Cross Ref
www.connectingforhealth.nhs.uk/systemsandservices/data/
clinicalcoding
Superseded Docs
n/a
Action Required
n/a
Timing
n/a
Contact details
[email protected]
Contents
1Chapter 1: Introduction and background
04
Foreword
05
Clinical coding and its importance
06
What information should be recorded?
07
Using this guide
1Chapter 2: Recording and coding of renal activity - examples :
Acute kidney injury examples
19
2.1 Acute kidney injury
22
2.2 Diverticulitis with a generalised peritonitis
23
2.3 Thrombotic thrombocytopenic purpura (TTP)
Nephrology examples
24
3.1 Nephrotic syndrome
24
3.2 Brachial PTFE graft insertion
CONTENTS
Renal dialysis examples
09
1.1 Haemodialysis
12
1.2 Peritoneal dialysis
14
1.3 Haemodialysis
17
1.4 Haemodialysis
Kidney transplantation examples
25
4.1 Pre and post-transplant care at non-transplanting centre
Chapter 3: Recording and coding of renal activity within paediatric renal units - examples :
Chronic renal failure and dialysis in an infant
29
1.1 Inpatient admission from birth
30
1.2 Each session of Peritoneal dialysis
31
1.3 Each session of Haemodialysis
Acute renal failure
32
Acute renal failure
General nephrology
33
General nephrology
1Appendices
34
Appendix 1:
Common renal terms and acronyms
36
Appendix 2:
Mapping common renal procedures to OPCS-4 codes
40
Appendix 3:
UK Renal Registry list of possible adult renal comorbidities
41
Appendix 4:
Additional sources of information
03
Foreword
In healthcare, coding of clinical information is not just an administrative necessity. Recording accurate
information about the treatment patients receive underpins the provision of high quality, safe and
efficient care.
In simple terms, coding is the process through which clinical information recorded in patient notes is
translated into coded data and entered onto hospital information systems in a consistent way. The
information collected is vitally important for:
•
•
•
•
•
•
Enabling good clinical governance
Monitoring the provision of health services across the UK
Research and the monitoring of health trends and variations
Local and national clinical audit and case-mix analysis
Providing information to enable effective service planning
Ensuring that hospitals are paid for the work they carry out through Payment by Results
In renal services, a Payment by Results tariff for dialysis was introduced from April 2011. This means
that it is more important than ever that renal services are coded accurately. Renal units will need to
ensure they are appropriately reimbursed for the care they provide and there will also be incentives to
provide treatments in ways that are proven to have better clinical outcomes.
Improved coding will support the development of the National Renal Dataset (NRD) which enables
kidney care networks to assess progress against the national clinical strategy. By ensuring information
from different networks is accurate and directly comparable, the NRD will help drive improvements in
the quality, safety and cost effectiveness of renal services for the benefit of all patients.
This document has been produced to support clinicians, coders and information system managers
working with renal units to ensure that patients’ diagnoses and treatments are recorded accurately.
It contains an introduction to clinical coding and its importance, gives detailed examples of how renal
activity should be recorded, and contains useful reference materials and links to further sources.
Hugh Cairns
Consultant Nephrologist, King’s College Hospital, London
Chair, Expert Working Group, NHS Information Centre
04
Beverley Matthews
Director
NHS Kidney Care
Clinical coding and its importance
Coded data has many uses, as shown in this diagram from NHS Connecting for Health:
Cost analysis
Commissioning
Epidemiological
studies
Aetiology
studies
1
Treatment
effectiveness
Outcome
measurement
Clinical
Clinical audit
Statistical
Health Trends
Clinical
Indicators
Casemix
planning
Financial
flows
CHAPTER ONE
Clinical
Governance
The NHS Classifications Service is the definitive source of clinical coding standards and guidance
for clinical classifications ICD-10 and OPCS-4:
•
ICD-10 is the internationally defined set of codes for diagnostic clinical data
•
OPCS-4 is the UK-specific set of codes for surgical interventions and procedures.
2
Information about a patient’s condition and treatment is recorded on the patient’s notes by the
clinician. Coders use these notes, other clinical records, local databases and correspondence
(such as discharge letters) to extract the patient’s clinical information and translate this in to the
correct codes to record their complaint, diagnosis and treatment.
3
Accurate records are important because they are the primary source of information for all
healthcare professionals and may form the basis of a discharge summary to inform the patient’s
GP of the treatment provided in hospital. Accurate coding, consistent with national standards,
ensures that:
•
units are able to easily report activity based on the national casemix measures (the
classification recognised by commissioners and finance teams)
•
accurate information related to patient care is reported to commissioners
•
national reference cost returns (relating to renal) are as accurate as possible.
05
What information should be recorded?
06
4
Clinicians should record all information on a patient’s diagnoses, including any comorbidities (see
below), as accurately and completely as possible. To support the clinical coder, the clinician
should ensure the information they record:
•
is clear, detailed and as comprehensive as possible
•
accurately reflects the care the patient has received
•
avoids the use of abbreviations where possible
•
is legible and in pen, if hand-written (not pencil, as this fades).
5
Coders should take into account all the information available about a patient’s episode of care
and ensure they are coding accurately and in line with the latest classification version, rules and
national standards.
6
Any comorbidity (a condition in addition to the primary disease or disorder) that affects the
management of a patient and contributes to an accurate clinical picture of their current episode
of care must be recorded within the patient notes. Conditions that relate to an earlier episode but
do not have a bearing on the current episode should not be recorded.
7
The UK Renal Registry specifies a list of possible renal comorbidities that must be recorded and
this is included at Appendix 3.
Using this guide
8
This guide contains an introduction to clinical coding and its importance, gives detailed
examples of how renal activity should be recorded, and contains useful reference
materials and links to further sources.
9
This document has been written to support accurate clinical coding in renal services,
rather than as a precise guide. It does not replace the standards and guidance provided
by the NHS Classifications Service. The codes assigned by a clinical coder for an episode
of care will depend on the information within the individual patient clinical record,
classification version, rules and latest national standards which are available at:
10
The document mainly focuses on the recording and coding of inpatient activity.
However, there is a drive towards more detailed reporting of outpatient activity and an
example has been included to illustrate this (see Example 4.1). Coding of outpatient
activity is also referenced in Appendix 2.
11
Although this document is not focused specifically on the National Renal Dataset (NRD),
it recognises the importance and significance of this coding dataset in supporting the
implementation of the National Service Framework for Renal Services. It is hoped, as the
NRD develops, that future editions of this document will be developed to reflect this.
CHAPTER ONE
www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding
Additional sources of information are detailed in Appendix 4.
07
Recording and coding
of renal activity - examples
The coding used in the following examples (1.1 – 1.4) is ICD-10 (diagnosis code) and OPCS-4.6
(procedure code). The 2011/12 Local Payment Grouper has been used to generate the Healthcare
Resource Groups (known as HRGs, they are groups of clinically similar treatments that use similar levels
of resources).
The coding of renal activity can be complicated and involves the application of both specific and general
national standards, rules and guidance which have not been included in these examples to avoid
confusion.
The diagnoses and procedures in the tables are for the different elements of care over a period of time
and not strictly separated for each attendance/episode of care.
The sequencing of ICD-10 codes provided in these tables may change depending on the main condition
treated or investigated. It may also be possible that certain procedure codes would either be added in
addition or excluded depending if any other procedures were performed concurrently or during the
same episode of care or according to certain classification standards.
Haemodialysis and Peritoneal dialysis HRG are no longer generated from OPCS procedure codes. Whilst
it remains good coding practice to include these codes in the clinical coding of an episode, the dialysis
HRG are separately generated from data items in the National Renal Dataset (NRD).
08
Renal dialysis examples
Example 1.1: Haemodialysis
A 58 year old patient with known chronic renal disease (CKD) secondary to type 2 diabetes
progresses to end stage renal disease (ESRD) requiring dialysis. The patient wishes to have
haemodialysis (HD) as their first form of renal replacement therapy (RRT). An arteriovenous fistula has
already been created (this activity would have previously been recorded in patient notes) but the
fistula is not yet ready for use. Therefore a tunnelled line is inserted as a daycase and HD is started in
satellite unit. The patient then receives HD as an outpatient three times per week and, after four
weeks, they start using the fistula for access and the tunnelled line is removed.
Diagnosis
Recorded by clinician
in patient notes
Specific notes
on recording
ESRD due to type
2 diabetes
It is important to log
any comorbidities
Examples of ICD-10 (diagnosis) codes
assigned OPCS-4 (procedure) codes
assigned
N18.0 End-stage renal disease
E11.2D Non-insulin-dependent
diabetes mellitus with renal complications
CHAPTER TWO
Daycare admission for insertion of tunnelled line:
N08.3A Glomerular disorders in diabetes
mellitus (E10-E14D with common fourth
character .2)
Procedure/Clinical
Intervention
Tunnelled line insertion
L91.5 Insertion of tunnelled venous catheter
This clinical coded activity would generate the following HRG:
QZ13A - Vascular Access for Renal Replacement Therapy with CC
09
Initial dialysis session at satellite unit:
Recorded in notes and
renal system
Diagnosis
NRD data elements recorded. Those used to derive HRGs in bold
ESRD due to type 2 diabetes Cause kidney disease (Renal Care 10 – Type 2 diabetes – 81)
Co-morbidity codes at ESRD need completing (Renal Care codes 22 – 44)
Blood Tests
Relevant blood tests i.e.
indicate isolation required
Blood test HBV surface antigen (Renal Care 75 - NEG)
Blood test HCV antibody (Renal Care 77 - NEG)
Blood test HIV (Renal Care 79 - NEG)
Procedure/Clinical Haemodialysis via tunnelled Date referred for access (Dialysis 180 – date)
Intervention
CV line
Date of access creation (Dialysis 181 – date)
Type of dialysis access (Dialysis 182 – 02 Tunnelled line)
Site, side and anaesthetic used (Dialysis 183 – 185)
Start date of renal treatment modality (Renal Care 2 – date)
Date 1st ESRF treatment (Renal Care code 5 – date)
Access used first dialysis (Dialysis 2 – 02 Tunnelled line)
Renal treatment modality (Renal Care 1 - 05 Haemodialysis)
Treatment supervision code (Renal Care 6 – 03 Satellite unit)
Dialysis times per week (Dialysis 23 - 3)
Treatment centre code (Dialysis 1 – code)
For each session of dialysis the HRG generated would be:
LD05A Satellite Haemodialysis/Filtration with access via haemodialysis catheter 19 years
and over
Subsequent outpatient attendance for removal of tunnelled line:
Recorded by clinician
in patient notes
Procedure/Clinical
Intervention
Tunnelled line removal
Specific notes
on recording
Examples of ICD-10 (diagnosis) codes
assigned OPCS-4 (procedure) codes
assigned
L91.4 Removal of central venous catheter
This clinical coded activity would generate the HRG:
QZ13B - Vascular Access for Renal Replacement Therapy without CC
Note, as no diagnosis codes are recorded in outpatients no CC
10
Subsequent dialysis session at satellite unit:
Recorded in notes and
renal system
Diagnosis
NRD data elements recorded. Those used to derive HRGs in bold
ESRD due to type 2 diabetes Cause kidney disease (Renal Care 10 – Type 2 diabetes – 81)
Co-morbidity codes at ESRD need completing (Renal Care 22 – 44)
Blood Tests
Relevant blood tests i.e.
indicate isolation required
Blood test HBV surface antigen (Renal Care 75 - NEG)
Blood test HCV antibody (Renal Care 77 - NEG)
Blood test HIV (Renal Care 79 - NEG)
Start date of renal treatment modality (Renal Care 2 – date)
Date 1st ESRF treatment (Renal Care code 5 – date)
Access used first dialysis (Dialysis 2 – 02 Tunnelled line)
Renal treatment modality (Renal Care 1 - 05 Haemodialysis)
Treatment supervision code (Renal Care 6 – 03 Satellite unit)
Dialysis times per week (Dialysis 23 - 3)
Treatment centre code (Dialysis 1 – code)
CHAPTER TWO
Procedure/Clinical Haemodialysis via AV fistula Date referred for access (Dialysis 180 – date)
Intervention
Date of access creation (Dialysis 181 – date)
Type of dialysis access (Dialysis 182 – 03 Arteriovenous fistula
(AVF))
Site, side and anaesthetic used (Dialysis 183 – 185)
For each session of dialysis the HRG generated would be:
LD06A Satellite Haemodialysis/Filtration with access via arteriovenous fistula or graft 19
years and over
11
Example 1.2: Peritoneal Dialysis
A 49 year old patient with hypertension and chronic renal failure CKD due to type 2 diabetes
progresses to end stage renal disease (ESRD). Patient now requires dialysis. In view of biochemistry,
peritoneal dialysis (PD) planned. PD catheter inserted as a daycase. PD started and patient trained to
do own exchanges (APD). Machine and fluids delivered to patient’s home.
Daycase admission for insertion of PD catheter
Recorded by clinicians Specific notes
in patient notes
on recording
Diagnosis
Hypertension and ESRD
due to type 2 diabetes.
It is important to log
any comorbidities
Examples of ICD-10 (diagnosis) codes
assigned and OPCS-4 (procedure) codes
assigned
I12.0 Hypertensive renal disease with renal
failure
E11.2D Non-insulin-dependent diabetes
mellitus with renal complications
N08.3A Glomerular disorders in diabetes
mellitus (E10-E14D with common fourth
character .2)
Procedure/Clinical
Intervention
Insertion of ambulatory
PD catheter, started on
PD
X41.1 Insertion of ambulatory peritoneI
dialysis catheter
X40.5 Automated peritoneal dialysis
This coded clinical activity would generate the HRG:
LA05A - Renal Replacement Peritoneal Dialysis Associated Procedure with CC
12
For each day of PD:
Recorded in notes and
renal system
Diagnosis
NRD data elements recorded. Those used to derive HRGs in bold
ESRD due to type 2 diabetes Cause kidney disease (Renal Care 10 – Type 2 diabetes – 81)
Co-morbidity codes at ESRD need completing (Renal Care 22 – 44)
Relevant blood tests i.e.
indicate isolation required
Procedure/Clinical APD at home
Intervention
Blood test HBV surface antigen (Renal Care 75 - NEG)
Blood test HCV antibody (Renal Care 77 - NEG)
Blood test HIV (Renal Care 79 - NEG)
Date referred for access (Dialysis 180 – date)
Date of access creation (Dialysis 181 – date)
Type of dialysis access (Dialysis 182 – 06 PD catheter)
Site, side and anaesthetic used (Dialysis 183 – 185)
Start date of renal treatment modality (Renal Care 2 – date)
Date 1st ESRF treatment (Renal Care code 5 – date)
Access used first dialysis (Dialysis 2 – 06 PD catheter)
Renal treatment modality (Renal Care 1 - 04 CCPD (6/7
nights/wk))
Treatment supervision code (Renal Care 6 – 01 Home)
Dialysis times per week (Dialysis 23 - 7)
Treatment centre code (Dialysis 1 – code)
CHAPTER TWO
Blood Tests
For each day of dialysis the HRG generated would be:
LD12A Automated Peritoneal Dialysis 19 years and over
13
Example 1.3: Haemodialysis
A 53 year old patient known to renal service for one month with small kidneys requires urgent
haemodialysis as in-patient due to poor biochemistry. The cause of CKD is unknown. A temporary
(non-tunnelled) vascular catheter is inserted on the ward by the renal physicians and haemodialysis is
started. Two dialysis sessions are required as an inpatient. The temporary vascular catheter is
changed to a tunnelled line on the ward by the renal physicians and the patient is discharged home
to continue HD three times per week in main HD unit.
Inpatient admission for emergency dialysis:
Recorded by clinicians Specific notes
in patient notes
on recording
Diagnosis
ESRD with Bilateral Small
Kidney
Examples of ICD-10 (diagnosis) codes
assigned and OPCS-4 (procedure) codes
assigned
N18.0 End-stage renal disease
N27.1 Small kidney, bilateral
Procedure/Clinical
Intervention
Temporary non-tunnelled
CV line insertion
L91.2 insertion of central venous catheter NEC
Y70.5 Temporary operations
Haemodialysis
X40.3 Haemodialysis NEC
Note: X40.3 must be assigned twice here. A code from
category X40.- Compensation for renal failure must be
assigned every time dialysis is carried out
Replacement of
temporary with
tunnelled line
L91.5 Insertion of tunnelled venous catheter
This coded clinical activity would generate the following HRG:
LA08C Chronic Kidney Disease with length of stay 2 days or more without CC
14
For each session of dialysis while an inpatient:
Recorded in notes and
renal system
NRD data elements recorded. Those used to derive HRGs in bold
Diagnosis
ESRD unknown cause
Cause kidney disease (Renal Care 10 – unknown)
Blood Tests
Relevant blood tests i.e.
indicate isolation required
Blood test HBV surface antigen (Renal Care 75 - NEG)
Blood test HCV antibody (Renal Care 77 - NEG)
Blood test HIV (Renal Care 79 - NEG)
Date referred for access (Dialysis 180 – date)
Date of access creation (Dialysis 181 – date)
Type of dialysis access (Dialysis 182 – 01 Non-tunnelled line)
Site, side and anaesthetic used (Dialysis 183 – 185)
Start date of renal treatment modality (Renal Care 2 – date)
Date 1st ESRF treatment (Renal Care code 5 – date)
Access used first dialysis (Dialysis 2 – 01 Non-tunnelled line)
Renal treatment modality (Renal Care 1 - 05 Haemodialysis)
Treatment supervision code (Renal Care 6 – 02 Hospital)
Dialysis times per week (Dialysis 23 - 3)
Treatment centre code (Dialysis 1 – code)
CHAPTER TWO
Procedure/Clinical Haemodialysis via
Intervention
temporary non-tunnelled
CV line
For each session of dialysis the HRG generated would be:
LD01A Hospital Haemodialysis/Filtration with access via heamodialysis catheter 19 years
and over
15
For each subsequent session of dialysis:
Recorded in notes and
renal system
NRD data elements recorded. Those used to derive HRGs in bold
Diagnosis
ESRD unkown cause
Cause kidney disease (Renal Care 10 – unknown)
Blood Tests
Relevant blood tests i.e.
indicate isolation required
Blood test HBV surface antigen (Renal Care 75 - NEG)
Blood test HCV antibody (Renal Care 77 - NEG)
Blood test HIV (Renal Care 79 - NEG)
Procedure/Clinical Haemodialysis via tunnelled Date referred for access (Dialysis 180 – date)
Intervention
CV line
Date of access creation (Dialysis 181 – date)
Type of dialysis access (Dialysis 182 – 02 Tunnelled line)
Site, side and anaesthetic used (Dialysis 183 – 185)
Start date of renal treatment modality (Renal Care 2 – date)
Date 1st ESRF treatment (Renal Care 5 – date)
Access used first dialysis (Dialysis 2 – 02 Tunnelled line)
Renal treatment modality (Renal Care 1 - 05 Haemodialysis)
Treatment supervision code (Renal Care 6 – 02 Hospital)
Dialysis times per week (Dialysis 23 - 3)
Treatment centre code (Dialysis 1 – code)
For each session of dialysis the HRG generated would be:
LD01A Hospital Haemodialysis/Filtration with access via haemodialysis catheter 19 years
and over
16
Example 1.4: Haemodialysis
A 35 year old patient with ESRD due to a chronic glomerulonephritis (IgA nephropathy) and who is
Hepatitis B positive, is already on haemodialysis via brachial fistula. It is noted that the fistula is
clotted when in haemodialysis unit and the patient is admitted for fistula declotting in radiology.
This was unsuccessful. Tunnelled line was therefore inserted and the patient was discharged home to
continue HD in satellite unit (i.e. no change in dialysis site or schedule although access changed).
Diagnosis
Recorded by clinicians Specific notes
in patient notes
on recording
Examples of ICD-10 (diagnosis) and
OPCS-4 (procedure) codes assigned
ESRD due to chronic
glomerulonephritis
(IgA nephropathy) Hep B positive
N18.0 End-stage renal disease
N03.9 Chronic nephritic syndrome, unspecified
N02.8 Recurrent and persistent haematuria, other
B16.9 Acute hepatitis B without delta-agent
and without hepatic coma
Note: ICD-10 code Z22.5 Carrier of viral hepatitis would
instead be recorded if the patient is a carrier.
Procedure/clinical
intervention
Patient already on HD
via fistula which is
clotted
Z99.2 Dependence on renal dialysis
Unsuccessful fistula
declotting in radiology
Note: The declotting was unsuccessful, therefore OPCS-4 codes
for the intended procedure would not be assigned. The procedure
would be coded up to the stage reached at the time of
abandonment of the operation or procedure; the intention must
not be coded.
If the declotting had been successful, information regarding how
the fistula was declotted would define the OPCS-4 code.
If done under image control a code from category Y53.Approach to organ under image control would also be assigned
in a secondary position
Insertion of tunnelled
line instead
L91.5 Insertion of tunnelled venous catheter
CHAPTER TWO
Daycase admission for AV fistula declotting:
T82.8 Other complications of cardiac and vascular
prosthetic devices, implants and grafts
This coded clinical activity would generate the following HRG:
QZ13A - Vascular Access for Renal Replacement Therapy with CC
17
Initial dialysis session at satellite unit:
Diagnosis
Recorded in notes and
renal system
NRD data elements recorded. Those used to derive HRGs in bold
ESRD due to
glomerulonephritis (IgA
Cause kidney disease (Renal Care 10 – Glomerulonephritis)
Co-morbidity codes at ESRD need completing (Renal Care codes 22 – 44)
Hep B positive
Blood test HBV surface antigen (Renal Care 75 - POS)
Blood test HCV antibody (Renal Care 77 - NEG)
Blood test HIV (Renal Care 79 - NEG)
nephropathy),
Blood Tests
Procedure/Clinical Haemodialysis via tunnelled Date referred for access (Dialysis 180 – date)
Intervention
CV line
Date of access creation (Dialysis 181 – date)
Type of dialysis access (Dialysis 182 – 02 Tunnelled line)
Site, side and anaesthetic used (Dialysis 183 – 185)
Start date of renal treatment modality (Renal Care 2 – date)
Date 1st ESRF treatment (Renal Care 5 – date)
Access used first dialysis (Dialysis 2 – 03 Arteriovenous Fistula)
Renal treatment modality (Renal Care 1 - 05 Haemodialysis)
Treatment supervision code (Renal Care 6 – 03 Satellite unit)
Dialysis times per week (Dialysis 23 - 3)
Treatment centre code (Dialysis 1 – code)
For each session of dialysis the HRG generated would be:
LD07A Satellite Haemodialysis/Filtration with access via haemodialysis catheter with
blood borne virus 19 years and over
18
Acute kidney injury
Example 2.1: Acute kidney injury
A 69 year old patient presents to a district general hospital with acute kidney injury. Investigations reveal
likely cause is glomerular. Patient is then transferred to a specialist renal unit at a neighbouring trust, as
an inpatient, for investigation. A renal biopsy is performed (percutaneous needle biopsy of lesion of
kidney), which reveals crescentic glomerulonephritis. immunology tests show anti GBM disease. The
patient is started on haemodialysis via femoral vascular catheter initially and then internal jugular
vascular catheter. Daily plasma exchange is started. Ten sessions of plasma exchanges are given. The
patient develops pulmonary haemorrhage and requires three days on HDU/ITU for CPAP (continuous
positive airways pressure) but is not intubated or ventilated. Respiratory status improves and patient
returns to renal ward. There is no evidence of recovery of kidney function. A tunnelled line is inserted.
Patient is discharged after 16 day admission. Patient continues HD three times per week in main unit.
Diagnosis
Recorded by clinicians Specific notes
in patient notes
on recording
Acute kidney injury
(acute renal failure)
likely glomerular
Procedure/Clinical Investigations
Intervention
Examples of ICD-10 (diagnosis) codes
assigned OPCS-4 (procedure) codes assigned
N17.9 Acute renal failure, unspecified
N05.9 Unspecified nephritic syndrome,
unspecified
N/A
CHAPTER TWO
Emergency inpatient admission at a District General Hospital:
This coded clinical activity would generate the HRG:
LA07C - Acute Kidney Injury without CC
19
Inpatient admission at specialist renal centre:
Diagnosis
Recorded by clinicians Specific notes
in patient notes
on recording
Examples of ICD-10 (diagnosis) codes
assigned OPCS-4 (procedure) codes assigned
Acute kidney injury
(acute renal failure) due
to crescentic
glomerulonephritis
N17.9 Acute renal failure, unspecified
Note: Includes acute crescentic glomerulonephritis
Anti GBM disease
(Goodpastures
syndrome)
M31.0D Hypersensitivity angiitis
N08.5A Glomerular disorders in systemic
connective tissue disorders.
N00.7 Diffuse concentric glomerulonephritis
Note: Includes goodpastures syndrome
Patient develops
pulmonary
haemorrhage
Procedure/Clinical Percutaneous kidney
Intervention
biopsy
Femoral vascatheter
Internal jugular
vascatheter
Haemodialysis
Plasma exchange
x 10 sessions
R04.8 Haemorrhage from other sites in
respiratory tract
The type of biopsy needs M13.1 Percutaneous needle biopsy of lesion
to be recorded e.g. open, of kidney
percutaneous, endoscopic
L91.2 Insertion of central venous catheter NEC
Z98.8 Specified vein of lower limb NEC
L91.2 Insertion of central venous catheter NEC
Z39.8 Specified vein NEC
ICU clinicians should add X40.3 Haemodialysis NEC
Note: A code from category X40.- Compensation for renal
details of treatments to
the critical care dataset in failure must be assigned every time dialysis is carried out.
the patient record
X32.4 Exchange of plasma (10-19)
Transferred to ICU for
CPAP
Note: OPCS-4 code assignment is dependent on the number
Insertion of tunnelled
line
E85.2 Non-invasive ventilation NEC
of sessions performed during the episode of care.
L91.5 Insertion of tunnelled venous catheter
This coded clinical activity would generate the HRG:
LB05B - Kidney Intermediate, Endoscopic and Percutaneous Interventions 19 years and
over with Intermediate CC
Each day on ICU/HDU would generate an unbundled critical care HRG:
XC05Z Adult Critical Care - 2 Organs Supported (kidneys and lungs)
Note: As the NRD is only for chronic kidney disease, patients with acute kidney injury
requiring dialysis do not generate any HRG specific to this dialysis as is the case for
patients with chronic kidney disease.
In this example, once the patient has been accepted as a chronic kidney disease patient
the activity would be recorded in the NRD.
20
For each subsequent session of dialysis:
Recorded in notes and
renal system
NRD data elements recorded. Those used to derive HRGs in bold
Diagnosis
ESRD due to crescentic
glomerulonephritis
Cause kidney disease (Renal Care 10 – Glomerulonephritis)
Co-morbidity codes at ESRD need completing (Renal Care codes 22 – 44)
Blood Tests
Relevant blood tests i.e.
indicate isolation required
Blood test HBV surface antigen (Renal Care 75 - NEG)
Blood test HCV antibody (Renal Care 77 - NEG)
Blood test HIV (Renal Care 79 - NEG)
Start date of renal treatment modality (Renal Care 2 – date)
Date 1st ESRF treatment (Renal Care 5 – date)
Access used first dialysis (Dialysis 2 – 02 Tunnelled line)
Renal treatment modality (Renal Care 1 - 05 Haemodialysis)
Treatment supervision code (Renal Care 6 – 02 Hospital)
Dialysis times per week (Dialysis 23 - 3)
Treatment centre code (Dialysis 1 – code)
CHAPTER TWO
Procedure/Clinical Haemodialysis via tunnelled Date referred for access (Dialysis 180 – date)
Intervention
CV line
Date of access creation (Dialysis 181 – date)
Type of dialysis access (Dialysis 182 – 02 Tunnelled line)
Site, side and anaesthetic used (Dialysis 183 – 185)
For each session of dialysis the HRG generated would be:
LD01A Hospital Haemodialysis/Filtration with access via heamodialysis catheter 19 years
and over
21
Example 2.2: Diverticulitis with a generalised peritonitis
A 48 year old patient presents to A&E with an acute abdomen injury – this is shown to be due to
diverticulitis with a generalised peritonitis. The patient is admitted to a surgical ward. A laparotomy
is performed at which a colectomy and a defunctioning colostomy are performed. Following this,
the patient is on ITU for five days and develops an acute kidney injury requiring renal support due to
acute renal failure. A tunnelled line is inserted. The patient has three days of haemofiltration and is
then transferred to the renal ward for continued intermittent haemodialysis. Ten sessions of
haemodialysis are given. The patient is an inpatient for a further ten days and becomes dialysis
independent two days before discharge. Discharged home for follow up by surgeons and in renal
outpatients. Patient does not require continued dialysis.
Emergency inpatient admission:
Diagnosis
Recorded by clinician Specific notes
in patient notes
on recording
by clinical coder
Examples of ICD-10 (diagnosis) and
OPCS-4 (procedure) codes assigned
Acute abdomen due to
Diverticulitis with a
generalised peritonitis.
K57.8 Diverticular disease of intestine, part
unspecified, with perforation or abscess
Develops acute kidney
injury (acute renal failure)
N17.9 Acute renal failure, unspecified
Procedure/clinical Colectomy and a
ICU clinicians should add H11.5 Colectomy and exteriorisation of bowel NEC
intervention
defunctioning colostomy details of treatments to
the critical care dataset in H15.1 Loop colostomy
the patient record
Transferred to ICU for
post-surgical recovery
Any treatment provided by L91.5 Insertion of tunnelled venous catheter
renal clinicians during stay
in ICU would be logged
in patient record
This clinical coded activity would generate the HRG:
FZ08A - Complex Large Intestine Procedures with Major CC
Each day on ICU/HDU would generate an unbundled critical care HRG:
XC06Z Adult Critical Care - 1 Organ Supported (kidneys)
Note: As the NRD is only for chronic kidney disease patients with acute kidney injury
requiring dialysis do not generate any HRG specific to this dialysis as is the case for
patients with chronic kidney disease.
22
Example 2.3: thrombotic thrombocytopenic purpura (TTP)
A 50 year old patients presents to haematology with a thrombotic thrombocytopenic purpura (TTP).
Kidney function is normal but the patient requires daily plasma exchange for 10 days. This is
performed on the renal ward although the patient remains an inpatient under haematology. After
10 days there is an improvement in platelet count and patient discharged home for haematological
follow up.
Diagnosis
Recorded by clinicians Specific notes
in patient notes
on recording
Examples of ICD-10 (diagnosis) codes
assigned OPCS-4 (procedure) codes assigned
Thrombotic
thrombocytopenic
purpura (TTP)
M31.1 Thrombotic microangiopathy
Procedure/Clinical Kidney function tests
Intervention
Plasma exchange
X 10 sessions
All tests requested should X32.4 Exchange of plasma (10-19)
be recorded even though Note: OPCS-4 code assignment is dependent on the number
they may not be clinically of sessions performed during the episode of care.
coded
This clinical coded activity would generate HRG:
SA15Z - Plasma Exchanges 10 to 19
CHAPTER TWO
Inpatient admission for plasma exchanges:
Even though renal unit facility is used as no dialysis has taken place no information
would be recorded in the NRD
23
Nephrology examples
Example 3.1: Nephrotic syndrome
A 26 year old patient with nephrotic syndrome with significant localised oedema. Patient is admitted
for fluid management and a renal biopsy (percutaneous needle biopsy). The renal biopsy confirms
membranous nephropathy. The patient requires 3 days on diuretics and ACEi and warfarin after
which they are discharged.
Inpatient admission for fluid management:
Diagnosis
Recorded by clinicians Specific notes
in patient notes
on recording
Examples of ICD-10 (diagnosis) codes
assigned OPCS-4 (procedure) codes assigned
Nephrotic syndrome with
significant oedema
N04.8 Nephrotic syndrome, other
R60.0 Localised oedema
Procedure/Clinical Fluid management and The type of biopsy needs M13.1 Percutaneous needle biopsy of kidney
Intervention
percutaneous needle
to be recorded e.g. open,
biopsy of kidney
percutaneous, endoscopic Y53.9 Approach to organ under image control
Note: A code from category Y53.- is assigned in a secondary
position, if image control has been used; if the method of
image control is unspecified, Y53.9 is assigned
This clinical coded activity would generate the HRG:
LB05A - Kidney Intermediate, Endoscopic and Percutaneous Interventions 19 years and
over with Major CC
Example 3.2: Brachial PTFE graft insertion
A 44 year old patient with known chronic kidney disease (not end stage), is admitted for a brachial
PTFE graft insertion. The post operative period is complicated by significant arm swelling and wound
infection and the patient’s diabetes becomes poorly controlled. The patient remains an inpatient for
five days but is not dialysed and is discharged home for continued follow up in the Pre dialysis / Low
clearance clinic.
Inpatient admission:
Diagnosis
Recorded by clinicians Specific notes
in patient notes
on recording
Examples of ICD-10 (diagnosis) codes
assigned OPCS-4 (procedure) codes assigned
CKD
N03.9 Chronic nephritic syndrome, unspecified
Post-op significant arm
swelling and wound
infection
T81.4 Infection following a procedure, not
elsewhere classified
R22.3 Localized swelling, mass and lump,
upper limb
Note: If the swelling was due to the wound infection R22.3
would not be coded.
Procedure/Clinical Brachial PTFE graft
Intervention
insertion
L74.1 Insertion of arteriorvenous prosthesis
Z36.4 Brachial artery
This clinical coded activity would generate the HRG:
LA09F General Renal Disorders with length of stay two days or more with
Intermediate CC
24
Kidney Transplantation examples
Example 4.1: Pre and post kidney transplantation care at non transplanting centre, transplant
at specialist transplant centre
A 30 year old patient with ESRD due to type I diabetes with retinopathy and previous BK (below knee)
amputation for PVD (peripheral vascular disease). Patient is already on automated peritoneal dialysis and
now has a live donor transplant workup as an outpatient within a non transplanting renal unit and four
sessions of plasma exchange due to ABO incompatibility. The patient is transferred to a transplanting
centre for live donor kidney transplant from wife. The transplant is successful and the patient is discharged
home after six days. Regular outpatient follow-ups at originating renal unit (non transplanting).
Outpatient attendance for pre-transplantation work-up:
Procedure/Clinical Transplant work-up
Intervention
Examples of ICD-10 (diagnosis) codes
assigned OPCS-4 (procedure) codes
assigned
It needs to be flagged that M17.2 Pre-transplantation of kidney
the workup has been carried work-up - recipient
so that the coder can pick
this activity up
This clinical coded activity would generate the HRG:
LA12A Kidney pre-transplantation work-up of recipient 19 years and over
CHAPTER TWO
Recorded by clinicians Specific notes on
in patient notes
recording
For each of the four daycase admissions for plasma exchange:
Diagnosis
Recorded by clinicians Specific notes on
in patient notes
recording
Examples of ICD-10 (diagnosis) codes
assigned OPCS-4 (procedure) codes
assigned
ESRF due to type I
diabetes with retinopathy
N18.0
End-stage renal disease
E10.2D Insulin-dependent diabetes mellitus
with renal complications
N08.3A Glomerular disorders in diabetes
mellitus
E10.3D Insulin-dependent diabetes mellitus
with ophthalmic complications
H36.0A Diabetic retinopathy
Z99.2 Dependence on renal dialysis
Procedure/Clinical Plasma exchange
Intervention
X32.2 exchanges of plasma (single)
This clinical coded activity would generate the HRG:
SA13Z Single Plasma Exchange, Leucophoresis or Red Cell Exchange
25
Inpatient admission at specialist centre for kidney transplant:
Diagnosis
Recorded by clinicians Specific notes on
in patient notes
recording
Examples of ICD-10 (diagnosis) codes
assigned OPCS-4 (procedure) codes
assigned
ESRF due to type I
diabetes with retinopathy
N18.0
End-stage renal disease
E10.2D Insulin-dependent diabetes mellitus
with renal complications
N08.3A Glomerular disorders in diabetes
mellitus
E10.3D Insulin-dependent diabetes mellitus
with ophthalmic complications
H36.0A Diabetic retinopathy
Z99.2 Dependence on renal dialysis
Procedure/Clinical Kidney transplant from
Intervention
live donor
M01.2 Allotrasplantation of kidney from live
donor
This clinical coded activity would generate the HRG:
LA03A Kidney Transplant 19 years and over from Live donor
Outpatient attendance for post-transplantation follow-up:
Recorded by clinicians Specific notes on
in patient notes
recording
Procedure/Clinical Post- transplant
Intervention
Examples of ICD-10 (diagnosis) codes
assigned OPCS-4 (procedure) codes
assigned
It needs to be flagged that M17.4 Post-transplantation of kidney
the post-transplant
examination - recipient
follow-ups have been
carried out so that the coder
can pick this activity up.
Each post-transplant visit
should be recorded and
coded separately
This clinical coded activity would generate the HRG:
LA13A examination for post-transplantation of Kidney of recipient 19 years and over
Note: The donor would generate own outpatient attendances and inpatient admission which
would be coded and generate HRGs accordingly e.g. LA11Z Kidney pre-transplantation
work-up of live donor, LB46Z Live Donation of Kidney and LA14Z Examination for
post-transplantation of Kidney of live donor
26
Recording and coding activity within
paediatric renal units
Introduction
Many of the examples shown on pages 8 to 26 (specifically related to adults) are also applicable to
children. The presentations and complications of renal disease such as anaemia, renal osteodystrophy
and hypertension are similar and many of the operative procedures are the same.
However the co-morbidities in children are very different. Cardiovascular disease, cerebro-vascular
disease and even diabetes are rare, but other co-morbidities are common. Examples of paediatric
specific co-morbidities are shown below. Some specific examples of recording and coding in paediatric
renal units are shown on pages 28 to 33.
Congenital abnormalities
For example a child may have congenital heart disease and develop acute renal failure as part of that.
Many children have renal disease as part of a syndrome e.g. Jeune’s syndrome, mitochondrial
cytopathies, VATER syndrome, ARC syndrome etc.
Adverse peri-natal factors
For example prematurity, fetal distress and other adverse peri-natal factors may cause both
neurological problems and renal problems. Therefore cerebral palsy, hypoxic ischaemic encephalopathy
neuro-developmental delay and renal failure are commonly co-existent.
Those who have had renal failure in utero have lungs that do not develop normally and so may have
broncho-pulmonary dysplasia.
CHAPTER THREE
Paediatric renal co-morbidities
Failure to thrive/growth failure
A fundamental difference between adults and children is that children are growing. Renal failure
interferes with that normal growth. Children with renal disease often have failure to thrive, growth
failure, feeding difficulties, nasograstric and gastrostomy feeding and gastro-oesophageal reflux
require nasogastric and gastrostomy feeding.
Associated urological problems
Children with renal disease much more commonly have underlying urological abnormalities than their
adult counterparts and posterior urethral valves, nephrectomy, mitrofanoff, neuropathic bladder. Self
intermittent catheterisation urodynamics are all common.
Childhood illness
Children with renal disease are more than usually prone to common intercurrent infections and are
often more seriously ill with them, for example bronchiolitis , gastroenteritis and chickenpox can be life
threatening in children.
27
Recording and coding activity within
paediatric renal units - some specific
examples
The coding used in the following examples (1 - 3) is ICD-10 (diagnosis code) and OPCS-4.6 (procedure
code). The 2011/12 Local Payment Grouper has been used to generate the HRGs.
The coding of renal activity can be complicated and involves the application of both specific and
general national standards, rules and guidance which have not been included in these examples to
avoid confusion.
The diagnoses and procedures in the tables are for the different elements of care over a period of time
and not strictly separated for each attendance/episode of care.
The sequencing of ICD-10 codes provided in these tables may change depending on the main
condition treated or investigated. It may also be possible that certain procedure codes would either be
added or excluded depending if any other procedures were performed concurrently or during the
same episode of care or according to certain classification standards.
In example 1, the relevant National Renal Dataset (NRD) coding is also shown where dialysis has taken
place (as NRD coding for dialysis is now a national requirement in order to generate appropriate
dialysis HRGs – from 1st April 2011). It should be noted however that the paediatric dialysis HRGs are
not yet within the scope of PbR so locally agreed pricing continues to apply in this area.
Example 1: Chronic renal failure and dialysis in an infant
Baby born at 2.5 kg and 35 weeks gestation with anternatal hydronephrosis, oligohydramnios and
suspected urinary tract obstruction. Postnatally required ventilation for bronchopulmonary dysplasia for
48 hours. MCUG confirmed posterior urethral valves and bilateral reflux. Despite valve resection,
urinary output was poor and renal function deteriorated to chronic renal failure so a peritoneal dialysis
catheter was inserted at five days. Required acute 24 hour dialysis for several weeks before able to
tolerate volumes required for overnight cycling dialysis via a cycling machine. Vomiting on nasogastric
feeding. Ph studies revealed severe gastro-oesophageal reflux and so gastrostomy and fundoplication
performed. Temporary vascular catheter (non tunnelled) inserted and interim haemodialysis (three
sessions) delivered whilst abdomen healed.
28
1.1 Inpatient admission from birth:
Diagnosis
Recorded by clinicians Specific notes
in patient notes
on recording
Examples of ICD-10 (diagnosis) codes
assigned OPCS-4 (procedure) codes assigned
Prematurity (2.5kg at
35 weeks)
P07.3 Other preterm infants
Z38.0 singleton, born in hospital
Bronchopulmonary
dysplasia
P27.1 Bronchopulmonary dysplasia originating in
the perinatal period
Posterior urethral valves
and bilateral congenital
vesico-ureteric reflux
Q64.3 Other atresia and stenosis of urethra and
bladder neck
Q62.7 Congenital vesico-uretero-renal reflux
Renal dysplasia with
chronic renal failure
Q61.4 Renal dysplasia
Gastro- oesophageal
reflux
Procedure/Clinical Intermittent positive
Intervention
pressure ventilation
Endoscopic destruction Neonatologists should add
of urethral valves
details of treatments to
the neonatal critical care
Insertion of PD catheter dataset in the patient
and continuous cycling record
peritoneal dialsysis
Any treatment provided
Insertion of temporary by renal clinician or
gastrostomy
surgeons during stay in
neonatal critical care
Fundoplication using
should be logged in
abdominal approach
patient record
Insertion of temporary
non-tunnelled vascular
catheter
3 session of
haemodialysis
K21.9 Gastro-oesophageal reflux disease without
oesophagitis
E85.2 Non-invasive ventilation NEC
Note: Includes intermittent positive pressure ventilation
M76.5 Endoscopic destruction of urethral
valves
CHAPTER THREE
N18.9 Chronic renal failure, unspecified
X42.1 Insertion of temporary peritoneal dialysis
catheter
X40.2 Peritoneal dialysis
Note: A code from category X40 - Compensation for renal
failure must be assigned every time dialysis is carried out
G34.2 Creation of temporary gastrostomy
G24.3 Antireflux fundoplication using abdominal
approach
L91.2 Insertion of central venous catheter NEC
Y70.5 Temporary operations
X40.3 Haemodialysis NEC
Note: X40.3 must be assigned 3 times here. A code from
category X40 - Compensation for renal failure must be
assigned every time dialysis is carried out
This coded clinical activity would generate the HRG:
FZ05C Major Stomach or Duodenum Procedures 1 year and under
Each day on NICU/HDU/SCBU would generate an unbundled critical care HRG:
XA01Z Neonatal Critical Care Intensive Care
29
1.2 for each session of peritoneal dialysis: recording of relevant renal dataset codes is now
required (from 1.4.11), to generate the correct dialysis HRG. It should be noted however that the
paediatric dialysis HRGs are not yet within the scope of PbR so locally agreed pricing continues to
apply in this area:
Recorded in notes and
renal system
NRD data elements recorded. Those used to derive HRGs in bold
Diagnosis
ESRD with renal dysplasia
Cause kidney disease (Renal Care 10 – renal Dysplasia)
Comorbidity codes at ESRD need completing (Renal Care 22 - 44)
Blood Tests
Relevant blood tests i.e.
indicate isolation required
Blood test HBV surface antigen (Renal Care 75 - NEG)
Blood test HCV antibody (Renal Care 77 - NEG)
Blood test HIV (Renal Care 79 - NEG)
Procedure/Clinical Haemodialysis via
Intervention
temporary non-tunnelled
CV line
Date referred for access (Dialysis 180 – date)
Date of access creation (Dialysis 181 – date)
Type of dialysis access (Dialysis 182 – 07 PD catheter temp)
Site, side and anaesthetic used (Dialysis 183 – 185)
Start date of renal treatment modality (Renal Care 2 – date)
Date 1st ESRF treatment (Renal Care code 5 – date)
Access used first dialysis (Dialysis 2 – 07 PD catheter temp)
Renal treatment modality (Renal Care 1 - 03 CCPD (6/7 nights/wk))
Treatment supervision code (Renal Care 6 – 02 Hospital)
Dialysis times per week (Dialysis 23 - 3)
Treatment centre code (Dialysis 1 – code)
For each session of dialysis the HRG generated would be:
LD12B automated Peritoneal Dialysis 18 years and under
30
Recorded in notes and
renal system
NRD data elements recorded. Those used to derive HRGs in bold
Diagnosis
ESRD with renal dysplasia
Cause kidney disease (Renal Care 10 – Renal dysplasia)
Comorbidity codes at ESRD need completing (Renal Care 22 - 44)
Blood Tests
Relevant blood tests i.e.
indicate isolation required
Blood test HBV surface antigen (Renal Care 75 - NEG)
Blood test HCV antibody (Renal Care 77 - NEG)
Blood test HIV (Renal Care 79 - NEG)
Procedure/Clinical Hospital haemodialysis
Intervention
Date referr for access (Dialysis 180 – date)
Date of access creation (Dialysis 181 – date)
Type of dialysis access (Dialysis 182 – 01 Non-tunnelled line)
Site, side and anaesthetic used (Dialysis 183 – 185)
Start date of renal treatment modality (Renal Care 2 – date)
Date 1st ESRF treatment (Renal Care code 5 – date)
Access used first dialysis (Dialysis 2 – 07 PD catheter temp)
Renal treatment modality (Renal Care 1 - 05 Haemodialysis)
Treatment supervision code (Renal Care 6 – 02 Hospital)
Dialysis times per week (Dialysis 23 - 3)
Treatment centre code (Dialysis 1 – code)
CHAPTER THREE
1.3 For each session of haemodialysis: recording of relevant renal dataset codes is now required
(from 1.4.11), to generate the correct dialysis HRG. It should be noted however that the paediatric
dialysis HRGs are not yet within the scope of PbR so locally agreed pricing continues to apply in this
area:
For each session of dialysis the HRG generated would be:
LD01B Hospital Haemodialysis/Filtration with access via haemodialysis catheter 18 years
and under
31
Example 2: Acute renal failure
Six month old child with known Down’s syndrome was admitted with a chest infection requiring
oxygen via Vapotherm. Respiratory syncytial virus (RSV) confirmed. Noted to have low platelets, rising
creatinine, high LDH and low complement. Diagnosis of atypical haemolytic uremic syndrome made.
Non tunnelled vascular line inserted and started on daily plasma exchange. Genetic mutation studies
pending. Had a grand mal seizure and was severely hypertensive. MRI inconclusive about cerebral
involvement. Received 10 days plasma exchange before going into remission. Discharged and returns
three times weekly for plasma exchange.
Inpatient admission:
Diagnosis
Recorded by clinicians Specific notes
in patient notes
on recording
Examples of ICD-10 (diagnosis) codes
assigned OPCS-4 (procedure) codes assigned
Acute renal failure due
to atypical haemolytic
uraemic syndrome
N17.9 Acute renal failure, unspecified
D59.3 Haemolytic-uraemic syndrome
Q90.9 Down’s syndrome, unspecified
Down’s syndrome
J21.0 Acute bronchiolitis due to respiratory
syncytial virus
Grand mal seizure
G40.6 Grand mal seizures, unspecified (with or
without petit mal)
Hypertension with
hypertensive
encephalopathy
Procedure/Clinical Oxygen therapy
Intervention
32
I67.4 Hypertensive encephalopathy
I10.X Essential primary hypertension
Intensivists would add
details of treatments to
the paediatric critical care
dataset in the patient
record
Insertion of
non-tunnelled
vascatheter
Any treatment provided
by renal clinician during
stay in paediatric critical
care should be logged in
patient record
L91.2 Insertion of central venous catheter NEC
Plasma exchanges
X 10 sessions
Number of plasma
X32.4 exchange of plasma
exchange sessions during Note: OPCS-4 code assignment is dependent on the number
the episode needs to be of sessions performed during the episode of care
recorded
MRI scan
The location of the MRI
U21.1 Magentic resonance imaging NEC
scan needs to be specified Y98.1 Radiology of one body area
to provide a more specific (or <20 minutes)
OPCS-4.6 code
This coded clinical activity would generate the following HRGs:
SA15Z Plasma Exchanges 10 to 19
RA01Z Magnetic Resonance Imaging Scan, one area, no contrast
Each day on PICU or HDU would generate an unbundled critical care HRG:
XB05Z Paediatric Critical Care Intensive Care Basic
Note: The National Renal Dataset (NRD) only covers activity for patients with chronic kidney
disease. Therefore, as this patient has acute kidney injury, any dialysis undertaken would not
be recorded in the NRD and therefore no additional HRGs specific to the renal dialysis for
acute kidney injury are generated.
Diagnosis
Recorded by clinicians Specific notes
in patient notes
on recording
Examples of ICD-10 (diagnosis) codes
assigned OPCS-4 (procedure) codes assigned
Gastroenteritis
(rotovirus positive)
A08.0 Rotoviral enteritis
Athrogryposis
Q68.8 Other specified congenital
musculoskeletal deformities
Cholestasis
K83.1 Obstruction of the bile duct
Fanconi (-de Toni)
(- debre) syndrome
E72.0 Disorders of amino-acid transport
Note: Include Fanconi syndrome
Severe dehydration with
hypokalaemia and
acidosis
E86.X Volume depletion
E87.6 Acidosis
Rib fractures to two ribs
S22.40 Multiple fracture of ribs, closed
X59.9 Exposure to unspecified factor,
unspecified place
Gastrostomy in situ
Z93.1 Gastrostomy status
Procedure/Clinical IV bolus fluids
Intervention
CHAPTER THREE
Example 3: General nephrology
A baby with known arthrogryposis, cholestasis and renal syndrome (Fanconi (ARC) syndrome) was
admitted with gastroenteritis (Rotavirus positive). He was found to be severely dehydrated,
hypokalemic and acidotic, and required intravenous resuscitation. Although established back on
gastrostomy feeds and his usual electrolyte supplements, he remained unsettled with respiratory
difficulty and was found to have two rib fractures but no evidence of chest infection. He settled
with analgesia and discharged after 10 days.
Inpatient admission:
Intensivists should add
N/A
details of treatments to
the paediatric critical care
dataset in the patient
record
This coded clinical activity would generate the following HRG:
PA21A Infectious and Non-Infectious Gastroenteritis with CC
Each day on PICU or HDU would generate an unbundled critical care HRG:
XB06Z Paediatric Critical Care High Dependency Care Advanced
33
Appendix 1:
Guide to common renal terms/acronyms
AKD
AKI
Advanced kidney disease
Acute Kidney injury
APKD Adult polycystic kidney disease
APD
ARF
AVF
Assisted peritoneal dialysis
Acute renal failure
Arteriovenous fistula
CAPD
CKD
CRF
DM
DRIL
Continuous ambulatory peritoneal dialysis
Chronic kidney disease
Chronic renal failure
Diabetes Mellitus
Distal revascularisation – interval ligation
ERF
ESKD
ESRD
Established renal failure
End stage kidney disease
End stage renal disease
ESRF
FSGN
GN
HB
End stage renal failure
Focal and segmental glomerulonephritis
Glomerunephritis
Heart beating
Haemodiafiltration
Haemofiltration
HD
Haemodialysis
HHD
Home haemodialysis
Kidney transplant
34
See CKD below
Occurs when there is a rapid loss of renal function.
Formerly known as acute renal failure (ARF)
inherited kidney disease leading to cyst development and
deteriorating kidney function
As PD - machine assisted, often done at night
See AKI above
Surgical anastomosis between artery and vein, used
for haemodialysis
As PD - regular exchanges throughout the day
Loss of renal function over a period of months or years.
see CKD above
frequent comorbidity with renal disease
Alters the flow into or around a fistula to increase
flow to distal arm
see ESRD below
see ESRD below
ESRD refers to kidney function that has deteriorated
to a level where renal replacement therapy (RRT) treatment
is required to sustain life. ESRD is the main internationally
accepted term but is also synonymous with the terms end
stage renal failure (ESRF); end stage kidney disease (ESKD)
and established renal failure (ERF)
see ESRD above
glomerular renal disease
glomerular renal disease
status of deceased kidney donor
The combination of haemodialysis and haemofiltration
either simultaneously or sequentially
Renal replacement therapy similar to haemodialysis which is
used almost exclusively in the intensive care setting. Thus, it
is almost always used for acute renal failure. It is a slow
continuous therapy in which sessions usually last between
12 to 24 hours and are usually performed daily
treatment for patients with ESRD. A method for removing
waste products, as well as free water from the blood
Haemodialysis treatment that happens in people's own
homes. Home haemodialysis patients cease to be classed
as such if they need longer than two weeks of hospital
dialysis when not an in-patient
The organ transplant of a kidney into a patient with ESRD.
Kidney transplantation is typically classified as
deceased-donor (cadaveric) or living-donor transplantation
depending on the source of the donor organ.
Immunosuppressant drugs are used to suppress the
immune system from rejecting the donor kidney
Nephropathy
NHB
PKD
PD
Non heart beating
Polycystic kidney disease
Peritoneal dialysis
PE
Plasma exchange
PTFE
(artificial vein graft) Polytetrafluorethylene
RRT
Renal replacement therapy
Renal transplant
Satellite dialysis unit
TX
Transplant
status of kidney donor
glomerular renal disease
Concerns the diagnosis and treatment of kidney diseases
and other general diseases which have an effect on the
kidney
Degeneration of the kidney (damage or disease)
status of deceased kidney donor
as APKD
Treatment for patients with ESRD. A method by which
fluids and waste products are exchanged from the blood
across the peritoneal membrane lining the inside of the
abdomen
Removal of a volume of blood plasma in an extracorporeal
circuit
Artificial vein graft - made from various materials including
polytetrafluorethylene (PTFE) and bovine vein
term used to encompass life-supporting treatments for
ESRD. It includes • haemodialysis • peritoneal dialysis •
haemofiltration • transplantation
See kidney transplant
Linked to a main renal centre, not autonomous for medical
decisions, provide chronic outpatient maintenance
haemodialysis but with no acute or in-patient nephrology
beds on site
renal transplant (other organs may also be transplanted in
conjunction with the kidney)
APPENDIX 1
LR
Living related
MCGN Mesangiocapillary glomerulonephritis
Nephrology
35
Appendix 2: Renal services mapping common renal procedures to OPCS-4 codes
Renal category
sub category
procedure
OPCS-4 code(s)
OPCS-4 code description
(with notes added where applicable that are not OPCS-4 classification related)
Kidney transplant
Kidney insertion
Recipient work up (usually done in outpatients)
Renal transplant cadaveric heart beating donor (done as non elective only)
M17.2
M01.4
Renal transplant cadaveric non heart beating donor (done as non elective only)
M01.5
Renal transplant live donor (done as elective only)
M01.2
Recipient follow ups - up to 3 months post kidney transplant (outpatients)
other open operations on kidney
M17.4
M08.4 or
M01.1 or
M01.3 or
M01.8 or
M01.9
Pre-transplantation of kidney work-up - recipient
Allotransplantation of kidney from cadaver heart beating
note: this procedure is carried out as NON ELECTIVE only
Allotransplantation of kidney from cadaver heart non-beating
note: this procedure is carried out as NON ELECTIVE only
Allotransplantation of kidney from live donor
note: this procedure is carried out as ELECTIVE only
Post-transplantation of kidney examination - recipient
Exploration of transplanted kidney
Autotransplantation of kidney (note: very rare procedure)
Allotransplantation of kidney from cadaver NEC
Other specified transplantation of kidney
Unspecified transplantation of kidney
Kidney donor screening (usually done in outpatients)
M17.1
Live donor work up (usually done in outpatients)
M17.3
Live donor nephrectomy/donation of kidney – open
Live donor nephrectomy/donation of kidney – hand assisted laparoscopic procedure
X45.1
X45.1 plus
Y75.2 or
Y75.4
M02.6
M02.1 or
M02.2 or
M02.3 or
M02.4 or
M02.5 or
M02.8 or
M02.9 or
M03.- or
M04.2
M17.5
Live kidney donor screening
note: normally carried out in outpatients
Pre-transplantation of kidney work-up - live donor
note: normally carried out in outpatients
Donation of kidney NEC
Donation of kidney
Laparoscopic approach to abdominal cavity NEC
Hand assisted minimal access approach to abdominal cavity
Excision of rejected transplanted kidney
Nephrectomy and excision of perirenal tissue
Nephroureterectomy NEC
Bilateral nephrectomy
Excision of horseshoe kidney
Nephrectomy NEC
Other specified total excision of kidney
Unspecified total excision of kidney
Partial excision of kidney
Open excision of lesion of kidney NEC
Post-transplantation of kidney examination - live donor
M13.1 plus
Y53.M13.1 plus
Y53.-
Percutaneous needle biopsy of lesion of kidney
Approach to organ under image control
Percutaneous needle biopsy of lesion of kidney
Approach to organ under image control
kidney removal
Transplant nephrectomy
Other open excisions of Kidney (not for donation)
Live donor follow ups - up to 3 months post donation (outpatients)
percutaneous biopsy
percutaneous biopsy
needle biopsy of native kidney
needle biopsy of transplant kidney
36
APPENDIX 2
Note: The OPCS-4 codes provided below are correct according to the procedure description in the table. Where a number of possibilities exist because the procedure description is too broad and/or non-specific; codes have not been provided. Where codes have
been provided we recommend caution is exercised as other more appropriate codes may exist or additional subsidiary codes may be added depending on the actual procedure description recorded. Site codes have not been included.
The codes assigned by a clinical coder for an episode of care will depend on the information within the individual patient clinical record and/or the local renal database; the classification version, rules and latest national standards and guidance.
37
Appendix 2: Renal services mapping - common renal procedures to OPCS-4 codes
Renal category
sub category
procedure
OPCS-4 code(s)
OPCS-4 code description
(with notes added where applicable that are not OPCS-4 classification related)
Kidney transplant
Kidney insertion
Recipient work up (usually done in outpatients)
Renal transplant cadaveric heart beating donor (done as non elective only)
M17.2
M01.4
Renal transplant cadaveric non heart beating donor (done as non elective only)
M01.5
Renal transplant live donor (done as elective only)
M01.2
Recipient follow ups - up to 3 months post kidney transplant (outpatients)
other open operations on kidney
M17.4
M08.4 or
M01.1 or
M01.3 or
M01.8 or
M01.9
Pre-transplantation of kidney work-up - recipient
Allotransplantation of kidney from cadaver heart beating
note: this procedure is carried out as NON ELECTIVE only
Allotransplantation of kidney from cadaver heart non-beating
note: this procedure is carried out as NON ELECTIVE only
Allotransplantation of kidney from live donor
note: this procedure is carried out as ELECTIVE only
Post-transplantation of kidney examination - recipient
Exploration of transplanted kidney
Autotransplantation of kidney (note: very rare procedure)
Allotransplantation of kidney from cadaver NEC
Other specified transplantation of kidney
Unspecified transplantation of kidney
Kidney donor screening (usually done in outpatients)
M17.1
Live donor work up (usually done in outpatients)
M17.3
Live donor nephrectomy/donation of kidney – open
Live donor nephrectomy/donation of kidney – hand assisted laparoscopic procedure
X45.1
X45.1 plus
Y75.2 or
Y75.4
M02.6
M02.1 or
M02.2 or
M02.3 or
M02.4 or
M02.5 or
M02.8 or
M02.9 or
M03.- or
M04.2
M17.5
Live kidney donor screening
note: normally carried out in outpatients
Pre-transplantation of kidney work-up - live donor
note: normally carried out in outpatients
Donation of kidney NEC
Donation of kidney
Laparoscopic approach to abdominal cavity NEC
Hand assisted minimal access approach to abdominal cavity
Excision of rejected transplanted kidney
Nephrectomy and excision of perirenal tissue
Nephroureterectomy NEC
Bilateral nephrectomy
Excision of horseshoe kidney
Nephrectomy NEC
Other specified total excision of kidney
Unspecified total excision of kidney
Partial excision of kidney
Open excision of lesion of kidney NEC
Post-transplantation of kidney examination - live donor
M13.1 plus
Y53.M13.1 plus
Y53.-
Percutaneous needle biopsy of lesion of kidney
Approach to organ under image control
Percutaneous needle biopsy of lesion of kidney
Approach to organ under image control
kidney removal
Transplant nephrectomy
Other open excisions of Kidney (not for donation)
Live donor follow ups - up to 3 months post donation (outpatients)
percutaneous biopsy
percutaneous biopsy
needle biopsy of native kidney
needle biopsy of transplant kidney
36
APPENDIX 2
Note: The OPCS-4 codes provided below are correct according to the procedure description in the table. Where a number of possibilities exist because the procedure description is too broad and/or non-specific; codes have not been provided. Where codes have
been provided we recommend caution is exercised as other more appropriate codes may exist or additional subsidiary codes may be added depending on the actual procedure description recorded. Site codes have not been included.
The codes assigned by a clinical coder for an episode of care will depend on the information within the individual patient clinical record and/or the local renal database; the classification version, rules and latest national standards and guidance.
37
Appendix 3: UK Renal Registry List of
possible adult renal comorbidities
•
Amputation for peripheral vascular disease
•
Angina
•
Angioplasty, stenting, vascular graft (all non coronary)
•
Arterial hypertension
•
Cerebrovascular disease
•
Chronic obstructive pulmonary disease
•
Claudication
•
Diabetes mellitus (not causing ESRD)
•
Ischaemic / neuropathic ulcers
•
Liver disease
•
Malignancy
•
Smoking
•
Previous Coronary Artery Bypass Graft (CABG) or coronary angioplasty
•
Previous episode of heart failure
•
Previous Myocardial Infarction (MI) within last three months
•
Previous Myocardial Infarction (MI) longer than three months ago
Definitions for each of the above comorbidities can be found section B:5 of the 2009 Renal Registry
report at:
www.renalreg.com/Report-Area/Report%202009/Appen-B_Renal09_web.pdf
40
Appendix 4:
Additional sources of information
Development of new HRGs and Tariffs for renal dialysis
Department of Health PbR website contains information on the development of new HRGs and
tariffs for renal dialysis:
http://www.dh.gov.uk/en/Managingyourorganisation/NHSFinancialReforms/DH_105080
The Casemix Service, NHS Information Centre for Health and Social Care
NHS Information Centre for Health and Social Care
The Casemix Service designs and refines classifications that are used by the English NHS to describe
healthcare activity. These classifications underpin PbR from costing through to payment, and support
local commissioning and performance management.
http://www.ic.nhs.uk/services/the-casemix-service
The National Renal Dataset
http://www.ic.nhs.uk/services/datasets/dataset-list/renal
APPENDIX 3/4
Clinical coding standards and guidance
The NHS Classifications Service within Data Standards and Products Directorate, part of the
Technology Office, is the definitive source of clinical coding standards and guidance for clinical
classifications ICD-10 and OPCS-4.
http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/
UK Renal Registry
A resource for the development of patient care in renal disease.
http://www.renalreg.com/
41