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To code some diagnoses as part of [[ICD10 collection]], several lines of entries in the [[Patient viewer tab ICD10]] need to be grouped together.
To code some diagnoses as part of [[ICD10 collection]], several lines of entries in the [[Patient Viewer Tab ICD10]] need to be grouped together.


To group diagnoses together, use the same [[Dx Priority]] for all of them.  
To group diagnoses together, use the same [[Dx Priority]] for all of them.
 
Combined coding does not apply to [[CCI Collection]] (there is no priority), and there is nothing in the data that links a CCI code to the Dx it is related to.  


== Coding instructions ==
== Coding instructions ==
=== Introduction ===
=== Introduction ===
*There are numerous situations in which multiple codes need to be listed in order to accurately reflect what's going on medically.  
*There are numerous situations in which multiple codes need to be listed in order to accurately reflect what's going on medically.  
*For some situations it's just a matter of ensuring that the multiple codes are all in the diagnosis list.
*For some situations the multiple codes need to be '''''linked together''''' (we use the term "combined").  
*For other situations the multiple codes need to be '''''linked together''''' (we use the term "combined").  
*For other situations it's just a matter of ensuring that the multiple codes are all in the diagnosis list -- i.e. they don't need to be combined.
*For some entities there is no single ICD10 code, and the only way to code that entity is to combine two codes.  An example is that to identify Retroperitoneal hemorrhage one must link two codes '''[[Hemorrhage, NOS]]''' and '''[[Retroperitoneal area, diagnostic imaging, abnormal]]'''. So, alongside each of those is a message about this.
* There are some Dxs that can only be expressed as combinations, see [[#Some specific cases]]
 
=== Clinical Situation Plus its Cause ===
*Many ICD10 codes are for manifestations of disease, not a specific disorder ''per se''.   
*In their Wiki articles it will say something like "also code cause if known" e.g: '''[[Hematemesis]]'''
*If the cause is an infection, the Wiki article will instruct to "also code infection source", e.g:  '''[[Shock, septic]]'''
*In general, when you have a manifestation and a cause, the two codes should be combined.
** For example, in Septic Shock that has led to liver failure, the two should be coded with the same priority.
 
=== Situations in which linking is completely reasonable: ===
*link bugs with an infection,
*link trauma with its mechanism,
*link codes to “create” an entity for which no separate ICD10 code exists, such as retroperitoneal hemorrhage,
*to connect cause with effect(s), e.g. a trauma combined with all the separate fractured bones.


=== Malignancy with Metastasis ===
=== Q&A: Just How Far Should You Go in Linking Cause and Effect Diagnoses? ===
*Here, code BOTH the primary site and the location(s) of mets -- and these need to be combined because the codes for mets don't specify the primary site, only the site of the mets.
*If it is abundantly clear that A caused B that caused C and all of A, B, and C are all Admit or all Acquired, then combine them together.  '''If it is possible but not COMPLETELY clear that the items are causally linked, then do NOT combine them'''
*There are codes for mets to the following places: {{ListICD10Category | categoryName = Metastasis}}
*Example#1:  Stabbed --> lots of internal organ injuries from the stabbing --> big blood loss ---> hemorrhagic shock --> cardiac arrest.
*If the site of the mets isn't in the list, use '''[[Site NOS, metastatic malignancy to it (also code primary site)]]'''
*Example #2:  Chemotherapy --> N/V as an adverse effect --> dehydration --> orthostatic syncope.  But Chemo also caused drug-induced thrombocyotopenia as an adverse effect.  And Chemo also caused Skin rash as an adverse effect.  And all were present on admission (or all occurred after admission and so are Acquired diagnoses). In this case we have the Chemo causing problems in 3 separate pathways. Here again, we want you to combine all 6 codes together with the same priority number.
*If there are mets to multiple sites, then combine all together the primary malignancy code to the codes for the different sites of the mets.
    Rash
    /\
    |
    |
    Adverse effect of chemo ---> N/V --> dehydration --> syncope
    |
    |
    \/
    Drug-induced thrombocytopenia


=== Infections, Antibiotic Resistance ===
*What about when there's a diagnosis (A) which is a known risk factor for another diagnosis (B).  But in fact B is influenced by other things, not only A. In this case, do NOT combine A and B.
*There are some single infection codes that incorporate the organism in the name, e.g: '''[[Salmonella enteritis]]'''
**Example:  Diabetes is a risk factor for MI.  But so are hypertension, hyperlipidemia and genetic factors.  So here do NOT combine the MI with the diabetes (or the hypertension or hyperlipidemia) because it's not a direct arrow from diabetes to MI.  But of course, do code all of these diagnoses that are present (in the example that means code the diabetes and the MI, and hypertension if present, etc).
*But for most infections, they don't, e.g: '''[[Pneumonia, bacterial]]'''
Thanks for clarifying the diabetes issue. [[User:DPageNewton|DPageNewton]] 12:21, 2019 October 10 (CDT)
**In these cases it is '''''required''''' to combine with the infection code the code for the organism from the "buglist":  {{ListICD10Category | categoryName = Pathogens}}
*The buglist contains specific codes for a number of different bacteria, viruses, fungi/yeast, mycobacteria and miscellaneous types of organisms.
**If you don't see the specific organism in your case, then there are wastebasket codes: 
***[[Bacteria, NOS]]
***[[Virus, NOS]]
***[[Fungus or yeast, NOS]]
***[[Nontuberculous mycobacteria]]
***and finally when you don't have any idea even what type of bug it is:  [[Infectious disease NOS OR for buglist organism NOS]]


*NEXT, if the bug is resistant to antimicrobials, the infection/bug combination should be further combined with a code for antibiotic resistance -- thus in this situation there will be 3 or more codes all combined together (the infection, the bug, the antibiotic resistance(s)).
=== Primary Admit Diagnosis in Combined Codes  ===
{{ListICD10Category | categoryName = Antibiotic resistance}}
See [[Primary Admit Diagnosis]]


=== Trauma/injury with mechanism ===
=== Dxs that can only be expressed as combinations ===
*There are numerous codes for "mechanical" injuries to various body parts.
Some entities can only be coded with a combination of two codes. 
*What these have in common is that they are caused by an "external agent" -- such as being hit by a car, falling on your head, etc.
*For these codes, it is required that the injury be combined with the external mechanism of the injury:
{{ListICD10Category | categoryName = Mechanism}}


=== Fractures ===
'''Examples''':
see also [[Coding fractures in ICD10]]
* retroperitoneal hemorrhage; code combined
{{discussion}} not yet integrated...
** '''[[Hemorrhage, NOS]]'''
** '''[[Retroperitoneal area, diagnostic imaging, abnormal]]'''
* [[Hospital-acquired pneumonia (HAP) in ICD10]]


=== Other co-codes? ===
== Some specific cases ==
{{discussion}} Are there others? What are they?
{{ICD10 Guideline Combined dx metastasis primary}}
{{ICD10 Guideline Trauma w mechanism}}
{{ICD10 Guideline Infection}}
{{ICD10 Guideline Combined dx AB resistance}}
{{ICD10 Guideline Signs Symptoms Test Results not needed when cause known}}


== '''NOT YET FIGURED OUT''' ==
=== Other co-codes ===
=== General instruction when to code together ===
*In addition to the combined coding situations listed above, you can combine codes when it makes sense to you to do so.  The general guideline should be that codes be combined (instead of just both listed in the diagnosis list) when they are '''strongly''' related to each other. 
{{Discuss@task | When should two diagnoses be coded as a combined code (ie same priority) vs two tenuously related diagnoses simply both being coded, ie under separate priorities?}}
*Use your judgement.  Either listing them separately, or combined ensures that they're all there.


=== Primary Diagnosis within Combined Codes ===
== CCMDB Data Integrity Checks ==
{{Discuss@task | How to determine the [[Primary Admit Diagnosis]] in combined codes. Will that patient have more than one?}}
Some codes always need to be combined with one or more others.
 
Most infection codes require combined-coding of a pathogen (some have it implied, like [[Mumps]]), and some disorders can have a pathogen if their cause is infectious. See [[Bug required]] for details.


== Transition notes ==
== Transition notes ==
Yes, this different from how we used to use dx priorities where they had to be unique.  
Yes, this different from how we used to use dx priorities where they had to be unique.


== Data ==
== Data ==
The records are combined by same [[L_ICD10 table|L_ICD10]].[[Dx Priority]].
The records are combined by same [[L_ICD10 table|L_ICD10]].[[Dx Priority]].


[[Category: ICD10]]
== Related articles ==
[[Category: ICD10/CCI Conversion]]
{{Related Articles}}
 
[[Category:ICD10]]
[[Category:ICD10/CCI Conversion]]
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