Audit Case Discussions

A

• Abandoned procedures, conditions after admission (PDF 235KB)
• Abscess, dental, drainage of (PDF 86KB)
• Abscess, Peritonsillar, Drainage of (PDF 88KB)
• Acute stress (PDF 71KB)
• Admission for convalescence/aftercare, hospital in the home (HITH) transfer, post total knee replacement (PDF 187KB)
• Adverse drug reaction after same day chemotherapy admission (PDF 136KB)
• Adverse effects of radiotherapy (PDF 241KB)
• Aftercare surgical Z48.8 (PDF 136KB)

• Alcohol abuse and paranoid psychosis (PDF 78KB)
• Alcohol and cannabis abuse (PDF 134KB)
• Alcohol intoxication (PDF 236KB)
• Alcoholic (conditions described as alcoholic) (PDF 136KB)
• Alcoholic gastritis (PDF 66KB)
• Allergic reaction to food (PDF 92KB)
• Allergy, Wasp Sting (PDF 62KB)
• Amputation of finger with laceration of finger tendons (PDF 136KB)
• Anaemia coding from haemoglobin result documentation (PDF 92KB)

• Anaemia due to CKD (PDF 108KB)
• Anal ulcer, with scar (cicatrix) due to Bowen Disease (PDF 243KB)
• Aneurysm, intracerebral, internal carotid (PDF 141KB)
• Anxiety/Depression in a puerperal episode (PDF 93KB)
• APO in Fluid Overload (PDF 83KB)
• Ascites, malignant (PDF 116KB)
• Ascites with ovarian cancer (PDF 97KB)
• Atrial myxoma (PDF 192KB)

B

• Back pain, with hypertrophy, breast (PDF 86KB)
• Biopsy of malignant lesion, no definite evidence of malignancy on histology (PDF 116KB)
• Birth weight (PDF 134KB)
• Brachytherapy, prostate (PDF 68KB)
• Breast, hypertrophy of, with back pain (PDF 86KB)

C

• Caesarean, booked elective, presenting in labour (PDF 146KB)
• Caesarean, emergency vs elective (PDF 92KB)
• Calculus, Urinary, Infected (PDF 83KB)
• Cancelled elective procedure (PDF 197KB)
• Cancer as principal diagnosis in same day endoscopy (PDF 273KB)
• Cancer colon in day case that stayed overnight (PDF 78KB)
• Carcinomatosis peritonei (PDF 116KB)
• Causal link, endoscopy (PDF 241KB)
• Cataract, with diabetes, sequencing (PDF 86KB)
• Cellulitis due to steroid injection (PDF 178KB)

• Cerebral Palsy, sequencing issues (PDF 96KB)
• Charcot's joint disease and peripheral sensory neuropathy (PDF 134KB)
• Chemical pharyngitis (PDF 288KB)
• Chemotherapy (same day) coding (PDF 108KB)
• Chemotherapy coding (PDF 123KB)
• Chemotherapy review 2016 (PDF 250KB)
• Chest Pain with Increased Troponin (PDF 62KB)
• Complication (hypotension) arising during booked chemotherapy day case (PDF 262KB)

• Constipation, Cause of, Urine Retention (PDF 332KB)
• Contaminant in blood culture (PDF 146KB)
• Cord compression due to neoplasm (PDF 116KB)
• Crush Injury, Foot (PDF 332KB)
• CVA, ischaemic, with facial palsy and dysphasia (PDF 134KB)
• CVA with diabetes (PDF 71KB)
• Cyst, epidermoid, not of skin (PDF 96KB)

D

• Debridement of Amputation Stump with Ulcer (PDF 37KB)
• Debridement of plantar wound (PDF 197KB)
• Deep wound repair (PDF 241KB)
• Deflexed occipitoposterior position(POP), a brow presentation (PDF 132KB)
• Delirium due to treatment with Fentanyl and Tegretol (PDF 81KB)
• Diabetes (type 2) with CKD - 'use additional code' note at E11.22 (PDF 99KB)
• Diabetes, eradicated conditions - 7th edition (PDF 99KB)
• Diabetes, with cataract, sequencing (PDF 86KB)

• Diabetes, sequencing changes, 7th - 8th edition (PDF 86KB)
• Diabetic foot ulcer (PDF 375KB)
• Diabetic foot (PDF 121KB)
• Diabetic foot with osteomyelitis (PDF 141KB)
• Diabetic Toe (PDF 332KB)
• Dialysis Audit Findings - Summary (PDF 83KB)
• Dialysis review 2016 (PDF 250KB)
• Dialysis, Same Day, Extended to Multi-day (PDF 302KB)
• Dialysis, Same Day, With Other Day Procedure (PDF 302KB)
• Dialysis, with stay of less than 2 days (PDF 235KB)

• Drainage, abscess, dental (PDF 86KB)
• Drainage, abscess, pelvic, by laparotomy (PDF 192KB)
• Drainage, Peritonsillar Abscess (PDF 88KB)
• Drainage, pyothorax (PDF 192KB)
• Drainage, Quinsy (PDF 88KB)
• DRG 801 (PDF 88KB)
• DRG 801 part 2 (PDF 86KB)
• DVT of leg, index pathway (PDF 134KB)

E

• Endoscopy, causal link (PDF 241KB)
• Endometritis post incomplete miscarriage (PDF 178KB)
• Enteral feeds (PDF 134KB)
• Epidermoid cyst, not of skin (PDF 96KB)
• Error DRG due to data-entry error (PDF 112KB)
• ESRF with APO and Fluid Overload (PDF 83KB)
• Excision, cyst, bone, parietal (PDF 96KB)
• Excision, muscle, extraocular (PDF 96KB)
• Excision skin lesions with soft tissue involvement (PDF 93KB)

• Excision skin lesions with removal of bone (PDF 104KB)
• Eye injury with endophthalmitis (PDF 121KB)

F

• Failure, Transplant, Kidney (PDF 302KB)
• Fall, admitted for, no injury (PDF 262KB)
• Fall with fracture of humeral epicondyle (PDF 78KB)
• Febrile Neutropenia Following Chemotherapy (PDF 62KB)
• Femoral- Femoral Crossover Graft, Infected (PDF 37KB)
• Fistula Joint, Postprocedural (PDF 83KB)
• Follow-up of colon polyp (adenocarcinoma in-situ) (PDF 66KB)
• Food allergy (PDF 92KB)
• Foot, diabetic (PDF 121KB)

• Foreign body removal - superficial vs deep (PDF 104KB)
• Fracture, epicondyle humeral with fall (PDF 78KB)
• Fracture, vertebral, due to neoplasm (PDF 116KB)
• Fractured ribs versus chest infection (PDF 87KB)
• Freeing of bowel ends vs division of adhesions (PDF 92KB)

G

• Gastric polyp not seen on biopsy (PDF 241KB)
• Gastroenteritis due to salmonella typhi-murium (PDF 134KB)
• GI bleed causing multiple organ failure (PDF 134KB)
• Group A streptococcal infection (PDF 136KB)

H

• Harmful use of alternative medicines causing haemochromatosis (PDF 235KB)
• Harmful use or use disorder (overuse) of laxatives (PDF 194KB)
• High residuals, bladder, postprocedural (PDF 141KB)
• Histiocytoma, malignant fibrous (PDF 99KB)
• Histopathology result failing to confirm documented diagnosis or procedure (PDF 236KB)
• Hydronephrosis with Calculus, with Infection (PDF 83KB)
• Hypercalcaemia due to paraneoplastic syndrome (PDF 185KB)

I

• Infant in MVA (PDF 87KB)
• Infected cat bite (PDF 250KB)
• Infected Femoral-Femoral Crossover Graft (PDF 37KB)
• Infertility and augmentation mammoplasty, mismatched body systems (PDF 176KB)
• Injuries, artery and nerve, sequencing of (PDF 116KB)
• Injuries, multiple - finger dislocation, open wound, nerve damage (PDF 93KB)
• Injuries, multiple - rib fractures with injury to internal organs (colon and spleen) (PDF 93KB)

• Injuries, multiple, sequencing, principal diagnosis (PDF 86KB)
• Injuries, multiple, sequencing of (PDF 96KB)
• Injuries whilst pregnant (PDF 87KB)
• Intracranial haemorrhage due to high INR (PDF 375KB)
• Intramuscular chemotherapy (PDF 250KB)
• Interhospital transfer post surgery (PDF 136KB)
• Intoxication (PDF 62KB)

L

• Lacerations to head without closed head injury (PDF 250KB)
• Lacunar infarct with diabetes (PDF 71KB)
• Lesion, Vulval (PDF 62KB)
• Loss of consciousness resulting in injury (PDF 194KB)
• Lower respiratory tract infection vs pneumonia (PDF 262KB)
• Lung Disease in a Child (PDF 62KB)

M

• Malposition, affecting labour and delivery (PDF 116KB)
• Manifestations of an overdose (PDF 228KB)
• Metastatic cancer, sequencing principal diagnosis - bone metastases and vertebral fracture with cord compression (PDF 116KB)
• Metastatic cancer, sequencing principal diagnosis - disseminated bronchogenic cancer (PDF 99KB)
• Metastatic melanoma (PDF 68KB)
• Mucous extravasation cyst (PDF 288KB)
• Multiple coding in secondary hyperparathyroidism of renal origin (PDF 243KB)
• Multiple injuries, sequencing of (PDF 96KB)

• Multiple injuries - finger dislocation, open wound, nerve damage (PDF 93KB)
• Multiple injuries - rib fractures with injury to internal organs (colon and spleen) (PDF 93KB)
• Multiple injuries, sequencing, principal diagnosis (PDF 86KB)
• Multiple procedures on the same day, the principal diagnosis (PDF 176KB)
• Myectomy, for paralytic strabismus (PDF 96KB)
• Myxoma, atrial, benign, connective tissue neoplasm (PDF 192KB)

N

• Narrow pelvic inlet (PDF 92KB)
• Neoplasm, clinically diagnosed, documentation lesion vs tumour vs growth (PDF 273KB)
• Neuro-obs without head injury documented (PDF 250KB)
• Neurological observations but only superficial facial injury documented (PDF 66KB)
• Newborn coding (PDF 123KB)

O

• Operating Room Procedure Unrelated to Principal Diagnosis (PDF 88KB)
• Operating Room Procedure Unrelated to Principal Diagnosis - DRG 801 (PDF 192KB)
• Operating Room Procedures Unrelated to Principal Diagnosis part 2 (PDF 86KB)
• Osseo-integration procedure with no documented diagnosis (PDF 104KB)
• Osteitis pubis secondary to radiotherapy (PDF 241KB)
• Osteomyelitis with diabetic foot (PDF 141KB)
• Ovarian cancer with severe ascites (PDF 97KB)

P

• Pain and swelling following assault, no documentation of injury (PDF 121KB)
• Palsy, Cerebral, sequencing issues (PDF 96KB)
• Palsy, facial, with dysphasia in ischaemic stroke (PDF 134KB)
• Paralytic ectropion due to postop facial weakness (PDF 288KB)
• Paranoid psychosis and alcohol abuse (PDF 78KB)
• Pelvic abscess, drained in theatre under laparotomy (PDF 192KB)
• Peritoneal Catheter, Removal of (PDF 37KB)
• Peritonitis cacinomatosis (PDF 116KB)
• Peritonitis due to infected peritoneal dialysis catheter, incorrect procedure code (PDF 176KB)
• Peritonitis due to or associated with peritoneal dialysis (PDF 81KB)
• Plantar fibromatosis excision (PDF 93KB)
• Polyp, gastric, not seen on biopsy (PDF 241KB)
• Post-acute care for stoma education and allied health rehab (PDF 375KB)
• Post-op delirium with Alzheimer's (PDF 178KB)

• Post-partum complications following caesarean twin delivery (PDF 197KB)
• Postprocedural high (bladder) residuals (PDF 141KB)
• Postprocedural Joint Fistula (PDF 83KB)
• Postural Hypotension, Query (PDF 332KB)
• Pre-eclampsia with Type 2 diabetes/hypertension (PDF 93KB)
• Pregnancy induced hypertension(PIH) or intended delivery episode (PDF 132KB)
• Premature rupture of membranes (PROM) (PDF 92KB)
• Principal Diagnosis, multiple injuries, sequencing (PDF 86KB)
• Principal Diagnosis, sequencing, multiple injuries (PDF 96KB)
• Principal Diagnosis, sequencing, presenting problem/underlying cause (PDF 96KB)
• Principal diagnosis selection, in post-operative transfer for pelvic infammatory disease (PDF 187KB)
• Principal diagnosis selection - GI bleed vs cut wrists (suicide attempt) (PDF 134KB)
• Principal diagnosis selection - alcohol intoxication vs closed head injury (PDF 136KB)

• Principal diagnosis selection - carcinoma colon vs bowel obstruction (PDF 97KB)
• Principal diagnosis selection - pyelonephritis vs sepsis (PDF 81KB)
• Principal diagnosis selection - two conditions equally meeting critera (ingrown toenail and claw toe) (PDF 93KB)
• Principal Diagnosis Sequencing - Two or More Conditions Equally Meeting Principal Diagnosis Definition (PDF 88KB)
• Prolonged premature rupture of membranes (PDF 236KB)
• Prophylactic salpingo-opherectomy to prevent progression of breast cancer (PDF 104KB)
• Psychiatric condition in the puerperal period (PDF 93KB)
• Psychosis due to drug and alcohol abuse (PDF 116KB)
• Pulmonary oedema (PDF 185KB)
• Pus in joint cavity (PDF 104KB)
• Pyonephrosis with Calculus (PDF 83KB)
• Pyothorax without fistula, drainage (PDF 192KB)

Q

• Query Postural Hypotension (PDF 332KB)
• Quinsy, Drainage of (PDF 88KB)

R

• Radiotherapy causing osteitis pubis (PDF 241KB)
• Raised intra-ocular pressure (PDF 121KB)
• Rejection, Transplant, Kidney (PDF 302KB)
• Repair of chin laceration (PDF 241KB)
• Repair of deep wound (PDF 241KB)
• Removal of Peritoneal Catheter (PDF 37KB)
• Rhabdomyosarcoma, alveolar, originating in the pelvis (PDF 68KB)

S

• Salmonella typhi-murium (PDF 134KB)
• SCC skin of scalp with direct intracranial invasion (PDF 97KB)
• Scope performed for symptoms and follow up (PDF 71KB)
• Screening, variceal, in liver cirrhosis patient (PDF 146KB)
• Seizure due to alcohol withdrawal, with delirium (PDF 93KB)
• Selective Internal Radiation Therapy (SIRT) (PDF 273KB)
• Sepsis due to aspiration pneumonia (PDF 375KB)
• Septic shock secondary to bacterial meningitis (PDF 108KB)
• Sequencing, multiple injuries (PDF 96KB)

• Situational crisis (PDF 185KB)
• Situational crisis with intoxication (PDF 375KB)
• Skin lesion due to amyloidosis, principal diagnosis sequencing (PDF 176KB)
• Skin metastasis from parotid primary neoplasm (PDF 273KB)
• Squint, paralytic, myectomy for (PDF 96KB)
• Summary, Audit Findings, Dialysis (PDF 83KB)
• Surgical aftercare (PDF 136KB)
• Suspected conditions, chest infection in an asthmatic (PDF 187KB)
• Suspected conditions, "? febrile neurtopenia" (PDF 243KB)

• Suspected snake bite (PDF 93KB)
• Suspected sepsis, symptomatic premature newborn (PDF 228KB)
• Stress, acute (PDF 71KB)
• Stoke, ischaemic, with facial palsy and dysphasia (PDF 134KB)
• Swelling and pain following assault, no documentation of injury (PDF 121KB)
• Symptoms coding when condition unknown (PDF 194KB)
• Syncope resulting in injury (PDF 194KB)

T

• Tattooing of malignant polyp, booked colonoscopy for (PDF 262KB)
• Thrombosis, intracranial/cerebral venous (PDF 236KB)
• Transluminal balloon angioplasty with no stated diagnosis (PDF 93KB)
• Tubulovillous neoplasm (PDF 116KB)
• Two or More Conditions Equally Meeting Principal Diagnosis Definition (PDF 88KB)

U

• Ulcer, diabetic foot, with abscess (PDF 121KB)
• Ulcer, diabetic foot, with cellulitis (PDF 121KB)
• Urine Retention due to Constipation (PDF 332KB)
• Urosepsis with septic shock (PDF 228KB)
• Use disorder (overuse) of alternative medicines causing haemochromatosis (PDF 235KB)
• Use disorder or harmful use (overuse) of laxatives (PDF 194KB)

V

• Vulval haematoma and trial of void (TOV) (PDF 132KB)
• Vulval Lesion (PDF 62KB)

W

• Wasp Sting Allergy (PDF 62KB)
• Wound flare and excoriation, operative wound (PDF 92KB)

Z

• Z codes for personal history (PDF 92KB)