Episode of care—additional diagnosis, code (ICD-10-AM 11th edn) ANN{.N[N]}

Identifying and definitional attributes

Metadata item type:Data Element
Short name:Additional diagnosis
METeOR identifier:699606
Registration status:Health, Standard 12/12/2018
Tasmanian Health, Endorsed 08/04/2019
Definition:

A condition or complaint either coexisting with the principal diagnosis or arising during the episode of admitted patient care, episode of residential care or attendance at a health-care establishment, as represented by a code.

Data Element Concept:Episode of care—additional diagnosis

Value domain attributes

Representational attributes

Classification scheme:International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification 11th edition
Representation class:Code
Data type:String
Format:ANN{.N[N]}
Maximum character length:6

Data element attributes

Collection and usage attributes

Guide for use:

Record each additional diagnosis relevant to the episode of care in accordance with the International statistical classification of diseases and related health problems, 10th revision, Australian modification (ICD-10-AM) Australian Coding Standards. Generally, external cause, place of occurrence and activity codes will be included in the string of additional diagnosis codes. In some data collections these codes may also be copied into specific fields.

The diagnosis can include a disease, condition, injury, poisoning, sign, symptom, abnormal finding, complaint, or other factor influencing health status.

Additional diagnoses give information on the conditions that are significant in terms of treatment required, investigations needed and resources used during the episode of care. They are used for casemix analyses relating to severity of illness and for correct classification of patients into Australian Refined Diagnosis Related Groups (AR-DRGs).

Collection methods:

An additional diagnosis should be recorded and coded where appropriate upon separation of an episode of admitted patient care or the end of an episode of residential care or attendance at a health-care establishment. The additional diagnosis is derived from and must be substantiated by clinical documentation.

Comments:

Additional diagnoses should be interpreted as conditions that significantly affect patient management in terms of requiring any of the following:

  • commencement, alteration or adjustment of therapeutic treatment
  • diagnostic procedures
  • increased clinical care

In accordance with the Australian Coding Standards, a condition may be documented by the treating clinician/team due to its 'clinical significance', however some conditions are not normally coded as additional diagnoses in certain circumstances.

Additional diagnoses are significant for the allocation of AR-DRGs. The allocation of a patient to major problem or complication and co-morbidity Diagnosis Related Groups is made on the basis of the presence of certain specified additional diagnoses. Additional diagnoses should be recorded when relevant to the patient's episode of care and not restricted by the number of fields on the morbidity form or computer screen.

External cause codes, although not diagnosis of condition codes, should be sequenced together with the additional diagnosis codes so that meaning is given to the data for use in injury surveillance and other monitoring activities.

Source and reference attributes

Origin:

Independent Hospital Pricing Authority

Australian Consortium for Classification Development

Relational attributes

Related metadata references:

Is used in the formation of Episode of admitted patient care—diagnosis related group, code (AR-DRG v 10.0) ANNA Tasmanian Health, Endorsed 19/06/2020

Supersedes Episode of care—additional diagnosis, code (ICD-10-AM 10th edn) ANN{.N[N]} Health, Superseded 12/12/2018, Tasmanian Health, Archived 08/04/2019, ACT Health, Final 09/08/2018

Has been superseded by Episode of care—additional diagnosis, code (ICD-10-AM 12th edn) ANN{.N[N]} Health, Standardisation pending 20/09/2021

See also Episode of care—principal diagnosis, code (ICD-10-AM 11th edn) ANN{.N[N]} Health, Standard 12/12/2018, Tasmanian Health, Endorsed 08/04/2019

Implementation in Data Set Specifications:
All attributes +

Activity based funding: Mental health care NBEDS 2019-20 Health, Superseded 17/01/2020

DSS specific attributes +

Activity based funding: Mental health care NBEDS 2020–21 Health, Superseded 23/12/2020

DSS specific attributes +

Activity based funding: Mental health care NBEDS 2021–22 Health, Standard 23/12/2020

DSS specific attributes +

Admitted patient care clinical related data elements (TDLU) cluster Tasmanian Health, Endorsed 18/05/2021

Admitted patient care NMDS 2019-20 Health, Superseded 18/12/2019

DSS specific attributes +

Admitted patient care NMDS 2020–21 Health, Superseded 05/02/2021

DSS specific attributes +

Admitted patient care NMDS 2021–22 Health, Standard 05/02/2021

DSS specific attributes +

Allied health admitted patient care NBPDS Health, Standard 12/12/2018

Residential mental health care NMDS 2019–20 Health, Superseded 16/01/2020

DSS specific attributes +

Residential mental health care NMDS 2020–21 Health, Superseded 20/01/2021

DSS specific attributes +

Residential mental health care NMDS 2021–22 Health, Standard 20/01/2021

DSS specific attributes +

Tasmanian Admitted Patient Data Set - 2019 Tasmanian Health, Archived 17/06/2020

DSS specific attributes +

Tasmanian Admitted Patient Data Set - 2020 Tasmanian Health, Endorsed 10/07/2020

DSS specific attributes +
Implementation in Indicators:Used as numerator
National Healthcare Agreement: PB f–By 2014–15, improve the provision of primary care and reduce the proportion of potentially preventable hospital admissions by 7.6 per cent over the 2006-07 baseline to 8.5 per cent of total hospital admissions, 2022 Health, Standard 24/09/2021
National Healthcare Agreement: PI 18–Selected potentially preventable hospitalisations, 2022 Health, Standard 24/09/2021
National Healthcare Agreement: PI 27–Number of hospital patient days used by those eligible and waiting for residential aged care, 2022 Health, Standard 24/09/2021