December 8, 2011 Coding Syndromes
The following guidance is intended to provide a basic standard approach which should ensure that, wherever possible, sites are enabled to correctly code syndromes without outside reference.
A syndrome is a group of signs and symptoms that collectively characterise or indicate a particular disease or abnormal condition. The names given to syndromes may be based on pathological, biochemical or genetic criteria and are also given to honour the discoverer. In ICD-10 many syndromes and their overriding manifestations, such as short stature, are listed in Volume II the Alphabetical index and the coder is directed to a specific code or set of codes. Syndromes may be found under the general heading of ‘Syndrome’ or under their syndrome name, or both. However, the lack of consistent naming of syndromes internationally inhibits a totally comprehensive list. In many cases a code will not completely describe the abnormal condition and a combination of codes is required.
- If, after the syndrome has been clinically diagnosed, the admission is for treatment of one or more manifestations of that syndrome, the manifestation(s) in question should be coded, with the appropriate code for the syndrome itself entered last.
- With regard to ‘the appropriate code for the syndrome’, the first stage in coding a syndrome itself is to check whether it is specifically indexed in the appropriate volume of ICD-10. If it is, the relevant code should be assigned. If the syndrome is not specifically indexed, further information should be sought as to whether the syndrome is ‘congenital’ or ‘acquired’. If congenital, it should be noted that not all congenital anomalies are of chromosomal origin. Therefore, in these cases, efforts should be made to determine whether or not it is. If it is ‘acquired’, efforts should be made to determine which body system it affects.
All of this information will enable the syndrome to be coded, at the very least, to the correct chapter ‘catch all’ category and, ideally, to a more specific code still within that chapter. Wherever the above instruction states that further information should be sought, it is recommended that, ideally, this is sought from the relevant clinician first. This is standard best practise in coding but is most particularly necessary in the area of syndromes because there is a significant lack of consistent naming of syndromes, both nationally and internationally. This not only prohibits production of a comprehensive list by WHO, but also demands availability of more precise information than the syndrome name often provides if these conditions are to be accurately and consistently indexed in ICD-10.
It should be noted that if there is no indication of any presenting or treated manifestations, then only a code for the syndrome itself can be assigned. In most cases there will be presenting manifestations, but unless these are detailed in the patients medical record, the coder is unable to assign ICD-10 codes for them.
Update history
12/2011: The syndromes guidance published in 12/1993 and 02/1995 have been combined as the principles detailed are the same in both. Guidance regarding specific syndromes referred to ICD-9 codes, these have been removed as ICD-10 is the current diagnostic classification in use.
02/1995: The update includes further examples of how syndromes are coded to support the principles outlined in12/1993 for the coding of syndromes.
Coding Clinic, NHS Classifications Service
www.connectingforhealth.nhs.uk/codingclinic
Tags: syndromes
CODES.AND.STUFF 
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