Refno:Q2644 Publishedon: 15-Jun-2013 Status:Current

RefNo:Q2644| PublishedOn: 15-Jun-2013| Status:Current

Anaemiasecondaryto angiodysplasiaof thecolon

What codesshould beused if a patientis admittedfor anaemiasecondaryto angiodysplasiaof thecolon?

Clinicaladviceconfirmsthatthediagnosticstatement'anaemiasecondaryto angiodysplasiaof thecolon'indicatesa causal link,thatis, thereis bleedingfromthesite of theangiodysplasiaresultingin theanaemia.Codes should be assignedas follows:

Anaemia- D50.0Iron deficiencyanaemia secondaryto blood loss (chronic)orD62Posthaemorrhagicanaemiaas appropriate,followingan index pathwaysuch as:

Anaemia/dueto/haemorrhage(chronic) Anaemia/secondaryto/bloodloss (chronic) Haemorrhage,haemorrhagic/anaemia(chronic)

Angiodysplasia- K55.22Angiodysplasiaof colon withhaemorrhagefollowingtheindex pathway: Angiodysplasia/withhaemorrhage.

Can angiodysplasiaof thecolonwithouthaemorrhagestillresultin anaemia?

Angiodysplasiawillonly causeanaemiawhen it bleeds.

Does thehaemorrhagefromtheangiodysplasiahaveto bean overthaemorrhage,orcan it beveryslow and slightas mightbeexpectedfroma vascularlesion?

The blood loss maybeof varyingdegrees,froma low grade,chronicbleed,whichmaybeindicatedby a positivefaecalocculttestormelaena,throughto an acute,profoundbleedwhichis life threatening.

Does thehaemorrhagehaveto bepresentin theepisodein orderto code theangiodysplasiaas 'withhaemorrhage'?

Bleedingfromangiodysplasiais usuallyintermittentand thereforemaynot beapparentin theadmission,however whereindicatedby theclinicaldocumentation,eg.'angiodyplasiaof colonwithhaemorrhage'or'anaemiasecondaryto angiodysplasiaof thecolon',theconditionshould beconsideredas being'due to'/'with'haemorrhage.

(Coding Q&A,June 2013)

RefNo:Q2680| PublishedOn: 15-Jun-2013| Status:Current

Sedationand ventilation

Shoulda sedationcode beassignedwhen sedationis administeredfor initiationof ventilation?

Sedationthatis administeredto achieveanaesthesiafor initiationof intubation/ventilationshould becodedas perACS

0031Anaesthesia/2.Sedation.

Shoulda sedationcode beassignedwhen ongoingsedationis administeredwithventilation?

Ongoingsedationis administeredwithmanyproceduresfor patient͛s comfort,controlof anxietyand pain reliefand should not becoded.

Bibliography:

Hogarth,DKand Hall, J(2004),Managementof sedationin mechanicallyventilatedpatients,accessed:23/4/2013,available: conference.org/data/upload/consensus/1/pdf/737.pdf.

Brush,DR and Kress,JP(2009),Sedationand analgesia for themechanicallyventilatedpatient,Clinics in Chest Medicine,Vol. 30,No. 1,pp.ϭϯϭʹϭϰϭ͘

(Coding Q&A,June 2013)

RefNo:Q2730| PublishedOn: 15-Jun-2013| Status:Current

Fluidoverload,ESKD(end-stagekidneydisease)and pulmonaryoedema

What should beassignedas theprincipaldiagnosisfor fluid overloadwithend-stagekidneydisease (ESKD) with/withoutpulmonary oedema?

Fluid overloadresultsfromdiseases wherethereis compromisedregulationof sodiumand watersuch as renal failure,congestive heartfailure(CHF) and liverfailure.Fluid overloadin a patientwithESKD maycausecardiopulmonarycomplicationssuch as pulmonaryoedema(PO) and CHF. Patientsmaypresentwitha combinationof multiplecardiacand/or liverdiseases and/or non- compliancewithtreatmentwhichmaycontributeto fluid overload.

The selectionof principaldiagnosis(PDx) for a patientadmittedwithfluid overloaddependson what otherconditionsare documentedand thecircumstancesof theadmission.Coders should beguidedby ACS 0001Principaldiagnosis/Problemsand underlyingconditionsand ACS 0002Additionaldiagnoses/Problemsand underlyingconditions.

Each caseshould bereviewedbased on documentationand codersshould seekclarificationfromtheclinicianwherethereis uncertaintyregardingtheprincipal diagnosis.

References:

Galanes,S and Gulanick,M(2012),Fluid Volume Excess - Hypervolemia;Fluid Overload,Elsevier,accessed:20March2013,available:

Ronco,C,Rossa Costanzo, M,Bellomo,Rand Maisel,AS (2010),Fluid Overload:Diagnosis and Management,S.KargerAG,Basel (Switzerland).

(Coding Q&A,June 2013)

RefNo:Q2719| PublishedOn: 15-Jun-2013| Status:Current

Managementof tracheostomy

Could theNCCC clarifyin what circumstancesit is appropriateto assign thefollowingACHIcode:

90179-06[568]Managementof tracheostomy?

Tracheostomymanagementincludescaresuch as suctioningand cleaning.Assign90179-06[568]Managementof tracheostomy wheremanagementof thetracheostomyalone is providedduringan episodeof care.

Do not assign this code:

wherethetracheostomyis initiatedduringtheepisodeof care(seeblock[536]Tracheostomy)
whereassociatedventilatorysupportis beingprovided(seeblock[569]Ventilatorysupport)
for replacementorremovalof tracheostomytubes(seeblock[568]Airwaymanagement)
for revisionof tracheostomy(41881-02[541]Revisionof tracheostomy)
for closureof tracheostomy(41879-02[539]Closureof externalfistulaof trachea).

Could theNCCC clarifyin what circumstancesit is appropriateto assign thefollowingICD-10-AMcode: Z43.0Attentionto tracheostomy?

Wherea patientis admittedwithan in situ tracheostomywhichreceivesattentionormanagementduringtheepisode; such as revision,closure,tubereplacement,orcleaning,also assign Z43.0Attentionto tracheostomy. This code is not assignedwherethereis a malfunctionorcomplicationof thetracheostomy,as in theexcludesnoteatZ43.0.

Could theNCCC clarifyin what circumstancesit is appropriateto assign thefollowingICD-10-AMcode: Z93.0Tracheostomystatus?

AssignZ93.0Tracheostomystatuswherea patientis admittedwithan in situ tracheostomyand it is determinedthat thepresenceof thetracheostomymeetsthecriteriain ACS 0002Additionaldiagnoses;howeverit does not fall within thebounds of thescenarioscitedabove.

(Coding Q&A,June 2013)

RefNo:Q2723| PublishedOn: 15-Jun-2013| Status:Current

Spontaneousprematureruptureof membranes

Could theNCCC please clarifythecodingof 'prematureruptureof membranes',includingwhetherthereis a requirementfor theword 'spontaneous'to bespecified?

Prematureruptureof membranes(PROM),also knownas pre-labourruptureof membranes,is 'thespontaneous ruptureof theamnioticsacbeforetheonsetof labour'(Mosby,2009).PROMcan occuratterm,thatis, atorbeyond

37completedweeksof gestation,orpreterm(PPROM),before37completedweeksof gestation,whichcan pose a significantriskfor morbidityand mortalityin both themotherand thefetus,and is a major causeof pretermdelivery (Jazayeri,2011).

The appropriatecode for both termand pretermPROMis assignedfollowingtheindex pathway:

Rupture,ruptured

- membranes(spontaneous)

- - premature

As'spontaneous'is not an essentialmodifierit does not needto bespecifiedin orderto assign a code for premature ruptureof membranes,howeverit is implicitin thecondition.

Acode fromO42Prematureruptureof membranesshould not beassignedwheremembranesarerupturedartificially. NCCC notesthata publicsubmissionhas beensubmittedrequestingindex entriesfor 'pre-labourruptureof membranes'.This willbeconsideredalong withotherindex entriesfor PROMand PPROMfor a futureeditionof ICD-10

-AM.

References:

Jazayeri,A(2011),Prematureruptureof membranes,Medscapereference,accessed:11February2013,available:

Mosby (2009),Mosby͛s MedicalDictionary,8th edn,accessed:11February2013,available:

+membranes.

(Coding Q&A,June 2013)

RefNo:Q2669| PublishedOn: 15-Jun-2013| Status:Current

Principaldiagnosisassignmentfor syndromes

Wherea patientis admittedfor treatmentof a particularcomponentof a syndrome,should a code for thesyndrome ortheparticularcomponent,beassignedas theprincipaldiagnosis?

Wherea patientpresentsfor managementof a componentof a previouslydiagnosedsyndrome,a code for the componentshould beassignedas theprincipaldiagnosis.WhereICD-10-AM:

providesa specificcode for theunderlyingsyndrome,assign this code as an additionaldiagnosis(referACS 0001Principal diagnosis/Problemsand underlyingconditions).

does not providea specificcode for theunderlyingsyndrome,referto ACS 0005Syndromes for instructionregarding assignmentof additionaldiagnosiscodes.

(Coding Q&A,June 2013)

RefNo:Q2724| PublishedOn: 15-Jun-2013| Status:Current

Transvenousabdominisplane(TAP)blocks

What is thecorrectcode assignmentfor TAPblocks?

Atransversusabdominisplane (TAP)blockis a regionalblockof theabdominalwall whichis primarilyused in surgeriesinvolving thelowerabdominalwall, such as bowelsurgery,appendicectomy,hernia repairand gynaecologicalsurgery.TAPblocksarealso used for postproceduralpain and, less commonly,otherpain management.

TAPblockscan beadministeredvia an injectionoras a continuousorintermittentinfusion,using eithersurfaceanatomylandmarks orultrasoundguidedtechniqueto depositlocal anaestheticinto thetissueplane betweentheinternalobliqueand thetransversusabdominis.

Assign codes for TAPblocksas follows:

foroperativeanaesthesia-- 92510-XX[1909]Regionalblock,nerveof trunkusing index pathways:

Administration/nerve/for/operativeanaesthesia/trunkAnaesthesia/conduction/regionalblock/nerveof/trunk

Block/nerve/for/operativeanaesthesia/trunkInjection/nerve/for/operativeanaesthesia/trunk

forpostproceduralanalgesiafollowinginitiationin theatreorrecovery-- 92517-01[1912]Managementof regional

block, nerveof trunkusing index pathways:Analgesia/postprocedural/managementof/regionalblock/nerveof/trunkManagement/block/postprocedural/regional/trunk

forpainmanagementanaesthesia-- 90022-00[63]Administrationof anaestheticagentaround other

peripheralnerveusing theindex pathway:Administration/nerve/peripheral

The additionof index entriesfor transversusabdominisplane (TAP)blockswill beconsideredfor a futureeditionof ACHI.

Bibliography:

Webster,K(2008),The TransversusAbdominisPlane (TAP)block:abdominalplane regionalanaesthesia,Updatein Anaesthesia, Vol. 214,pp. 24-29. (Coding Q&A,June 2013)

RefNo:Q2771| PublishedOn: 15-Jun-2013| Status:Current

Obstetricprincipaldiagnosisanddeliveryoutcome codes

What is theappropriateprincipaldiagnosisand outcomeof deliverycode to assign in thefollowingscenario:

Motheradmittedto hospitalafterdeliveringTwin 1by breechextractionin theambulanceon thewayto hospital,then delivers

Twin 2by emergencycaesareansection?

O84.82Multipledeliveryby combinationof methodsshould beassignedas theprincipaldiagnosisand assign Z37.2Twins, both livebornas theoutcomeof deliverycode.

Z39.03Postpartumcareafterunplanned,out of hospitaldeliveryshould also beassignedto indicatethat Twin 1wasdeliveredprior to admission.Asthis is an exceptionto theguidelinesin ACS 1548Postpartumconditionorcomplicationfor assigninga code from Z39.0- Postpartumcareand examinationimmediatelyafterdeliveryas an additionaldiagnosis,thestandardwill bereviewedfor inclusionof this scenarioin a futureedition.

(Coding Q&A,June 2013)

RefNo:Q2758| PublishedOn: 15-Jun-2013| Status:Current

Ruschballooncatheterfor cervicalectopicpregnancy bleeding

What is thecorrectcode to assign for managementof bleedingfroma cervicalectopicpregnancyusing a Ruschballoon catheter?

Cervicalectopicpregnancyis theraresttypeof ectopicpregnancy,occurringin approximately1in 9,000pregnancies.Initial presentationis usuallyprofuse,painlessvaginalbleeding.Whileit is potentiallya life threateningcondition,it can betreated conservativelyfollowingan earlydiagnosisby ultrasound.

Cervicalbleedingresultingfroman ectopicpregnancycan betreatedusing a Ruschcatheter.The catheteris placedin thecervix and inflatedwithsaline to createa balloon whichplaces pressureon theblood vessels.

AsACHIdoes not containa specificcode for theinsertionorreplacementof Ruschcathetersto controlcervicalbleeding,the appropriatecode to assign for both insertionand replacementis 35618-03[1278]Otherprocedureson cervixfollowingtheindex pathway:

Procedure

- cervixNEC35618-03[1278]

The additionof index entriesfor Ruschballoon catheterfor controlof cervicalbleedingwill beconsideredfor a futureeditionofACHI.

Bibliography:

Kirk,E and Bourne,T (2009),Diagnosis of ectopicpregnancywith ultrasound,BestPracticeand ResearchClinical Obstetricsand Gynaecology, Vol. 23,No. 4,pp. 501-

508.Heer,J,Chao, D and McPheeters,R(2012),Cervicalectopicpregnancy,WestJournal of EmergencyMedicine, Vol. 13,No. 1,pp. 125-126. (Coding Q&A,June 2013)

RefNo:Q2788| PublishedOn: 15-Jun-2013| Status:Current

Removalof urethralsling followingmalestress incontinenceprocedure

What is thecorrectcode to use for removalof urethralsling followingmalestressincontinenceprocedure?

Thereis no specificprocedurecode for removalof urethralsling followingpreviousstressincontinenceprocedurefor malepatients.ACHIdoes not distinguishbetweenremovaland revisionproceduresfor malestressincontinence.The appropriatecode for removalof a urethralsling for a malestressincontinenceprocedureis 37044-03 [1109]Revision of retropubicprocedurefor stressincontinence,malefollowingindex pathways:

Revision(partial)(total)

- sling procedurefor stressincontinence

- - female35599-01[1110]

- - male37044-03[1109]

Slingprocedure

- for

- - stressincontinence

- - - male37044-00[1109]

- - - - revision37044-03[1109]

- - - revision

- - - - female35599-01[1110]

- - - - male37044-03[1109]

NCCC willconsiderimprovementsto ACHIfor this procedurefor a futureedition.

(Coding Q&A,June 2013)

RefNo:Q2794| PublishedOn: 15-Jun-2013| Status:Current

Pressureinjury

What is thecorrectcode to assign for a pressureinjury,documentedas 'suspecteddeeptissueinjury:depthunknown'or

'unstageablepressureinjury:depthunknown'?

In 2009,newdefinitionsand a six stageclassificationfor pressureinjuryweredevelopedby theAmericanNationalPressureUlcer AdvisoryPanel (NPUAP)and EuropeanPressureUlcerAdvisoryPanel (EPUAP).Australiaand otherAsia Pacificcountriesadopted this newclassificationof pressureinjuriesin the'PanPacificClinicalGuidelinefor thePreventionand Managementof Pressure Injury(AbridgedVersion)'(AWMA2012).

The newclinicalguidelineuses theterm'pressureinjury'for thesynonymoustermspressureulcer,decubitusulcerand bedsore; and has added two newstagesof pressureinjuryto theexistingfour stageclassificationfor those pressureinjurieswhereit is not possibleto specifythedepth,namely:

Suspecteddeeptissueinjury:depthunknown
Unstageablepressureinjury:depthunknown.

'Unstageablepressureinjury:depthunknown'is definedas:

Full thicknesstissueloss in whichactualdepthof theulceris completelyobscuredby slough (yellow,tan,grey,greenorbrown) and/or eschar(tan, brownorblack)in thewound bed. Untilenoughslough and/or escharareremovedto expose thebase of the wound,thetruedepthcannotbedetermined;but it will beeithera Category/StageIIIorIV (NPUAPEPUAP2009;NPUAP2013).

'Suspecteddeeptissueinjury:depthunknown'is definedas:

Purpleormaroonlocalisedareaof discolouredintactskin orblood-filledblisterdue to damageof underlyingsoft tissuefrom pressureand/or shear. The areamaybeprecededby tissuethat is painful,firm,mushy,boggy,warmerorcooleras comparedto adjacenttissue.Deeptissueinjurymaybedifficultto detectin individualswithdarkskin tones.Evolutionmayincludea thin blister overa darkwound bed. The wound mayfurtherevolveand becomecoveredby thin eschar.Evolutionmayberapid, exposing additionallayersof tissueevenwithoptimaltreatment(NPUAPEPUAP2009;NPUAP2013).

Currentlythereis no specificcode in ICD-10-AMto classify'suspecteddeeptissueinjury:depthunknown'and 'unstageable pressureinjury:depthunknown',howevera proposalto updateICD-10in line withthenewguidelineshas beensubmittedto the WHOICD-10Updateand RevisionCommittee(WHO-URC).

In theinterim,clinicaladviceconfirmsthat L89.9Decubitusulcerand pressurearea,unspecifiedshould beassignedwhen eitherof thesetwo newstagesof pressureinjuryaredocumented.

References:

NationalPressureUlcerAdvisoryPanel (NPUAP)(2013),NPUAPPressureUlcerStages/Categories,accessed:6March2013,available: (NPUAP)and European PressureUlcerAdvisoryPanel (EPUAP)(2009),InternationalGuideline:PressureUlcerTreatmentTechnicalReport,accessed:6March2013,available: ManagementAssociation(AWMA)(2012), PanPacificClinicalPracticeGuidelinefor thePreventionand Managementof PressureInjury(AbridgedVersion),accessed:6March2013,available:

(Coding Q&A,June 2013)

RefNo:Q2808| PublishedOn: 15-Jun-2013| Status:Current

Insertionof fiducialmarkersintothelung percutaneously

What is thebest procedurecode to assign for insertionof fiducialmarkersinto thelung percutaneously?

Fiducialmarkersaremetalmarkersimplantedinto a lesion orsoft tissueas a radiographicreferencepointfor provisionof external beamradiotherapyorradiosurgery.Whenused to treatlung cancer,themarkersareinsertedinto thelesion and its adjacentsites throughneedles,using a percutaneousapproach.This proceduretechnicallyresemblesthat of CT guidedbiopsy of lung (Sotiropoulouetal., 2013).

Currentlythereis no specificcode in ACHIto classifyinsertionof fiducialmarkersinto lung. Giventheprocedureis technically similarto a CT guidedbiopsy,NCCC considersthebest fit code to be38812-00[550]Percutaneousneedlebiopsy of lung. This code can beaccessedvia index pathway:

Puncture

- lung 38812-00[550]

Pleasenote that 38456-02[558]Otherprocedureson lung orpleura,intrathoracicapproachis not an appropriatecode for this procedureas this interventioncode is for lung proceduresperformedvia an open intrathoracicapproach.

The NCCC will considerimprovementsto theclassificationof fiducialmarkersimplantationfor a futureeditionof ACHI.

References:

Sotiropoulou,E,Georgiadi,V,Stathochristopoulou,I,Stathopoulos,K,Salvaras,Nand Thanos, L (2013),InternationalHospital Equipment & Solutions:CT-guided fiducial implantationin radiosurgeryof extracranialparenchymal cancer,accessed:12February2013,available: guided-fiducial-implantation-in-radiosurgery-of-extracranial-parenchymal-cancer/.

(Coding Q&A,June 2013)

RefNo:TN474| PublishedOn: 15-Jun-2013| Status:Current| Supersedes:TN207

Cysticfibrosis(3of 3)

Does therehaveto bedocumentationin theclinicalrecordlinkingthemanifestationto theCF? Sometimestheclinicalrecorddoes not documentthelink althoughmedicalliteraturerefersto linkagebetweenCF and its manifestations.Can thelink beassumed in orderto assign E84.-?

Theremust bedocumentationin theclinicalrecordthat statesa problemis a manifestationof CF in orderfor it to becodedas one. If thereis uncertaintyas to whethera conditionis a manifestationof CF, then therelationshipbetweentheconditionand CFshould beverifiedwiththeclinician.

(Coding Q&A,June 2013)

RefNo:TN474| PublishedOn: 15-Jun-2013| Status:Current| Supersedes:TN207

Cysticfibrosis(2of 3)

ACS 0402Cystic Fibrosis states:"Cysticfibrosisshould becodedwiththeappropriatecode fromE84.-Cystic fibrosisfollowedby a code for any specifiedmanifestation. Example1:Patientadmittedfor reductionof fracturedshaft of tibia followingfall from ladder.Patientalso treatedfor bronchiectasisassociatedwithcysticfibrosis.Codes: S82.28Otherfractureof shaft of tibiaW11Fall on and from ladderAn appropriateplace of occurrencecode (Y92.-)and activitycode (U50-U73)E84.0Cystic fibrosiswith pulmonary manifestationsJ47Bronchiectasis If thepatientmentionedin

Example1abovedid not havetreatmentfor theirCF and/or themanifestation(s)then code(s)would not beassignedfor CF. Is this correct?

If cysticfibrosisorits manifestationsdo not meetthecriteriafor code assignmentas pertheguidelinesin ACS 0001Principal diagnosis orACS 0002Additionaldiagnoses, thereis no requirementto code theseconditions.ACS 0402providesguidanceon how cysticfibrosisshould becoded,ratherthan whetherornot it should becodedin thefirst instance.

(Coding Q&A,June 2013)

RefNo:TN474| PublishedOn: 15-Jun-2013| Status:Current| Supersedes:TN207

Cysticfibrosis(1of 3)

Whena patientis admittedwithcysticfibrosis(CF) and has manifestations,how should theybecodedin thefollowingscenario?

Patientadmittedfor surgeryfor nasal polyps (wherenasal polyps aredocumentedas a manifestationof CF).Thepatientalso has bronchiectasisand pancreaticinsufficiencydue to CF. Do themanifestationsof bronchiectasisand pancreaticinsufficiencyhaveto meetACS 0002Additionaldiagnosesto becoded?WhichE84.-code should beassigned?

Whendeterminingwhethercysticfibrosisorits manifestationsshould becoded,referto theguidelinesin ACS 0001and ACS 0002, as well as theguidelinesspecifiedin ACS 0402Cystic fibrosis. In this scenarionasal polyps meetthecriteriafor code assignmentas perACS 0001Principaldiagnosis, and then ACS 0402specificallystates:"Cysticfibrosisshould becodedwiththeappropriatecode fromE84.-Cystic fibrosis... followedby a code for any specifiedmanifestation.

Morethan one code fromE84.-Cystic fibrosisshould beused if thepatientpresentswithmultiplemanifestationsof CF." Therefore,for theabovescenarioassign thefollowingcodes:

E84.8Cystic fibrosiswith otherspecifiedmanifestations

J33.9Nasal polyp, unspecified

E84.0Cystic fibrosiswith pulmonary manifestations

J47Bronchiectasis

K86.8Otherspecifieddiseases of pancreas.

Whencysticfibrosismeetsthecriteriafor code assignmentas perACS 0001PrincipaldiagnosisorACS 0002Additionaldiagnoses, all manifestationsshould becodedregardlessof whethertheymeetACS 0002.

(Coding Q&A,June 2013)

RefNo:TN393| PublishedOn: 15-Jun-2013| Status:Current| Supersedes:TN207

Viralhepatitis

Patientswithchronicviral hepatitisareoften asymptomaticormayhaveabnormalliverfunctiontests(LFTs). An indicationof chronicviral hepatitisis a raised levelof alanine transaminase(ALT) and/or aspartateaminotransferase(AST), in theabsenceof othercauses of liverinflammationsuch as alcohol,non-alcoholicfattyliverdisease.Generally,patientswithchronicviral hepatitis arefollowedup 6-12monthlywithblood tests.Six monthlyultrasoundsarerecommendedfor surveillanceof hepatocellular carcinoma(primarylivercancer)in all patientswithcirrhosis,and in somepatientswithchronicHBV infectionin theabsenceof cirrhosis.

Generally,afterrecoveryfroman infectionwithan organism,a person will developantibodiesto thepathogenicorganism. Antibodiesto certaininfectiousdiseases can also beproducedby vaccination.In thesevaccinatedpeople,futureblood tests demonstratingtheantibodieswill indicatepast infectionorimmunisation.Detectionof antibodiesdoes not indicateactive infection;this is confirmedby detectingthevirus in theblood. Aperson withdetectablevirus in theirblood mayormaynot manifestsymptomsbut is potentiallyinfectiousand thevirus can betransmittedto others.

Itis importantto understandthedistinctionbetweena person who has an activeinfection(at riskof transmissionof infectionto othersand disease progression)and a person whose antibodyresultsindicatepast infectionorimmunisationto an infectious disease (not an infectionrisk,and usuallynot atriskof disease progression).The role of antibodytestsin distinguishingbetween disease statusand past infectionvariesdependingon theinfection.In somesituations,testingfor viral nucleicacid (DNAorRNA)is requiredto determineif actualinfectionis present.

HepatitisA

Transmissionwithinfamiliesis common.In developingcountries,theusual sourceof infectionis faecal contaminationof drinking water.The hepatitisAvirus (HAV) is detectedby two antibodytests:

1. IgMantibody:positiveresultindicatesrecentinfection.2. IgGantibody(anti-HA):positiveresultindicatespast infection

(previousexposureto HAV) orimmunitythroughvaccination.

HepatitisB

Most peoplewho areinfectedwithHBV as adolescentsoradults do not developsymptomsand clearinfectionspontaneously- theymakea full recoveryand areleft withimmunityfor life. However,followingacuteinfection,a small minority(approximately5%)of patientswill progressto a chronicinfection.

In contrast,most of theglobal burdenof chronichepatitisBresultsfrommotherto infant transmissionsorinfectionin early childhood,in high prevalencecountries.Newbornbabies of motherswho havehepatitisB(HBsAgpositive)areatriskof infection and should receiveHBV vaccinationand immunoglobulin(within12hours of birthand completea full HBV vaccinationschedule). Peoplewho areinfectedwithHBV as infantsorin earlychildhoodareoften asymptomatic,but usuallyprogressto chronicHBV infection.

Therearetwo categoriesof testsused to diagnoseand manageHBV infection:

serologicalassays:enzymeimmunoassay(EIA) detectsspecificantibody(ies)to HBV and antigen(s)and includesHBsAg,anti-HBs, HBeAg,anti-HBe,anti-HBcAg.2. molecularassays:detectand/or quantifytheamountof viral nucleicacid (HBV DNA [deoxyribonucleicacid]).Tests aredividedinto two types:

qualitativeassays:detectspresenceorabsenceof HBV DNA
quantitativeassays:measurestheamountof HBV DNA('viralload') in serum(this is thepreferredtestingmethodandincludespolymerasechain reaction(PCR) and transcription-mediatedamplification(TMA) assays).

Antiviraltherapyis used to treatpatientswithHBV infection,withthecurrentaim of treatmentsto suppressvirus replicationand preventprogressionof liverdisease (EASL 2012).Spontaneousclearanceof HBV infectionmayoccurwithouttreatment.This is commonin adults followingacuteinfection,but can also occurin peoplewithchronicHBV infection.Resolutionof HBV infectionis rarewithcurrenttreatment.ResolvedHBV infectionis definedas 'previousHBV infectionwithoutfurthervirologic,biochemicalor histologicalevidenceof activevirus ordisease'(Lok & McMahon2009,p. 4).

HepatitisC

The majorityof patients(60-70%)withacuteHCV infectionwill progressto a chronicinfection.Spontaneousviral clearanceafter acuteHCV infectionoccurswithouttreatmentin 30-40%of people,usuallywithinthefirst 6monthsafterinfection.Therearetwo categoriesof testsused to diagnoseand manageHCV infection:

serologicalassays:enzymeimmunoassay(EIA) detectsspecificantibodyto HCV (anti-HCV)2. molecularassays:detectand/or quantifytheamountof viral nucleicacid (HCV RNA[ribonucleicacid]).Tests aredividedinto threetypes:

qualitativeassays:detectspresenceorabsenceof HCV RNA

quantitativeassays:measurestheamountof HCV RNA('viralload') in serum.This is usuallyby polymerasechain reaction (PCR).

genotypeassay:thereare6main genotypesof HCV. Choiceand durationof antiviraltreatment,as well as likelihoodofresponseis stronglyrelatedto theinfectinggenotype.

Antiviraltherapyis used to treatpatientswithHCV infection,withtheaim of virologicalcure.Therapyis for a definedtimeperiod, usually24or48weeks.HCV infectionis consideredto besuccessfullytreatedwhen SVR (sustainedvirologicalresponse)is attained. SVR is definedas theabsenceof HCV RNAin serum24weeksafterdiscontinuingtherapy(Ghanyetal. 2009,p. 1341).

HepatitisD

Testingfor HDV involvesserologyfor hepatitisD antibodies(anti-HDV).However,this does not allow determinationof active infectionorpriorexposure.HepatitisD virus RNAtestinghas only limitedavailabilityin researchsettings.

HepatitisE

Itis endemicin South-EastAsia,countriesof theSovietregion,India,mid-eastAfricaand CentralAmerica.Largeoutbreaksare usuallyspread by contaminatedwater.Directperson to person spread can occurbut is less common.The normalcourseof infectionis an acuteand a relativelybenignillness.Whereas,HEV in pregnancycan causefulminanthepaticfailure,particularlyin thethirdtrimester,withmortalityratesof 15-25%.

Itwaspreviouslythoughtthat HEV isnevera chronicinfection.However,it has beenrecentlyrecognisedthat hepatitisE mayresult in chronicinfection,particularlyin immunosuppressedindividualssuch as organ transplantrecipients(Kamaretal. 2012,p. 6).

Ackowledgements:

The NCCC would like to thank DrMarkDouglas,AssociateProfessorSimoneStrasserand AssociateProfessorStuartRobertsfor theirinvaluablecontributionto updatingviral hepatitisin theclassificationsystem.

References:

EuropeanAssociationfor theStudyof theLiver (EASL)2012,'EASLClinicalPracticeGuidelines:Managementof chronichepatitisBvirusinfection',Journal of Hepatology, vol.57,pp.167-185.

Ghany,MG,Nelson,DR,Strader,DB,Thomas, DL and Seeff,LB 2011,'AnUpdateon Treatmentof Genotype1Chronic HepatitisC Virus Infection:2011PracticeGuidelineby theAmericanAssociationfor theStudy of LiverDiseases',Hepatology,vol. 54,no. 4,pp. 1433-1444.

Kamar,N,Bendall,R,Legrand-Abravanel,F,Xia, N,Ijaz,S,Izopet,J and Dalton, HR 2012,'HepatitisE',The Lancet,vol. 11,pp. 1-12. Lok,ASF and McMahon,BJ2007,Chronic HepatitisB,Hepatology,vol. 50,no. 3,pp. 1-36.

(Coding Q&A,June 2013)