– General Theory Questions

Question 1

What does the cross reference ‘See also’ used in the ICD-10 5th Edition Alphabetical Index instruct the coder to do?

Answer 1

This is a reminder to look under another lead term if the term the coder is looking for cannot be found modified in any way under the first lead term.

Question 2

Describe the standard that must be applied when assigning OPCS-4 codes
for ‘maintenance’ and ‘attention to’ procedures.

Answer 2

A supplementary code from Chapter Y must be added in addition to the
maintenance / attention to code, when doing so provides additional
information.

Question 3

When is it applicable to assign ICD-10 5th Edition code Z75.1 Persons
awaiting admission to adequate facility elsewhere in a secondary
position?

Answer 3

When the medical record clearly state that they are ‘bed-blocking’ or
medically fit for discharge (MFD) but awaiting suitable accommodation
elsewhere, such as a nursing or residential home.

Question 4

A code from category Y80 General anaesthetic must be assigned following
which intervention?

Answer 4

Radiotherapy

Question 5

What must be considered when applying the standard for the coding of ‘high
cholesterol’ or ‘Cholesterol’?

Answer 5

They must only be coded to E78.0 Pure hypercholesterolaemia if confirmed
to be a definitive diagnosis of hypercholesterolaemia by the responsible
consultant and it is not merely an abnormal test result.
Abnormal cholesterol detected from a blood test without a definitive diagnosis
of hypercholesterolaemia must be coded to R79.8 Other specified abnormal
findings of blood chemistry instead.

Question 6

If both congestive cardiac failure (CCF) (I50.0) and left ventricular failure
(LVF) (I50.1) are documented in the medical record, what must be coded and
why?

Answer 6

Only assign code I50.0 Congestive heart failure as this code includes both
right and left ventricular failure

Question 7

Describe the OPCS-4 standard when a patient is admitted for a
gastrointestinal tract endoscopy and the patient is unable to tolerate the
scope and it is documented as a ‘failed intubation’.

Answer 7

The procedure must not be coded unless the point of abandonment is beyond
the mouth.

Question 8

If a patient is admitted for the removal of an indwelling urinary catheter or trial
without catheter (TWOC), and on removal the patient is unable to void
resulting in the catheter being reinserted, how should this be coded in OPCS-4?

Answer 8

This must be coded to M47.3 Removal of urethral catheter from bladder
and M47.9 Unspecified urethral catheterisation of bladder in this
sequence.

Question 9

When conditions such as deep vein thrombosis (DVT) are linked to travel,
what fourth character must be assigned to the external cause code X51
Travel and motion, and why?

Answer 9

As it is impossible to define at which point on a journey a DVT occurred, the
place of occurrence fourth character .9 must be used.

Question 10

Describe when and how a code from Chapter S must be assigned to enhance
a code from another body system chapter.

Answer 10

• When it provides further information about the procedure that is not
specified in the primary body system code.
• In a secondary position, directly after the body system code it is
enhancing.

Question 11

Describe the standard when a patient is diagnosed with sepsis in the medical
record but the description of the ICD-10 5th Edition code assigned does not
specifically classify sepsis.

Answer 11

An additional code that specifically classifies sepsis must be assigned in any
secondary position, in order to describe the condition fully.

Question 12

Name the two anatomical structures that determine the coding for the release
of tennis elbow in OPCS-4.

Answer 12

Tendon or joint.

Question 13

Describe the standard when the medical record documents a secondary
neoplasm or metastases from a haematological malignancy.

Answer 13

Codes in the range C77-C79 must never be assigned to indicate a secondary
neoplasm due to/from a haematological malignancy.
Diagnostic statements indicating that metastases are the result of a
haematological malignancy must be referred back to the responsible
consultant to clarify that this is spread of the haematological malignancy. If
this is confirmed only the code from categories C81-C96 is assigned.

Question 14

What are the two occasions when the OPCS-4 code Q55.6 Genital swab
can be used?

Answer 14

It must only be used for outpatient coding, or if the patient is admitted solely
for the purpose of this procedure.

Question 15

When discectomy is performed in order to decompress, only the OPCS-4
code that classifies the spinal decompression operation is necessary, as long
as what two criteria are met?

Answer 15

• The decompression and discectomy must have been performed on the
same disc or group of vertebrae or motion segment
and
• The responsible consultant must have stated that discectomy was
performed in order to result in decompression.

Question 16

What is the duration stated in categories I21-I25 Ischaemic heart diseases
relating to the interval elapsing between the onset of the ischaemic episode
and admission to hospital?

Answer 16

Four weeks (28 days)

Question 17

What should be coded when a patient with chronic kidney disease stages 1-3
is stated to have renal failure, and why?

Answer 17

Patients with CKD stages 1-3 (codes N18.1 to N18.3) are not always
considered to have renal failure. When it is documented in the medical record
that the patient also has renal failure this must be coded in addition.

Question 18

When 3D mapping of the heart is performed with an ablation of the heart,
does the 3D mapping require coding? Explain the reason for your answer.

Answer 18

3D mapping of the heart must not be assigned in addition to an ablation code,
as it is an inherent part of ablation of the conducting system of the heart and
is rarely performed on its own

Question 19

Describe the sequencing rule when assigning codes from categories P00-P04
Fetus and newborn affected by maternal factors and by complications
of pregnancy, labour and delivery.

Answer 19

They must be sequenced in a secondary position to the code that classifies
the morbid condition, except when the baby is stillborn and the cause is
known.

Question 20

Name the type of image control always used for obstetric scans (R36-R43) in
OPCS-4.

Answer 20

Ultrasound

Question 21

Describe the use of the ‘Brace’ punctuation in the Tabular List.

Answer 21

Braces are used in inclusion and exclusion notes to indicate that both the
listed condition and one of its modifiers must be present in order to complete
the instruction. Braces enclose a series of terms, modified by the statement
appearing at the right of the brace.

Question 22

Describe the use of the relational term ‘With’.

Answer 22

This is used either when two or more conditions combine to form another
condition or to provide additional four character specificity. These terms
indicate that both elements in the code description must be present in the
diagnostic statement in order to assign the code.
These terms do not necessarily indicate a cause-effect relationship.

Question 23

For the purposes of clinical coding, what is a co-morbidity defined as?

Answer 23

• Any condition which co-exists in conjunction with another disease that is
currently being treated at the time of admission or develops subsequently,
and
• affects the management of the patient’s current consultant episode.

Question 24

Describe the use of the fifth character in Chapter XIX Injury, poisoning and
certain other consequence of external causes.

Answer 24

Supplementary fifth characters are used in this chapter to identify open and
closed fractures, intracranial injuries with or without open intracranial wound
and internal injuries with or without open wound into cavity. They must be
assigned when instructed by the note at code, category or block level.
An injury not indicated as ‘open’ or ‘closed’ must be recorded using fifth
character ‘0’.

Question 25

Describe the standard for the coding of burns and corrosions.

Answer 25

Burns and corrosions of the same site that exhibit multiple degrees must be coded to the most severe degree of that site using codes in categories T20- T30 Burns and corrosions. A code from categories T31.- Burns classified according to extent of body surface involved or T32.- Corrosions classified according to extent of body surface involved must be assigned in addition to a code from categories T20-T25 Burns and corrosions of external body surface, specified by site or T29.- Burns and corrosions of multiple body regions when the total percentage of body surface involved in a burn or corrosion is documented. When the site of the burn is unspecified and only the total percentage of body surface is documented only a code from categories T31.- or T32.- is required.

Question 26

Describe the standard for the use of Y10-Y34 Event of undetermined intent.

Answer 26

Event of undetermined intent codes (Y10-Y34) must only be used when undetermined intent is stated by a medical or legal authority, such as a coroner at an inquest. It must not be used when no information has been given about the circumstances of an event. If the intent is not known, a code that classifies an accidental external cause must be assigned.

Question 27

The Note instructional notes provide instructions for coding; describe how they may be used.

Answer 27

• To advise coders to include or omit additional or subsidiary codes • To direct coders elsewhere in the classification for more appropriate categories • To clarify the intended use of codes in a particular chapter, category or subcategory • To provide specific instruction on the correct sequencing of codes when used together (paired codes

Question 28

Describe the use of surgical eponyms for the assignment of procedural codes.

Answer 28

Section II Alphabetical Index of Surgical Eponyms within Volume II - Alphabetical Index must only be used as a guide when coding. Where an eponym is used in the medical record the coder must analyse the procedural information and ensure that code assignment fully reflects the procedure performed. Where the coder is unsure what procedure the eponym describes, they must seek advice from the responsible consultant to ensure that the correct codes are assigned

Question 29

Within the OPCS-4 classification what does HFQ stand for and describe its use?

Answer 29

HFQ (However Further Qualified) Signifies that a statement may be further qualified/described in a number of ways, which will not affect the code assignment, It refers to the part of the procedural statement that immediately precedes the abbreviation HFQ.

Question 30

Describe the coding standard for the removal of bypass grafts in Chapter L Arteries and Veins.

Answer 30

The removal of bypass grafts must be coded to the original operation bypass category with the fourth-character to describe an ‘other specified’ procedure (.8) plus a code from Chapter Y to specify the removal of repair material (Y26.4 Removal of other repair material from organ NOC) unless there is a specific fourth-character code that classifies removal of the bypass graft.

Question 31

Describe when it is acceptable to code interventions on specifically classifiable arteries in Chapter L Arteries and Veins, and what must be done when they aren’t specifically classifiable. [

Answer 31

Only when an artery or its branches is specified in the category/code description or at the category inclusions can these codes be assigned. A site code must be assigned in addition when the artery is listed as an inclusion term. Where the artery is not specifically referred to within the code description or inclusion, even if the origin is known, do not assign a code from these categories. A code from categories L65–L72 must be used instead with the addition of a site code from Chapter Z where available.

Question 32

Where in ICD-10 5th Edition is the point dash (.–) punctuation found and what is its purpose?

Answer 32

It is used in both the Tabular List and the Alphabetical Index to indicate there are fourth character subdivisions.

Question 33

Where both a skin graft and skin debridement have been performed, which procedure must be selected as the primary code?

Answer 33

The skin graft.

Question 34

Describe the ICD-10 5th Edition standard when it has been documented in the medical record that a patient with diabetes has hypoglycaemia without a coma, and this is not related to an adverse effect or a poisoning.

Answer 34

``` A code from category E16.- Other disorders of pancreatic internal secretion must be assigned followed by the code that classifies the type of diabetes from categories E10-E14, with the fourth character subdivision .9 Without complications (as hypoglycaemia is not classified as a complication in ICD-10). ```

Question 35

Describe the OPCS-4 standard relating to the use of a code from Chapter S to enhance a code from another body system chapter.

Answer 35

The code from Chapter S must be assigned: • When it provides further information about the procedure that is not specified in the primary body system code • In a secondary position, directly after the body system code it is enhancing.

Question 36

In accordance with standard DCS.XI.5: Parastomal hernia, what must be assigned in addition to the code for a parastomal hernia?

Answer 36

A code from category Z93.- Artificial opening status

Question 37

Describe the ICD-10 5th Edition standard where preventative surgery is being performed as a precautionary measure for a current condition.

Answer 37

The code classifying the condition must be assigned in a primary position and a code from category Z40.- Prophylactic surgery must be assigned in a secondary position.

Question 38

The fourth characters .8 and .9 are available in both principal and the extended categories within OPCS-4; why is this and describe the standard for their use in these categories?

Answer 38

In order to maintain the structure of the classification .8 and .9 codes are available in both principal and the extended categories. Only the .8 and .9 codes in the principal category can be used. The .8 and .9 codes from the extended category must not be used

Question 39

Codes in OPCS-4 categories U22-U33 and U40 classify diagnostic tests and are only for use in an outpatient setting, or for day cases and inpatients if a patient has been admitted solely for the purpose of the diagnostic test. What test is the exception and must always be coded on inpatient and outpatient hospital episodes?

Answer 39

U22.1 Electroencephalograph telemetry

Question 40

Describe the ICD-10 5th Edition standard for the coding of infected open wounds.

Answer 40

They must be coded in the same way as a non-infected open wound, i.e. code assignment is the same but if the organism causing the infection is known, a code from categories B95–B98 Bacterial, viral and other infectious agents must be coded in addition

Question 41

In accordance with the OPCS-4 standard, when is it appropriate to use codes G20.1 Fibreoptic endoscopic coagulation of bleeding lesion of oesophagus and G46.2 Fibreoptic endoscopic coagulation of bleeding lesion of upper gastrointestinal tract?

Answer 41

They must only be assigned when coagulation of bleeding lesion(s) is performed as a therapeutic procedure. These codes must not be used to classify coagulation as a means of haemostasis at the end of a procedure.

Question 42

Describe the ICD-10 5th Edition standard for the coding of infertility

Answer 42

When a patient has infertility and the cause is known, both conditions must be coded. Sequencing will depend on the main condition treated or investigated

Question 43

Codes in category X59 Anaesthetic without surgery must only be used to classify patients who receive which two types of anaesthesia, but subsequently do not undergo any procedure or intervention?

Answer 43

General and spinal anaesthesia.

Question 44

Where there is a documented diagnosis of cerebrovascular accident (CVA) or stroke and this is confirmed by the responsible consultant to be due to a thrombosis or embolism, what type of stroke must this be coded to?

Answer 44

Cerebral infarction

Question 45

State the sequencing of codes that must be observed in OPCS-4 when a mastectomy is performed with a breast reconstruction and an axillary lymph node clearance.

Answer 45

The code for the mastectomy (categories B27, B28 or B41) must be coded first, immediately followed by the lymph node clearance (T85), followed by code(s) for the breast reconstruction (B29, B38 or B39).

Question 46

Describe the OPCS-4 standard for the coding of an episiotomy and its subsequent repair.

Answer 46

This must be sequenced in a secondary position to the delivery code. The subsequent repair of an episiotomy must not be coded in addition. The exception is where the episiotomy has extended to a perineal tear.

Question 47

What does the fifth character in ICD-10 5th Edition category I70 Atherosclerosis indicate and what is the default?

Answer 47

Fifth character subdivisions are for use with this category to indicate the absence (0) or presence (1) of gangrene associated with the sites mentioned at fourth character level. Where there is no information available within the medical record the coder must use the default ‘0’ to indicate without gangrene.

Question 48

Describe the ICD-10 5th Edition standard when a patient is diagnosed with sepsis but the code assigned does not specifically classify sepsis (e.g. A54.8 Other gonococcal infections).

Answer 48

A code that classifies sepsis must be assigned in any secondary position.

Question 49

Describe the OPCS-4 standard for the removal of vascular bypass grafts.

Answer 49

They must be coded to the original operation bypass category with the fourthcharacter .8 plus code Y26.4 Removal of other repair material from organ NOC unless there is a specific fourth-character code that classifies removal of the bypass graft.

Question 50

Describe the standard when the primary diagnostic statement records two or more independent primary malignant neoplasms none of which clearly predominates

Answer 50

Code C97.X Malignant neoplasms of independent (primary) multiple sites must be assigned as the main condition. Additional codes must be used to identify the individual malignant neoplasms recorded in the medical record and may be sequenced in any order after C97.X.

Question 51

The ‘body areas’ referred to in the codes in OPCS-4 category Y98 Radiology procedures relate to nine anatomical regions of the body; list three.

Answer 51

``` • Head • Neck (including cervical spine) • Thorax (including thoracic spine) • Abdomen (including lumbar spine) • Pelvic region (including all organs in genitourinary system, sacral spine and groin) • Right leg • Left leg • Right arm • Left arm ```

Question 52

Define an incomplete spontaneous miscarriage and describe the related coding standard for fourth character assignment.

Answer 52

Incomplete miscarriage – the miscarriage has started before 24 completed weeks of gestation, bleeding is present but not all of the foetal tissue has been passed, i.e. retained products of conception are present. The fourth character assignment is from .0-.4 depending on whether there were any maternal complications.

Question 53

``` Describe the standard for coding the first admission of a medical termination of pregnancy (O04). ```

Answer 53

This category must be assigned with the appropriate fourth character from the range .5 to .9. This includes patients who: • are kept in hospital and abort the pregnancy whilst in hospital • are discharged to abort the pregnancy at home • begin to bleed before discharge home to abort the pregnancy

Question 54

Describe the timeframe associated with the perinatal period and the standard for coding conditions that originate within this period.

Answer 54

The perinatal period must be regarded as the period before birth through to the 27th day, 23rd hour and 59th minute of life, i.e. the period before the start of the 28th day. A code from Chapter XVI Certain conditions originating in the perinatal period must only be assigned for conditions that originate in the perinatal period. Where a condition arises in the perinatal period it must be coded to Chapter XVI even when the condition persists beyond the perinatal period. A code from outside Chapter XVI must also be assigned where this provides additional information about the condition which is not contained in the code from Chapter XVI.

Question 55

Describe the standard that applies when both low birth weight and short gestational age are documented in the medical record.

Answer 55

Two codes from category P07.- Disorders related to short gestation and low birth weight, not elsewhere classified must be assigned. The low birth weight code must be sequenced before the code for the short gestational age.

Question 56

Describe the standard for the coding of manifestations related to poisonings.

Answer 56

Assign a code(s) for any manifestations or reactions, if stated in the medical record • Manifestations or reactions classified within Chapter XVIII Signs, symptoms and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) must be coded in a secondary diagnosis position following the external cause code for the poisoning. • Manifestations and reactions classified outside of Chapter XVIII Signs, symptoms and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) must be coded in a secondary diagnosis position following the external cause code for the poisoning unless it is clear that the reaction or manifestation is the main condition treated.

Question 57

Describe the standard for coding co-morbidities on multiple consultant episodes within one hospital provider spell.

Answer 57

The coder may code the comorbidities recorded on the first consultant episode on each subsequent consultant episode within that hospital provider spell and any other co-morbidities that develop during the current hospital provider spell. However, as it is possible that some co-morbidities may resolve during a hospital provider spell, care must be taken, and any uncertainty about the presence of a comorbidity should be clarified with the responsible consultant

Question 58

Describe the standard when a documented diagnosis of ‘delirium’ or ‘acute confusional state’ is made in the patient’s medical record, including those with known dementia

Answer 58

This must be coded using the appropriate ICD-10 code. Where the cause of the delirium or acute confusional state is known, this must also be coded using the appropriate ICD-10 code. The correct sequencing will depend on the main condition treated or investigated during the consultant episode. A documented diagnosis of ‘delirium’ together with a documented comorbidity/diagnosis of ‘dementia’ must be coded using the following code: F05.1 Delirium superimposed on dementia

Question 59

Describe the ‘diagnostic versus therapeutic procedures’ standard. It is not necessary to describe the listed exceptions.

Answer 59

If a diagnostic procedure proceeds to, or is performed at the same time as, a therapeutic procedure on the same site then only the code for the therapeutic procedure is required. This includes: • diagnostic endoscopies performed prior to an open procedure • diagnostic endoscopies performed prior to a therapeutic endoscopic procedure. When a diagnostic (exploratory) laparotomy performed to search for possible pathology progresses to therapeutic procedure(s) as a result of the exploration, only the therapeutic procedure(s) is coded.

Question 60

Describe the standard for the coding of endoscopic excisions with a concurrent biopsy

Answer 60

The biopsy must only be coded if it is taken from a different site to the excision, using the following codes and sequencing: • Endoscopic excision code • Chapter Z site code (if doing so adds further information) • Y20 Biopsy of organ NOC • Chapter Z site code (for the site of the biopsy) Where multiple excisions have been performed site codes must be assigned for each site of excision.

Question 61

Describe the standard for the coding of ‘conversion’ procedures.

Answer 61

‘Conversion to’ and ‘Conversion from’ codes must always be: • sequenced with the ‘Conversion to’ code preceding the ‘Conversion from’ code • used together, except where there is a note indicating that a code not specifically described as a ‘conversion to’ or ‘conversion from’ can be used • assigned from different three-character categories.

Question 62

Describe the paired code convention and its related coding standard.

Answer 62

Paired codes relate to interventions/procedures that are frequently carried out together but are classified at separate codes or categories. Where this is the case the categories concerned contain instructional Notes to indicate the associated code and correct sequencing. • ‘Use a supplementary code/Use an additional code/Use a subsidiary code’ – use the code this note appears at in primary position. • ‘Use as a supplementary code/Use as an additional code/For use as a subsidiary code, Use as a secondary code’ - use the code this note appears at in a secondary position. Paired codes may be classified within the same or a different body system chapter.

Question 63

Describe the standard for the coding of deliveries using categories

Answer 63

All live born infants, regardless of the number of week’s gestation, must be coded as a delivery. For all delivery episodes: • A code from categories R17-R25 must be assigned in a primary procedural position • Code R24.9 All normal delivery must only be assigned for a normal delivery, i.e. when no other code in categories R17–R25 describing the delivery applies • If one type of delivery method is used and subsequently changed to another type; only the method used to successfully deliver the baby must be recorded. When coding caesarean sections: • Assign a code from category R17 Elective caesarean delivery for caesarean sections performed when the patient IS NOT in labour. • Assign a code from category R18 Other caesarean delivery for caesarean sections performed when the patient IS in labour (and for all emergency caesarean sections). When coding multiple deliveries (twins, triplets): • Each different type of delivery must be recorded with the most serious being sequenced first. • Where all methods of delivery are identical, only one code is required.

Question 64

Where in ICD-10 5th Edition is the point dash (.–) punctuation found and what is its purpose?

Answer 64

It is used in both the Tabular List and the Alphabetical Index to indicate there are fourth character subdivisions.

Question 65

Where both a skin graft and skin debridement have been performed, which procedure must be selected as the primary code?

Answer 65

The skin graft.

Question 66

Describe the ICD-10 5th Edition standard when it has been documented in the medical record that a patient with diabetes has hypoglycaemia without a coma, and this is not related to an adverse effect or a poisoning.

Answer 66

``` A code from category E16.- Other disorders of pancreatic internal secretion must be assigned followed by the code that classifies the type of diabetes from categories E10-E14, with the fourth character subdivision .9 Without complications (as hypoglycaemia is not classified as a complication in ICD-10). ```

Question 67

Describe the OPCS-4 standard relating to the use of a code from Chapter S to enhance a code from another body system chapter.

Answer 67

The code from Chapter S must be assigned: • When it provides further information about the procedure that is not specified in the primary body system code • In a secondary position, directly after the body system code it is enhancing.

Question 68

In accordance with standard DCS.XI.5: Parastomal hernia, what must be assigned in addition to the code for a parastomal hernia?

Answer 68

A code from category Z93.- Artificial opening status

Question 69

Describe the ICD-10 5th Edition standard where preventative surgery is being performed as a precautionary measure for a current condition.

Answer 69

The code classifying the condition must be assigned in a primary position and a code from category Z40.- Prophylactic surgery must be assigned in a secondary position.

Question 70

The fourth characters .8 and .9 are available in both principal and the extended categories within OPCS-4; why is this and describe the standard for their use in these categories?

Answer 70

In order to maintain the structure of the classification .8 and .9 codes are available in both principal and the extended categories. Only the .8 and .9 codes in the principal category can be used. The .8 and .9 codes from the extended category must not be used.

Question 71

Describe the ICD-10 5th Edition standard for the coding of infected open wounds.

Answer 71

They must be coded in the same way as a non-infected open wound, i.e. code assignment is the same but if the organism causing the infection is known, a code from categories B95–B98 Bacterial, viral and other infectious agents must be coded in addition

Question 72

Describe the ICD-10 5th Edition standard for the coding of infertility

Answer 72

When a patient has infertility and the cause is known, both conditions must be coded. Sequencing will depend on the main condition treated or investigated

Question 73

Where there is a documented diagnosis of cerebrovascular accident (CVA) or stroke and this is confirmed by the responsible consultant to be due to a thrombosis or embolism, what type of stroke must this be coded to?

Answer 73

Cerebral infarction

Question 74

Describe the OPCS-4 standard for the coding of an episiotomy and its subsequent repair.

Answer 74

This must be sequenced in a secondary position to the delivery code. The subsequent repair of an episiotomy must not be coded in addition. The exception is where the episiotomy has extended to a perineal tear.

Question 75

Describe the ICD-10 5th Edition standard when a patient is diagnosed with sepsis but the code assigned does not specifically classify sepsis

Answer 75

A code that classifies sepsis must be assigned in any secondary position.

Question 76

Describe the standard when the primary diagnostic statement records two or more independent primary malignant neoplasms none of which clearly predominates.

Answer 76

Code C97.X Malignant neoplasms of independent (primary) multiple sites must be assigned as the main condition. Additional codes must be used to identify the individual malignant neoplasms recorded in the medical record and may be sequenced in any order after C97.X.

Question 77

What us the definition of an intervention

Answer 77

Treatment for prevention, diagnosis, care or relief of disease For correction of deformity or deficit including for cosmetic reasons Associated with pregnancy, childbirth pr contraceptive or procreative management ``` Typically this will be: Surgical in nature Carries procedure risk Carries anaesthetic risk Requires specialist training Requires special facilities or equipment only available in an acute care setting ```