Patient—additional body function or structure affected, body function or structure code N[N]

Guide for use:

This data element should be used in conjunction with the data element Patient—primary body function or structure affected, body function or structure code N[N] to provide a greater depth of information on the harm alleged to have resulted from the health-care incident.

Up to three codes may be selected for this data element.

Code 9 'Death' is an invalid code for this data element but is a valid response for the data element: Patient—primary body function or structure affected, body function or structure code N[N].

Psychological harm as an additional body function or structure affected should be coded as 1 'Mental functions or structures of the nervous system'. Where a cancer has progressed and affects major body systems, but the organ or body part where the cancer originated is known, record the appropriate code for that organ or body part as the additional body function or structure affected.

Where the patient experiences pain as a result of the incident, and this pain is an additional body function or structure affected, record Code 2 'Sensory functions and pain of the eye, ear and related structures'. Where the pain experienced by the patient is deemed to be more disabling than the associated physical or mental damage to the patient, record the body structure or structures with which the pain is closely associated as an additional body function or structure affected.

Code 99 'Not stated/Inadequately described' should be used only when the information is not currently available, but is expected to become available as the claim progresses.