ICD Fundamentals
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A presentation about ICD-10 and ICD-9-CM disease classification systems used in Thailand. It was presented to a group of new medical residents at my institution in Thailand back in 2005. Parts of ...

A presentation about ICD-10 and ICD-9-CM disease classification systems used in Thailand. It was presented to a group of new medical residents at my institution in Thailand back in 2005. Parts of presentation in Thai.

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ICD Fundamentals Presentation Transcript

  • 1. ICD Fundamentals Nawanan Theera-Ampornpunt, M.D. Medical Informatics Division Faculty of Medicine Ramathibodi Hospital 18 May 2005 Reproduced Nov. 23, 2008 for publishing on SlideShare.net. Parts of the presentation may be specific to the use of ICD-9-CM and ICD-10 in the author’s organization or country (Thailand) and may not be applicable to other settings. Some contents are adopted from “ICD-10-TM Standard Coding Guidelines” by Bureau of Policy and Strategy, Office of the Permanent Secretary, Ministry of Public Health, Thailand, 2004
  • 2. What is ICD-10? International Statistical Classification of Diseases and Related Health Problems, Tenth Revision Effective 1 Jan. 1993 Adopted in Thailand since 1994
  • 3. Current Usage in Thailand Governmental reimbursement ICD-10 for diagnoses ICD-9-CM-2000 for operations Developed ICD-10-TM based on international ICD-10 to better categorize diagnoses of tropical and endemic diseases ICD-10-TM has been adopted increasingly in various institutions, but not yet supported by reimbursement organizations
  • 4. Why ICD-10? International cooperation & standard Accepted standard for national statistics Governmental reimbursement (DRG) National Health Security Office Social Security Office Central Office for Healthcare Information Thai DRG uses ICD-10 for calculating proper RW (Relative Weight) for reimbursement
  • 5. RW Relative Weight (for reimbursement) More RW = More severe = More money RW calculations are based on Number of diseases Complexity and severity of diseases Principle diagnosis Operations done Age, sex, weight Discharge type
  • 6. Data Completeness and RW RW depends on completeness of diagnoses proper diagnosis entry Priority (Principal vs. Secondary) Severity Specificity
  • 7. A patient with underlying beta thalassemia was admitted due to Streptococcus pneumoniae pneumonia and during admission had experienced ARDS and needed ET tube and ventilator support. Later, pneumothorax occurred and ICD was done. After 1 month, patient improved and was discharged. Diagnosis Entry RW PDx J13 Pneumonia due to Streptococcus pneumoniae 0.7142 PDx J13 Pneumonia due to Streptococcus pneumoniae 1.6884 SDx D561 Beta thalassemia PDx D561 Beta thalassemia SDx J13 Pneumonia due to Streptococcus pneumoniae 1.2256 PDx J13 Pneumonia due to Streptococcus pneumoniae SDx D561 Beta thalassemia 1.6884 J80 Adult respiratory distress syndrome PDx J13 Pneumonia due to Streptococcus pneumoniae 1.8631 SDx D561 Beta thalassemia J80 Adult Respiratory Distress Syndrome POp 9672 Continuous mechanical ventilation for 96 consecutive hrs. or more
  • 8. A patient with underlying beta thalassemia was admitted due to Streptococcus pneumoniae pneumonia and during admission had experienced ARDS and needed ET tube and ventilator support. Later, pneumothorax occurred and ICD was done. After 1 month, patient improved and was discharged. Diagnosis Entry RW (Previously) 1.8631 PDx J13 Pneumonia due to Streptococcus pneumoniae SDx D561 Beta thalassemia J80 Adult Respiratory Distress Syndrome POp 9672 Continuous mechanical ventilation for 96 consecutive hrs. or more PDx J13 Pneumonia due to Streptococcus pneumoniae 2.3146 SDx D561 Beta thalassemia J80 Adult Respiratory Distress Syndrome J939 Pneumothorax POp 9672 Continuous mechanical ventilation for 96 consecutive hrs. or more SOp 9604 Insertion of endotracheal tube 3404 Insertion of intercostal catheter for drainage
  • 9. Concept of Diagnosis Principal diagnosis (PDx) One condition Diagnosed at the end of care (Final Dx) Main reason for the admission In case of more than one main reason, use the most resource-consuming Dx In case of no definitive Dx, use most appropriate signs/symptoms or findings Some codes may be valid only in specific gender or specific age groups
  • 10. Concept of Diagnosis Secondary diagnosis (SDx) Comorbidity Condition(s) existing before admission May exist before or at the same time with the PDx Includes underlying diseases Causes more expenses or higher patient risks Unlimited items Complication Condition(s) occurring after admission Causes more expenses or higher patient risks May not be related to PDx Unlimited items
  • 11. Examples – PDx & SDx A patient with underlying DM, HT, IHD presents with severe headache and BP = 200/140 mmHg PDx I10 Essential (malignant) Hypertension SDx E119 NIDDM without complications I259 Chronic ischaemic heart disease, unspecified
  • 12. Examples – In case of 2 potential PDx Use the most resource-consuming A patient was admitted due to bacterial pneumonia with respiratory failure. PDx J960 Acute respiratory failure SDx (comorbid) J159 Bacterial pneumonia, unspecified Note!! If respiratory failure occurs after admission, then the PDx must be bacterial pneumonia and the respiratory failure must be the SDx (complication)
  • 13. Examples – PDx must be at the end of care A patient with acute abdominal pain was admitted, the provisional diagnosis was peritonitis. Surgical findings revealed perforated chronic duodenal ulcer PDx K265 Duodenal ulcer : chronic or unspecified with perforation SDx -
  • 14. Examples – PDx as signs/symptoms A patient with RLQ pain was admitted for observation, later discharged without definitive diagnosis because the symptoms finally resolved PDx R103 Pain localized to other parts of lower abdomen SDx -
  • 15. Examples – Complications related to PDx A patient with deep vein thrombosis was admitted. After admission, pulmonary embolism occurs. PDx I801 Phlebitis and thrombophlebitis of femoral vein SDx (complication) I269 Pulmonary embolism without mention of acute cor pulmonale
  • 16. Examples – Complications not related to PDx A patient with pneumonia was admitted. After admission, acute gastroenteritis occurred. PDx J159 Bacterial pneumonia, unspecified SDx (complication) A09 Diarrhoea and gastroenteritis of presumed infectious origin
  • 17. Examples – Comorbids vs complications A patient with underlying DM and diabetic retinopathy was admitted due to bacterial pneumonia. After admission, acute gastroenteritis that resulted in hypovolemia occurred. PDx J159 Bacterial pneumonia, unspecified SDx (comorbids) E116 NIDDM with ophthalmic complications H360 Diabetic retinopathy SDx (complications) A09 Diarrhoea and gastroenteritis of presumed infectious origin E86 Volume depletion
  • 18. Concept of Diagnosis Principal Operation (POp) Procedure/Operation primarily done for the admission Mostly done for PDx, but may be done for SDx Mostly the major operative procedure is done in OR, but not necessarily (can be a non-OR procedure) If more than 1 potential procedure, use clinical judgement for what is the most important procedure for the admission One condition allowed Secondary Operation (SOp) All other significant procedures/operations Unlimited items Avoid insignificant procedures, like IV infusion, dressings
  • 19. Examples – Principal vs Secondary Ops. A patient with indirect inguinal hernia was admitted. Herniorrhaphy was done. After admission, pleural effusion was found and subsequent ICD was done. PDx K409 Unilateral or unspecified inguinal hernia, without obstruction or gangrene SDx J90 Pleural effusion, not elsewhere classified POp 5302 Repair of indirect inguinal hernia SOp 3404 Insertion of intercostal catheter for drainage
  • 20. Examples – Principal Ops. for PDx A patient with indirect inguinal hernia was admitted. After admission, pneumonia occured. Herniorrhaphy was done during the admission after treatment of pneumonia. PDx K409 Unilateral or unspecified inguinal hernia, without obstruction or gangrene SDx J159 Bacterial pneumonia, unspecified POp 5302 Repair of indirect inguinal hernia SOp -
  • 21. Examples – Principal Ops. for SDx A patient with pneumonia was admitted. After admission, indirect inguinal hernia was found and herniorraphy was done during the admission after treatment of pneumonia. PDx J159 Bacterial pneumonia, unspecified SDx K409 Unilateral or unspecified inguinal hernia, without obstruction or gangrene POp 5302 Repair of indirect inguinal hernia SOp -
  • 22. Examples – Principal Ops. Outside OR A patient with pneumonia and pleural effusion was admitted. After admission, ICD was done. PDx J159 Bacterial pneumonia, unspecified SDx J90 Pleural effusion, not elsewhere classified POp 3404 Insertion of intercostal catheter for drainage SOp -
  • 23. Examples – Non-OR Principal Ops. A patient with pneumonia and pleural effusion was admitted. After admission, ICD was done. PDx J159 Bacterial pneumonia, unspecified SDx J90 Pleural effusion, not elsewhere classified POp 3404 Insertion of intercostal catheter for drainage SOp -
  • 24. Examples – Non-OR Principal Ops. A preterm newborn with respiratory distress syndrome was admitted. After admission, NEC occured and small intestine resection with end-to- end anastomosis was done. PDx P220 Respiratory distress syndrome of newborn SDx (Comorbid) P073 Other preterm infants SDX (Complication) P77 Necrotizing enterocolitis of fetus and newborn POp 4562 Other partial resection of small intestine SOp 4591 Small-to-small intestinal anastomosis
  • 25. ICD-10 Chapters Certain infectious and parasitic diseases Neoplasms Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Endocrine, nutritional and metabolic diseases Mental and behavioural disorders Diseases of the nervous system Diseases of the eye and adnexa Diseases of the ear and mastoid process
  • 26. ICD-10 Chapters (Cont.) Diseases of the circulatory system Diseases of the respiratory system Diseases of the digestive system Diseases of the skin and subcutaneous tissue Diseases of the musculoskeletal system and connective tissue Diseases of the genitourinary system Pregnancy, childbirth and the puerperium Certain conditions originating in the perinatal period
  • 27. ICD-10 Chapters (Cont.) Congenital malformations, deformations and chromosomal abnormalities Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified Injury, poisoning and certain other consequences of external causes External causes of morbidity and mortality Factors influencing health status and contact with health services
  • 28. External Causes of Morbidity and Mortality (E-codes) External causes of trauma/injury/poisoning that results in morbidity/mortality Important for national statistics and prevention measures If not specified, it’s incomplete
  • 29. External Causes of Morbidity and Mortality (V, W, X, Y) Classified into Accidents Intentional self-harm Assault Event of undetermined intent Legal intervention and operations of war Complications of medical and surgical care Sequelae of external causes Supplementary factors related to causes... (eg. alcohol level, nosocomial condition, etc.)
  • 30. Accidents as External Causes Transport accidents Non-transport
  • 31. Accidents as External Causes Transport accidents Pedestrian injured Pedal cyclist injured Motorcycle rider injured Occupant of three-wheeled motor vehicle injured Car occupant injured Occupant of pick-up truck or van injured Occupant of heavy transport vehicle injured Bus occupant injured Other land transport accidents Water transport accidents Air and space transport accidents Other and unspecified transport accidents Non-transport
  • 32. Accidents as External Causes Transport accidents Non-transport Falls Exposure to inanimate mechanical forces (includes GSW) Exposure to animate mechanical forces Accidental drowning and submersion Other accidental threats to breathing Exposure to electric current, radiation and extreme ambient air temperature and pressure Exposure to smoke, fire and flames Contact with heat and hot substances Contact with venomous animals and plants Exposure to forces of nature Accidental poisoning by and exposure to noxious substances Overexertion, travel and privation Accidental exposure to other and unspecified factors
  • 33. Transport Accidents Any accident involving device designed primarily for conveying persons or goods from one place to another Classified into Traffic accident Any vehicle accident occuring on the public highway (e.g. originating on, terminating on, involving a vehicle partially on the highway) Nontraffic accident occurs entirely in any place other than a public highway, e.g. off-road motor vehicle accidents
  • 34. Transport Accidents Pedestrian = any person involved in the accident that is not in any vehicle or animal Includes: person changing wheel of vehicle making adjustment to motor of vehicle on foot person with baby carriage ice-skaters person with push-cart or push-chair Roller-skaters Scooter rider, skateboard rider, skier, person with (powered) wheelchair Driver = occupant of a transport vehicle who is operating or intending to operate it Passenger is other person than driver Person on outside of vehicle = any person being transported by a vehicle but not occupying the space normally reserved for driver & passengers Includes: person travelling on bodywork (ตัวถังรถ), bumper (กันชน), hanging outside, on roof, etc.
  • 35. Transport Accidents Pedal cycle = bicycle & tricycle Pedal cyclist = any person riding on pedal cycle or in a sidecar attached to it Motorcycle includes: Motor scooter Motorcycle with sidecar Motorized bicycle Excludes motor-driven tricycle Motorcycle rider includes person riding on or in a sidecar Three-wheeled motor vehicle includes: motor-driven tricycle, three-wheeled motor car Car = 4 wheeled motor vehicle, including minibus
  • 36. Transport Accidents Pick-up Truck or van = 4 or 6 wheeled motor vehicle designed primarily for carrying property, weighing less than local limit for classification as heavy goods vehicle, not requiring special driver’s license Heavy transport vehicle = over pick-up truck, usually carrying above 3,500 kg), requiring special driver’s license Bus = motor vehicle designed for carrying > 10 persons, requiring special driver’s license Railway train includes BTS and Subway Streetcar includes tram (รถราง)
  • 37. Transport Accidents Other types of vehicles Special vehicle mainly used on industrial premises Special vehicle mainly used in agriculture Special construction vehicle Special all-terrain vehicle Watercraft Aircraft
  • 38. Transport Accident Coding Instructions If event is unspecified whether traffic or nontraffic accident, it is: Trafffic accident if occurred with vehicles normally used for traffic Nontraffic accident if occurred with special vehicles If can’t specify the victim as vehicle occupant and the victim is crushed/dragged/hit/injured/killed/knocked down/run over by vehicles, classify the victim as pedestrian
  • 39. Transport Accident Coding Instructions In transport accident involving vehicle collision/accident/crash/wreck, if can’t specify the victim’s role, classify the victim as occupant or rider of vehicle specified If more than one vehicle is mentioned, do not make assumption which vehicle was occupied by victim unless vehicles are the same, but use codes with “Victim’s mode of transport unknown” instead
  • 40. Transport Accident Coding Instructions Collision Includes collision after breakage of any part explosion of any part fire starting in vehicle hit by object thrown into or onto vehicle object falling in or on etc. Includes collision between vehicle and vehicle or vehicle and: animal (สัตว์ที่อยูเ่ ฉยๆ ในทางจราจร) nonmotor vehicle animal-driven vehicle ํ animal being ridden (สัตว์ที่กาลังถูกขี่) bridge fallen stone fence inter-highway divider landslide object thrown in front of motor vehicle safety island (เกาะกลางถนน) tree traffic sign other object - either fixed/movable/moving Noncollision fall or thrown away from vehicle without prior collision overturning without collision
  • 41. Intentional Self-Harm Suicide and suicidal attempt Non-suicidal but intentional self- injury/poisoning Intentional self-poisoning Hanging, strangulation & suffocation Drowning & submersion GSW Sharp object Blunt object Jumping from high place Jumping or lying before moving objects Crashing of motor vehicle
  • 42. Assault Drugs and biological substance Chemical or noxious substances Hanging, strangulation & suffocation drowning and submersion GSW Explosive material Smoke, fire and flames Steam, hot vapours and hot objects Sharp object Blunt object Pushing from high place Pushing or placing victim before moving object Crashing of motor vehicle By bodily force (Unarmed fight) Sexual assault by bodily force Neglect and abandonment Other maltreatment syndromes
  • 43. Event of Undetermined Intent Similar to intentional self-harms and assaults Legal Intervention and Operations of War Legal actions Legal execution (ประหารชีวต) ิ War operations
  • 44. Complications of Medical and Surgical Care Includes Complications of medical devices Correct drug administered in therapeutic dosage but cause adverse effect Misadventures to patients during surgical/medical care Surgical and medical procedures causing abnormal reaction or immediate or later complication Excludes Accidental drug over-dosage Wrong drug given or taken
  • 45. Adverse Drug Effects in Therapeutic Use Systemic antibiotics (Y40) Penicillins Cefalosporins & other beta-lactams Chloramphenicol Macrolides Tetracyclines Aminoglycosides Rifamycins Systemic antifungal antibiotics Other systemic anti-infectives Other systemic anti-infectives (Y41) Sulfonamides Anti-TB Antimalarials & drugs acting on blood protozoa Other antiprotozoal Anthelminthics Antiviral drugs Others
  • 46. Adverse Drug Effects in Therapeutic Use Hormones & Antagonists (Y42) Glucocorticoids Thyroid hormones Antithyroid drugs Insulin and oral hypoglycemic drugs etc. Primarily systemic agents (Y43) Antiallergic & antiemetic drugs Antineoplastic drugs Immunosuppressive agents Acidifying & alkalizing agents etc.
  • 47. Adverse Drug Effects in Therapeutic Use Agents primarily affecting blood constituents (Y44) Iron and other anti-hypochromic anemia preparations Anti-megaloblastic anemia preparations Anticoagulants Vit. K & coagulants Thrombolytic drugs etc. Analgesics, antipyretics, anti-inflammatory (Y45) Antiepileptics & antiparkinsonism (Y46) Sedatives, hypnotics & antianxiety drugs (Y47) Anesthetics & therapeutic gases (Y48) Psychotropic drugs NEC (Y49) TCA, MAOI, antipsychotics, neuroleptics CNS stimulants NEC (Y50) Drugs affecting ANS (Y51)
  • 48. Adverse Drug Effects in Therapeutic Use Agents affecting CVS (Y52) Agents affecting GI (Y53) Agents affecting water-balance & mineral & uric acid metabolism (Y54) Agents acting on smooth & skeletal muscles and respiratory system (Y55) Oxytocins Muscle relaxants Antitussives Expectorants Anti-common-cold drugs Antiasthmatics NEC Topical agents on skin, eye, ENT & dental drugs (Y56) Others (Y57) Antidotes & chelating agents NEC X-ray contrast media Bacterial vaccines (Y58) Other vaccines & biological substances (Y59) Immunoglobulin
  • 49. Misadventures to patients during surgical and medical care Unintentional cut, puncture, perforation or hemorrhage during surgical and medical care (Y60) Foreign object accidentally left in body during surgical and medical care (Y61) Failure of sterile precautions during surgical and medical care (Y62) Failure in dosage during surgical and medical care (Y63) Excludes accidental overdose of drug or wrong drug given in error (X40-X44) Contaminated medical or biological substances (Y64) Others (Y65) Mismatched blood used in transfusion Wrong fluid used in infusion Failure in suture or ligature during surgical operation ET Tube wrongly placed during anesthetic procedure Failure to introduce or to remove other instruments Performance of inappropriate operation Nonadministration of surgical and medical care (Y66)
  • 50. Medical devices associated with adverse incidents in diagnostic and therapeutic use Anesthesiology devices (Y70) CVS devices (Y71) ENT devices (Y72) GI & urology devices (Y73) General hospital and personal-use devices (Y74) Neurological devices (Y75) Obstetric & gynecological devices (Y76) Ophthalmic devices (Y77) Radiological devices (Y78) Orthopedic devices (Y79) Physical medicine devices (Y80) General surgery and plastic surgery devices (Y81) Other (Y82)
  • 51. Surgical and other medical procedures as the cause of abnormal reaction, without mention of misadventure at the time of procedure Surgical operation and other surgical procedures (Y83) Transplant of whole organ Implant of artificial internal device Anastomosis, bypass or graft Formation of external stoma Other reconstructive surgery Amputation of limb(s) Removal of other organ (partial/total) Other Other medical procedures (Y84) Cardiac catheterization Kidney dialysis Radiological procedure and radiotherapy Shock therapy Aspiration of fluid Insertion of gastric or duodenal sound Urinary catheterization Blood-sampling Other
  • 52. Notes If there is any S or T code in PDx or SDx, there must be external causes If the diagnosis is drug-induced or poisoning, there must be external causes If the diagnosis is trauma-related, there must be external causes External causes must not be used as PDx
  • 53. Examples – External causes A man riding motorcycle was hit by truck during his way home after work. He experienced cerebral concussion and close fracture of Rt. femur, after admission, aspiration pneumonia occured PDx S7230 Fracture of shaft of femur : closed SDx (comorbid) S0600 Concussion, without open intracranial wound SDx (complication) J690 Pneumonitis due to food and vomit External cause V2442 Motorcycle rider injured in collision with heavy transport vehicle or bus, driver injured in traffic accident, while working for income
  • 54. Activity Code While engaged in sports activity While engaged in leisure activity Hobby Leisure-time activities with entertainment element Voluntary activities While working for income Includes during transportation to and from working While engaged in other types of work Cleaning, cooking, gardening, etc. While resting, sleeping, eating or engaging in other vital activities Personal hygiene While engaged in other specified activities During unspecified activity
  • 55. Examples – External causes A woman with CA cervix who underwent radiotherapy came to the hospital due to radiation cystitis PDx N304 Irradiation cystitis SDx C539 Malignant neoplasm of cervix uteri, unspecified External cause Y842 Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure
  • 56. Examples – External causes A woman with acute pyelonephritis was admitted to the hospital and was given Ceftriaxone. After drug administration, she experienced urticaria and hypotension. PDx N10 Acute tubulo-interstitial nephritis SDx L500 Allergic urticaria T886 Anaphylactic shock due to adverse effect of correct drug or medicament properly administered External cause Y401 Cefalosporins and other beta-lactam antibiotics causing adverse effects in therapeutic use
  • 57. Note!! In the software in Ramathibodi wards, some items show only the name of the drugs causing adverse effects. For example, T361 Cefalosporins and other beta- lactam antibiotics Y401 Cefalosporins and other beta- lactam antibiotics What’s their differences???
  • 58. Note!! In the ICD search screen, try choose T36, you’ll see Poisoning by systemic antibiotics, so T361 is poisoning by cefalosporins and other beta-lactam antibiotics Similarly, try choose Y40, you’ll see Systemic antibiotics It’s still not understood... Knowing that Y items are external causes would be beneficial. In this case, it is the code for drugs causing adverse effects in therapeutic use
  • 59. Examples – External causes A woman who previously broke up with boyfriend intentionally took 30 tablets of paracetamol. She was then taken to the hospital. PDx T391 Poisoning by 4-Aminophenol derivatives External cause X600 Intentional self-poisoning by and exposure to nonopioid analgesics, antipyretics and antirheumatics at home Please note that paracetamol is 4-Aminophenol derivatives
  • 60. Place of Occurrence Home Apartment Farmhouse Private places, etc. Residential institution Children’s home Dormitory Home for the sick Military camp Nursing home Old people’s home Prison
  • 61. Place of Occurrence School, other institution and public administrative area Campus, college Church Cinema Court-house Gallery, museum Hospital Library Public hall Post office Sports and athletics area Street and highway Freeway, motorway, pavement, sidewalk Trade and service area Airport Bank Casino Gas station Hotel Restaurant Market Shop Shopping mall Supermarket Bus station
  • 62. Place of Occurrence Industrial and construction area Farm Other specified places Unspecified places
  • 63. Factors Influencing Health Status and Contact with Health Services (Code Z) In some cases, provision of supplemental codes Z would be beneficial for statistical completeness and medical record review Problems related to lifestyle (Z72) Tobacco use (Z720) Alcohol use (Z721) Drug use (Z722) Inappropriate diet and eating habits (Z724) High-risk sexual behaviour (Z725) Family history of diseases (Z80-Z84) Personal history of diseases (Z85-Z88) Acquired absence of limb or other organ (Z89-Z90) Risk factors and personal history of medical treatment (Z91-Z92) Personal history of self-harm Personal history of major surgery Personal history of irradiation
  • 64. Factors Influencing Health Status and Contact with Health Services (Code Z) Artificial opening status (Z93) Tracheostomy Gastrostomy Ileostomy Colostomy Cystostomy etc. Transplanted organ and tissue status Kidney transplant status Heart transplant status Lung transplant status Liver transplant status Bone transplant status Bone marrow transplant status (Z948) etc. Presence of cardiac and vascular implants and grafts (Z95) Presence of other functional implants (Z96) Presence of intraocular lens Presence of insulin pump (endocrine implants) Presence of orthopaedic joint implants, etc.
  • 65. Factors Influencing Health Status and Contact with Health Services (Code Z) Presence of other devices (Z97) Presence of artificial eye Presence of artificial limb Presence of intrauterine contraceptive device Other postsurgical states (Z98) Intestinal bypass and anastomosis status Arthrodesis status Presence of CSF shunt, etc. Dependence on enabling machines and devices (Z99) Dependence on aspirator Dependence on respirator Dependence on renal dialysis Dependence on wheelchair, etc. These codes must not be used as PDx
  • 66. How To Choose The Proper Code in the Software? Start search by most relevant keyword(s) Don’t be too specific, it may have no results Asthma instead of Acute severe asthma Don’t be too generic, it may have extensive results enteritis instead of infection Avoid uncommon terms, they may have no results Pneumonia instead of Pulmonary infection Be aware of incorrect sequence of keywords Tuberculosis of lung instead of Lung tuberculosis Use generic form of the words first Asthma instead of Asthmatic Anaphyla instead of Anaphylaxis, Anaphylactic (because you don’t know what words are used in ICD-10) Infection instead of infections
  • 67. How To Choose The Proper Code in the Software? Choose most specific and relevant code (need human decision) Acute pharyngitis instead of URI See description for more details (inclusions, exclusions) N811 Cystocele Cystocele with urethrocele Prolapse of (anterior) vaginal wall NOS Excludes: cystocele with prolapse of uterus (N812-N814) NOS Not Otherwise Specified NEC Not Elsewhere Classified Use the most detailed items Don’t use N81 but use N811
  • 68. How To Choose The Proper Code in the Software? If can’t find the proper specific code, try using related-words British terms (Diarrhoea, Oedema, Haemorrhage, Centre, Labour, Programme, Licence) Other word forms Amoeba, Amoebic, Amoebiasis Infection, Infectious, Infective, Inflammation, more specific conditions Tuberculosis, tuberculous Try other similar words LBP -> Dorsalgia bacteremia -> septicaemia / sepsis Oral candidiasis -> Candidal stomatitis Enterocolitis -> Enteritis, colitis, gastroenteritis, etc. Liver failure -> Hepatic failure Try other disease/syndrome names Colle’s fracture -> Fracture of lower end of radius Try avoid abbreviations Tuberculosis instead of TB Upper respiratory tract infection instead of URI If still can’t find the proper code, use the diagnosis tree If still can’t find the proper code, use ‘Other’ if the disease is specific, or use ‘Unspecified’ if non-specific
  • 69. Dual Code System Appears as dagger (+) and asterisk (*) Some codes need multiple entry, e.g. TB Meningitis A17.0+ Tuberculous meningitis (G01*) G01* Meningitis in bacterial diseases classified elsewhere Notice the + and * sign, if present, consider using the other code, too + must always be present, * is optional If * is entered, + must first be present
  • 70. Examples – Dual Codes A patient was admitted due to cryptococcal meningitis. PDx B451 Cerebral cryptococcosis (G021*) SDx (Comorbid) G021 Meningitis in mycoses classified elsewhere
  • 71. Examples – Dual Codes A patient was admitted due to histoplasmosis with pneumonia. PDx B394 Histoplasmosis capsulati, unspecified SDx (Comorbid) J172 Pneumonia in mycoses
  • 72. Examples – Dual Codes A patient was admitted due to amoebic lung abscess. PDx A065 Amoebic lung abscess (J99.8*) SDx (Comorbid) J998 Respiratory disorders in other diseases classified elsewhere
  • 73. ICD-10 In Particular Diseases Chemotherapy/Radiotherapy In OPD case or patients with less than 24 hours length of stay, use this as PDx Z511 Chemotherapy session or Z510 Radiotherapy session In IPD case with more than 24 hours length of stay, use Z511 or Z510 as SDx and use proper diagnosis (e.g. CA colon) as PDx
  • 74. ICD-10 In Particular Diseases DM IDDM Coma DKA With renal complications With ophthalmic complications With neurological complications With peripheral circulatory complications With other specified complications With multiple complications With unspecified complications Without complications NIDDM Malnutrition-related DM Other specified DM Unspecified DM
  • 75. ICD-9-CM Used for operations and procedures Consists of 3- to 4-digit codes Categorized by systems Nervous system Endocrine system Eye Ear Nose, mouth and pharynx Respiratory system Cardiovascular system Hemic and lymphatic system Digestive system Urinary system Male genital organs Female genital organs Obstetrical procedures Musculoskeletal system Integumentary system Miscellaneous
  • 76. Commonly Used ICD-9CM 9604 Insertion of endotracheal tube 3322-24 Bronchoscopy 4413 Other gastroscopy 4414 Gastroscopy with biopsy (Brush biopsy of stomach) 311 Temporary tracheostomy 9671 Continuous mechanical ventilation for less than 96 consecutive hours 9672 Continuous mechanical ventilation for 96 consecutive hours or more
  • 77. Commonly Used ICD-9-CM 3894 Venous cutdown 3893 Central venous catheterization NEC 8604 Other incision with drainage of skin and subcutaneous tissue 3404 Insertion of intercostal catheter for drainage 8872 Diagnostic ultrasound of heart (echocardiography) Sometimes, need to use categorized trees to find codes. If can’t find proper code, use “others”