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8.1 Medical Coding1.pdf medical coding .
- 1. Placeholder confidentiality disclosure.Edit or delete from layout master if not needed. Use this second line if additional confidentiality disclosure information is required. Medical Coding 6 February 2025
- 2. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. The objective of this session is to • Understand the Purposes and uses of the ICD classification • Underline the basic difference between the two types of classification i.e. ICD and ICF. • Acquire knowledge of the various ICD and ICF codes available • Select the up-to-date ICD and ICF coding mechanism and software • Understand the ICD and ICF thoroughly, accurately and quickly • Understand ow to refer the manuals and guidelines of using the coding whenever required • Gain knowledge of referring, allotting or discarding medical codes • Determine that how to find the main term in the Alphabetic Index. • Determine that how to refer to the notes, modifiers, and sub terms under the main term. • Determine that how to follow any cross–reference instructions. Medical Coding 2 6 February 2025 Medical Coding
- 3. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. The objective of this session is to • Determine that how to assign the Code Number thus obtained. • Provide correct code to a particular disease accurately • Ascertain the discrepancies in information and confirm from the doctor for clarification of the diagnosis before putting the Code • Ensure that the discharged inpatient medical records should be coded daily and regularly against the discharge census • Acquire knowledge and skills to check the records that are not coded Medical Coding 3 6 February 2025 Medical Coding
- 4. International Statistical Classification ofDiseases and Related Health Problems (ICD)
- 5. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. International Statistical Classification of Diseases and Related Health Problems (ICD)
- 6. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. ICD is the diagnostic classification standard followed globally for all clinical and research purposes • Defines all diseases, disorders, injuries and other related health conditions • Comprehensive listing of diseases • Hierarchal distribution • Helps in easy storage, retrieval and analysis of Health Information • Helps in evidenced-based decision-making • Helps in Sharing and comparing health information between hospitals, regions, settings and countries • Data comparisons in the same location across different time periods • Based on clinical input, research and epidemiology, International Statistical Classification of Diseases and Related Health Problems (ICD) 6 6 February 2025 Medical Coding
- 7. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. ICD is the diagnostic classification standard followed globally for all clinical and research purposes • There are many diseases, there is need to have a common language for reporting and data analysis across world. ICD is a classification. In a population, they define set of entities that are studied, and they highlight the relevant aspects of the information that has been collected. • ICD classifications facilitates the – storage, – retrieval, – analysis, – Interpretation of data and their comparison • within populations over time and • between populations at the same point in time as well as the • compilation of internationally consistent data. • The population of the study may be as large as a nations, states and territories, regions, minority groups or other specified groups International Statistical Classification of Diseases and Related Health Problems (ICD) 7 6 February 2025 Medical Coding
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- 9. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. ICD has been a tool used for • Monitoring of the incidence and prevalence of diseases, External causes of illness • Causes of death • Billing and reimbursement of hospital treatments • Codes for antimicrobial resistance • Primary care and family medicine • Medicaments, allergens and chemicals, histopathology • Codes for full documentation of patient safety, • Dual coding for traditional medicine diagnoses • Diagnosis Related Groupings (DRG) • Resource allocation in Healthcare providers ICD classification - Uses 9 6 February 2025 Medical Coding
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- 11. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. ICD vs ICF 11 • The ICD classifies disease entities and other health conditions to gather diagnostic information • Manual of all causes of disease and health conditions. • Tracking health international health trends. • Standard diagnostic classification system. • ICF classifies the impact of health conditions on functional ability of a person. • ICF classifies health and disability both at individual and population levels • ICF provides components of total health picture • ICF classified Functional capability of individuals ICD ICF 6 February 2025 Medical Coding
- 12. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. ICD vs ICF 12 • Defines every disease, disorder and injury that can be said to cause adverse health symptoms. • Classified in a hierarchical manner so that the information provided by health organizations is easily accessed • Information can be shared universally and so that trends within a single geographical region can be easily monitored. • Impairments are defined as the loss or abnormality of body function or structure • Activities are execution of tasks or activities by an individual • Activity limitations are difficulties individuals may have in executing activities • Classified solely by the presence or absence a health condition ICD ICF 6 February 2025 Medical Coding
- 13. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. ICD vs ICF 13 • Helps in tracks the efficacy of Health Guidelines • Monitors health costs • Accounts for all mortality statistics from disease and others causes of death. • Function is based upon body functions, body structures, activities, and participation. • ICF complements ICD ICD ICF 6 February 2025 Medical Coding
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- 15. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. International Statistical Classification of Diseases and Related Health Problems (ICD) • Is The global standard for health data, clinical documentation, and statistical aggregation • It has Multiple uses, • Present ICD 11 includes primary care • The codes are scientifically up-to-date, Codes are designed for use in a digital world • Helps in reducing the costs of training and implementation • Versatile, easy to use in multiple languages, and across world with ease • Permits counting of diseases, injuries, symptoms, reasons for encounter • Maps with factors that influence health status, and external causes of disease and death, such as accidents. ICD Codes 15 6 February 2025 Medical Coding
- 16. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. International Statistical Classification of Diseases and Related Health Problems (ICD) • The International Classification of Diseases is designed to serve as a way to capture mortality and morbidity data for reporting for public health, epidemiology and treatment, and allows comparison of frequencies of e.g. causes of death from community level up to the whole world. • ith all WHO members states having committed to report causes of death and illness to WHO since 1967 • is a classification that is used in 194 countries. I ICD Codes 16 6 February 2025 Medical Coding
- 17. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. History • First started as the International List of Causes of Death in 1893 • Regularly revised and published to reflect advances in health and medical science over time. • WHO was entrusted with the ICD at its creation in 1948 • Morbidity was included in 1948 • ICD-10 was endorsed in May 1990 • ICD-10 is used in 150 countries • ICD-10 is translated in 40 languages • ICD-10 is cited in more than 20,000 scientific articles ICD Codes 17 6 February 2025 Medical Coding
- 18. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. History • Latest version is ICD-11 • ICD-11 has been adopted by the Seventy-second World Health Assembly in May 2019 • ICD-11 comes into effect on 1 January 2022 • ICD -11 focuses on digitization • ICD 11 includes primary care • ICD-11 migrated coding from a statistical framework to a clinical classification for statistical use. ICD Codes 18 6 February 2025 Medical Coding
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- 20. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. International Classification of Functioning, Disability and Health (ICF) • Provides a framework to understand functioning and disability, in a disease and disorder • E.g Two persons with same disorder may have different grade of impact, hence the impact is important • Creates common language to support communication to reduce overlaps, redundancies and gaps – Among Professionals – Across levels of care – Among Sectors • Facilitates sharing of information on functioning and disability helping in more coordinated approach while providing care • Supports monitoring health status, before and after interventions (E.g. Patient with Hepatis B positive may be sick in bed, after intervention may be back to work, Disease remains to be Hepatitis) • Disability’s are mapped across geography, timelines with help of ICF ICF Codes 20 6 February 2025 Medical Coding
- 21. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. International Classification of Functioning, Disability and Health (ICF) • Helps in identifying the health status and the needs of individuals and populations • Helps in developing functioning profile of a person with health condition over and above the diagnosis • Helps to monitor the impact of interventions on functioning • Helps in comparing data by providing an standard for capturing disability data • Provides scientific basis for health outcomes • Provides systematic coding for Health Information Systems • Has been widely accepted framework for health and health related research • Enables identification of overlapping responsibilities among different sectors E.g. Disabled friendly access, Medical cover for disabled, Tax exemptions for specific conditions ICF Codes 21 6 February 2025 Medical Coding
- 22. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. ICF is complementary to ICD. ICF coding is used in wider areas like • Medical and Healthcare Services • Community Development Services • Livelihood and Sustainability • Education • Policy planning • Advocacy ICF Codes 22 6 February 2025 Medical Coding
- 23. Latest ICD andICF versions
- 24. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. Medical Records Department should • Adopt latest versions of ICD Codes and ICF Codes • The software used should be compatible to latest versions • Software provider should upgrade the tools to newer versions as and when their release • On release of new version/ update team should undergo training in new version Latest ICD and ICF versions 24 6 February 2025 Medical Coding
- 25. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. Latest version of ICD Code • ICD-10 is the latest code • ICD-10 Version 2019 is the latest version • ICD-10 Version 2019 is eleventh revision • ICD-11 has been adopted by the Seventy- second World Health Assembly in May 2019 • ICD-11 comes into effect on 1 January 2022. • ICD-11 includes primary health • ICD-11 codes support digital entries Latest ICD Version 25 6 February 2025 Medical Coding
- 26. Comprehend the ICDand ICF thoroughly, accurately and quickly
- 27. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. Its important to provide correct code to particular disease accurately. The ways to check accuracy of coding are • Sensitivity • Specificity, • Positive predictive value • Negative predictive value • κ coefficient. Comprehend the ICD and ICF code correctly 27 6 February 2025 Medical Coding
- 28. Way to referto the manuals
- 29. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. The ICD-10 manual is of three parts • Introduction to classification • Structure of Classification • Chapters (Each chapter) – Introduction and objectives – Overview – Coding - Review of the chapter – Review of the chapter – Self-check test – Exercises – Summary – Medical Science Way to refer to ICD-10 manual 29 6 February 2025 Medical Coding
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- 31. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. ICD-10 Code Set • The codes in ICD-10-CM code set can have 3- 7 charecters • More characters indicate more specific diagnosis • First character is a letter (Alpha) • Characters 2 – 7 can be (Alpha-Numeric) • First three characters indicate Category E.g – J20.6 Acute Bronchitis due to rhinovirus – Chapter 10 (J) – Diseases of Respiratory System • Etiology – Next three characters indicate the related etiology • Extension – Next character is extension, indicating characteristic of encounter Medical Coding 31 6 February 2025 Medical Coding
- 32. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. The manual comprises of 22 chapters as per ICD-10 Version 2019 • I Certain infectious and parasitic diseases • II Neoplasms • III Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism • IV Endocrine, nutritional and metabolic diseases • V Mental and behavioral disorders • VI Diseases of the nervous system • VII Diseases of the eye and adnexa • VIII Diseases of the ear and mastoid process • IX Diseases of the circulatory system • X Diseases of the respiratory system • XI Diseases of the digestive system Medical Coding 32 6 February 2025 Medical Coding
- 33. Placeholder confidentiality disclosure.Edit or delete from master slide if not needed. The manual comprises of 22 chapters as per ICD-10 Version 2019 (Covid expanded) • XII Diseases of the skin and subcutaneous tissue • XIII Diseases of the musculoskeletal system and connective tissue • XIV Diseases of the genitourinary system • XV Pregnancy, childbirth and the puerperium • XVI Certain conditions originating in the perinatal period • XVII Congenital malformations, deformations and chromosomal abnormalities • XVIII Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified • XIX Injury, poisoning and certain other consequences of external causes • XX External causes of morbidity and mortality • XXI Factors influencing health status and contact with health services • XXII Codes for special purposes Medical Coding 33 6 February 2025 Medical Coding