Medical Record - International Classification of Diseases(ICD) and Procedures, the method of indexing data

Why do we need to code?

Coding is done in order to group conditions and procedures that are similar for statistical tabulation. Medical and health statistics are generally used to

• Review previous cases of a given disease in order to provide insight into the management of current patient's health problems
• Test theories and compare data on certain diseases or treatments in order to conduct research and prepare scientific papers
• Procure data on the utilisation of hospital facilities and to establish a hospital's need for new equipment, beds, staff, etc., in various departments
• Evaluate the quality of care in the hospital.
• Conduct epidemiological and infection control studies on the work environment.
• To accumulate risk management data, such as the incidence of medical and surgical complications.

In order to develop the best possible health care delivery system with preventive, curative and rehabilitative components, it is necessary to have comprehensive information on morbidity and mortality. While making efforts to achieve this the need for the disease classification acceptable throughout the globe was felt. It led to the development of ICD .

Code numbers

• The code numbers that follow the terms refer to categories and subcategories under which the terms should be classified. If the code has only three characters, it can be assumed that the category has not been subdivided. In most instances where the category has been subdivided, the code number will give the fourth character. A dash in the fourth position (003. -) means that the category has been subdivided and that the fourth character can be found by referring to the tabular list.
• In listing inclusions and exclusion terms in the tabular list, the ICD employs some special conventions relating to the use of the abbreviations "NOS", "NEC" use of parentheses, square brackets, colons, braces, the word "and" in titles. These need to be clearly understood both by coders, and by anyone wishing to interpret statistics based on the ICD.

Introduction to Ophthalmology ICD-9-CM

This ophthalmology coding book is divided into three sections.

• The first section contains the introduction, guidelines for use and the outline of the ICD-9-CM, showing the major categories of diseases and where they may be found in the tabular columns
• The second section is an Alphabetical indexing of specific diseases entries
• The third section is the most important for proper coding, the tabular list. This section will guide you for proper and accurate coding
• While searching for a specific code, it is always easy to refer alphabetical indexing. Here most of the diseases are cross referenced in several ways making it easier
• You can refer to the tabular list for more precise guidelines of coding. When you become more familiar with the coding process you may find that you will refer to the alphabetical indexing less often. However, coding will be more accurate if you refer to the tabular list since more precise guidelines are found there

Introduction of ICD- 10

This general coding book is divided into three volumes.

• Volume 1 of the ICD contains the classification itself. It indicates the categories into which diagnoses are to be allocated, facilitating their sorting and counting for statistical purposes.
• Although it is theoretically possible for a coder to arrive at the correct code by the use of volume 1 alone, this would be time-consuming and could lead to errors in assignment.
• An alphabetical index guide to the classification is contained in volume 3. The introduction to the code provides important information about its relationship with volume 1.
• Volume 2 of the Tenth Revision of the International Statistical Classification of Diseases and Related Health problems contains guidelines for recording and coding, together with much new material on practical aspects of the classification's use, as well as an outline of the historical background to the classification.
• Volume 2 is presented as a separate volume for ease of handling when reference needs to be made at the same time to the classification (Volume 1) and the instructions for its use.
• Detailed instructions on the use of the Alphabetical indexing are contained in the introduction to Volume 3.
• On the other hand Volume 3 of the International Statistical Classification of Diseases and Related Health Problems is an alphabetical indexing to the Tabular List of Volume 1.
• Although the index reflects the provisions of the Tabular List in regard to the notes varying the assignment of a diagnostic term when it is reported with other conditions, or under particular circumstances (e.g. certain conditions complicating pregnancy), it is not possible to express all such variations in the code terms.
• Volume 1 should therefore be regarded as the primary coding tool. The Alphabetical indexing is however, an essential adjunct to the tabular list, since it contains a great number of diagnostic terms that do not appear in Volume 1. Therefore the two volumes must be used together.

Classification of diseases

• All medical records of patients treated in both outpatient and inpatient services must be coded for classification of disease by the medical record assistant according to the International classification of diseases.
• Various classification systems have been used, but the one in common use today is the International Classification of Diseases Adapted in the United States (ICD-9-CM) which is exclusively intended for ophthalmology coding.
• This classification is an adoption of the World Health Organization's clinical modification, 9th revision designed to serve various statistical purposes including hospital indexing.

Classification of procedures

• All medical files of patients treated in both the outpatient and inpatient departments must be coded for operation classification by the medical record department according to the International Classification of Procedures (ICP). Usually ICP-9 is in use to day to code medical records for minor and major procedures performed.

Manual indexing

• An important function of the medical record department is the compilation of patient care data from medical records. This means that certain information about patient care is extracted from medical records and hand posted on ledger sheets or cards. This method of hand posting in cards is called as manual indexing.
• Manual index means that disease and procedure code numbers are entered on each appropriate disease or procedural index cards.
• The disease conditions for which patients were treated are coded and then posted on a set of index cards, which comprises the "Disease Index" and "Operation Index" . While there are many manually maintained indexes still in existence, the trend is the increasing computerization of this activity.

Automated Indexing

• Many health care facilities have incorporated are considering the inclusion of the disease and procedural coding in their data processing system. Abstracts should be designed to correspond to the procedure for retrieval of information from the patients' health records.
• The coding is usually done in computer to reduce workload and to increase speed in computing data.
• The disease and procedure codes are the most expensive indexes to maintain in the department.
• The medical record assistant must not only be a capable individual, but also extremely accurate in making the entries.
• Coding systems may be effectively designed for computerised entry into a data processing system. Programs can be written to extract information and routine printouts; however, the needs of the persons using the stored information should be considered of prime importance. Related patient information on printouts should be grouped together for easy retrieval.

Coding Control

• There must be some method for ensuring that every record is coded. Every day disposed medical records may be placed on the coding person's desk at a prescribed time.
• Coding may be done after the doctor has completed the record and it has been checked for completion by medical record assistant.
• Coding is the last step before the medical records are sent to the filing area.
• Incorrect coding, as well as incorrect terminology, results in a loss of research material.
• Ideally one or two medical records assistants can be appointed exclusively to do all the coding as this fixes responsibility for the work and should result in a more consistent code

Quality control in coding

• Diagnosis and procedure code are not simply used to provide data for doctor's research. Once an appropriate classification system has been chosen and implemented in a health care facility, it is extremely important that continuous internal quality control measures are used to ensure the accuracy of the collected information. Because of the vast usage of recorded information, it is essential that coded diagnoses and operations are accurate and readily retrievable.
• The codes used should describe the patient's condition and treatment as definitively as the classification system will allow.
• Classification of diseases and procedures should be accurate in three areas – individual codes should correctly classify patient information according to the classification system used. The collection of code numbers for each patient should reflect the totality of his medical condition at the time of treatment.
• Finally, the code numbers must be assigned in proper sequence to reflect the principal reason for the episode of care and any contributing secondary diagnoses and procedures.

Summary

Our health care delivery system has become more specialized, so too have specialty classification systems been developed for use in recording valuable medical statistical information. Health care institutions often require the medial records technician to make individual decisions regarding an appropriate classification system for use. The medical records technician must constantly stay abreast of changes and innovations in published coding systems. No single classification will satisfy everyone's needs. A careful appraisal of the needs of the facility and an up-to-date knowledge of coding possibilities will result in selection of an appropriate coding system by the health care institution.

The medical records technician is facing a continuous challenge to stay abreast of changes which affect the coding function. The amount and type of data to be stored for each patient's stay continues to rise. Professional users of the stored data increase every day. Data processing innovations are regularly introduced to assist the medical records professional in efficient retrieval and storage of required information. It is vital for the medical record professional to keep abreast of developments so that continuous adaptations to change in data collection can be conducted as smooth as possible.

Key points to remember

• Classification of diseases and procedures is one of the most important functions of the medical records department.
• Coding is the translating of narrative descriptions of diseases, injuries and procedures into numeric codes.
• Coding is done in order to group conditions and procedures that are similar for statistical tabulation.
• In order to develop the best possible health care delivery system with preventive, curative, primitive and rehabilitative components, it is necessary to have comprehensive information or morbidity and mortality.
• All medical files of patients treated in both outpatient and inpatient department must be coded for disease classification by the medical record department according to the latest International classification of diseases.
• A disease index lists diseases and conditions and an operation index lists surgical and procedures according to the classification system or code numbers.
• Finally, code numbers must be assigned in proper sequence to reflect the principal reason for the episode of care and any contributing secondary diagnoses and procedures.

Student exercise

Answer the following

1. What is coding? Why do we need to code?
2. Discuss the use of ICD-9-CM in the field of Ophthalmology? Explain how this differs from ICD-10.
3. Explain the classification of diseases and operations adopted in ICD book?
4. State the factors to be considered in designing the manual index card?
5. Discuss the method adopted to evaluate the quality of coding function?