ICD-10 Theory Flashcards
What is the function of the ICD-10?
To permit the systematic recording, analysis, interpretation and comparison of mortality and morbidity data collected in different countries or areas and at different times. The ICD is used to translate diagnoses and other health problems from words into alphanumeric codes, which permits easy storage, retrieval and analysis of data.
What is Clinical Coding?
The translation of medical terminology that describes a patient’s complaint, problem, diagnosis, treatment or other reason for seeking medical attention into codes that can then be easily tabulated, aggregated and sorted for statistical analysis in an efficient and meaningful manner.,
What do Health Records typically contain?
Handwritten notes
Computerised records
Correspondence between health professionals
Discharge letters and forms
Clinical work-sheets
Nursing care pathways
Histology and diagnostic test reports
What is a Health Record, according to the Data Protection Act 2018?
A record which consists of data concerning health, and has been made by or on behalf of a health professional in connection with the diagnosis, care or treatment of the individual to whom the data relates. The health record can be held partially or wholly electronic or on paper.
When is Local Coding Policy acceptable?
Local coding policy is acceptable to agree provided this does not contravene any national coding standard. When agreement has been reached through local governance on how to address a documentation or recording issue the outcome must be documented in the departmental policy and procedure document. This must be agreed and signed-off by the clinical director and/or governance authority dependent on local arrangements. Local coding policies should be reviewed regularly as part of the organisation’s review process.
What is Uniformity of coding?
Uniformity means that whenever a given condition or reason for an episode is coded, the same code is always used to represent that condition or reason for the encounter. Uniformity is essential if the information is to be useful and comparable.
What are the key components of Uniformity?
Code the minimum number of codes which accurately reflect the patient’s condition during the episode.
Code every condition or reason for encounter which affects the care, or influences health status during the episode, which is available in the classification and supported by the medical record.
Code each problem to the furthest level of specificity, i.e. third, fourth or fifth character, which is available in the classification and supported by the medical record.
Do not code background information or chronic problems which are no longer active and which do not influence the health care being provided in the relevant episode.
It is not always intended that symptoms or history be coded.
Just because a condition can be coded does not mean it should be coded each time the patient is admitted.
Any uncertainty around issues of relevance or inactive problems should be discussed with the responsible consultant.
What are the Three Dimensions of Coding Accuracy?
Individual Codes
Totality of Codes
Sequencing of Codes
What are the key components of the Individual Codes Dimension of Coding Accuracy?
Each clinical statement of diagnosis must have the correct code assignment.
An individual patient may have many diagnoses (or procedures).
A coded record for an episode will have at least one or potentially many individual codes.
What are the key components of the Totality of Codes Dimension of Coding Accuracy?
All codes necessary to give an accurate clinical picture of the patient’s diagnosis, problems or other reasons for an episode encounter, must be assigned in accordance with the rules, conventions and standards of the classification.
This is important as it is possible for a list of codes to describe an episode incorrectly in terms of clinical coding rules and standards even though the individual codes selected are correct.
What are the key components of the Sequencing of Codes Dimension of Coding Accuracy?
Codes must be sequenced in accordance with clinical coding standards to provide consistent data for statistical analysis.
A significant aspect of sequencing is the selection of the main condition treated.
What are the Four Steps of the Coding Process?
Analyse medical terminology to determine the lead term(s) and modifier(s);
Locate the lead term(s) in the alphabetical index;
Assign (a) tentative code(s) using the alphabetical index and taking into account all rules, conventions and standards;
Verify the code(s) using the tabular list and taking into account instructional notes.
