Indexes and classification system syllabus
1435-1436 year
Given by : Abeer bassam shaban
week
1
2
Lecture title
Indexes
(Introduction, indexes definition, type of indexes1. Master patient index,
2.disease and operations indexes, 3. Physician index and 4. Special index)
Medical coding system, classifications and nomenclatures
(introduction, definition of coding, why do we need code, example of the
coding system , typical use of classification, typical use of nomenclatures,
Important of medical coding systems)
Part 1
3
Quiz 1
Medical coding system, classifications and nomenclatures
(introduction, definition of coding, why do we need code, example of the
coding system , typical use of classification, typical use of nomenclatures,
Important of medical coding systems)
Part 2
4
First exam
5
Current procedural terminology (CPT)
1. Describe the structure of code in CPT4
2. recognize the symbols used in CPT manual
3. understand the surgery section and subsection formats
4. explain the format of the pathology
Part 1
6
Quiz 2
Current procedural terminology (CPT)
1. Describe the structure of code in CPT4
2. recognize the symbols used in CPT manual
3. understand the surgery section and subsection formats
4. explain the format of the pathology
Part 2
7
Healthcare common procedure coding system
International classification of diseases (I.C.D)
History of ICD 9-CM
Tabular list
V codes and E codes
Alphabetic index
Procedure index
Example and exercises
Part 1
8
9
10
11
12
Second exam
Healthcare common procedure coding system
International classification of diseases (I.C.D)
History of ICD 9-CM
Tabular list
V codes and E codes
Alphabetic index
Procedure index
Example and exercises
Part 2
Healthcare common procedure coding system
International classification of diseases (I.C.D)
History of ICD 9-CM
Tabular list
V codes and E codes
Alphabetic index
Procedure index
Example and exercises
Part 3
Reimbursement
Understand patient accoutrement role in reimbursement
Final exam
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http://faculty.ksu.edu.sa/76216/default.aspx
Medical index
Hospital maintain various indexes and register so that so that each health records and
other health information can be located and classified for
1.
2.
3.
4.
5.
Patient care management and research purposes
Quality of care review
Utilization management
Administrative and financial purposes
Compliance with regulations or licensure requirement
Increasing demands for information and the availability of computerized systems
continue to increase the use of computerization in these areas. manual systems are still
in use in some facilities
Index is an alphabetical listing of items and their location.
Indexes may be
1. computerization index
2. manual indexes
a. card
b. note book
Manual indexes
computerization index
cheaper
Expensive
slow
Fast
Limited information according
small size of manual card
Give availability to add huge data and details
Just can use name of patient for
search
Give more chance to search about one
information
we can find data just in record
store room
We can find data anywhere for medical stuff
All section have data for patient
We save patient data just one time for all
medical section
Characters of success and good index are
1.
2.
3.
4.
5.
Cheap cost and maintenance.
Use small size for indexes
Easy to correct any mistake in system
Flexible uses the system by adding or delete data.
Long period uses system without any damage occur
We have more than one type of medical indexes
1.
2.
3.
4.
i.
Master patient index (MPI)
Disease and operation indexes
Physician index
Other special index
Master patient index (MPI)
MPI is a file that identifies patients and their health records. All patients who are
registered to receive hospital care as




Inpatients
Outpatients
Emergency care patients
Home care patients
Are entered in individually identifiable form into the MPI
Required information in the MPI to identification the patients
1.
2.
3.
4.
5.
6.
7.
8.
Last name, firs name, and middle initial
Birth date by month, day, and year
Sex
Address by street and city
Date of admission
Name of attending physician or clinical service assignment
Health record number
More information may be added as needed such as social security number
In computerized systems in which updating information is easy and not too time
consuming the dates of admission and discharge as well as clinic and emergency
service visits are entered.
There are no recommended periods for retention of names in the MPI
The filling arrangement with in MPI usually follows one of two systems
1. Alphabetical
2. Phonetic
1. Alphabetical system patients name are filed in Alphabetical order by last name with
secondary Alphabetical fling by first name.
2. The Phonetic system which is used by many hospitals that serves communities with
greater diversity of last name
ii.
Disease and operation indexes
List is arranged by
Illness
Injury
Procedure
That gives the record numbers of patients health records in which information on
specific Illness, Injury or Procedure can be indexes and registers found.
The indexes are cross reference tool for locating health records by diagnosis or
procedure to carry out activities related to the following
1.
2.
3.
4.
5.
6.
7.
8.
Continuing medical education programs
Epidemiologic and biomedical studies
Health services research studies
Statistical data on occurrence rate age sex and complications or assocated
conditions.
Continuous quality improvement and total quality management activities.
Consultation on patient response to treatment in previous cases for
applicability in a current case
The disease and operation indexes are accessible only to authorized personnel
Control measures are needed to ensure that every inpatient health record is
accounted in the disease and operation indexes
Required information
The number of data items included in the disease and operation indexes depends on
the needs of the individual hospital .
Basic data for any type of disease indexes include






Illness, injury, and procedure classification code.
The patient's health record number
The sex and age of patient
Identification of the responsible physician by code or name
The dates of admission and discharge or the year of hospitalization and length
of stay in days
Any outcome of death and the findings from any autopsy and additional
disease or procedure codes.
3. Physician index
The Physician index is a list arranged by Physicians' names or numbers that gives the
health record numbers of patient who received treatment or consultation from a
particular Physician.
The minimum data requirements for an entry into a Physician index are:
-The patient's health record number.
- The patient's age and sex.
- The date of admission and the length of stay in days
-Identification of a the patient's death and any autopsy findings
Consultation entries usually require:
-
-The patient's health record number.
- The date of admission.
-
-Identification of the entry as a consultation provided to another physician's patient.
The Physician index is regarded as a confidential record, and access to it must be
limited to authorized persons
Physicians have the right of access to their own data recorded in the Physician index
The hospital's governing board and chief executive officer (CEO) have the right of
access in accordance with their duties and responsibilities for ensuring the quality of
patient care and conducting hospital affairs
Other special Indexes
Special subject indexes may be maintained by the hospital, but the needed for these
indexes should first justify on the basis of:
1- The interest and actual use of the data or as required for participation in payment
programs. For example, hospitals with trauma or burn centers may wish to maintain
an index that provides specific statistical data on the treatment provided and on the
utilization of the specialized service. A facility treating HIV- positive and AIDS
patients may develop a special registry for research purposes.
2- An index often is maintained to identify the organs or tissues removed from brain –
dead patients for transplantation purposes.
The index identifies items such as the patient's health record number, the organ( s)or
tissue removed, the date of the procedure, and identification of any outside team who
performed the procedure
3- Special indexes can also be established to meet the needs of an individual or group
of staff Physician.
-
Medical Coding System
Introduction
To find specific pieces of information within documentation, It is necessary to use
documentary language. To put it into simple terms, you need a set of keywords ( or
authorized terms) and rules for their application.
So we call the documentary language a coding system.
In medical field, coding systems are common to document diagnosis and therapies.
Coding means translation or converting the verbal description of disease, injuries,
diagnosis, and services into numerical and /or alphanumeric designations for statistical
reporting and reimbursement purpose.
The transference of words to numbers
Coding was developed for a number of reasons
1. Tracking disease processes
2. Classification of medical procedures
3. Medical research.
4. Evaluation of hospital utilization.
5. To facilitate the processing of large number of insurance claims.
6. Study hospital cost.
7. Predict health care trends.
8. Plan for future health care needs.
Coding system: Why we need them?
Problems:
1-The freedom of expression can cause certain problems
Every term may have more than one possible spelling, several synonymous labels may be
selected and the whole statement may be structured according to the author's preference
Example liver rupture, hepatic laceration, hepatorrhexis
2- The usage of homonymous terms may lead selection of irrelevant data
Example in search of MI means myocardial infarction and can produce mesenteries
infection.
3- The terms used in documentation do not indicate the degree of similarity.
Ex. Two diagnosis as liver cirrhosis and subacute alcoholic hepatic dystrophy similar in
administrative analysis but different in epidemiological study
Solutions of these problems by coding system
Restrict the variability of expression and convert the authorized terms into a short and
formal code easier to record.
For example: to record the diagnosis of acute appendicitis, you might have to use the code
540
Standards of ethical coding
The following standards for ethical coding developed by American Health Information
Management Association (AHIMA) on coding and classification are offered to guide the
coder in this process
1-Diagnosis that are present on the admission or diagnosis and procedures that occur during
the current encounter are to be abstracted after a thorough review of entire medical record.
Those diagnoses not applicable to the current encounter should not be abstracted.
2- Selection of the principal Diagnosis and procedures along with other diagnoses and
procedures must meet the definition the uniform Hospital discharge Data set (UHDDS)
3-assessment must be made of the documentation in the chart to assure that it is adequate
and appropriate to support the diagnosis and procedures selected to be abstracted
4- Medical record coders should use their skills, their knowledge of ICD_9-CM and CP and
any other available resource.
5-medical record coders should not change codes so that the meaning of this represented
.Nor should diagnosis or procedure be included or excluded because the payment will be
affected, statistical database maintaining a quality database should be a conscientious goal
6- Physicians should be consulted for clarification when they enter conflicting
documentation in the chart
7- The Medical record coders is a member of the healthcare team, and as such, should assist
physicians who are unfamiliar with ICD_9-CM and CP and DRG methodology
8- The Medical record coder is expected to strive for the optimal payment to which the
facility is legally entitled but it is unethical and illegal to maximize payment by means that
contradict regulatory guidelines
Classification and nomenclature
In planning a data management system, you must decide for every attribute if you
should apply a coding system for the objectives of the system, and if it's better to
choose a classification or nomenclature
Classification (classification system)
Are coding systems founded on the \constructing classes? Classes form an
aggregation of concepts that match in (at least) one classifying attribute
Classification is the categorizing arranging and grouping of diseases, diagnoses,
surgical and nonsurgical procedures that have common attributes or characteristics
that would signify classifying them in a group such as the body system,
communicable diseases, and operational procedures of the digestive system and so on.
Example
All diseases with classifying attributes of an inflammation of the myocardium as well
as of an infectious etiology may be aggregated to the class (infections
myocarditis).IM
You can think of class as a container for objects having this particular attribute. In the
example above this could be all discharge diagnoses of the health care institution
involving infectious myocarditis.
The classes of the classification should cover the relevant domain completely and
their contents should not overlap. Each object has to be assigned to exactly one class.
When this is done the object is classified. The diagnosis of septic myocarditis, ex
might be assigned to the class (infections myocarditis) mentioned above. For the sake
of brevity as well as of language independence (if you have edition of the
classification in different languages), each class is provided with a code. This could
be '357' for infectious myocarditis
'3..' –denoting diseases of cardiovascular system and '35.'- An acute inflammation of
heart. The hierarchy expressed in the coding example is typical construction principle
of larger classifications.
 Now, to document a medical fact all you have to do is to find out the
appropriate class (put it in the right container) and record the class code. This
is what we call coding a medical fact.
o Application
Classifications are useful in those cases where documentation is used:
1. For patient group analyses (ex. To find out the frequency of cases of infectious
myocarditis in the PMC 'Ploetzberg Medical Center' during the last year.
2. To find out all objects that is similar in certain respect (ex. All patient of the
PMC having an extended hemicolectomy).
o forms
The structure of the classification can exhibit certain peculiarities
1. hierarchy:
The classes of a hierarchical classification are related exclusively either in a generic
or in a portative way, ex the subordinate concept, or class, in the hierarchy is either a
specialization, or a part of the super ordinate concept.
2. Monohierarchy vs. polyhierachy
In monohierarchy classification there is exactly one superordainate class to every
class (expect the topmost or the root of hierarchy).
In polyhierarchy classification allow classes to be subordinate to more than one class,
which results in several overlying hierarchies.
3. Multiaxial classification (or multidimensional classification)
Consist of two or more independent partial classifications. Here, a classifying
attribute for each axis is needed, describing an object within different semantic
dimension. The object is
Typical axes or dimensions you will find in multiaxial disease classification are
etiology, topography, and pathology.
The partial classifications may themselves be structured hierarchically. In this case
you can think of axes as a separate branch or sub- tree of the hierarchy.
Example
A simple monoaxial and monohierarchial classification of diagnoses is as follows
D1 Disorders of fat metabolisim
D11 hyperlipiemia
D12lipoproteinemia
D121 Tangier Disease
D122 A-Beta-Lipoproteinemia
D123 other Lipoproteinemia
D13 other sidorders of fat metabolism
D2 Disorder of carbohydrate metabolism
An additional axis for etiology could contain the classes
A1 Nutritional
A2 Congenital
A3 mixed or other etiology
Together with the first axis (what would be its semantic dimension),it forms atow –
axial classification (multiaxial classification). hyperlipidemia caused by dietary habits
would be code as A1- D11
If you find one class (ex. Viral meningitis) subordinate to two or more different
superordinate classes (ex neurological diseases as well as viral diseases)you are
dealing with a polyhierarchical classification.
o Checklist classification
Classification consists of classes that should not overlap and that completely
cover the relevant domain completely to achieve completeness, all hierarchical
levels should include a class for other however this class will contain little
information.
Classification of real –life complexity is usually structured hierarchically. You
should distinguish between mono-and poly hierarchical classification.
A multiaxial classification originates by dividing a classifications concept
system into several independent semantic dimensions.
Assigning an object to exactly one class is called classifying, assigning the
class code to the object (which includes classifying) and recording it is called
coding classification rules can help to find the right class.
Classifying always leads to a loss of information (you focus on similarities to
other objects in the class and neglect the differences), on the other hand it
enables patient –group analyses as well as the complete retrieval of similar
objects.
To answer the question whether a classification is good or bad, you have to
know what kind of analysis you want to do. You need to determine whether it
is appropriate or not.1
Nomenclatures
Basically a nomenclature is no more than a systematic compilation of authorized
terms or descriptors for a certain documentation task.
Due to their systematic structure and the provision of codes,nomenclatures usually
take the form of coding system.
Additionally the authorized terms may be complemented by definitions synonymous
terms, and other terminological notes, in that case the nomenclature takes the form of
a thesaurus.
A nomenclature is used to mark objects by assigning them all authorized terms (often
called descriptors) that apply. We say that an object is indexed. In contrast to
classifications; the concepts labeled by the descriptor may overlap. Moreover an
object is usually indexed with more than one descriptor.
If an object is not indexed completely ex. Not all appropriate descriptors have been
selected there will be problems in retrieving the data object reliably.
For example if you have recorded the descriptor (localization head) in documentation
of pain symptoms, but have forgotten to record "characteristic: throbbing" you will
miss the patient in a retrieval of all patients suffering a throbbing headache.
For the sake of brevity as well as for language independence, the authorized terms of
a nomenclature are usually provided with a code. As for classifications, assigning a
code is called coding.
Application
Nomenclatures are useful in those cases where documentation is used to
1. Retrieve the data on objects with a particular combination of attributes (ex. All
patients having had a meniscectomy under epidural anesthesia).
2. And also to let computer programs process the information about objects (ex.
To translate it into another langusge, to warn of contraindications or to suggest
atreatment).
Retrieval quality:
To measure the quality of the result of specific retrieval you have to check:
-
Wheather all relevant cases or patients have been retrieved.
Wheather the retrieved patients are all relevant.
Later we will introduce the measures of precision and recall for this purpose. These
quality indicators are essential for the usefulness of a nomenclature , to a great degree,
they are determined by how precisely relevant object features are expressed by the
descriptors of the nomenclature.
For example if you only have the descriptors {operation on the knee} and “local
anesthesia” to index a menisectomy under epidural there might be too many irrelevant
retrievals results for the question above.
Forms
Just like classifications nomenclatures can have different constructions
1. Hierarchy
For easier orientation, extensive nomenclatures can exhibit hierarchical structures (ex.
Can be based on a hierarchical concept system.
2. Multiple axes or dimension:
dividing the set of authorized terms into several semantic dimensions will
lead to multiaxial nomenclatures. By checking the dimensions on after the
other applicable descriptors, the completeness of indexing is improved.
Moreover, the reduced complexity serves the user with better orientation. In
contrast to multiaxial classifications (where you have to choose exactly one
class in every axis ), you may well assign several descriptors per axis to one
object.
Example
Simple monoaxial nomenclature.
Imagine this list of descriptors for the localization of pain:
L1 head
L2 Back
L3 extremities
L4 joints
Assuming a hierarchical construction, this is a possible subdivision:
L1 head
L11 Face
L12 Forehead
L13 Temples
L14 Skull
By adding another partial nomenclature for the quality of pain, a tow axial
nomenclature emerges:
Q1 dull pressing
Q2 Burning, hot
Q3 Stabbing, searing
Q4 Tearing
A stabbing, hot pain at the wrist would be coded as (L3, L4,Q2,Q3)
A dull pain at the forehead and a pressing pain at the temples would be two
separate facts:( L12,Q1) AND (L13,Q1).
Checklist: nomenclature
Nomenclatures are systematically complied sets of authorized terms or
descriptors for a specific documentation task. As for classifications, rules
can improve clarity.
In contrast to classifications, the aim of a nomenclature is not to assign
objects to categories but to describe them unambiguously and precisely in
order to make them retrievable and processable.
A nomenclature can be a simple alphabetical list of descriptors, or it can
provide hierarchical structures to aid orientation.
Dividing the set of authorized terms into different semantic dimensions
creates a multiaxiality does not extend expressional power, but it
facilitates handling.
A simple example
The coding systems
To record discharge diagnoses the neurological department of the ploetzberg medical
center and medical school (PMC) has two coding systems: a classification and
nomenclature.

This is an excerpt from the classification
K433,0 A. bailaris
K433,1 A. carotis
K 433,8 occlusion or other precerebral arteries
This is an excerpt of the two –axial nomenclature
Axis 1 morphology
M341- stenosis
axis 2 topography
T45- Precerebral arteries
M3411 STONOSIS DUE TO Calcification
COMM
T4511 A. CAROTIS
T4512 A. carotis
comm.sin
M351- THROMBOSIS
M3411 obturating thrombus
At the neurological department the classification is used to tabulate the frequency of
the diseases that were diagnosed over time.
The nomenclature is intended to facilitate the retrival of cases with certain attributes.
A diagnosis
The disease of the patient is diagnosed as “stenosis of the left arteries carotis
communis with obstructive thrombosis.
Using the coding system above, the diagnosis can indexed and classified as follows:
Classification:K433.1 (occlusion or stenosis of the A.carotis)
Indexing: M3511( Obturating thrombus)
M3411(Stenosis due to calcification)
T4512 (A. carotis comm..sin.)
Coding the diagnosis of all patients of a health care institution in this way will enable
the data management system to answer various questions.in the next paragraphs, we
will give two typical example.
Typical use of a classification /;
Classifications are intended to describe the set of all objects aggregated in one
class,eg. As an answer to the question
Q1 how many patient with the diagnosis falling into the class ’occlusion or stenosis of
the precerebral arteries “ (K433.) have been treated in our institution in the previous
year?
Using a nomenclature?
This information could also be obtained using the indexed diagnosis. You would have
to look for the simultaneous appearance of the code T45- (Precerebral arteries) and
the codes M351- (thrombus) or M341- (Stenosis). The problem is however to
guarantee that.



Topography and morphology are indexed completely for all patient.
All relevant indices are taken into account in the query.
A patient is not counted more than once (this would particularly bias the
comparison of class frequencies).
Typical use of a nomenclature :
Nomenclatures are designed for the retrieval of data objects using differentiated,
flexibly formulated criteria, ex. As an answer to the following question:
Q2: who are the patients that suffered from a thrombosis of the arteria carteria carotis
communist without having a stenosis?
To answer this question, you would look for the simultaneous appearance of the codes
M 351-(Thrombus) and T451-( A. carotis comm.), but without the codeM341(stenosis)
Using a classification?
This analysis is hardly possible when using the classified diagnosis because patients
with and without stenosis belong to the same class, and the parts of the A. carotis are
not differentiated.
Using a classification for reteieval , the search criteria are limited to the classifying
attributes.
In our case, you could search, for example, for all cases with an occlusion or with a
stenosis of the arteria carotis (K433.1) and subsequently browse the patient records to
determine ehether the patient had a thrombosis without stenosis at the A. carotis
comm.
Important of medical coding system
In this topic we introduce important medical coding systems.
There are many other systems, some of which are very common in their specialized
filed. For specific research projects, dedicated coding systems must be developed. As
even the most specialized systems usually serve multiple purposes, some of them
externally motivated, they should be designed as an extension to a more general,
standard system.
`
Healthcare Common Procedure Coding System (HCPCS)
Introduction
In 1983, Medicare created Healthcare Common Procedure Coding System (HCPCS)
(pronounced hick picks).
HCPCS codes are required when
1. reporting services
2. Procedures provided to medicare and Medicaid beneficiaries.
HCPCS is three- level coding system
Level 1- CPT codes
The physicians current procedural Terminology (CPT ), published by the American
medical Association
CPT
Is a listing of descriptive terms with codes for
1. reporting medical services
2. and procedures performed by health care providers.
CPT provides uniformity in accurately describing medical, surgical, and diagnostic
services for effective communication among physicians, patients, and third party
payers
CPT was introduced in 1966 ,and has undergone editing and modification to the
current revision.
The greatest change in CPT, having a major impact on coders occurred in 1992 when
" evaluation and management services were created
This CPT section requires practitioners to make a decision as to level of service for
offices, hospitals, nursing home services etc…
Level 2- National codes ( referred to as HCPCS)
Level 2 consists of alphanumeric "National codes" . These codes supplement CPT
codes enabling providers to report non physician services such as
 durable medical equipment
 ambulance services
 supplies and medications
 particularly injectable drugs .
Level 3- Local codes
Level 3 codes called "Local codes" were deleted 31-12-2013 under HIPAA
regulations (Health Insurance Portability and Accountability Act ) . Many local
codes concepts were moved to level 2
How was CPT developed?
The American Medical Association (AMA) first developed and published CPT in
1966.
The first edition helped encourage the use of standard terms and descriptors to
document procedures in the medical record; helped communicate accurate
information on procedures and services to agencies concerned with insurance claims;
provided the basis for a computer oriented system to evaluate operative procedures;
and contributed basic information for actuarial and statistical purposes.
The first edition of CPT contained primarily surgical procedures, with limited sections
on medicine, radiology, and laboratory procedures.
The second edition was published in 1970, and presented an expanded system of
terms and codes to designate diagnostic and therapeutic procedures in surgery,
medicine, and the specialities. At that time, a five-digit coding system was introduced,
replacing the former four-digit classification. Another significant change was a listing
of procedures relating to internal medicine.
In the mid to late 1970s, the third and fourth editions of CPT were introduced. The
fourth edition, published in 1977, represented significant updates in medical
technology and a system of periodic updating was introduced to keep pace with the
rapidly changing medical environment. In 1983, CPT was adopted as part of the
Centers for Medicare and Medicaid Services (CMS), formerly Health Care Financing
Administration's (HCFA), Healthcare Common Procedure Coding System (HCPCS).
With this adoption, CMS mandated the use of HCPCS to report services for Part B of
the Medicare Program. In October 1986, CMS also required state Medicaid agencies
to use HCPCS in the Medicaid Management Information System. In July 1987, as
part of the Omnibus Budget Reconciliation Act, CMS mandated the use of CPT for
reporting outpatient hospital surgical procedures.
Today, in addition to use in federal programs (Medicare and Medicaid), CPT is used
extensively throughout the United States as the preferred system of coding and
describing health care services.
.
HIPAA and CPT
The Administrative Simplification Section of the Health Insurance Portability and
Accountability Act (HIPAA)of 1996 requires the Department of Health and Human
Services to name national standards for electronic transaction of health care
information. This includes; transactions and code sets, national provider identifier,
national employer identifier, security, and privacy. The FinalRule for transactions and
code sets was issued on August 17, 2000. The rule names CPT (including codes and
modifiers) and HCPCS as the procedure code set for:
• Physician services.
• Physical and occupational therapy services.
• Radiological procedures.
• Clinical laboratory tests.
• Other medical diagnostic procedures.
• Hearing and vision services.
• Transportation services including ambulance.
The Final Rule also named ICD-9-CM volume 1 and 2 as the code set for diagnosis
codes, ICD-9-CM volume 3 for inpatient hospital services, CDT for dental services,
and NDC codes for drugs.
All health care plans and providers who transmit information electronically are
required to use established national standards by the end of the implementation
period, October 16, 2003. In addition, all local codes have been eliminated and
national standard code sets must be used after October 16, 2003.
International Classification of Diseases (ICD)
It is the coding system that classification different diseases in grouped according same
attributed , and give each disease number or alphabetic number to easily revision,
easy to coding and to help in statically report special to its.
ICD is published by world health organization (WHO) with 10 revisions
Revision
Years Covered
1st
1900-09
2d
1910-20
3d
1921-29
4th
1930-38
5th
1939-48
6th
1949-57
7th
1958-67
8th
1968-78
9th
1979-98
10th
1999-present
WHO put 2 volumes for ICD
Volume 1: is a tabular listing containing a numerical list of the disease code numbers.
This volume is have three digital number start from (001- 999)
The 999 digital number to 17 main section for diseases and, injures and surgery and
else.
Each 17 main part are divided to 10 branch
Inside each group the 3 digital numbers specialize for main case then for less
important case.
Volume 2: is an alphabetical index to the disease entries.
Why is the ICD important?
The ICD is important because it
1.
Provides a common language for reporting and monitoring diseases. This
allows the world to compare and share data in a consistent and standard
way – between hospitals, regions and countries and over periods of time.
2.
It facilitates the collection and storage of data for analysis and evidencebased decision-making.
3. Easley the statically report.
Who uses it?
Users include physicians, nurses, other providers, researchers, health information
managers and coders, health information technology workers, policy-makers,
insurers and patient organizations.
ICD has been translated into 43 languages and it is being used by all member
States. Most countries (117) use the system to report mortality data, a primary
indicator of health status.
All Member States are expected to use the most current version of the ICD for
reporting death and disease statistics (according to the WHO Nomenclature
Regulations adopted by the World Health Assembly in 1967).
International Classification of Diseases (ICD)-9
In 1979 the WHO modifite the revision of ICD to ICD-9 and translate to Arabic
Languge to used it in Arabic country hospital.
ICD -9 have 4 volumes
Volume 1 :
This volume is have three digital number start from (001- 999)
The 999 digital number to 17 main section for diseases and, injures and surgery and
else.
Chapter Titles
Code categories
1- Infectious and parasitic disease
001-139
Example1
Chapter 1: Infectious and parasitic disease
001-139
-Cholera 001
Typhoid and paratyphoid
002
-TB 010-018
Primary tuberculosis infection 010
TB of lung 011
-Zoonotic bacterial diseases 020-027
Plague 020
Brucellosis 023
-Other bacterial diseases 030-041
Leprosy 030
Diphtheria 032
Whooping cough 033
2-Neoplasms
140-239
3- Endocrine, nutritional and metabolic Disease and Immunity disorder 240-279
4- Diseases of the blood and blood forming organs
280-289
5- Mental disorders
290-319
6- Diseases of the nervous system and Sense organs
320-389
7- Diseases of the Circulatory system
390-459
8- Diseases of the Respiratory system
460- 519
9- Diseases of the Digestive system
520-579
Disease of oral cavity, salivary glands and jaws 520-529
Disease of oesophagus, stomach and duodenum 530-537
Appendicitis 540-543
Hernia of abdominal cavity 550-553
10- Diseases of the Genitourinary system
11-complication of pregnancy, childbirth, and the puerperium
580-629
630-679
e.g. pregnancy with abortive outcome 630-639
complication with puerperium 670-676
12- Diseases of the of skin and subcutaneous tissue
680-709
13- Diseases of the musculoskeletal system and connective tissue
710-739
14-Congenital anomalies
15-certain conditions originating in the prenatal period
16- symptoms, signs, and Ill –defined conditions
740-759
760-779
780-799
e.g symptom 780-789
17-Injury and poisoning
e.g fracture of skull 800-804
fracture of spine and track 805-809
800-999
fracture of upperlimb 810-819
Volume 2:
Supplementary classification for external causes of injury and poisoning
This code is (800 s- 999 s) and divided to many section
1. Railway accidents : ( 800 S - 807 S)
2. Traffic accidents caused by motorized vehicles: (810 S- 819 S)
3. Accidents vehicles but not traffic: (820 S- 825 S)
4. Another accidents traffic vehicles : (826 S- 829 S)
5. Accidents aquatic transport :( 830 S- 838 S).
6. Accidents by plane and space transport :( 840 S- 845 S).
7. Accidents not classify in another place like left :( 846 S- 848 S).
8. Toxic in vaccine, drugs and biology material:( 850 S- 858 S)
e.g. Accidental poisoning of tranquillizers (S853)
9. Toxic in solid, liquid, gases and vapor material :( 860 S- 869 S).
10. Medical error during surgery or treatments :(870 S-876 S)
11. Bad response for patient or compilation after surgery or medical procedures:(
878 S-879 S).
12. Fall down from high place ( 880 S-888 S)
13. Fire accident :(890 S-899 S)
14. Natural and environmental accident :(900 S- 909 S)
e.g. Excessive heat 900S
15. Accidents caused by diving or choking or strange objects:(910 S-915 S)
16. Pump of pressure container :(916 S-928 S)
17. Late appear for some injury:(929 s)
18. Side effect for some drugs, vaccine and biology material:(930 S-949 S)
19. Self- injury and Suicide( self-murder): (950 S-959 S)
20. Killing people :(960 S-969 S)
21. Injuries caused by firearms:(970 S-978 S)
22. Unspecified injuries that were casual or deliberate or spend as much:(980 S989 S)
23. Injuries resulting from war operations:(990 S-999 S)
Volume 3
Also supplementary classification list for factor influencing health status and contact
with health service it takes code from (01 F-82 F)
This volume is divided to many sections
1. Medical risk for communicable disease :(01 F- 7 F)
2. Medical risk for genetics disease :(10 F-19 F)
3. Person attached with medical service for reproduction and growth :(20 F-28 F)
4. New health born with kind of delivery type:(30 F-39 F)
5. Person that have special case effect on its health :(40 F-49 F)
6. Person attached with medical service for care after treatment:(50 F-59 F)
7. Person attached with medical service for another state:(60 F- 68 F)
8. Person without diagnosis meet with them during Examination and survey of
individuals and communities:( 70 F- 82 F)
Volume 4
Its contain special tabulation lists
1. The basic Tabulation list in volume 1 for disease.
2. Fifty list for disease reasons.
3. Fifty list for death reasons.
And volume 4 has many international classifications like
1. International classification of procedures in medicine
Publications of the World Health Organization for laboratory tests, surgery, radiation
treatment and chemotherapy.
2. International classification disease for oncology
Publications of the World Health Organization .This classification is to determination
of the oncology position and kind of it if its Malignant cancer or benign cancer.
3. Diagnostic and statistical manual of mental disorders
This classification for mental disease and treatment this classification is special for
psychosomatic hospital.
Publications by American psychiatric association.
ICD-9- CM codes
The International Classification of diseases ICD, 9th revision, clinical modification
(ICD-9- CM) is a modification of ICD-9 which are created by the world health
organization (WHO).
Since 1979, ICD-9- CM has provided a diagnostic coding system for the compilation
and reporting of morbidity and mortality statistics for reimbursement purposes in
United States.
It allows for reporting of conditions, injuries, and traumas along with complications
and circumstances occurring with the illness or injury. It also provides the reason for
patient care
The ICD-9- CM contains three volumes. All health care facilities utilize volume 1
|( Tabular list of disease ) and vol.2 ( Alphabetic Index of Diseases) report diagnoses.
Hospitals use Vol 3 to report inpatient procedures ( CTP is used to report procedures
performed in physician offices, ambulatory care centers and hospital outpatient
departments).
ICD-9-CM requires assignment of the most specific code to represent the problem
being treated by provider. This means the primary diagnosis should be the one for the
condition indicated within the medical record as the primary reason the patient sought
medical care in an outpatient or office setting, or the principal diagnosis in an
inpatient setting.
History and usage of ICD-9-CM
ICD-9-CM stands for International Classification of Disease, Ninth revision,
Clinical Modification. It is used for coding and classify diagnoses and procedures by a
numerical system. Classifying diseases by their cause has been done in various forms
for many years, even as far back as the Greek civilization.
The ICD-9-CM code book is updated every year with changes effective October 1 of
that year. It is essential that code books and coding software be updated yearly with
the revisions.
Tabular list (volume1)
volume1, the " Classification of Diseases and Injuries " is the tabular listing of
diagnoses. 1) Once a coder has identified a code in the alphabetic index. 2) It must be
vertified in the tabular list, codes are arranged numerically in 17 chapters and are
grouped according to their cause (etiology ), such as fractures, or body system, such
as digestive system.
Chapter Titles
1- Infectious and parasitic disease
2-Neoplasms
Code categories
001-139
140-239
3- Endocrine, nutritional and metabolic Disease and Immunity disorder 240-279
4- Diseases of the blood and blood forming organs
280-289
5- Mental disorders
290-319
6- Diseases of the nervous system and Sense organs
320-389
7- Diseases of the Circulatory system
390-459
Disease of circulatory system ( 390-459)
Hypertensive diseases(401-405)
Hypertensive heart diseases 402
Malignant 402,0
Malignant with congestive heart failure 402,01
8- Diseases of the Respiratory system
9- Diseases of the Digestive system
Example
Chapter 9: Disease of digestive system (520-579)
460- 519
520-579
Section: Hernia of abdominal cavity (550-553)
Category :other hernia of abdominal cavity ,with gangrene (551)
Subcategory : ventral hernia ,with gangrene 551,2
Subclassification: incisional, with gangrene 551,21
10- Diseases of the Genitourinary system
580-629
11-complication of pregnancy, childbirth, and the puerperuim
630-679
12- Diseases of the of skin and subcutaneous tissue
680-709
13- Diseases of the musculoskeletal system and connective tissue
710-739
14-Congenital anomalies
740-759
15-certain conditions originating in the prenatal period
760-779
16- symptoms, signs, and Ill –defined conditions
780-799
17-Injury and poisoning
800-999
Supplementary Classifications
There are two Supplementary Classifications included in the tabular list (volume1)
these are:
1- V codes ( V01-V83)
V codes can be used to describe the main reason for the pateint's visit in cases where
the patient is not " Sick" or used as a secondary diagnosis to provide further
information about the patient 's medical condition. One example would be a patient
who is not sick and comes in to receive a TB skin test. There is a V code,V74.1,
Screening for pulmonary tuberculosis that is used if a diagnosis is not identified for
the patient.
2- E Codes (E800-E999)
E codes are external causes of injury and poisoning. E codes are used as
secondary diagnosis to show the cause of injury, such as fall or automobile
accident, if it is known.
An example of injury E code is E828.2, accident involving animal being ridden,
rider of animal.
The Alphabetical index (Volume2)
The Alphabetical index (Volume2) of ICD-9-CM consists of an alphabetic list of
terms and cods, two supplementary sections following the alphabetic listing.
Procedures :tabular list and alphabetic index (Volume3)
Volume3 consists of two sections, tabular list and alphabetic index. These codes
define procedures instead of diagnosis.
Operations on the nervous system01-05
Operations on the endocrine system06-07
Operations on the eyes08-16
Operations on the ear18-20
Operations on nose, mouth and pharynx 21-29
Operations on the respiratory system30-34
Operations on the cardiovascular system35-39
Example of Vol 3(ICD9-CM)
Operations on the cardiovascular system35-39
Operations on valves and septa 35
Open heart valvulopasty 35.1
Open heart valvulopasty of mitral valve without replacement 35,12
Operations on the lymphatic system40-41
Operations on the digestive system42-54
Operations on the urinary system55-59
Operations on the male genital system60-64
0perations on the female genital system65-71
Obstetric procedures72-75
Operations on the integumentary system76-84
Miscellaneous diagnostic and therapeutic procedure 87-99