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 it change 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
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
,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 (infectious 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 mycarditis.
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.
•Application
Classifications are useful in those cases where documentation is
used:
•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.
•To find out all objects that is similar in certain respect (ex. All
patient of the PMC having an extended hemicolectomy).
•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.
•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