In most hospital settings, assigning a clinical code for an identified cause of death is the responsibility of medical records personnel.
In such a scenario, your primary responsibility as an attending/certifying physician would be to correctly identify and fill in the cause of death – that is, one that can be coded/ has a code.
This would assist the medical records department personnel in coding accurately for purposes of analysis and reporting of the relevant epidemiology of causes of death.
However, in select hospitals, the physicians may be responsible for filling in death certificates as well as assigning the codes. In both settings, but more so in the latter, it is vital to understand the basic concepts related to coding and learn the skills of assigning correct codes to the causes of death.
Clinical Coding - Need and Definition
Consider the following scenarios
3 doctors from 3 different departments are meeting for a cup of coffee late in the evening at the hospital cafeteria. They are discussing the 3 patients they have lost in the last few days.
The Medical Superintendent of the hospital walks in at that time.
The first doctor narrates about the young girl with Koch’s disease who had died in her ward. The second doctor discusses his patient with multi-drug resistant pulmonary tuberculosis (MDR Pulm Tb) who had died the previous night. The third doctor tells of his middle-aged male patient who had died of tuberculosis with massive hemoptysis.
All these deaths get recorded and then sent to the medical records department for data entry.At the monthly death audit meeting in the Medical Superintendent’s office, the reports on the various causes of death in the hospital are read out.
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Total number of Tb deaths = 1
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The Medical Superintendent remembers his conversation with the doctors and knows there are more Tb deaths. So she asks the data analyst to search in the Excel sheet using the keyword ‘Tb’, the answer comes back as 1.She asks him to repeat the search but now with the search term as ‘Tuberculosis’, the answer still comes back as 1
Why is it that the 3 deaths due to Tb were not picked up by the hospital medical records department?
The computer can recognize deaths based on the search term provided.
So if the death certificates of 3 Tb cases are written in 3 different ways (Koch's disease; MDR Pulm Tb; tuberculosis), there’s no way the computer would know.
This example stresses on the need to use a universal language that can be understood irrespective of the different terminologies used for the same disease by different healthcare professionals in the same or different settings — that is, the need to identify and assign a code for a particular disease — this is called ‘clinical coding’.
Clinical Coding is defined as “the translation of diagnoses of diseases, health-related problems and procedural concepts from text to alphabetic/numeric codes for easy storage, retrieval, and uniformity of comparison and analyses”.
Definition of Clinical Coding -
Classifications have been used to describe diseases over the ages.
Since the seventeenth century, pioneers such as John Graunt, William Farr, Florence Nightingale and Jacques Bertillon attempted to classify diseases systematically.
Subsequently, the World Health Organization (WHO) has been responsible for continued revisions of the Bertillon classification; the current version is the tenth revision of the International Classification of Diseases and Related Health Problems (ICD-10).
History and Need for classification of diseases
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To allow easy storage, retrieval, analysis and compilation of internationally consistent data
Need for classification of diseases
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To allow systematic recording, analysis, interpretation and comparisons of mortality and morbidity data between hospitals, provinces or countries
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To allow comparisons
- within populations over time and
- between populations at the same point in time
The International Classification of Diseases (ICD) is the standard classification system for epidemiology, health management and clinical purposes.
It contains a finite number of mutually exclusive code categories (>10,000), describing all disease conditions. The classification is hierarchical in structure with subdivisions to identify broad groups and specific entities.
ICD classification of diseases
1. It has 3 volumes
There are 3 key elements to the structure of ICD-10:
2. It has 21 chapters
3. The structure of the ICD code is alphanumeric
1. It has 3 volumes - they are:
i. Volume 1 -- a tabular listing of diseases
ii. Volume 2 -- an instruction manual
iii. Volume 3 -- the comprehensive alphabetical index of diseases
2. It has 22 chapters
a. Each chapter is identified by a Roman numeral, i.e., I, II, III, IV, V etc. and associated alphabet(s). These 22 chapters cover 2046 disease categories
The chapters are associated with either:
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particular organ systems
Eg. Chapter IX: Diseases of the circulatory system
OR
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special diseases (affecting any part of the body)
Eg. Chapter II: Neoplasm
OR
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external causes
Eg. Chapter XX: External causes of morbidity and mortality
OR
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one chapter with no specific disease terms but only signs & symptoms
Eg. Chapter XVIII: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
b. Each chapter is divided into blocks of related conditions
Eg. Chapter IV: Endocrine, nutritional and metabolic diseases includes the following blocks
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Disorders of thyroid gland
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Diabetes mellitus
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Other disorders of glucose regulation and pancreatic internal secretion
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Disorders of other endocrine glands
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Malnutrition
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Other nutritional deficiencies
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Obesity and other hyper alimentation and
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Metabolic disorders
c. Each block is made up of individual codes for specific disease
entities.The code range for the chapter starts at 00 and ends at 99 or earlier
Eg.
Chapter
Block
Code
a. That means it is a code with an alphabet first followed by numerals
Eg
A15 is the code for tuberculosis (first character from A to Z, followed by 2 digits)
3. The structure of the ICD code is alphanumeric
b. Most categories are further divided into subcategories to enable coding of a disease condition more specifically
Eg
A15.1 (first character from A to Z, followed by 2 digits, then a decimal point and finally another digit)
This means
A15 is respiratory tuberculosis, bacteriologically and histologically confirmed
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A15.0 is tuberculosis of the lung, confirmed by sputum microscopy with or without culture, and
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A15.1 is tuberculosis of the lung, confirmed by culture only
In this course, we will concentrate only on 3-digit coding
In most hospital settings, assigning a clinical code for an identified cause of death is the responsibility of medical records personnel. In such a scenario, your primary responsibility as an attending/certifying physician would be to correctly identify and fill in the cause of death – that is, one that can be coded/ has a code. This would assist the medical records department personnel in coding accurately for purposes of analysis and reporting of the relevant epidemiology of causes of death.