ICD-10 & TB

Rehab Rayan

HIFB, PharmD

www.hitsi.org

Agenda

ICD10 & TB

Session-1 (Theoretical)

1. Overview

2. Introduction to ICD-10

3. Structure of the Classification and How to Code

4. Morbidity Coding

5. Certification

6. Statistical Presentation

Session-2 (Practice)

1. Brief Coding Rules

2. Coding

3. Morbidity Practice

4. Certification Practice

5. Statistical Presentation Practice

6. Summary & Conclusion

Overview

Session-1_1

ICD10 & TB

www.hitsi.org

Overview

• Methods to assess TB mortality1

– Direct measurement: Vital Registration (VR)

– Direct measurement: Verbal Autopsy (VA)– Demographic Surveillance Sites (DSS)

– Sample Vital Registration

– Indirect estimation: = (estimated) disease

incidence * case fatality

1: State of the art review. IJTLD 2009;13:283-303

ICD10 & TB

www.hitsi.org

Overview

ICD10 & TB

• Vital Registration

–Direct, continuous measurement – in broader

context of national public health monitoring

–Quality / Completeness

• Diagnosis of cause-of-death on death certificates

• Adequate coding ? ICD-10

Ana Bierrenbach

WHO /STB / TME

Introduction to ICD-10

Session-1_2

ICD10 & TB

www.hitsi.org

Introduction to ICD-10

• To make people count,

• we first need to count people!

ICD10 & TB

www.hitsi.org

Introduction to ICD-10

• ICD is an internationally endorsed classifications facilitate

the:– storage,

– retrieval,

– analysis, and

– interpretation

• of data and their comparison– within populations over time and

– between populations at the same point in time as well as the

– compilation of internationally consistent data.

• Populations may be nations, states and territories, regions,

minority groups or other specified groups.

ICD10 & TB

www.hitsi.org

Introduction to ICD-10

• For comparison and communication– The ICD is designed to capture mortality and morbidity data for

reporting for public health, epidemiology and treatment, and

allows comparison of frequencies of e.g. causes of death from

community level up to the whole world

– ICD is the international standard for this purpose, with all WHO

members states having committed to report causes of death and

illness to WHO since 1967 (Nomenclature regulations). The ICD is

a classification that is used in 194 countries. It has been developed

internationally since 1893. There have been ten major revisions with

the most recent being ICD-10.

ICD10 & TB

www.hitsi.org

Introduction to ICD-10

• The WHO Family of International Classifications in health consists

of :

– Reference classifications cover the diseases and related health

problems (ICD), disability (ICF) and health interventions (ICHI, under

development).

– Other members of the Family cover drugs, causes of injury and

reasons for encounter, or provide more detail, for use in oncology.

• These classifications are the building blocks of health

information used for measures to help provide the best

possible health to all people.

ICD10 & TB

www.hitsi.org

Introduction to ICD-10

ICD10 & TB

www.who.int/classifications

Structure of the Classification and How to Code

Session-1_3

ICD10 & TB

www.hitsi.org

Structure of the Classification and How to Code

ICD10 & TB

www.hitsi.org

Structure of the Classification and How to Code

ICD10 & TB

• To code correctly, there are various rules and coding

conventions that must be followed, spread across all three

volumes. Coding consists of the following steps:

– Determining from the medical documentation, the conditions that

need to be coded, following the ICD rules.

– Using the Alphabetical Index (Vol 3) to locate the condition and

allocate the code.

– Using the Tabular List (Vol 1) to ascertain that the code found in the

Index is correct by reviewing all coding instructions related to that

code (e.g. inclusion note, exclusion note).

– Using the Instruction Manual (Vol 2) for any rules regarding the

selection of a particular code for reporting mortality or morbidity

data.

Morbidity Coding

Session-1_4

ICD10 & TB

www.hitsi.org

Rules and guidelines for morbidity coding

• ICD was first used as a classification system of

causes of death, and is since 1948 used for both

mortality coding (causes of death) and morbidity

coding (illness, injuries and reasons for contact with

health services).

ICD10 & TB

www.hitsi.org

Rules and guidelines for morbidity coding

ICD10 & TB

• Sources and uses of morbidity data• Hospital medical records

• Outpatient records (ambulatory care)

• School medical records

• Maternal and child health services records

• Occupational medical records

• Armed services records

• Death certificates – providing information also about certain diseases which, by

themselves, have not caused death but which have contributed to the

decedent’s overall morbidity and contributed to the death

• Health surveys

• Cancer and chronic disease registry records

www.hitsi.org

Rules and guidelines for morbidity coding

ICD10 & TB

• Once the morbidity data has been collected from these

various sources it may be used for a variety of purposes.

Some examples of what morbidity data is used for include:

– Providing information about a particular disease – causes, frequency

etc.

– Forming the basis on which decisions are made about health care

management and the allocation of resources

– Providing information to help with the prioritisation of disease

prevention programs

– Clinical research

– Education

– Epidemiology

www.hitsi.org

Rules and guidelines for morbidity coding

ICD10 & TB

• Section 4.4 Morbidity in Volume 2 of ICD (the instruction

manual) contains the rules and guidelines adopted by the

World Health Assembly regarding the selection of the

appropriate conditions from morbidity records, as well as

guidelines for the application of the rules for coding of the

conditions selected.

• National health systems have differing definitions of

treatment episodes, and nationally different rules. Thus

comparability of morbidity data is subject to limitations.

Certification

Session-1_5

ICD10 & TB

www.hitsi.org

Certification

ICD10 & TB

• Goal:

– To correctly report and interpret the events and

conditions leading to death using the ICD as

recommended by the WHO, including:

• the immediate cause of death

• the sequence from the underlying cause to the

immediate cause

• any conditions not directly leading to death but

contributing to it

• the duration of the reported conditions.

www.hitsi.org

Certification

ICD10 & TB

• The death certificate is the main source of

mortality data.

• The death certificate recommended by the WHO,

which you will find in Volume 2 of ICD-10 in section

4.1.3.

• The information on a death certificate may be

provided ideally by:

– an experienced medical practitioner that is well informed

about the medical history of the dead person, and has

carefully carried out a post mortem examination.

www.hitsi.org

Certification

ICD10 & TB

• The death certificate has two parts:

– Part I: It has four lines to record the sequence of events leading to

death.

– The disease or condition directly leading to death (the immediate

cause) is always recorded at line I(a). This may be the only

condition recorded if there are no other conditions in the sequence.

– Other conditions leading to I(a) are entered in sequence on lines (b),

(c) and (d) with the underlying cause on the lowest line used.

– The underlying cause of death is defined by the WHO as (a) the

disease or injury which initiated the train of morbid events leading

directly to death.

www.hitsi.org

Certification

ICD10 & TB

• Part II is used to record other significant conditions

contributing to the death but not relating to the disease or

condition causing it.

• The right hand column is used to report the duration of the

conditions recorded in Parts I and II. Conditions should be

listed with the oldest conditions lowest, so that the timing of

the sequence confirms the cause-based sequence.

www.hitsi.org

Certification

ICD10 & TB

• Durations– On the right hand side of the certificate is a column headed

Approximate interval between onset and death. This is for

reporting the duration or the time interval between:

• the onset of each condition entered on the certificate and

the date of death.

– Where the time or date of onset is not known, a

best estimate should be recorded. It is also

acceptable to put ‘unknown’ if it is not possible to

establish or estimate the duration.

www.hitsi.org

Certification Rules

ICD10 & TB

• All entries should be typed or written legibly in black ink,

without the use of abbreviations, alterations or erasures.

• As much detail as possible should be recorded so that it can

be used to assign complete and specific codes from the ICD.

• The mode of dying, such as cardiac arrest or respiratory

failure, should not be reported as the immediate cause of

death.

• If the cause of death is unknown, even after investigation, it

is correct to record it as ‘unknown’.

www.hitsi.org

Certification Rules

ICD10 & TB

• The starting point of the sequence should never be

entered in Part II because of lack of space in Part I. Instead,

extra lines can be added to Part I if needed to report a long

or complicated sequence.

• Only one condition should be entered on each line, with the

following exception. In the unusual situation where two

independent diseases are thought to have contributed

equally to the sequence at a particular point, they may be

entered on the same line.

www.hitsi.org

Certification

ICD10 & TB

Dr. Ali Sadek

Direct

Intervening

Intervening

Underlying

Contributing

D

u

r

a

t

i

o

n

www.hitsi.org

Certification

ICD10 & TB

• A separate certificate is available to record perinatal

death. An international format is also recommended

for this certificate.

Statistical Presentation

Session-1_6

ICD10 & TB

www.hitsi.org

Rules and guidelines for statistical presentation

ICD10 & TB

• Regulations and guidelines for presentation of coded statistical data

facilitate international comparisons.

• The source used to obtain mortality data is the medical certificate of

the cause of death. The coding of the reported causes of death in

accordance with ICD provides us with a workable database of

information data with which to perform comparisons and statistical

analyses.

• Where no better system is in place, verbal autopsy may be an

alternative. However data from medical certification and those from

verbal autopsy differ in their level of detail, and in their reliability. They

can be compared, but they should not be merged.

www.hitsi.org

Rules and guidelines for statistical presentation

ICD10 & TB

• The regulations also apply to morbidity data. However, with morbidity

international comparability is limited by the differences in health

systems, and nationally modified rules.

• Section 5 Statistical Presentation in Volume 2 of ICD (the Instruction

Manual) provides the regulations and guidelines of the WHO for

statistical presentation. These include various tabulation lists,

definitions, standards and reporting requirements.

Questions?

Session-1_End

ICD10 & TB

Let’s Practice!

Session-2

ICD10 & TB

Brief Coding Rules

Session-2_1

ICD10 & TB

www.hitsi.org

Chapters

ICD10 & TB

Dr. Ali Sadek

www.hitsi.org

Volume-1

ICD10 & TB

Dr. Ali Sadek

www.hitsi.org

Volume-1 Imp Conventions

Parentheses ( ) used in :

1. Enclose supplementary words, NOT affecting code

2. Enclose code referring exclusion

3. Block titles, to enclose three character codes of categories

4. To enclose the dagger code in an asterisk category or the asterisk code following a dagger term

Square brackets [ ] used to :

1. Enclose synonyms, alternative words

2. For referring to previous notes or stated sets [see…..]

ICD10 & TB

Dr. M.M. Singh

www.hitsi.org

Volume-1 Imp Conventions

Point dash .-

• Indicates existence of a fourth character

Colon :

• To list inclusion and exclusion terms

• When insertion of modifying words is required indiagnosise.g. K36 Other appendicitis

Appendicitis :

. Chronic

. recurrentICD10 & TB

Dr. M.M. Singh

www.hitsi.org

Dagger & Asterisk

ICD10 & TB

• Coding of conditions to which the dagger and

asterisk system applies

– The dagger and asterisk codes should be used together,

wherever possible, because they describe different

aspects of the condition. This dual coding system

provides information on the aetiology (cause) (dagger

code) and the manifestation (asterisk code) of the

condition.

– The dagger code (underlying cause) is the preferred and

reported main condition.

www.hitsi.org

Volume-1 Imp Conventions

NOS

• Not otherwise specified or unspecified/ unqualified

NEC

• Not elsewhere classified

• Serves a warning that certain variants are listedsomewhere

ICD10 & TB

Dr. M.M. Singh

www.hitsi.org

Volume 3 : Alphabetical index

Sections :

• I – list of all terms classifiable to Chapters I-XIX,and XXI, EXCEPT drugs and other chemicals

• II – index of external causes of morbidity and mortality, all terms classifiable to Chapter XX, EXCEPT drugs and other chemicals

• III – table of drugs & chemicals

ICD10 & TB

Dr. M.M. Singh

www.hitsi.org

Volume 3 : Alphabetical index

LEAD TERMS :

• key words (extreme left)/ Bold

• name of disease/pathological condition/ diagnosis

Indented :

• (in right after dash)

• the modifiers/ qualifier – variety, site, etc.

o -

o --

o ---

o ----ICD10 & TB

Dr. M.M. Singh

www.hitsi.org

Golden Rules

<

ICD10 & TB

www.hitsi.org

Coding Rules Quiz

ICD10 & TB

• What are the names of the three

volumes of the ICD-10?

• Volume 1 is called the

• Volume 2 is called the

• Volume 3 is called the

Tabular List

Instruction Manual

Alphabetical Index

Coding

Session-2_2

ICD10 & TB

www.hitsi.org

Chapter I – Certain infectious and parasitic diseases

ICD10 & TB

www.hitsi.org

Chapter I – Certain infectious and parasitic diseases

ICD10 & TB

• Would you use Chapter I to code all of these

diseases?

www.hitsi.org

Chapter I – Certain infectious and parasitic diseases

ICD10 & TB

• Would you use Chapter I to code all of these

diseases?

www.hitsi.org

Chapter I – Certain infectious and parasitic diseases

ICD10 & TB

• The second block in Chapter I is A15-A19 which is for

coding Tuberculosis. The categories in this block identify the site of

the tuberculosis.

• For respiratory tuberculosis, the codes also specify whether the

diagnosis was confirmed and what method was used for the

confirmation e.g. sputum microscopy, chest x-ray.

www.hitsi.org

Chapter I – Certain infectious and parasitic diseases

ICD10 & TB

• For mortality coding, section 4.2.4 of Volume 2 states that codes in this

block should be used for underlying cause coding to indicate that death

resulted from the late (or residual) effects of a given disease, rather than

during the active phase.

www.hitsi.org

Lead Term

• Modifiers

Vol-3

• Notes

• ( )

• -

• --

• ---

• ----

• †/* (dual)

-Ref

• See

• See also

Vol-1 (Confirm)

• Inclusion

• Exclusion

• •.- (4th )

Coding!

• Done!

ICD10 & TB

Coding!

Coding Practice

ICD10 & TB

www.hitsi.org

Chapter I – Certain infectious and parasitic diseases

ICD10 & TB

• Now let’s find the code for Tuberculous meningoencephalitis.

www.hitsi.org

Chapter I – Certain infectious and parasitic diseases

ICD10 & TB

• Mr. Sami currently suffers from tuberculous bronchiectasis which was

confirmed by histological testing.

– How would this disease be coded?

Morbidity Practice

Session-2_3

ICD10 & TB

www.hitsi.org

Morbidity Quiz

ICD10 & TB

• Match the following terms with their correction

definitions.

Episode of heath care

Morbidity coding

Mortality coding

1. The coding performed in hospitals.

2. The coding of causes of death.

3. A period of inpatient care or contact with a health care

practitioner for the same condition.

www.hitsi.org

Morbidity Quiz

ICD10 & TB

• Are these three statements true or

false?

–The asterisk code may be used to specify the

manifestation. Use of an asterisk code with

the dagger code is optional. The asterisk

code must never be used without an

appropriate dagger code.”

True

false

www.hitsi.org

Morbidity Quiz

ICD10 & TB

• A clinician records a patient’s conditions

as Tuberculous mastoiditis.

– What would be the correct code assignment for this

case in a multiple-condition coding episode?

A18.0† alone

H75.0* alone

A18.0† H75.0* together

H75.0* A18.0† together

Certification Practice

Session-2_4

ICD10 & TB

www.hitsi.org

Certification Quiz

ICD10 & TB

• On which line do you think the condition thought to be the

immediate cause of death should appear?

www.hitsi.org

Certification Quiz

ICD10 & TB

• There must always be an entry on line I(a). Do you think this

can be the only condition reported in Part I?

www.hitsi.org

Certification Quiz

ICD10 & TB

• Is it correct?

www.hitsi.org

Certification Quiz

ICD10 & TB

• If four entries are required on Part I of the certificate,

where will you put each of the following?

– The condition that initiated the train of events

– The direct cause of death

– The intervening causes of the direct cause of death

Statistical Presentation Practice

Session-2_5

ICD10 & TB

www.hitsi.org

Statistical presentation Quiz

ICD10 & TB

• Look at the following statement, and say

whether it is true or false.

– “If medical certification of the cause of death is

incomplete then the figures for deaths not

medically certified should be published separately.”

True

False

Summary & Conclusion

Session-2_6

ICD10 & TB

www.hitsi.org

Summary for morbidity coding

ICD10 & TB

• Morbidity coding usually refers to the coding

performed using the medical records of inpatients or

outpatients.

• Coding is usually performed on each episode of

health care in a health institution, but it may also be

used in surveys or research programs or

registries.

• Due to the variable definitions of morbidity, the

comparability of morbidity data is limited

www.hitsi.org

Direct

Intervening

Intervening

Underlying

Contributing

D

u

r

a

t

i

o

n

Summary of Certification

ICD10 & TB

• The format for completion of the standard international

death certificate recommended by the WHO is as follows:

– Part I

• (a): immediate cause of death due to

• (b): Intervening cause due to

• (c): Intervening cause due to

• (d): underlying cause of death

– Part II

• Any other significant disease or condition that contributed to

death.

www.hitsi.org

Summary of Certification

ICD10 & TB

• Entries in Part I should be in a sequence with

the underlying cause of death reported on the

lowest used line.

– All entries should be recorded legibly without the

use of abbreviations.

–As much detail as possible should be

recorded so that it can be used to assign

complete and specific codes from the ICD.

www.hitsi.org

Conclusion

• ICD derived Information is:

– reported, categorized, analysed, presented, and decisions

are made at any level of a health system.

• Such health information is used for:

– epidemiology, prevention, managing health care, allocation

of resources, outcomes monitoring, in research, and

primary care.

• ICD makes people count!

ICD10 & TB

www.hitsi.org

Resources

• ICD 10 Interactive Self-learning Tool:

– http://apps.who.int/classifications/apps/icd/ICD10Tr

aining/

• ICD 10 Online Browser: Version 2016

– http://apps.who.int/classifications/icd10/browse/201

6/en#/

ICD10 & TB

www.hitsi.orgICD10 & TB

Rehab Rayan

HIFB, PharmD

rehab.a.rayan@gmail.com