ICD Fundamentals

ICD FundamentalsNawanan Theera-Ampornpunt, M.D.Medical Informatics DivisionFaculty of Medicine Ramathibodi Hospital18 May 2005

Some contents are adopted from “ICD-10-TM Standard Coding Guidelines” by Bureau of Policy and Strategy, Office of the Permanent Secretary, Ministry of

Public Health, Thailand, 2004

Reproduced Nov. 23, 2008 for publishing on SlideShare.net.Parts of the presentation may be specific to the use of ICD-9-CM and ICD-10 in the author’s organization or country (Thailand) and may not be applicable to other settings.

What is ICD-10?

International Statistical Classification of Diseases and Related Health Problems, Tenth RevisionEffective 1 Jan. 1993Adopted in Thailand since 1994

Current Usage in ThailandGovernmental reimbursement

ICD-10 for diagnosesICD-9-CM-2000 for operations

Developed ICD-10-TM based on international ICD-10 to better categorize diagnoses of tropical and endemic diseasesICD-10-TM has been adopted increasingly in various institutions, but not yet supported by reimbursement organizations

Why ICD-10?

International cooperation & standardAccepted standard for national statisticsGovernmental reimbursement (DRG)

National Health Security OfficeSocial Security OfficeCentral Office for Healthcare Information

Thai DRG uses ICD-10 for calculating proper RW (Relative Weight) for reimbursement

RW

Relative Weight (for reimbursement)More RW = More severe = More moneyRW calculations are based on

Number of diseasesComplexity and severity of diseasesPrinciple diagnosisOperations doneAge, sex, weightDischarge type

Data Completeness and RW

RW depends oncompleteness of diagnosesproper diagnosis entry

Priority (Principal vs. Secondary)SeveritySpecificity

Diagnosis EntryPDx J13 Pneumonia due to Streptococcus pneumoniae

PDx J13 Pneumonia due to Streptococcus pneumoniaeSDx D561 Beta thalassemia

PDx D561 Beta thalassemiaSDx J13 Pneumonia due to Streptococcus pneumoniae


J80 Adult respiratory distress syndrome


J80 Adult Respiratory Distress SyndromePOp 9672 Continuous mechanical ventilation for 96 consecutive

hrs. or more

RW0.7142

1.6884

1.2256

1.6884

1.8631

A patient with underlying beta thalassemia was admitted due to Streptococcus pneumoniae pneumonia and during admission had experienced ARDS and needed ET tube and ventilator support. Later, pneumothorax occurred and ICD was done. After 1 month, patient improved and was discharged.

A patient with underlying beta thalassemia was admitted due to Streptococcus pneumoniae pneumonia and during admission had experienced ARDS and needed ET tube and ventilator support. Later, pneumothorax occurred and ICD was done. After 1 month, patient improved and was discharged.

Diagnosis Entry(Previously)PDx J13 Pneumonia due to Streptococcus pneumoniaeSDx D561 Beta thalassemia

J80 Adult Respiratory Distress SyndromePOp 9672 Continuous mechanical ventilation for 96 consecutive

hrs. or more


J80 Adult Respiratory Distress SyndromeJ939 Pneumothorax

POp 9672 Continuous mechanical ventilation for 96 consecutive hrs. or more

SOp 9604 Insertion of endotracheal tube3404 Insertion of intercostal catheter for drainage

RW1.8631

2.3146

Concept of Diagnosis

Principal diagnosis (PDx)One conditionDiagnosed at the end of care (Final Dx)Main reason for the admissionIn case of more than one main reason, use the most resource-consuming DxIn case of no definitive Dx, use most appropriate signs/symptoms or findings

Some codes may be valid only in specific gender or specific age groups

Concept of DiagnosisSecondary diagnosis (SDx)

ComorbidityCondition(s) existing before admissionMay exist before or at the same time with the PDxIncludes underlying diseasesCauses more expenses or higher patient risksUnlimited items

ComplicationCondition(s) occurring after admissionCauses more expenses or higher patient risksMay not be related to PDxUnlimited items

Examples – PDx & SDx

A patient with underlying DM, HT, IHDpresents with severe headache and BP = 200/140 mmHg

PDx I10 Essential (malignant) HypertensionSDx E119 NIDDM without complications

I259 Chronic ischaemic heart disease, unspecified

Examples – In case of 2 potential PDxUse the most resource-consuming

A patient was admitted due to bacterial pneumonia with respiratory failure.

PDx J960 Acute respiratory failureSDx (comorbid)

J159 Bacterial pneumonia, unspecified

If respiratory failure occurs after admission, then the PDx must be bacterial pneumonia and the respiratory failure must be the SDx (complication)

Note!!

Examples – PDx must be at the end of care

A patient with acute abdominal pain was admitted, the provisional diagnosis was peritonitis. Surgical findings revealed perforated chronic duodenal ulcer

PDx K265 Duodenal ulcer : chronic or unspecified with perforation

SDx -

Examples – PDx as signs/symptoms

A patient with RLQ pain was admitted for observation, later discharged without definitive diagnosis because the symptoms finally resolved

PDx R103 Pain localized to other parts of lower abdomen

SDx -

Examples – Complications related to PDx

A patient with deep vein thrombosis was admitted. After admission, pulmonary embolism occurs.

PDx I801 Phlebitis and thrombophlebitis of femoral vein

SDx (complication)I269 Pulmonary embolism without mention

of acute cor pulmonale

Examples – Complications not related to PDx

A patient with pneumonia was admitted. After admission, acute gastroenteritisoccurred.

PDx J159 Bacterial pneumonia, unspecifiedSDx (complication)

A09 Diarrhoea and gastroenteritis of presumed infectious origin

Examples – Comorbids vs complications

A patient with underlying DM and diabetic retinopathy was admitted due to bacterial pneumonia. After admission, acute gastroenteritis that resulted in hypovolemiaoccurred.

PDx J159 Bacterial pneumonia, unspecifiedSDx (comorbids)

E116 NIDDM with ophthalmic complicationsH360 Diabetic retinopathy

SDx (complications)A09 Diarrhoea and gastroenteritis of presumed

infectious originE86 Volume depletion

Concept of DiagnosisPrincipal Operation (POp)

Procedure/Operation primarily done for the admissionMostly done for PDx, but may be done for SDxMostly the major operative procedure is done in OR, but not necessarily (can be a non-OR procedure)If more than 1 potential procedure, use clinical judgement for what is the most important procedure for the admissionOne condition allowed

Secondary Operation (SOp)All other significant procedures/operationsUnlimited itemsAvoid insignificant procedures, like IV infusion, dressings

Examples – Principal vs Secondary Ops.

A patient with indirect inguinal hernia was admitted. Herniorrhaphy was done. After admission, pleural effusion was found and subsequent ICD was done.

PDx K409 Unilateral or unspecified inguinal hernia, without obstruction or gangrene

SDx J90 Pleural effusion, not elsewhere classifiedPOp 5302 Repair of indirect inguinal herniaSOp 3404 Insertion of intercostal catheter for

drainage

Examples – Principal Ops. for PDxA patient with indirect inguinal hernia was admitted. After admission, pneumoniaoccured. Herniorrhaphy was done during the admission after treatment of pneumonia.

PDx K409 Unilateral or unspecified inguinal hernia, without obstruction or gangrene

SDx J159 Bacterial pneumonia, unspecifiedPOp 5302 Repair of indirect inguinal herniaSOp -

Examples – Principal Ops. for SDxA patient with pneumonia was admitted. After admission, indirect inguinal hernia was found and herniorraphy was done during the admission after treatment of pneumonia.

PDx J159 Bacterial pneumonia, unspecifiedSDx K409 Unilateral or unspecified inguinal hernia,

without obstruction or gangrenePOp 5302 Repair of indirect inguinal herniaSOp -

Examples – Principal Ops. Outside OR

A patient with pneumonia and pleural effusion was admitted. After admission, ICD was done.

PDx J159 Bacterial pneumonia, unspecifiedSDx J90 Pleural effusion, not elsewhere

classifiedPOp 3404 Insertion of intercostal catheter

for drainageSOp -

Examples – Non-OR Principal Ops.

A patient with pneumonia and pleural effusion was admitted. After admission, ICD was done.

PDx J159 Bacterial pneumonia, unspecifiedSDx J90 Pleural effusion, not elsewhere

classifiedPOp 3404 Insertion of intercostal catheter

for drainageSOp -

Examples – Non-OR Principal Ops.A preterm newborn with respiratory distress syndrome was admitted. After admission, NECoccured and small intestine resection with end-to-end anastomosis was done.

PDx P220 Respiratory distress syndrome of newborn

SDx (Comorbid) P073 Other preterm infantsSDX (Complication) P77 Necrotizing enterocolitis of fetus

and newbornPOp 4562 Other partial resection of small

intestineSOp 4591 Small-to-small intestinal

anastomosis

ICD-10 Chapters

Certain infectious and parasitic diseasesNeoplasmsDiseases of the blood and blood-forming organs and certain disorders involving the immune mechanismEndocrine, nutritional and metabolic diseasesMental and behavioural disordersDiseases of the nervous systemDiseases of the eye and adnexaDiseases of the ear and mastoid process

ICD-10 Chapters (Cont.)

Diseases of the circulatory systemDiseases of the respiratory systemDiseases of the digestive systemDiseases of the skin and subcutaneous tissueDiseases of the musculoskeletal system and connective tissueDiseases of the genitourinary systemPregnancy, childbirth and the puerperiumCertain conditions originating in the perinatal period

ICD-10 Chapters (Cont.)

Congenital malformations, deformations and chromosomal abnormalitiesSymptoms, signs and abnormal clinical and laboratory findings, not elsewhere classifiedInjury, poisoning and certain other consequences of external causesExternal causes of morbidity and mortalityFactors influencing health status and contact with health services

External Causes of Morbidity and Mortality (E-codes)

External causes of trauma/injury/poisoning that results in morbidity/mortalityImportant for national statistics and prevention measuresIf not specified, it’s incomplete

External Causes of Morbidity and Mortality (V, W, X, Y)

Classified intoAccidentsIntentional self-harmAssaultEvent of undetermined intentLegal intervention and operations of warComplications of medical and surgical careSequelae of external causesSupplementary factors related to causes... (eg. alcohol level, nosocomial condition, etc.)

Accidents as External Causes

Transport accidents

Non-transport

Accidents as External Causes

Transport accidentsPedestrian injuredPedal cyclist injuredMotorcycle rider injuredOccupant of three-wheeled motor vehicle injuredCar occupant injuredOccupant of pick-up truck or van injuredOccupant of heavy transport vehicle injuredBus occupant injuredOther land transport accidentsWater transport accidentsAir and space transport accidentsOther and unspecified transport accidents

Non-transport

Accidents as External CausesTransport accidentsNon-transport

FallsExposure to inanimate mechanical forces (includes GSW)Exposure to animate mechanical forcesAccidental drowning and submersionOther accidental threats to breathingExposure to electric current, radiation and extreme ambient air temperature and pressureExposure to smoke, fire and flamesContact with heat and hot substancesContact with venomous animals and plantsExposure to forces of natureAccidental poisoning by and exposure to noxious substancesOverexertion, travel and privationAccidental exposure to other and unspecified factors

Transport Accidents

Any accident involving device designed primarily for conveying persons or goods from one place to anotherClassified into

Traffic accidentAny vehicle accident occuring on the public highway (e.g. originating on, terminating on, involving a vehicle partially on the highway)

Nontraffic accidentoccurs entirely in any place other than a public highway, e.g. off-road motor vehicle accidents

Transport AccidentsPedestrian = any person involved in the accident that is not in any vehicle or animal

Includes:person changing wheel of vehiclemaking adjustment to motor of vehicleon footperson with baby carriageice-skatersperson with push-cart or push-chairRoller-skatersScooter rider, skateboard rider, skier, person with (powered) wheelchair

Driver = occupant of a transport vehicle who is operating or intending to operate itPassenger is other person than driverPerson on outside of vehicle = any person being transported by a vehicle but not occupying the space normally reserved for driver & passengers

Includes: person travelling on bodywork (ตวัถงัรถ), bumper (กนัชน), hanging outside, on roof, etc.

Transport Accidents

Pedal cycle = bicycle & tricyclePedal cyclist = any person riding on pedal cycle or in a sidecar attached to itMotorcycle includes:

Motor scooterMotorcycle with sidecarMotorized bicycleExcludes motor-driven tricycle

Motorcycle rider includes person riding on or in a sidecarThree-wheeled motor vehicle includes:

motor-driven tricycle, three-wheeled motor carCar = 4 wheeled motor vehicle, including minibus

Transport Accidents

Pick-up Truck or van = 4 or 6 wheeled motor vehicle designed primarily for carrying property, weighing less than local limit for classification as heavy goods vehicle, not requiring special driver’s licenseHeavy transport vehicle = over pick-up truck, usually carrying above 3,500 kg), requiring special driver’s licenseBus = motor vehicle designed for carrying > 10 persons, requiring special driver’s licenseRailway train includes BTS and SubwayStreetcar includes tram (รถราง)

Transport Accidents

Other types of vehiclesSpecial vehicle mainly used onindustrial premisesSpecial vehicle mainly used in agricultureSpecial construction vehicleSpecial all-terrain vehicleWatercraftAircraft

Transport Accident Coding InstructionsIf event is unspecified whether traffic or nontraffic accident, it is:

Trafffic accident if occurred with vehicles normally used for trafficNontraffic accident if occurred with special vehicles

If can’t specify the victim as vehicle occupant and the victim is crushed/dragged/hit/injured/killed/knocked down/run over by vehicles, classify the victim as pedestrian

Transport Accident Coding InstructionsIn transport accident involving vehicle collision/accident/crash/wreck, if can’t specify the victim’s role, classify the victim as occupant or rider of vehicle specifiedIf more than one vehicle is mentioned, do not make assumption which vehicle was occupied by victim unless vehicles are the same, but use codes with “Victim’s mode of transport unknown” instead

Transport Accident Coding InstructionsCollision

Includes collision afterbreakage of any partexplosion of any partfire starting in vehiclehit by object thrown into or onto vehicleobject falling in or onetc.

Includes collision between vehicle and vehicle or vehicle and:animal (สตัวท์ี่อยูเ่ฉยๆ ในทางจราจร)

nonmotor vehicleanimal-driven vehicleanimal being ridden (สตัวท์ี่กาํลงัถูกขี่)

bridgefallen stonefenceinter-highway dividerlandslideobject thrown in front of motor vehiclesafety island (เกาะกลางถนน)

treetraffic signother object - either fixed/movable/moving

Noncollisionfall or thrown away from vehicle without prior collisionoverturning without collision

Intentional Self-Harm

Suicide and suicidal attemptNon-suicidal but intentional self- injury/poisoning

Intentional self-poisoningHanging, strangulation & suffocationDrowning & submersionGSWSharp objectBlunt objectJumping from high placeJumping or lying before moving objectsCrashing of motor vehicle

AssaultDrugs and biological substanceChemical or noxious substancesHanging, strangulation & suffocationdrowning and submersionGSWExplosive materialSmoke, fire and flamesSteam, hot vapours and hot objectsSharp objectBlunt objectPushing from high placePushing or placing victim before moving objectCrashing of motor vehicleBy bodily force (Unarmed fight)Sexual assault by bodily forceNeglect and abandonmentOther maltreatment syndromes

Event of Undetermined Intent

Similar to intentional self-harms and assaults

Legal actionsLegal execution (ประหารชีวติ)

War operations

Legal Intervention and Operations of War

Complications of Medical and Surgical Care

IncludesComplications of medical devicesCorrect drug administered in therapeutic dosage but cause adverse effectMisadventures to patients during surgical/medical careSurgical and medical procedures causing abnormal reaction or immediate or later complication

ExcludesAccidental drug over-dosageWrong drug given or taken

Adverse Drug Effects in Therapeutic Use

Systemic antibiotics (Y40)PenicillinsCefalosporins & other beta-lactamsChloramphenicolMacrolidesTetracyclinesAminoglycosidesRifamycinsSystemic antifungal antibioticsOther systemic anti-infectives

Other systemic anti-infectives (Y41)SulfonamidesAnti-TBAntimalarials & drugs acting on blood protozoaOther antiprotozoalAnthelminthicsAntiviral drugsOthers


Hormones & Antagonists (Y42)GlucocorticoidsThyroid hormonesAntithyroid drugsInsulin and oral hypoglycemic drugsetc.

Primarily systemic agents (Y43)Antiallergic & antiemetic drugsAntineoplastic drugsImmunosuppressive agentsAcidifying & alkalizing agentsetc.


Agents primarily affecting blood constituents (Y44)Iron and other anti-hypochromic anemia preparationsAnti-megaloblastic anemia preparationsAnticoagulantsVit. K & coagulantsThrombolytic drugsetc.

Analgesics, antipyretics, anti-inflammatory (Y45)Antiepileptics & antiparkinsonism (Y46)Sedatives, hypnotics & antianxiety drugs (Y47)Anesthetics & therapeutic gases (Y48)Psychotropic drugs NEC (Y49)

TCA, MAOI, antipsychotics, neurolepticsCNS stimulants NEC (Y50)Drugs affecting ANS (Y51)


Agents affecting CVS (Y52)Agents affecting GI (Y53)Agents affecting water-balance & mineral & uric acid metabolism (Y54)Agents acting on smooth & skeletal muscles and respiratory system (Y55)

OxytocinsMuscle relaxantsAntitussivesExpectorantsAnti-common-cold drugsAntiasthmatics NEC

Topical agents on skin, eye, ENT & dental drugs (Y56)Others (Y57)

Antidotes & chelating agents NECX-ray contrast media

Bacterial vaccines (Y58)Other vaccines & biological substances (Y59)

Immunoglobulin

Misadventures to patients during surgical and medical care

Unintentional cut, puncture, perforation or hemorrhage during surgical and medical care (Y60)Foreign object accidentally left in body during surgical and medical care (Y61)Failure of sterile precautions during surgical and medical care (Y62)Failure in dosage during surgical and medical care (Y63)

Excludes accidental overdose of drug or wrong drug given in error (X40-X44)

Contaminated medical or biological substances (Y64)Others (Y65)

Mismatched blood used in transfusionWrong fluid used in infusionFailure in suture or ligature during surgical operationET Tube wrongly placed during anesthetic procedureFailure to introduce or to remove other instrumentsPerformance of inappropriate operation

Nonadministration of surgical and medical care (Y66)

Medical devices associated with adverse incidents in diagnostic and therapeutic use

Anesthesiology devices (Y70)CVS devices (Y71)ENT devices (Y72)GI & urology devices (Y73)General hospital and personal-use devices (Y74)Neurological devices (Y75)Obstetric & gynecological devices (Y76)Ophthalmic devices (Y77)Radiological devices (Y78)Orthopedic devices (Y79)Physical medicine devices (Y80)General surgery and plastic surgery devices (Y81)Other (Y82)

Surgical and other medical procedures as the cause of abnormal reaction, without mention of misadventure at the time of procedure

Surgical operation and other surgical procedures (Y83)Transplant of whole organImplant of artificial internal deviceAnastomosis, bypass or graftFormation of external stomaOther reconstructive surgeryAmputation of limb(s)Removal of other organ (partial/total)Other

Other medical procedures (Y84)Cardiac catheterizationKidney dialysisRadiological procedure and radiotherapyShock therapyAspiration of fluidInsertion of gastric or duodenal soundUrinary catheterizationBlood-samplingOther

Notes

If there is any S or T code in PDx or SDx, there must be external causesIf the diagnosis is drug-induced or poisoning, there must be external causesIf the diagnosis is trauma-related, there must be external causesExternal causes must not be used as PDx

Examples – External causes

A man riding motorcycle was hit by truckduring his way home after work. He experienced cerebral concussion and close fracture of Rt. femur, after admission, aspiration pneumonia occured

PDx S7230 Fracture of shaft of femur : closedSDx (comorbid)

S0600 Concussion, without open intracranial wound

SDx (complication)J690 Pneumonitis due to food and vomit

External causeV2442 Motorcycle rider injured in collision with

heavy transport vehicle or bus, driver injured in traffic accident, while working for income

Activity Code

While engaged in sports activityWhile engaged in leisure activity

HobbyLeisure-time activities with entertainment elementVoluntary activities

While working for incomeIncludes during transportation to and from working

While engaged in other types of workCleaning, cooking, gardening, etc.

While resting, sleeping, eating or engaging in othervital activities

Personal hygieneWhile engaged in other specified activitiesDuring unspecified activity


A woman with CA cervix who underwent radiotherapy came to the hospital due to radiation cystitis

PDx N304 Irradiation cystitisSDx C539 Malignant neoplasm of cervix uteri,

unspecifiedExternal cause

Y842 Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure


A woman with acute pyelonephritis was admitted to the hospital and was given Ceftriaxone. After drug administration, she experienced urticaria and hypotension.

PDx N10 Acute tubulo-interstitial nephritisSDx L500 Allergic urticaria

T886 Anaphylactic shock due to adverse effect of correct drug or medicament properly administered

External causeY401 Cefalosporins and other beta-lactam

antibiotics causing adverse effects in therapeutic use

Note!!

In the software in Ramathibodi wards, some items show only the name of the drugs causing adverse effects. For example,T361 Cefalosporins and other beta-lactam antibioticsY401 Cefalosporins and other beta-lactam antibiotics

What’s their differences???

Note!!

In the ICD search screen, try choose T36, you’ll see Poisoning by systemic antibiotics, soT361 is poisoning by cefalosporins and other beta-lactam antibiotics

Similarly, try choose Y40, you’ll seeSystemic antibiotics

It’s still not understood...

Knowing that Y items are external causes would be beneficial. In this case, it is the code for drugs causing adverse effects in therapeutic use


A woman who previously broke up with boyfriend intentionally took 30 tablets of paracetamol. She was then taken to the hospital.

PDx T391 Poisoning by 4-Aminophenol derivativesExternal cause

X600 Intentional self-poisoning by and exposure to nonopioid analgesics, antipyretics and antirheumatics at home

Please note that paracetamol is 4-Aminophenol derivatives

Place of Occurrence

HomeApartmentFarmhousePrivate places, etc.

Residential institutionChildren’s homeDormitoryHome for the sickMilitary campNursing homeOld people’s homePrison

Place of Occurrence

School, other institution and public administrative areaCampus, collegeChurchCinemaCourt-houseGallery, museumHospitalLibraryPublic hallPost office

Sports and athletics areaStreet and highway

Freeway, motorway, pavement, sidewalkTrade and service area

AirportBankCasinoGas stationHotelRestaurantMarketShopShopping mallSupermarketBus station

Place of Occurrence

Industrial and construction areaFarmOther specified placesUnspecified places

Factors Influencing Health Status and Contact with Health Services (Code Z)In some cases, provision of supplemental codes Z would be beneficial for statistical completeness and medical record review

Problems related to lifestyle (Z72)Tobacco use (Z720)Alcohol use (Z721)Drug use (Z722)Inappropriate diet and eating habits (Z724)High-risk sexual behaviour (Z725)

Family history of diseases (Z80-Z84)Personal history of diseases (Z85-Z88)Acquired absence of limb or other organ (Z89-Z90)Risk factors and personal history of medical treatment (Z91-Z92)

Personal history of self-harmPersonal history of major surgeryPersonal history of irradiation

Factors Influencing Health Status and Contact with Health Services (Code Z)

Artificial opening status (Z93)TracheostomyGastrostomyIleostomyColostomyCystostomyetc.

Transplanted organ and tissue statusKidney transplant statusHeart transplant statusLung transplant statusLiver transplant statusBone transplant statusBone marrow transplant status (Z948)etc.

Presence of cardiac and vascular implants and grafts (Z95)Presence of other functional implants (Z96)

Presence of intraocular lensPresence of insulin pump (endocrine implants)Presence of orthopaedic joint implants, etc.

Factors Influencing Health Status and Contact with Health Services (Code Z)

Presence of other devices (Z97)Presence of artificial eyePresence of artificial limbPresence of intrauterine contraceptive device

Other postsurgical states (Z98)Intestinal bypass and anastomosis statusArthrodesis statusPresence of CSF shunt, etc.

Dependence on enabling machines and devices (Z99)Dependence on aspiratorDependence on respiratorDependence on renal dialysisDependence on wheelchair, etc.

These codes must not be used as PDx

How To Choose The Proper Code in the Software?Start search by most relevant keyword(s)

Don’t be too specific, it may have no resultsAsthma instead of Acute severe asthma

Don’t be too generic, it may have extensive resultsenteritis instead of infection

Avoid uncommon terms, they may have no resultsPneumonia instead of Pulmonary infection

Be aware of incorrect sequence of keywordsTuberculosis of lung instead of Lung tuberculosis

Use generic form of the words firstAsthma instead of AsthmaticAnaphyla instead of Anaphylaxis, Anaphylactic

(because you don’t know what words are used in ICD-10)

Infection instead of infections

How To Choose The Proper Code in the Software?Choose most specific and relevant code (need human decision)

Acute pharyngitis instead of URISee description for more details (inclusions, exclusions)N811Cystocele

Cystocele with urethroceleProlapse of (anterior) vaginal wall NOSExcludes: cystocele with prolapse of uterus

(N812-N814)

NOS Not Otherwise SpecifiedNEC Not Elsewhere ClassifiedUse the most detailed items

Don’t use N81 but use N811

How To Choose The Proper Code in the Software?If can’t find the proper specific code, try using related-words

British terms (Diarrhoea, Oedema, Haemorrhage, Centre, Labour, Programme, Licence)Other word forms

Amoeba, Amoebic, AmoebiasisInfection, Infectious, Infective, Inflammation, more specific conditionsTuberculosis, tuberculous

Try other similar wordsLBP -> Dorsalgiabacteremia -> septicaemia / sepsisOral candidiasis -> Candidal stomatitisEnterocolitis -> Enteritis, colitis, gastroenteritis, etc.Liver failure -> Hepatic failure

Try other disease/syndrome namesColle’s fracture -> Fracture of lower end of radius

Try avoid abbreviationsTuberculosis instead of TBUpper respiratory tract infection instead of URI

If still can’t find the proper code, use the diagnosis treeIf still can’t find the proper code, use ‘Other’ if the disease is specific, or use ‘Unspecified’ if non-specific

Dual Code System

Appears as dagger (+) and asterisk (*)Some codes need multiple entry, e.g.

TB MeningitisA17.0+ Tuberculous meningitis (G01*)G01* Meningitis in bacterial diseases

classified elsewhereNotice the + and * sign, if present, consider using the other code, too+ must always be present, * is optionalIf * is entered, + must first be present

Examples – Dual Codes

A patient was admitted due to cryptococcal meningitis.

PDx B451 Cerebral cryptococcosis (G021*)SDx (Comorbid)

G021 Meningitis in mycoses classified elsewhere


A patient was admitted due to histoplasmosis with pneumonia.

PDx B394 Histoplasmosis capsulati, unspecifiedSDx (Comorbid)

J172 Pneumonia in mycoses


A patient was admitted due to amoebic lung abscess.

PDx A065 Amoebic lung abscess (J99.8*)SDx (Comorbid)

J998 Respiratory disorders in other diseases classified elsewhere

ICD-10 In Particular Diseases

Chemotherapy/RadiotherapyIn OPD case or patients with less than 24 hours length of stay, use this as PDx

Z511 Chemotherapy session orZ510 Radiotherapy session

In IPD case with more than 24 hours length of stay, use Z511 or Z510 as SDx and use proper diagnosis (e.g. CA colon) as PDx

ICD-10 In Particular DiseasesDM

IDDMComaDKAWith renal complicationsWith ophthalmic complicationsWith neurological complicationsWith peripheral circulatory complicationsWith other specified complicationsWith multiple complicationsWith unspecified complicationsWithout complications

NIDDMMalnutrition-related DMOther specified DMUnspecified DM

ICD-9-CMUsed for operations and proceduresConsists of 3- to 4-digit codesCategorized by systems

Nervous systemEndocrine systemEyeEarNose, mouth and pharynxRespiratory systemCardiovascular systemHemic and lymphatic systemDigestive systemUrinary systemMale genital organsFemale genital organsObstetrical proceduresMusculoskeletal systemIntegumentary systemMiscellaneous

Commonly Used ICD-9CM

9604 Insertion of endotracheal tube3322-24 Bronchoscopy4413 Other gastroscopy4414 Gastroscopy with biopsy

(Brush biopsy of stomach)311 Temporary tracheostomy9671 Continuous mechanical ventilation for

less than 96 consecutive hours9672 Continuous mechanical ventilation for

96 consecutive hours or more

Commonly Used ICD-9-CM

3894 Venous cutdown3893 Central venous catheterization NEC8604 Other incision with drainage of skin

and subcutaneous tissue3404 Insertion of intercostal catheter for

drainage8872 Diagnostic ultrasound of heart

(echocardiography)Sometimes, need to use categorized trees to find codes.If can’t find proper code, use “others”

Health & Medicine

ICD Fundamentals