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Guidebook On Government of the People's Republic of Bangladesh Ministry of Health and Family Welfare Guidebook on ICD 10 ICD-10 Coding January 2015 Third edition Management Information System (MIS) Directorate General of Health Services (DGHS) Mohakhali, Dhaka-1212 www.dghs.gov.bd in collaboration with Government of the People's Republic of Bangladesh Ministry of Health and Family Welfare Guidebook on ICD 10 ICD-10 Coding January 2015 Third edition Management Information System (MIS) Directorate General of Health Services (DGHS) Mohakhali, Dhaka-1212 www.dghs.gov.bd in collaboration with Special Acknowledgement: Professor Dr. Deen Mohammad Noorul Huq Director General of Health Services Dr. N. Paranietharan WHO Representative to Bangladesh Editorial Board For This Edition Editor: Professor Dr. Abul Kalam Azad ADG (Planning & development) & Director-MIS-Health, DGHS Contributors: Dr. Rashidun Nessa Deputy Director, Management Information System, DGHS Professor Dr. Md. Ayub Ali Chowdhury Professor of Nephrology, National Institute of Kidney Diseases & Urology, Dhaka Professor Dr. MAK Azad Chowdhury Professor, Dept. of Neonatology, Dhaka Shishu Hospital Professor Dr. Ismail Hossain Associate Professor, Dept. of Medicine Shaheed Suhrawardy Medical College Hospital Dr. Md. Habibullah Talukder Raskin Associate Professor, Dept. of Cancer Epidemiology, NICR & H Dr. Mahmudul Haque Assistant Professor, Dept. of Community Medicine, NIPSOM Dr. Motlabur Rahman Assistant Professor, Dept. of Medicine, DMCH Dr. Ashish Kumar Saha Assistant Director, MIS, DGHS Dr. Lokman Hakim Program Manager (HIS & eHealth), MIS, DGHS Dr. Gowsal Azam Deputy Chief (Medical), MIS, DGHS Dr. Sultan Shamiul Bashar Medical Officer, MIS, DGHS Dr. Jeenat Maitry Medical Officer, MIS, DGHS Contributors of Second Edition Editor: Professor Dr. Abul Kalam Azad Additional Director General (Planning & Development) & Director, MIS-Health, DGHS Contributors: Dr. Chand Sultana Chief (HIU) & Program Manager, WHO, MIS-Health, DGHS Professor Dr. Md Ayub Ali Chowdhury Professor of Nephrology, National Institute of Kidney Diseases & Urology, Dhaka Professor MAK Azad Chowdhury Bangladesh Institute of Child Health, Dhaka Shishu Hospital, Dhaka Professor Dr. ARM Lutful Kabir Professor of Pediatrics, Sir Salimullah Medical College, Dhaka Dr. Mahmudul Haque Assistant Professor, NIPSOM, Dhaka Dr. Abu Sadat Md. Sayem Manager Monitoring & Evaluation, ICDDRB, Dhaka Special Acknowledgement: Professos Dr. Khondhaker Md. Shefyetullah Director General of Health Services Dr. Thushara Fernando WHO Representative to Bangladesh Contributors of First Edition Prepared by: Professor Dr. Abul Kalam Azad Additional Director General (Planning &Development) & Director, MIS-Health, DGHS Professor Supten Sarbadhikari Visiting Professor in Health Informatics Bangladesh Institute of Health Sciences, Dhaka, Bangladesh Dr. Md Aminul Hasan Deputy Program Manager, Training (MCH & SPH) Improved Hospital Services Management Section, DGHS In accordance with guidelines given in a workshop by participants: Dr. Nasima Akhter Ex.-Chief (Deputy Director) & Program Manager, WHO, MIS-Health, DGHS Professor Dr. Md Ruhul Amin Professor of Pediatrics, Shishu Hospital, Dhaka Professor Dr. ARM Lutfur Kabir Professor of Pediatrics, Sir Salimullah Medical College, Dhaka Professor Dr. Md Ayub Ali Chowdhury Professor of Nephrology National Institute of Kidney Diseases and Urology, Dhaka Professor Dr. Shaila Hossain Head, Department of Community Medicine National Institute of Preventive & Social Medicine (NIPSOM), Dhaka Dr. Md Mahmudul Haque Assistant Professor, NIPSOM, Dhaka Table of Contents Sl No. Contents Page No. 1. Preface vi 2. Messages vii-viii 3. What do we understand by ICD 1 4. Global ICD-10 adoption 2 5. ICD-10 based morbidity and mortality reporting from public hospitals 2 6. Advantage of implementing ICD-10 2 7. How to use ICD 3 8. Chapter list of ICD-10 3 9. How each ICD block is constituted 5 10. 3-digits vs. 4-digit ICD codes 6 11. Why to write ICD-10 code 6 12. Who to write ICD-10 code 7 13. How to write ICD-10 code 8 14. Morbidity Coding Seal 8 15. ICD coding for morbidity 9 16. Two codes for certain conditions (Dual Coding) 10 17. List of asterisk 10 18. International classification of diseases for oncology (ICD-O) 11 19. ICD-O Seal 14 20. Writing medical certification of cause of death (Mortality Coding) 15 21. Mortality coding seal 15 22. Concept of underlying cause of death 16 23. How to complete the standard medical certification form? 16 24. International form of medical certification of cause of death 17 25. Death certificate quick reference guide 18 26. International form of medical certification of causes of perinatal death 21 27. Writing medical certification of causes of perinatal death 21 28. Statement of causes of perinatal death & seal for perinatal death 22 29. Recommendation 24 30. Recommended online resources 25 31. Appendix-A (Block list of ICD-10) 26 32. Appendix-B (ICD-10 codes) 34 33. Appendix-C (Morphology of Neoplasm codes) 154 Professor Dr Abul Kalam Azad Additional Director General (Planning & Development) Director, Management Information System (MIS) Directorate General of Health Services (DGHS) Preface Implementing ICD-10 codes for diagnosis and reporting in Bangladesh was a long lasting challenge faced by the Government. However, remarkable progress has been achieved in a relatively short period of time through initiatives taken by the Management Information System (MIS) of the Directorate General of Health Services (DGHS) under the Ministry of Health and Family Welfare (MoHFW) of Bangladesh with supports from the World Health Organization (WHO). ICD-10 based morbidity and mortality reporting for the indoor patients of all public hospitals is now a part of the routine health information system (HIS) which is developed and being maintained by the MIS. District Health Information System (DHIS2), the HIS backbone of the country, has been customized to capture ICD-10 based diagnoses of individual indoor patients of the hospitals, both public and private. We are providing related training to the doctors, nurses and the statisticians to facilitate the implementation. This guide book is playing an instrumented role in promoting the use of ICD-10. In the upcoming post-MDG era, universal health coverage (UHC) will be the priority health agenda for which using standard based diagnostic codes by all concerned entities will be an essential prerequisite. ICD-10 is so far the most suitable candidate for the standard diagnostic codes and hence we should now speedup the implementation process across the country. To meet the increasing demand of this Guidebook on ICD-10, we are going to publish this 3rd edition with the financial support of WHO, Bangladesh country office. I am thankful to our professional colleagues who assisted us to and revise the publication. I am also grateful to DR N. Paranietharan, the WHO Representative of Bangladesh country office for his support and cooperation in relation to the publication. Professor Dr. Abul Kalam Azad vi | Guidebook on ICD-10 Professor Dr Deen Mohammad Noorul Huq Director General Directorate General of Health Services (DGHS) Message I am glad to know that the third edition of the Guidebook on ICD-10 is going to be published by the Management Information System (MIS) of the Directorate General of Health Services (DGHS). I believe that the guidebook will serve as an important tool to the clinicians and other personnel involved in implementing ICD- 10 for diagnosis as well as morbidity and mortality reporting. We cannot over emphasize the importance of using ICD-10, the de facto global standard of disease classification, especially for the purposes of documentation and reporting from every healthcare entity of the country, be it public or private. Unfortunately, we are not yet very successful in ensuring the adoption of ICD-10 by all healthcare organizations. Lack of adequate human resources is obviously one of the most practical reasons for this. We should not worsen the over-burdened human resource situation by engaging a part of them exclusively for coding nor can we readily afford to appoint coders in all hospitals. Hence at present we are relying on the clinicians for the coding. I sincerely believe that our physicians are well capable to quickly learn the coding procedure. The MIS of DGHS, with support from WHO - Bangladesh are providing training on ICD-10 in a regular basis and this guidebook will support the capacity building. I hope that the clinicians will utilize the guidebook as well as other online tools and resources so that they can correctly encode all the diseases and conditions. By this their clinical skill will also be improved.The success of Bangladesh in full implementation of ICD 10 coding in all level of health services both public and private level is largely depending on the clinicians and the statistical staffs. Both of the groups will be benefited by this publication. The field level statistics will guide us to the right direction. Hope the data quality in case of reporting with ICD 10 will be improved day by day.I express special thanks to WHO for their supports in such a critical area of reporting and documentation. I also thank my colleagues at MIS-Health for their hard work in relation to this publication. Professor Dr. Deen Mohammad Noorul Huq Guidebook on ICD-10 | vii DR N. Paranietharan WHO Representative to Bangladesh Message I am pleased to learn that the third edition of the guide book for International Classification of Diseases
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