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 (ICD-10) is being published in Bangladesh. ICD-10 has been developed by the World Health Organization (WHO) which is now used world-wide for morbidity and mortality statistics, reimbursement systems and automated decision support in medicine.
The main purpose of ICD is to harmonize medical recording practices worldwide. ICD-10 was adopted by the World Health Assembly in May 1990 and we expect that all government and private health and medical institutions in the country essentially use this version in preparing their records and reports. All medical and health institutions, including hospitals in the country should equip themselves with the WHO publication on ICD-10 as a reference and we request the authorities to plan regular orientations on the use of it. I believe that implementation of ICD-10 will have a positive impact on the entire value chain of healthcare including insurance, service delivery, scheduling, patient registration, patient care, customer service, revenue and reimbursement management, network management and risk management.
With regard to achieving the objective of ICD-10, it is important for the concerned health managers, medical teachers, consultants and institute heads to play their roles proactively. I hope that this valuable publication will guide and facilitate them to perform their roles and responsibilities.
I would like to extend my sincere appreciation to all those in the Directorate General of Health Services who have contributed to the development and publication of this valuable guide.
Dr N. Paranietharan WHO Representative to Bangladesh
viii | Guidebook on ICD-10 What do we understand by ICD? ICD stands for International Statistical Classification of Diseases and Related Health Problems. This classification system has been developed by the World Health Organization (WHO). ICD is used world-wide for morbidity and mortality statistics, reimbursement systems and automated decision support in medicine. The design of ICD promotes international comparability in the collection, processing, classification and presentation of morbidity and mortality statistics.
ICD contains only diagnosis codes and the classfication is used to translate diagnosis of diseases & other health problems from clinical text into an alphanumeric codes. It permits easy storage, retrieval and analysis of the data. WHO revises the ICD code-set periodically and it is currently in it's 10th edition, which was introduced by WHO in 1993.
ICD-10 comprises three volumes: 1. Volume 1 contains the main classifications; 2. Volume 2 provides guidance to users of the ICD; and 3. Volume 3 is the Alphabetical Index to the classification.
Volume 1 is the Tabular list, which is an alphanumeric listing of diseases and disease groups, at the three-and four-character levels. It also includes the classification of the morphology of neoplasms along with inclusion and exclusion notes, special tabulation lists for mortality and morbidity, definitions and the nomenclature regulation.
Volume 2 is the Instruction Manual. It provides: