National Clinical Coding Standards ICD-10 5Th Edition (2017) Accurate Data for Quality Information
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National Clinical Coding Standards ICD-10 5th Edition (2017) Accurate data for quality information Clinical Classifications Service National Clinical Coding Standards ICD-10 Accurate data for quality information Produced by: Clinical Classifications Service NHS Digital Vantage House 40 Aire Street Leeds LS1 4HT [email protected] http://systems.digital.nhs.uk/data/clinicalcoding Date of issue: April 2017 Copyright © 2017 Health and Social Care Information Centre. The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. ICD-10 CONTENTS Introduction .............................................................................................................................. 3 Data Quality ............................................................................................................................. 6 National Clinical Coding Standards ICD-10 Reference Book ................................................ 11 Rules of ICD-10 ..................................................................................................................... 16 Conventions of ICD-10 .......................................................................................................... 17 General Coding Standards and Guidance ............................................................................. 28 Chapter I Certain Infectious and Parasitic Diseases .............................................................. 42 Chapter II Neoplasms ............................................................................................................ 49 Chapter III Diseases of the Blood and Blood-forming Organs and Certain Disorders Involving the Immune Mechanism ........................................................................................................ 66 Chapter IV Endocrine, Nutritional and Metabolic Diseases ................................................... 68 Chapter V Mental and Behavioural Disorders ....................................................................... 75 Chapter VI Diseases of the Nervous System ........................................................................ 83 Chapter VII Diseases of the Eye and Adnexa ....................................................................... 86 Chapter VIII Diseases of the Ear and Mastoid Process ......................................................... 88 Chapter IX Diseases of the Circulatory System ..................................................................... 89 Chapter X Diseases of the Respiratory System .................................................................. 104 Chapter XI Diseases of the Digestive System ..................................................................... 108 Chapter XII Diseases of the Skin and Subcutaneous Tissue .............................................. 114 Chapter XIII Diseases of the Musculoskeletal System and Connective Tissue ................... 115 Chapter XIV Diseases of the Genitourinary System ............................................................ 123 Chapter XV Pregnancy, Childbirth and the Puerperium ...................................................... 130 Chapter XVI Certain Conditions Originating in the Perinatal Period .................................... 160 Chapter XVII Congenital Malformations, Deformations and Chromosomal Abnormalities .. 166 Chapter XVIII Symptoms, Signs and Abnormal Laboratory Findings, Not Elsewhere Classified ............................................................................................................................. 168 Chapter XIX Injury, Poisoning and Certain Other Consequences of External Causes ........ 176 Chapter XX External Causes of Morbidity and Mortality ...................................................... 196 Chapter XXI Factors Influencing Health Status and Contact with Health Services .............. 207 Chapter XXII Codes for Special Purposes ........................................................................... 224 Index of Standards .............................................................................................................. 228 Table of Changes ................................................................................................................ 235 INTRODUCTION These national clinical coding standards are for use with the World Health Organisation (WHO) International Statistical Classification of Diseases and Related Health Problems, Tenth Revision 5th Edition (ICD-10) when translating diagnoses and other health related problems recorded in a patient’s medical record for morbidity coding. The classification of diagnoses using ICD-10 is a mandatory national requirement for the NHS Admitted Patient Care (APC) Commissioning Data Set (which includes day cases) and other data sets as outlined in the section below. WHO also refer to the ICD-10 5th Edition as the 2016 Edition. It includes updates that came into effect between 2011 and 2016. The WHO gives specific instruction on the use of the ICD-10 classification for morbidity coding in some areas, whilst it provides options and guidance of a general nature in others. This can lead to differences in interpretation and application of the classification and this, in turn, can reduce the consistency and comparability of the data at local and national levels. Specific instructions are provided in the following pages in the form of national clinical coding standards for those areas of potential ambiguity (as far as practically possible) to safeguard data consistency. The coding of diagnostic statements or elements of them is ‘mandatory’ only where the information is available in the medical record. The principles of the statistical classification, particularly those relating to basic coding guidelines and the structure of the classification, (as detailed in WHO ICD-10 Volume 2), are adopted as the standard and reinforced within this book where appropriate. Where a standard within the WHO ICD-10 Volume 2 differs to a national clinical coding standard, the national clinical coding standard must take precedence. Background The WHO states that ICD is to permit the systematic recording, analysis, interpretation and comparison of mortality and morbidity data collected in different countries or areas and at different times. The ICD is used to translate diagnoses and other health problems from words into alphanumeric codes, which permits easy storage, retrieval and analysis of data’1. ICD-10 is a vital component of national data sets, such as Hospital Episodes Statistics (HES) in England, Hospital In-patient Statistics (HIS) in Northern Ireland, Patient Episode Data for Wales (PEDW), Scottish Morbidity Records (SMR), Cancer Registries, National Service Frameworks, Care Pathways, Performance Indicators, Commissioning Data Sets (CDS) and other Central Returns. 1 World Health Organisation International Classification of Diseases and Related Health Problems’ ICD-10 Volume 2, 2.1 Purpose and applicability 3 Introduction The statistical classification underpins key information initiatives that support the monitoring of morbidity and health trends. NHS managers and health care professionals use it locally to support operational/strategic planning and performance management. For example: • Statistical uses include study of aetiology (cause or origin) and incidence of diseases, health care planning and casemix. • Epidemiologists use statistical data to study frequency and occurrence of disease. The aggregation of coded data enables health professionals to identify at risk populations based on demographic, diagnostic or environmental factors. • Planners and managers use statistical data to review caseloads to: determine specialty needs, inform staffing levels, patient admissions and clinic schedules in hospitals. • Clinical audit uses coded data to compare patient care and measure outcomes within specialities. Doctors may use extracts of local information for research purposes. The United Kingdom has a mandatory obligation to collect and submit ICD-10 data to the World Health Organisation (WHO) for the production of international statistical and epidemiological data. Morbidity versus mortality coding The ICD-10 is designed for international use in the collection of morbidity and mortality information. The classification permits the assignment of codes to diseases (morbidity) and to causes of death (mortality) according to established criteria, providing consistent information for statistical purposes. This reference book provides the national clinical coding standards for use with the ICD-10 for coding of the main condition (morbidity) and related health conditions as recorded in the hospital medical record. The ICD-10 rules for the selection and coding of the underlying cause of death (mortality) are outside the scope of this reference book. Clinical coding Clinical coding is the translation of medical terminology that describes a patient’s complaint, problem, diagnosis, treatment or other reason for seeking medical attention into codes that can then be easily tabulated, aggregated and sorted for statistical analysis in an efficient and meaningful manner. 4 Clinical coder A clinical coder is the health informatics professional that undertakes the translation of the medical terminology in a patient’s medical record into classification codes. A clinical coder will be accredited (or working towards accreditation) in this specialist field to meet a minimum standard. Clinical coders use their