Child of the New Century, Sweep 3– ICD-10 Coding (based on MCS1, ICD-coding & BCS70 2004 ICD-10 coding documents) Background During sweep 3 of the Child of the New Century 2006 survey, information was gathered from the parents of the cohort babies about their child’s health and health-related behaviour. This included the identification of specific health problems associated with longstanding illness and this information will be coded using the WHO International Classification of Diseases 10th revision, ICD10. Variables for ICD-10 coding The variables which need to be coded using ICD-10 are listed below. Question Question Text Routing ClsxC What is the matter with ^Cohort If answered ‘Yes’ to child’s name? "I'd now like to ask about any longstanding health conditions that ^childname may have. Does ^childname have any longstanding illness, disability or infirmity? By longstanding I mean anything that has troubled ^childname for a period of time or is likely to affect ^childname over a period of time." (question Clsi) EyexC Interviewer probe for detail and write If answered ‘Yes’ to ‘Has ^childname down (first/second/third) eye ever had any other problem(s) with problem as respondent reports it. his/her eyesight or ^his/her eyes?" (question Eyep) HerxC Interviewer probe for detail and write If answered ‘Yes’ to ‘Has ^childname down (first/second/third) ear ever had any other problem(s) with problem as respondent reports it. his/her hearing or ^his/her ears?" (question Herp) Coding instructions The object is to allocate a 3-character ICD-10 code to every response. In order to enable this to happen, the following are provided: Blaise CAPI edit program The searchable ICD-10 Index (based on Blackwell’s ‘IdeaList’ software) ICD-10 manuals (will be kept in the office) Guide to ICD-10 health coding (this document), including: Coding instructions Structure of the 3-character categories Alphabetical index of Blocks Alphabetical index of ICD-10 3-character codes Expert advice from the project researchers on problem codings. Child of the New Century 2006 ICD-10 Health Coding (Version 1: 19/7/2006) - 1 Coding 1. The Blaise CAPI edit will route you to the questions which need ICD-10 coding. 1. Read the ‘answer’ carefully, this is what must be coded. If there are two separate illnesses mentioned in the same response, then these should be coded as follows. Code the first mentioned illness. Then code ‘yes’ at the question ‘Editor: was more than one problem recorded at this question?’ You should remove the text for the second illness and put it into the blank question field, and code the second illness using the appropriate ICD-10 code. Remember: More than one problem may be reported – each must be given a code Medical terms may be used Spelling errors are common – the interviewer was typing at some speed 2. Identify the appropriate ICD-10 code(s). This may seem daunting at first, but it will become easier as you become more familiar with the ICD-10. To identify the appropriate code you can: Browse the printed copy of the ICD-10 structure, 3-character categories and the associated indexes. Check the printed ICD-10 alphabetical index12 Locate the lead term (name of disease/condition) and modifier (describes the condition/reason for condition). There are two types of modifiers: . Essential modifiers are indented and affect the assigned code . Non essential modifiers appear in brackets and have no bearing on the assigned ICD-10 code If the phrase ‘See’ or ‘See also’ appears in brackets after the lead term or modifier, then you should go to the new term that it refers to. The term ‘NEC’ (Not Elsewhere Classified) has two purposes ‘Firstly to warn the coder that specified forms of such conditions are classified elsewhere, and secondly to provide a direct reference to a residual category (.8 or .9) for a condition’. The term ‘NOS’ (Not Otherwise Specified) means that ‘When the clinician states a diagnosis, problem or reason for an encounter as a single term which has no modifiers …the code assigned is that which follows the lead term e.g. anemia (NOS) D64.9’ Aetiology and manifestation - dagger and asterisk system. The dagger represents aetiology or underlying disease and cause. The asterisk represents the manifestation and effect of the disease. The dagger must always be in the first position with the asterisk in the second position. E.g. diabetic cataracts could be two separate illnesses or one illness. 1 Please note that sometimes American spellings are used, especially with words containing ‘ae’ or ‘oe’ (e.g. anaemia, haemorrhage ). In these cases the ICD-10 index uses only the ‘e’ to spell the word (e.g. anemia). 2 This section uses information provided on the JRRP ICD-10 Clinical Coding course 8/11/2004. Child of the New Century 2006 ICD-10 Health Coding (Version 1: 19/7/2006) - 2 Use the interactive index to the full ICD-10 index. NB: This index identifies the 4-character ICD-10 categories. When coding only the first 3 characters must be used. To search this index: * Click on 'Search' in menu bar, or * Click on 'Magnifying glass' button, or * Depress 'F5' key You can select: * the entire Index to browse, or * those parts of the Index relating to a particular word or phrase (eg: disease, part of body, etc) You can also narrow or widen a search to exclude/include additional words or phrases * Click on 'Search' in menu bar, or * Depress ‘F7’/’F6’ to narrow/widen a search * Depress ‘F8’ to exclude a word or phrase Use the 'Arrow' buttons or the '+' and '-' keys to browse the selected parts of the Index If in doubt: * Click on 'Help' in the menu bar, or * Ask someone who should know Ask a passing ‘expert’. Rely on your growing knowledge of the ICD-10 – but always check, even experts make mistakes. 4. Remember, the aim is to reflect in the codes allocated as much detail as possible about the health problems reported. 5. If in doubt, do not forget that you can use the non-ICD-10 codes: 850 – Other specific answer 860– Vague/irrelevant answer 870– Editor cannot deal with All entries coded ‘850, 860, or 870’ will be reviewed and other codes allocated where possible. 6. Acute/chronic conditions. Always allocate the code for the acute condition unless there is clear evidence that the problem is chronic. Acute – health problem that is limited in time. Treatment has the potential to fully cure. Chronic - health problem that persists through time requiring ongoing health care. Treatment alleviates symptoms rather than provides a cure. IF IN DOUBT, NEVER BE AFRAID TO ASK. Child of the New Century 2006 ICD-10 Health Coding (Version 1: 19/7/2006) - 3 IF IT’S TAKING A LONG TIME TO DECIDE WHICH CODE TO ALLOCATE, USE ‘850, 860, or 870’ AND CONTINUE WITH THE NEXT ANSWER. These instructions may be revised, please check that you have the latest version. Child of the New Century 2006 ICD-10 Health Coding (Version 1: 19/7/2006) - 4 ICD 10 Interactive Index Screens This is the first screen that you will see when you enter the searchable index. To search the index, follow the instructions on this screen. ICD Three-character categories – STRUCTURE – Page 5 To find the ICD-10 code for e.g. abscess, select ‘search’ from the menu bar and then ‘find all records’. When the above box appears enter ‘abscess’. Remember: You can broaden / narrow a search in the index by selecting ‘search’ from the menu bar and then widen / narrow. When you type a term into the index, the index will select all references for e.g. abscess and highlight them. To scroll through each page of the index use the left and right arrow keys and sometimes you will need to scroll down the page. Always allocate the code for the acute condition unless there is clear evidence that the condition is chronic. If multiple medical conditions are mentioned in a verbatim response, you must code each condition in the order that they are mentioned.