Clinical coding secrets(part1)
by Dr Sedeek El Hakeem
These clinical coding standards have been written with the basic objective of satisfying sound coding convention according to ICD-10-AM and ACHI. Consideration of the various uses of inpatient data collections was secondary. Issues such as DRG allocation, research and planning aims were considered only after the requirement for accurate ICD-10-AM and ACHI coding was satisfied.
The clinical record should be the primary source for the coding of inpatient morbidity data. Accurate coding is possible only after access to consistent and complete clinical information. Without good documentation, coding guidelines are difficult, if not impossible, to apply. It is assumed that coding decisions are not made solely based on information provided on the clinical record front sheet (or a copy of same) but that analysis of the entire clinical record is performed before code assignment.
The responsibility for recording accurate diagnoses and procedures, in particular principal diagnosis, lies with the clinician, not the clinical coder.
The 'ICD' was first used to classify causes of mortality as recorded at the registration of death. Later, its scope was extended to include diagnoses in morbidity. It is important to note that although the ICD is primarily designed for the classification of diseases and injuries with a formal diagnosis, not every problem or reason for coming into contact with health services can be categorised in this way. Consequently, the ICD provides for a wide variety of signs, symptoms, abnormal findings, complaints and social circumstances that may stand in place of a diagnosis.
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