Coding
It is very difficult to measure the benefits of having a healthcare system, if we cannot describe the clinical status of the population, in other words: how ill or healthy is it? This is the diagnosis. In addition, if we want to know what the health care system did about it, we need to describe the procedures performed. This could be drugs prescribed or operations performed.
Diagnosis
There needs to be a language to describe the clinical status of the population. Ideally, the situation would be "one health system -- one language". However, this is currently not the case in the vast majority of health systems around the world. For instance, often no diagnosis is recorded in certain patient settings, e.g., primary care or outpatient care. In addition, different systems may be in use for the privte and public sector, between clinical and financial coding, or between providers. However, there is a substantial benefit to gain, if everyone would always use the same language.
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Clinicians and coders would be using only one terminology, building up institutional knowledge
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Clinical decision-making across care settings is improved (e.g., diabetic care between a hospital and primary care)
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It's much easier to explain one system to patients and the public
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It's much easier for the administration to support appropriate clinical decision-making, if the data is clear and consistent.
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It's much easier to create a simple and flexible payment system
Health Authority Abu Dhabi implemented the universal application of ICD-9CM as a classification system for all patient encounters.
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ICD (International Classification for Disease) was developed by the World Health Organisation and is the most widely known and used classification system in the world.
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Abu Dhabi is using ICD-9CM in large parts. For instance, the six largest public hospitals in Abu Dhabi already code their inpatient activity according to ICD-9CM. The
clinical coding steering committee has developed a manual for the public sector hospitals, which can be found here
CodingManual.doc and also provides regular training sessions for coders. In addition, all patient encounters in primary healthcare centers are recorded with an ICD-9 diagnosis.
Deaths are also recorded with an ICD-9 diagnosis . The missing elements are outpatient activity and private sector activity. For both, no diagnostic information is currently collected. One approach -- used in many parts of the world -- is to create a master list of the most common diagnoses, which the doctor can just tick off. An example, adapted for Abu Dhabi is shown here
Outpatient Form.pdf . Clinical Coding Steering Committee organize and facilitate twelve coding seminars throughout the year, on a rotating basis, at the five hospitals - Tawam, SKMC, Mafraq, Rahba & Corniche. One of the topic of the sixth coding seminar presentation is here
Fracture Management, Spinal surgery.ppt.
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There are a number of online resources related to ICD9-CM, such as
ICD9cm.net chrisendres including
online coding. Coding books are also available online from, for instance,
www.shopingenix.com and
www.channelpublishing.com . It is important to get the latest version of the coding books. The updates are usually made in October of each year. Some of the books will have binders where pages that have changed can be replaced instead of buying new books every year. This requires a subscription, but is cheaper than having to buy a new book every year.
Procedures
Countries also use different coding systems to describe what procedures were performed on patients. Various systems include OPS, OPCS, CPT, which are documented on wikipedia.
In Abu Dhabi, two procedure classification systems are currently being used: ICD-9CM procedures (used by public hospitals for coding inpatients), and CPT codes for outpatients. There should be a debate about how to move to a universally applicable procedure code
DRGs - Diagnosis Related Groups
Diagnosis Related Groups [DRGs] are a widely used way to create transparent and robust prices for inpatient treatments on the basis of diagnoses and procedures. The principles and how DRGs apply in Abu Dhabi are shown here 07-07-09 Introduction to DRGs .pdf
Comments (9)
Rob Challen said
at 11:24 pm on May 13, 2007
unified coding for clinical and central returns is going to be difficult to achieve using ICD9. It is designed for aggregation of data for statistical purposes but theoretically is not granular enough to support clinical care. Hence a lot of effort is spent developing newer clinically focussed terminologies (such as Read CTV3, SNOMED CT) ICD9 is a good output classification but would need refinement to support clinical data entry for clinical care.
Philipp said
at 10:10 pm on May 16, 2007
Do you have any suggestions for how one could build on or add to ICD-9 which would theoretically support clinical care? Can you give an example of a mainstream practical decision?
Mitchell said
at 7:55 am on Jun 7, 2007
I think we need to be very careful as an Emirate, nation and region when it comes to classification systems.
As classification systems go - ICD-10 is clearly a superior classification system and offers many advantages over ICD-9. It allows greater specificity and is far more geared towards ambulatory care.
The professional body in the USA (AHIMA) have been clear in their recommendations to the US Govt to adopt 10. The main issues that complicate the move in the USA are not yet factors here (HIPAA and the cost to re-working complex payer-provider relationships).
There is also the question of the broader Gulf region and other Emirates; to me the critical decision is that we all use the same classification system.
At the moment I think the more important issue is not the classification system itself but the infrastructure of quality coders across the region, coding to a high standard with access to continuing education, audit and HIM support.
In regards to the selection of the DRG system. Again I would place more importance on reaching a collective national and gulf regional decision - than the actual system itself.
Finally the only work I see significantly that falls on us is the importance of an accurate costing system which will give true regional meaning to the selected case weights.
Personally, I still think we should be targeting 10 in the medium term.
Thanks
Mitchell said
at 7:59 am on Jun 7, 2007
Sorry I should add - no classification system which is basically an output analysis is going to aid clinical decision making.
However the other uses - measuring care, planning, policy, targetting problematic health and research - would benefit.
Philipp said
at 10:20 am on Jun 11, 2007
Does that mean that, all things considered, you would still advocate the universal application of ICD9-CM in Abu Dhabi in the short term?
On DRG systems, there appears to be a version of the 3M grouper, (IR-DRGs -- international refined DRGs) which can take ICD-9, ICD-10 and ICD9-CM as inputs. This would allow the region to have consistent DRGs even if the paths to achieving a common classification might be different. What are your thoughts on this?
Ann Webster said
at 8:02 am on Jul 4, 2007
The purpose of the ICD9 coding system as developed by the WHO was to classify death cases. When the US clinically modified the ICD9 to ICD9-CM it was to classify morbidity cases as well as the mortality cases. The uses of the coded data were for statistics, to know how many of different diagnoses and procedures are present in a population and for research to aid clinicians in identifying and locating research information and subjects. Additionally it was taken on by the insurance companies and government to provide diagnosis and activity based reimbursement to the healthcare facilities. How does this support clinical care? Other than research to improve medical treatment, I don't see how. I have worked with physicians who have used coded data to improve their own practice. I have worked with QA departments who have used coded data to identify outliers and problem areas to target for audit, education and focused review to improve outcomes for patients. That has an impact on clincal care.
Ann Webster said
at 8:14 am on Jul 4, 2007
The other issue regarding which coding system to use, we have discussed this many times but the most important thing is that as an emirate we are all coding with the same system using the same rules and guidelines. In the UAE there are many versions of coding systems being used. It doesn't appear that there is any consistency or leadership in this area. Even those who profess to be using ICD10, what version are they using - WHO/ICD10AM/ICD10CA? Even if they are using one version or another, what rules are they following? What is their standard for consistency? I strongly advocate using one system with the same rules and guidelines for all. Since in Abu Dhabi we are already using ICD9CM, we should focus on perfecting that and achieving consistency across all hospitals instead of looking to change coding systems. I am not saying that ICD10 is not better than ICD9CM or more comprehensive. The AHIMA is desperate to move to ICD10CM. However the best use of our resources right now is to educate and orient all coders at all healthcare facilities within the emirate of Abu Dhabi to the same consistent, standardized system. Regarding which grouper to use, when we made the decision to go to the APRDRGs (all patient refined diagnosis related groups) I researched this and compared the three grouper options offered by 3M based on ICD9CM codes. It appeared that the APR DRGs suited us best, in my humble opinion. There are many technical reasons that are difficult to get into in this forum, however basically it was because they were strong in neonatal, OB, pediatrics and other non-geriatric type groupings. They also were superior at looking at the severity of illness differences between cases. This will help with communications with caregivers. This system is so sensitive in severity of illness differentiation that it will be difficult for caregivers to argue that point.
Ann Webster said
at 8:17 am on Jul 4, 2007
I ran out of space above :) My last comment is that I am unable to give an educated opinion regarding the IR DRGs as I have not read anything about them. I would need to do some research on them to be able to discuss it logically.
Jameel Ahmed said
at 9:08 am on Jul 25, 2007
Death Notificaiton/certificate must be coded using ICD-10 WHO version.UAE is the member of WHO and the Mortality reports are to be submitted by the member countries to WHO.A centralized reporting system for the whole UAE is to be established for reporting of deaths.
WHO stopped supporting ICD-9-WHO version and supports ICD-10-WHO for the Mortality reporting across the member countries. List of updates from 1995-2006 is available on the WHO website which is only for ICD 10 WHO.
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