MEDICAL RECORDS MANAGEMENT IN

EYE CARE SERVICES

6.International classification of Disease & Procedures and the

method of Indexing data

What is Coding? Coding is translating of

narrative descriptions of

diseases, injuries and

procedures into numeric codes.

Coding process involves of

assigning numbers to disease

and procedural terms.

A code number for each

disease and operation is

recorded in the system.

Why do we need to code?

To review previous cases of a given disease and to compare current patients health problem.

To test theories and compare date on certain diseases and treatments.

To procure data on utilization of hospital facilities & to establish hospitals need for new equipment.

To evaluate quality of care in the hospital.

To conduct epidemiological and infection control studies.

To accumulate incidences of medical & surgical complications.

Introduction to Ophthalmology ICD-9-CM

The ICD-9 book is divided into 3 sections.

The first section contains the introduction guidelines showing major categories of diseases.

The second section is alphabetical indexing of specific disease entries.

The third section is the most important tabular list for proper coding.

While searching for a specific code, it is always easy to refer alphabetical indexing.

Introduction to General ICD-10

This general coding book is divided into 3 volumes.

Volume-1 of the ICD contains the classification itself which indicates the categories into which diagnosis are to be allocated.

Volume-2 of the ICD contains guidelines for recording and coding together with much new material on practical aspects of the classification’s use.

Volume-3 on the ICD contains an alphabetical indexing to the tabular list of volume-1.

Since Volume-1 is regarded as the primary coding tool, it is essential to use both the volume 1 and 3 when coding a disease.

Classification of disease & procedure

All medical records of patients treated in both out-patient and in-patient services must be coded for classification of disease.

Various classification system have been used, but the one in common use today is the ICD-9-CM adapted in U.S which is exclusively intended for ophthalmology coding.

All medical records of patients in both the out-patient and in-patient must be coded for classification of operation.

Usually ICP-9 is in use today to code major and minor procedures performed.

Indexing of Patient Care Data

(Manual & Automated Indexing) Manual indexing is information about patient

care extracted from medical records are hand

posted on ledger sheets or cards.

The disease and procedure code numbers are

entered on each appropriate disease or

procedural index cards.

In automated indexing the coding is done in

computer to reduce workload and to increase

speed in computing data.

Coding system should be effectively designed for

computerized entry into a data processing

system.

Programs should be written to extract

information and routine printouts.

The medical records assistant must be a capable

individual and extremely accurate in making the

entries.

Quality control in coding

A method can be adopted to ensure that every record is coded.

Disposed medical records may be placed on the coding person desk at a prescribed time every day.

After checking the record for incompletion by the assistant, the record may be coded.

Coding should be the last step before the medical records are sent to the filing area.

Ideally one or two MRA’s can be appointed exclusively to do all the coding as this fixes the responsibility for the work and should result in more consistent code.

Key Points to Remember

Classification of disease and procedures is one of the most important functions of the medical records department.

Coding is the translating of narrative descriptions of diseases, injuries and procedures into numeric codes.

Coding is done in order to group conditions and procedures that are similar for statistical tabulation.

In order to develop the best possible health care delivery system with preventive, curative, primitive and rehabilitative components, it is necessary to have comprehensive information or morbidity and mortality.

All medical files of patients treated in both outpatient and inpatient department must be coded for disease classification by the medical record department according to the latest international classification of disease.

Key Points to Remember

A disease index lists diseases and conditions and an operation index lists surgical and procedures according to the classification system or code numbers.

Finally, code numbers must be assigned in proper sequence to reflect the principle reason for the episode of care and any contributing secondary diagnoses and procedures.

Key Points to Remember

1) What is coding? why do we need to code?

2) Discuss the use of ICD-9CM in the field of ophthalmology? Explain how this differs from ICD-10.

3) Explain the classification of diseases and operations adopted ICD book?

4) State the factors to be considered in designing the manual index card?

5) Discuss the method adopted to evaluate the quality of coding function?

Answer the following