Second Edition 2009

The traditional emphasis in medical records management around the world has been on what data to get, and not on how to get it. The more efficient health information systems of today, however, are interested in what data to get, how to get it, and how to synthesize these data into an understanding of the patient's total situation. Disease classification and coding is the principal tool used by medical records personnel to accomplish this, and is, therefore a skill, which the effective healthcare managers, medical records administrators, clinical statisticians, statistical technicians, and medical transcriptionists also must master. This book is designed to present the principles that will help the learner to acquire or improve that skill. The roots of the book go back to the teaching of ICD coding to doctors, medical records personnel and statistical technicians at the Department of Statistics & Medical Records, Ministry of Health, Kuwait for over two decades. While teaching the principles and techniques of disease coding through various revisions of the ICD we came across many areas which were not within easy reach of our students, leading to frustration among them. This led us to bring out this comprehensive guidebook on ICD-10 coding with detailed explanations, suitable examples and appropriate coding exercises for better comprehension. The book is divided into eight units. Unit 1 provides an introduction to disease coding. Unit 2 gives a brief history of the development of ICD Units 3 and 4 deal with the main classification and alphabetic index of ICD-10. Unit 5 explains the principles and techniques of using ICD-10 and Unit 6 does this on a chapter-by-chapter basis. Units 7 and 8 consider the special features of morbidity and mortality coding. Unit 9 emphasizes the various aspects of statistical presentation in accordance with the WHO regulations. Care has been taken all through these units to keep the matter as simple as possible. Appropriate examples are provided wherever needed. Suitable exercises are presented at the end of each unit, which the students can take to test their level of comprehension before embarking on to the next unit. Many people have contributed to this final product. Of these, special mention should be made of Dr. Abdul Aziz Khalaf, Director of Statistics & Medical Records Department at the Ministry of Health, Kuwait for his continuous support and encouragement. We are deeply indebted to Miss Zahra Awadh who reviewe d most of the chapters and made many helpful contributions to both style and content; and to Mr. Mohamed Bader and Mrs. Jaya Umaputhiran for secretarial assistance. We are especially grateful to hundreds of doctors, medical records administrators and technicians, health statisticians, and ICD coders who participated in our training programmes and workshops on ICD in Kuwait and other countries during the past 25 years. We trust that these many colleagues will find our account of some small value.