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Medical Coding

For a better health

By: Ihab Abu Hamdeh,CTR
What is coding and abstracting?
 Coding: the process of transforming verbal
descriptions of diseases, injuries, conditions and
procedures into a numeric or alphanumerical
designation using a published classification
system such as international classification of
diseases (ICD) or the current procedural
terminology (CPT).
 Abstracting: the process of extracting pertinent
information from the medical record to create a
History of coding
 1662: London Bills of Mortality was created.
 1837: Purposed classifying diseases by anatomical site.
 1893: Bertillon Classification of cause of death was
 1900: Bertillon Classification of cause of death renamed
to be International Classification of Death.
 1948: The World Health Organization (WHO) assumed
responsibility of what is known today as “International
Classification of Diseases” (ICD).
International Classification of
Diseases (ICD)
 A set of diagnostic codes, developed by
the world health organization, to promote
international comparability in the
collection, classification, processing and
presentation of mortality and morbidity.
 ICD is the most widely used classification
system in health care.
 No health care facility uses ICD as
published by the World Health
Organization to code inpatient discharges
or ambulatory encounters.
 The World Health Ogranizaton dose NOT
publish procedures codes.
 ICD-1 1900-1909
 ICD-2 1910-1920
 ICD-3 1921-1929
 ICD-4 1930-1938
 ICD-5 1939-1948
 ICD-6 1949-1957
 ICD-7 1958-1967
 ICD-8 1968-1978
 ICD-9 1979-1994
 ICD-10 1995-
 ICD-11 2013-
Types of coding
 Diagnosis:
 ICD 9 CM Vol.1+2
 ICD 10
 ICD 10 CM
 ICD 10 AM Vol.1+2

 Procedures and Medical Services:
 ICD 9 CM Vol. 3
 ICD 10 PCS
 ICD 10 AM Vol. 3+4
Types of coding
 Products and Supplies:
 HCPCS Level II
 Medical Supplies
 Orthotic and Prosthetic Devices
 Durable Medical Equipment
 Particularly Injectable drugs
 Drugs:
 MOH’s National Drug Codes
Types of coding
 Laboratory:
 CPT (Current Procedural Terminology)
 LOINC (Logical Observation Identifiers Name and Codes)

 Dental Procedure:
 USC&LS (The Canadian Dental Association Uniform System of
Codes and List of Services)
Types of coding
 Diagnosis Related to Group (DRG)
 A case-mix classification system in which diseases are
placed into a groups because related diseases and
treatments trend to consume similar amounts of healthcare
resources and therefore incure similar amount of cost.

 Several pieces of information are required to determine a
patient’s DRG:
 Patient’s principal diagnosis
 Patient’s secondary diagnosis
 Associated comorbidity and complications
 Treatment procedures
 Patient’s age and sex
 Patient’s status at discharge
Why to code?
 Uniformity in data
 Strategic planning
 Utilization monitoring
 Wellness initiatives
 Financial analysis
 Statistical analysis
 Research
 Tumor registry data
 Case management
 Clinical pathway development
 Marketing and allocation of resources
 Managerial planning and decision making
 Statistics of ministry of health
 Meet JCIA standard (if applicable)
What should be coded?
 Inpatient discharges
 Diagnostic
 Laboratory
 Radiology
 One-day surgeries
 Ambulatory encounters
 Dental encounters
 Hemodialysis
 Speech therapy
 Physical therapy
 Occupational therapy
 Dietary
When to begin coding……

Why should you start coding Now?
 Every patient encounter provides important
information for:
 Clinicians
 Management
 Research
 Outside agencies
 If this information is not coded and abstracted
 It will remain stored in voluminous files.
 It will lost for ever.
Who should code?

 Persons trained and qualified as
professional coders
Diagnosis and Procedure
 Principal diagnosis
 The condition determined after study to be chiefly responsible for
the patient visit to the hospital or clinic.
 Other diagnosis
 All conditions that coexist at the time of admission, develop
 Principal procedures
 The procedure performed for the definite treatment of a condition
 Other procedures
 Procedures performed for diagnostic or exploratory procedure that
are high risk, expensive, but are performed in the operating room,
such as: TPN, lumber puncture.
The Three Dimensions of Medical Coding

 The Accuracy of Individual Codes.

 The Accuracy of Totality of Codes.

 The Accuracy of Sequence in which the
codes are recorded.
How do you became a coder?
 Basic courses:
 Anatomy and physiology
 Medical terminology
 Pathophysiology/pharmacology
 Coding theory and application
 Coding internship or on-the-job training
 Commitment to ongoing education

 Certified Coding Associate (CCA)
 Entrey-level coders
 Certified Coding Specialist (CCS)
 Cerrtified experienced coders
 Certified coding specialist – Physician (CCS-P)
 Experienced coders for physician offices, multi-
specialty clinics and specialty ambulatory centers

 Certified Clinical Coder (CCC)
 4 years of coding experience.
 Demonstrates a high proficiency in coding

 Accredited Clinical Coder (ACC)
Where to code?
 Centralized coding
 Coding performed in the health information
management department
 Decentralized coding
 Coding performed at point of care
 Coding at home
Thank You