ICD10 collection

This article provides general information about collecting and coding a ICD10 Diagnosis.

They are entered in CCMDB.accdb in the L_ICD10 subform on the Patient Viewer Tab ICD10.

ICD10 coding guidelines apply to some diagnoses.

Collection Instructions

Timeline

• Start Date: 2019-01-01
• See Time Details Conversion from our old diagnosis schema_to_ICD10/CCI#Timeline

Determining which diagnosis to code

To find an ICD10 Diagnosis to code, try the following:

• search wiki for the dx name
• search wiki for a different name for the diagnosis, or an acronym
• find a related article and check it's
  • alternate diagnosis links
  • related articles links
  • categories
• if you can't find a code on our wiki for the term you are looking for, check one of the following:
  • An excellent source is the website https://www.icd10data.com/ICD10CM/Codes
  • Wikipedia has ICD-10 codes listed in the upper right hand corner and also in the infobox at the bottom of the page for most diagnoses
• When you find what you are looking for, make sure you add the search term that you could not find to the page on our wiki so the next person will find it by that name, and so we can code it consistently and the statistician can use it consistently.

Entering the diagnosis into CCMDB.accdb

ICD10 diagnoses are entered in the L_ICD10 subform on the Patient Viewer Tab ICD10 in CCMDB.accdb.

Some diagnoses are coded as several lines of data as combined ICD10 codes.

To enter one line of data,

1. If not already there, in Patient Viewer, click the ICD10 tab
2. click the dropdown for type and chose one of the following:
   • Admit - Admit Diagnosis
     • primary checkbox is the far left column. You must check ONE only as the Primary Admit Diagnosis, primary being the most responsible reason for admission to your specific unit.
       • If the Primary Admit Diagnosis is not a single ICD10 code but a case of combined ICD10 codes, check ONE which is the main diagnosis in the group.
       • Only ONE checked box must appear for each patient from the LOWEST priority number used.
     • Date of occurrence not allowed
   • Acquired - Acquired Diagnosis / Complication
     • Date of occurrence required
   • Comorbid - Comorbid Diagnosis
     • Date of occurrence not allowed
3. if you know the diagnosis name verbatim, you can click into the DX field and start typing; else, use the ICD10 Chooser form
4. if you are entering an Acquired Diagnosis / Complication, enter the Dx_Date
   • if the date is unavailable, check the Dx Date unknown checkbox.
   • you can use the *, +, - buttons to set the date
5. enter a Dx_Priority
   • For Admit, assign a number in order of importance (the lowest being the worst).
   • For Acquired, just assign a number for each code with no order of importance.
   • For Comorbid, just assign a number for each code with no order of importance.
   • Use the same number to group together combined ICD10 codes.
   • Use one number order set for each:
     • Admit Dx (1 to n)
     • Acquired Dx (restart at 1 to n)
     • Comorbid (restart at 1 to n)

"Suspected" Diagnoses

• We will NOT code things as suspected until we have confirmation (however that's done clinically) that it's actually present.
• Instead, code the manifestation:
  • Which could be a symptom, a sign, a diagnostic test abnormality
  • For a tumor which isn't known yet whether it's malignant or not, then you can use (as long as it remains unknown) Neoplasm of uncertain behavior (i.e. not clear if benign or malignant), NOS
    • If you know that there is a tumor in an organ, but don't yet know whether or not it's malignant, then code the clinical manifestation (as above) AND Neoplasm of uncertain behavior (i.e. not clear if benign or malignant), NOS
• If the patient dies or otherwise leaves your unit before you figure out the true cause/diagnosis, then don't try to go beyond coding the manifestation(s).