ICD10 collection: Difference between revisions

Revision as of 16:33, 2018 July 26

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

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

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

To enter one line of data,

If not already there, in Patient Viewer, click the ICD10 tab
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.
    - Date of occurrence, not required
- Acquired - Acquired Diagnosis / Complication
  - Date of occurrence, required.
- Comorbid - Comorbid Diagnosis
if you know the diagnosis name verbatim, you can click into the DX field and start typing; else, use the ICD10 Chooser form
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
enter a Dx_Priority to group together combined ICD10 codes

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).

@@ Line 22: / Line 22: @@
 To enter one line of data,
 # If not already there, in [[Patient Viewer]], click the '''ICD10 tab'''
-# click the dropdown for [[Dx_Type|type]] and chose one of the following
+# click the dropdown for [[Dx_Type|type]] and chose one of the following:
 #* Admit - [[Admit Diagnosis]]
-#** if it is the [[Primary Admit Diagnosis]] then check the [[Dx_Primary|primary checkbox]] to the left of the type
+#**[[Dx_Primary|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.
+#***Date of occurrence, not required
 #* Acquired - [[Acquired Diagnosis / Complication]]
+#**Date of occurrence, required.
 #* Comorbid - [[Comorbid Diagnosis]]
-# if you know the diagnosis name verbatim, you can click into the '''Dx''' field and start typing; else, use the [[ICD10 Chooser form]]
+# if you know the diagnosis name verbatim, you can click into the '''DX''' field and start typing; else, use the [[ICD10 Chooser form]]
 # if you are entering an [[Acquired Diagnosis / Complication]], enter the [[Dx_Date]]
 #* if the date is unavailable, check the [[Dx Date unknown]] checkbox.