ICD10 collection

From CCMDB Wiki
Jump to navigation Jump to search

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

See 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:
  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:
  • 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).