Synopsis
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.
About the Author
Dr. Dhirendra Verma received his Master's and Doctoral degrees from Canada's St. Mary's and Dalhousie Univeristy, respectively. He taught Anatomy & Physiology at the Faculty of Paramedical Sciences, Nova Scotia Institute of Technology, in Halifax for 16 years before joining Kuwait's Ministry of Health as a Specialist in Disease Classification & Coding. He also held the position of Administrative Director at two large hospitals of Kuwait. He has extensive experince of teaching ICD in several countries. His publications include over 45 research articles and four books, the most recent being A Concise Medical Dictionary for Healthcare Practitioners. Dr. Ali M. El-Sayed holds an MD and MPH degree from the Alexandria University, Egypt. For several years he worked on the project Ecology of Trachoma in Rural Egypt before joining the Ministry of Health as a Medical Biostatistician & Specialist in Disease Coding, a job that he currently holds. Apart from coding and analyzing morbidity and mortality data for the State of Kuwait he has held periodic workshops and orientation programmes in Disease Coding at Kuwait and other Gulf countries. He has 30 publications to his credit, including an Arabic translation of ICD-9 (3-Digit Categories) and a Manual in Arabic on determinig the underlying cause of death, as per WHO norms.
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