National Clinical Coding Standards ICD-10 5th Edition (2021)

1 Terminology and Classifications Delivery ServiceNational Clinical Coding Standards ICD-10 5th Edition (2021)Accurate data for quality information National Clinical Coding Standards ICD-10 5th Edition Accurate data for quality information Produced by: Terminology and Classifications Delivery Service NHS Digital 1 Trevelyan Square Boar Lane Leeds LS1 6AE Date of issue: April 2021 Copyright 2021 NHS Digital ICD-10 CONTENTS Introduction .. 3 Data Quality .. 6 National Clinical Coding Standards ICD-10 Reference Book ..11 Rules of ICD-10 ..16 Conventions of ICD-10 ..17 General Coding Standards and Guidance ..28 Chapter I Certain Infectious and Parasitic Diseases ..42 Chapter II Neoplasms ..52 Chapter III Diseases of the Blood and Blood-forming Organs and Certain Disorders Involving the Immune Mechanism ..69 Chapter IV Endocrine, Nutritional and Metabolic Diseases.

2 71 Chapter V Mental and Behavioural Disorders ..78 Chapter VI Diseases of the Nervous System ..86 Chapter VII Diseases of the Eye and Adnexa ..89 Chapter VIII Diseases of the Ear and Mastoid Process ..91 Chapter IX Diseases of the Circulatory System ..92 Chapter X Diseases of the Respiratory System ..108 Chapter XI Diseases of the Digestive System ..112 Chapter XII Diseases of the Skin and Subcutaneous Tissue ..118 Chapter XIII Diseases of the Musculoskeletal System and Connective Tissue ..119 Chapter XIV Diseases of the Genitourinary System ..127 Chapter XV Pregnancy, Childbirth and the Puerperium ..134 Chapter XVI Certain Conditions Originating in the Perinatal Period ..164 Chapter XVII Congenital Malformations, Deformations and Chromosomal Abnormalities ..171 Chapter XVIII Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified.

3 173 Chapter XIX Injury, Poisoning and Certain Other Consequences of External Causes ..181 Chapter XX External Causes of Morbidity and Mortality ..202 Chapter XXI Factors Influencing Health Status and Contact with Health Services ..213 Chapter XXII Codes for Special Purposes ..230 Index of Standards ..236 Summary of Changes ..243 National Clinical Coding Standards ICD-10 5th Edition 3 INTRODUCTION These National Clinical Coding Standards are for use with the World Health Organisation (WHO) International Statistical Classification of Diseases and Related Health Problems, Tenth Revision 5th Edition ( ICD-10 ) when translating diagnoses and other health related problems recorded in a patient s medical record for morbidity Coding . The classification of diagnoses using ICD-10 is a mandatory National requirement for the NHS Admitted Patient Care (APC) Commissioning Data Set (which includes day cases) and other data sets as outlined in the section below.

4 WHO also refer to the ICD-10 5th Edition as the 2016 Edition . It includes updates that came into effect between 2011 and 2016. The WHO gives specific instruction on the use of the ICD-10 classification for morbidity Coding in some areas, whilst it provides options and guidance of a general nature in others. This can lead to differences in interpretation and application of the classification and this, in turn, can reduce the consistency and comparability of the data at local and National levels. Specific instructions are provided in the following pages in the form of National Clinical Coding Standards for those areas of potential ambiguity (as far as practically possible) to safeguard data consistency. The Coding of diagnostic statements or elements of them is mandatory only where the information is available in the medical record. The principles of the statistical classification, particularly those relating to basic Coding guidelines and the structure of the classification, (as detailed in WHO ICD-10 Volume 2), are adopted as the standard and reinforced within this book where appropriate.

5 Where a standard within the WHO ICD-10 Volume 2 differs to a National Clinical Coding standard, the National Clinical Coding standard must take precedence. Background The WHO states that ICD is to permit the systematic recording, analysis, interpretation and comparison of mortality and morbidity data collected in different countries or areas and at different times. The ICD is used to translate diagnoses and other health problems from words into alphanumeric codes, which permits easy storage, retrieval and analysis of data 1. ICD-10 is a vital component of National data sets, such as Hospital Episodes Statistics (HES) in England, Hospital In-patient Statistics (HIS) in Northern Ireland, Patient Episode Data for Wales (PEDW), Scottish Morbidity Records (SMR), Cancer Registries, National Service Frameworks, Care Pathways, Performance Indicators, Commissioning Data Sets (CDS) and other Central Returns.

6 1 World Health Organisation International Classification of Diseases and Related Health Problems ICD-10 Volume 2, Purpose and applicability Introduction 4 The statistical classification underpins key information initiatives that support the monitoring of morbidity and health trends. NHS managers and health care professionals use it locally to support operational/strategic planning and performance management. For example: Statistical uses include study of aetiology (cause or origin) and incidence of diseases, health care planning and casemix. Epidemiologists use statistical data to study frequency and occurrence of disease. The aggregation of coded data enables health professionals to identify at risk populations based on demographic, diagnostic or environmental factors. Planners and managers use statistical data to review caseloads to: determine specialty needs, inform staffing levels, patient admissions and clinic schedules in hospitals.

7 Clinical audit uses coded data to compare patient care and measure outcomes within specialities. Doctors may use extracts of local information for research purposes. The United Kingdom has a mandatory obligation to collect and submit ICD-10 data to the World Health Organisation (WHO) for the production of international statistical and epidemiological data. Morbidity versus mortality Coding The ICD-10 is designed for international use in the collection of morbidity and mortality information. The classification permits the assignment of codes to diseases (morbidity) and to causes of death (mortality) according to established criteria, providing consistent information for statistical purposes. This reference book provides the National Clinical Coding Standards for use with the ICD-10 for Coding of the main condition (morbidity) and related health conditions as recorded in the hospital medical record.

8 The ICD-10 rules for the selection and Coding of the underlying cause of death (mortality) are outside the scope of this reference book. Clinical Coding Clinical Coding is the translation of medical terminology that describes a patient s complaint, problem, diagnosis, treatment or other reason for seeking medical attention into codes that can then be easily tabulated, aggregated and sorted for statistical analysis in an efficient and meaningful manner. National Clinical Coding Standards ICD-10 5th Edition 5 Clinical coder A Clinical coder is t he health informatics professional that undertakes the translation of the medical terminology in a patient s medical record into classification codes. A Clinical coder will be accredited (or working towards accreditation) in this specialist field to meet a minimum standard. Clinical coders use their skills, knowledge and experience to assign codes accurately and consistently in accordance with the classification and National Clinical Coding Standards .

9 They provide classification expertise to inform coder/clinician dialogue. Clinical coders must abide by local and National confidentiality policies and codes of practice as a breach may lead to disciplinary action, a fine or, in the case of a breach of the Gender Recognition Act 2004, possible prosecution. Hospital provider spell and consultant episode A Clinical coder must assign ICD-10 codes to t he diagnoses recorded in the medical record for each consultant episode (hospital provider) within the hospital provider spell for the Admitted Patient Care (APC) Commissioning Data Set (which includes day cases). A hospital provider spell may contain a number of consultant episodes (hospital provider) 2 and the definitions for these terms are found in the NHS Data Model and Dictionary at: The NHS Data Model and Dictionary is the source for assured information Standards to support health care activities within the NHS in England.

10 It is aimed at everyone who is actively involved in the collection of data and the management of information in the NHS. The concept of a finished consultant episode, commonly abbreviated to FCE is widely used in the NHS and has been used in previous Clinical Coding guidance. See the NHS Data Model and Dictionary frequently asked questions for more information at: a/nhsdmds/faqs 2 Consultant episode (hospital provider) is hereafter referred to as consultant episode. 6 DATA QUALITY Medical record A health record is defined in the Data Protection Act 1998 as a record consisting of information about the physical or mental health or condition of an individual made by or on behalf of a health professional in connection with the care of that individual. The health record can be held partially or wholly electronic or on paper. The health record (commonly referred to as the medical record and used hereafter) is the source documentation for the purposes of Clinical Coding .