COLLEGE OF HEALTH AND ENVIRONMENTAL

SCIENCES

FUNTUA

DEPARTMENT OF HEALTH INFORMATION

MANAGEMENT

COURSE CODE: HIM 312

COURSE TITLE: DISEASE CLASSIFICATION AND

CLINICAL CODING I

COURSE TUTOR: BILKISU ABBA

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 WHY ICD IS IMPORTANT

ICD is important because it provide common language for reporting and

monitoring disease. This allows the world compare and share data in a consistent
and standard way between hospitals,regions and countries and over period of time .
it facilitate the collection and storage of data for analysis and evidence based
decision making.

Data classification in a simple term means categorizing or grouping of disease and

operation in to homogeneous group with each group having detailed study of any
disease condition.

AIMS OF DATA CLASSIFICATION

There are basically three reason of data classification

1. To standardized medical terminology.

2. To retrieved the record for research.
3. Collection of statistical data for management planning.

IMPORTANCE OF HEALTH DATA CLASSIFICATION

1. For education and management.

2. For education and training
3. To compile morbidity and mortality for statistics.
4. To analyse the type cases coming to the hospital in order to plan for
equipment and facilities.
5. To compare the result of treatment between the institution and method of
treatment.
6. To prepare data for computerization e.g index card.

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AXIS OF DATA CLASSIFICATION

1. Alphabetical axis:this method provide foe disease to be arrange in

alphabetical as it was used by john grant.
2. Anatomical axis:this classification is based according to the parts of the
body or according to system of the body affected.
3. Etiological axis:the diseases are classified according to their causes. Is based
on the causative agent.
4. Epidemiological axis: this is the method of grouping disease according to
social condition such as incidence of infectious diseases.
NOMENCLATURE
The word nomenclature is a latin derivation ‘’NOMEN’’ which is means
name, ‘’clature’’ means [Link] means calling of names. But in
medical sciences,
Nomenclature is a systematic compilation of recognized name of disease,
conditions, operations and procedures.

TYPES OF NOMENCLATURE

1. Disease nomenclature
2. Operation nomenclature
3. Prescription nomenclature
1. DISEASE NOMENCLATURE: The disease nomenclature is used in
describing diagnosis Terms following clinical and pathological finding e.
g malaria, typhoid etc.
2. OPERATION NOMENCLATURE: it describe the operation
performed and procedure applied. E. g gastrectomy; surgical excision of
the stomach

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 3. PRESCRIPTION NOMENCLATURE: the prescription nomenclature
as name implied is use to denote approved or recognized medical
terminologies in prescription e. g QID, BID, TDS.

DIFFERENCE BETWEEN NOMENCLATURE AND CLASSIFICATION

CLASSIFICATION NOMENCLATURE

[Link] is a system of grouping Nomenclature is a systematic

and generalization of disease under compilation of approved terms of
broad categories. disease, condition and operation
without broad categories.
2. classification is sub divided into Nomenclature is sub-divided and
sections and arranged in logical arranged in any order.
sequence.
[Link] code and as such suitable for It’s not code and as such unsuitable for
statistical purposes. statistical purposes
[Link] are given numerical codes for Its not given numerical codes and so
statistical identification. difficult to be identified.
Classification is based on well defined Its conceptual framework for while
medical nomenclature of disease. statistical classifi8cation is based.

CODING CONVENTIONS

1. NEC (Not elsewhere classify)

2. NOS (Not otherwise specified)

3. PARENTHESIS

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4. SQUARE BRACKETS[]

5. COLON

6. BRACES

7. CROSS REFERENCES(“see” “see also”, “see categories”)

8. INCLUDE

9. EXCLUDE

10. POINT DASH

11. DAGGER (+) AND ASTERISK (*)

INTERNATIONAL CLASSIFICATION OF DISEASES INJURIES AND

CAUSES OF DEATH (ICD-9) EDITION

THE STRUCTURE OF ICD-9

The manual for the international classification of diseases injuries and causes of
death (ICD-9) was a book published by WHO reviewed in ten 10 years. This was
provided in two volume. Volume 1 (tabular list) is classified itself contains rules
and modes of usages;its otherwise known as tabular list. And volume 2 is the
alphabetical index to the tabular list its primary coding tools.

TABULAR LIST OF INCLUSION AND FOUR DIGIT SUB CATEGORIES

This refers to the 17th main categories of ICD-9 with four digit categories

i. Infectious and parasitic disease

ii. Neoplasm

iii. Endocrine,nutritional and metabolic disease and immunity disorder

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iv. Diseases of the blood and blood forming organs

v. Mental disorder

vi. Diseases of the nervous system and sense organs

vii. Diseases of the circulatory system

viii. Diseases of the respiratory system

ix. Diseases of the digestive system

x. Diseases of the genito-urinary system

xi. Complication, pregnancy, childbirth and perineum

xii. Diseases of the skin and subcutaneous tissue

xiii. Diseases of the musculo skeletal and connective tissue

xiv. Congenital abnormalities

xv. Certain condition originating in the prenatal period

xvi. Symptoms, sign, and ill-defined conditions

xvii. Injury and poisoning

STRUCTURE OF INTERNATIONAL CLASSIFICATION OF DISEASE

ICD-10

The tenth revision of ICD came into effects on 1st January 1993 and it consist of
three volumes. Volume 1 is the tabular list (alphanumeric) presentation of the
classification. Volume 2 provides instruction for use of the classification, including
rules and guidance for the single cause coding of mortality and the single condition

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coding of morbidity, definitions, recommendations and reporting requirements for
fatal perinatal, neonatal infant and maternal mortality, and a brief history of the
development of the ICD. Volume 3 is the alphabetical index, listing all items of the
classification alphabetically, as well as a large number of additional terms
synonyms that cannot be found in the tabular list.

TWENTY ONE 21TH CHAPTERS OF ICD-10

1. Infectious and parasitic diseases

2. Neoplasm

3. Diseases of blood and blood forming organs

4. Endocrine,nutritional and metabolic disease

5. Mental and behavioral disorder

6. Diseases of the nervous system

7. Diseases of the eye and adnexa

8. Diseases of the ear and mastoid process

9. Diseases of the circulatory system

10. Diseases of the respiratory system

11. Diseases of the digestive system

12. Diseases of the skin and subcutaneous tissue

13. Diseases of musculoskeletal and connective tissue

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14. Diseases of the genito-urinary system

15. Pregnancy, childbirth and pueperium

16. Certain condition originating in the perinatal period

17. Congenital,malformation,deformation and chromosomal

abnormalities

18. Symptoms,signs, and abnormal, clinical and laboratory finding(NEC)

19. Injury, poisoning and certain other consequences of external causes

20. External causes of morbidity and mortality

21. Factors influencing health status and contact with health services

DIFFERENCES BETWEEN ICD-9 AND ICD-10

ICD-9 REVISION ICD-10TH REVISION

1. It is numerical codes it is alphanumeric codes

[Link] into effects on 1978 Came into effects on 1993

[Link] consist 17th main chapter Consist 21th main chapter

[Link] has two volumes It has 3 volumes

[Link] antiquate terminology Uses much needed updates to medical

terminology and diseases classification

[Link] has supplementary classification (E- The supplementary classification are

code, v-code and M-code) core chapters

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[Link], nutritional and metabolic Diseases of the blood and blood forming
disorder is chapter 3 organs is chapter 3

INDEXING
INDEXING:
INDEX: In general term can simply be defined as a type of composite measures
that summarizes several specific observations and represents some more general
dimension in information management.
INDEXING: Indexing of disease and operations is a listing on a card for specific
disease or operations entity according to recognized classification, all essential data
on patient having that particular disease condition or operative procedure
performed.
Indexing is simply a way of entering coding data into index card.
The object of an index is to make it easy refer to any past record in a system.

PURPOSE OF INDEXING
1. To compare data on certain diseases and operations.
2. To conduct a research and prepare scientific paper.
3. To evaluate the quality of care in the hospital.
4. To provide educational materials for medical nursing and other professional
students.
5. To conduct epidemiological and infection studies on the work environment.

INFORMATION REQUIRED FOR INDEXING CARDS

There are several pieces of information that are typically included on an index card:
 The disease or procedure being indexed.

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 Date.
 Patients name.
 Age.
 Gender.
 Hospital/unit number.
 Date of admission.
 Date of discharge.
 Sometimes other information is included, such as the location of the procedure
or the referring physician. The information on the index card helps to make
sure that the right information is being recorded and is easy to find.
TYPES OF INDEXING
There are 3 types of indexing are:
 Manual indexing.
 Mechanical inexing.
 Computer indexing.
 MANUAL INDEXING: means that the disease or operation code numbers are
entered by hand or posted on each appropriate disease or operative index card.
 MECHANICAL INDEXING: this involves the use of machine for recording
information on the cards. All cards have hole punches in which needle will
pass through according to the number stated and when raised, the card for the
indicated number goes up with the needle and the rest fall down.
 COMPUTER INDEXING: this simply means making all the entries direct in to
the computer. ie using computer for indexing. In some of parts of Nigeria, the
mechanical and the computer indexing are not practicable due to unavailability
of machines and therefore everything is done manually.

METHOD OF MANUAL INDEXING

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 SIMPLE INDEXING: is the composite measure representing only dimension
of data entries without cross reference to other cards.
 CROSS INDEXING: this method is used to creating adequate data base for
multi disciplinary research. Cross indexing of disease and operations can be
defined a listing on a card for specific disease and operation procedure.
 MULTIPLE CARD INDEXING: in this type of index where by more than one
card will be used to index more diagnosis. It is useful in cross indexing
environment and also applicable to three card system environment.

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