Application of ICD-10-GM

This section provides you with information on the use of ICD-10-GM and the application rules that apply. In addition, we provide some examples on the purposes of encoding according to ICD-10-GM.

Detailed fundamentals: system of rules of ICD-10-WHO

Volume 2 of the ICD-10-WHO, the Instruction manual, describes the use of the Tabular List and the Alphabetical Index to the ICD-10-WHO. Most importantly, it contains an introduction to ICD, to the encoding guidelines for mortality and morbidity in addition to numerous encoding examples. Chapter 1 provides a brief introduction, Chapter 2 describes what encoding entails, the purpose and applicability of ICD, the concept of a "family" of disease and health-related classifications, general principles of disease classification as well as the basic structure and principles of classification in the ICD. Of particular importance for an initial understanding of ICD-10 are the explanations on the basic structure (Chapter 2.4) and on the use of Volume 1 (Chapter 3), because they focus on structure and formal agreements. The fundamental information in the ICD-10-WHO Instruction manual also apply to encoding using ICD-10-GM.

Encoding using ICD-10-GM - a practical example

ICD-10-GM is a diagnostic classification, i.e. a classification system to make content accessible, e.g. the contents of a health record or a case documentation: What is the group of diseases in the classification that the pathological conditions described in clear text in the documentation have to be assigned to? What code represents them accurately? The assignment of the relevant code is the codification or encoding.

How do you encode?

For encoding, you require:

What needs to be observed?

The most important basic rules are:

  • You can only encode what has been sufficiently and accurately documented.
  • Encoding should always be as specific as possible. Remainder groups such as "Other" or "Not specified in detail" are only encoded in the actual absence of specific information.

The brochure on basic knowledge encoding provides a brief introduction to the use of OPS and ICD-10-GM.

The preface to the Tabular list contains a Guide to Encoding.

The individual categories of the Tabular List often contain code-specific information, e.g. in the form of definitions of diagnoses, inclusions and exclusions, coding hints and subclassifications. Similar information may also be provided for the higher hierarchy levels, i.e. under subgroup, blockand chapter headings; this information needs to be heeded for subordinate codes.

The FAQs deal with general questions on ICD and encoding as well as some code-specific questions on ICD-10-GM (only available in German language).

Priority is to be given to coding guidelines issued by the self-governing partners for some specific areas of application: "Deutsche Kodierrichtlinien DKR" (German Coding Guidelines) for inpatient care and "Deutsche Kodierrichtlinien Psychiatrie/Psychosomatik DKR-Psych" (German Coding Guidelines for Psychiatry/Psychosomatics). You find the "Kodierrichtlinien" on the InEK website on the folder G-DRG-System and PEPP-Entgeltsystem of the respective year.

The Alphabetical Index contains an introduction with hints on the best approach to searching for a disease name.

The comprehensive Instruction Manual in Volume 2 of the ICD-10-WHO contains general rules for the encoding of mortality and morbidity together with numerous examples, knowledge of which is also useful for the understanding and application of ICD-10-GM.

Application example

The easiest option is to encode using the Alphabetical Index. It contains more than 120,000 diagnoses in alphabetical order, each associated with the appropriate ICD-10-GM code. However, you need to cross-check the code from the alphabetical index in the systematic index. First, this is to ensure that the code you have found is in the right context within the systematic index. Second, the various hierarchical levels of the classification may well contain specific coding notes pertaining to the code, the group of codes or the entire chapter.

How do you encode "Wirbelsäulenfraktur" (spinal fracture)?

  1. If the search term consists of several components, your first step is to identify the lead term or terms. In our example, the lead terms are "Fraktur" (fracture), "Wirbel" (spine) and "Wirbelsäule" (spinal column). Look up in the Alphabetical Index under "Fraktur, Wirbel" or "Fraktur, Wirbelsäule". There you find the code T08.0.
  2. If you now look up this code in the Tabular List, you find T08.-. For the fourth digit, there is a subclassification to differentiate between a closed ("geschlossen" 0) and an open ("offen" 1) fracture. You also find a reference that a fracture that is not described as closed or open should be classified as a closed fracture.
  3. The required code is T08.0, because there is no indication in the term in question as to whether the fracture is open or closed. However, be cautious: There is an exclusion for category T08.- that in case of multiple fractures ("Exkl.: Multiple Frakturen...") the correct code is T02.1- and not T08.-.
  4. Furthermore, you should make sure that there are no further encoding or exclusion terms under the heading of the higher level group "Verletzungen nicht näher bezeichneter Teile des Rumpfes, der Extremitäten oder anderer Körperregionen (T08-T14)" (Injuries to unspecified part of trunk, limb or body region) and under the chapter heading of "Verletzungen, Vergiftungen und bestimmte andere Folgen äußerer Ursachen (S00-T98)" (Injury, poisoning and certain other consequences of external causes) that are of relevance to the T08 code. For both, there are exclusion terms that you need to take into account. If the spinal fracture in your case is a birth trauma of a newborn baby ("Geburtstrauma beim Neugeborenen"), you need to select a code from P10-P15 instead of T08.-.
  5. The required code is indeed T08.0 if you have given correct consideration to all exclusion terms and other notes.
  6. For encoding in the inpatient sector in accordance with the G-DRG system, priority consideration is to be given.

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