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.
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.
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.
The most important basic rules are:
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.
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.