Recognizing the ICD-10-GM, German Coding Guidelines, and German Coders

Regina G. Weber

Note:   The following abstract is prepared solely for the use of reporting and informing the general public and healthcare field of ICD-10-GM and German coding guidelines. This abstract does not contain a formal position on production, subject, or issue from any institution or organization. This article is not intended to be perceived as a conflict of interest; economically or personally.

Introduction

The German ICD-10 Coding Guidelines (Deutsche Kodierrichtlinien - DKR ) have taken on an important role in Germany since 2002. Because of the cross mapping from the German payment system (known as the Fallpauschel [FP] and Sonderentgelt [SE]) for the hospital inpatient billing requirements to the implementation of the German DRG (G-DRG) payment system, we will see an increasing awareness for the necessity of correct coding.

In Germany, the attending hospital physician is legally responsible for documentation and coding of the hospital inpatient/outpatient admissions. With the usage of the German Coding Guidelines (DKR) and because of the increased health information that needs to be abstracted from the chart and entered into the organization's computerised health information system, we will see a need for German Coders. At the same time we will truly recognize the need for international Coders.

After long discussions and debates in 1996, after a test phase from April til September in 1997, and after the declining of the ICD-10 implementation from the Bundesminsterium für Gesundheit (BMG) (known as the German Ministry for Healthcare) in 1998; Germany finally began coding with the ICD-10 on January 1st, 2000. Since 2000, Germany has been coding with the ICD-10-SGBV (Sozialgesetzbuch - Social Law Book; Number Five; Paragraph 301) in both the inpatient and outpatient care. The Cause of Death Statistics has been coded with the ICD-10 since 1998. As of August 15, 2003, Germany named the ICD-10 version ICD-10-GM (German Modification). The Deutsche Institute Medizinische Dokumentation Information (DIMDI) of Köln, Germany, translated the three books of ICD-10 (now known as the ICD-10-GM) and the Operationen- und Prozedurenschlüssel (OPS-301 - known as the operative and procedure coding book).1

The International Statistical Classification of Diseases and Related Health Problems, 10th Revision

  • Band 1 - Text (known as the Systemic List)
  • Band 2 - Introduction to ICD-10 and Coding Rules (with examples)
  • Band 3 - Alphabetic Disease Index - the alphabetical listing offers about 50,000 diagnoses to code and should not be confused with the Systemic List. The alphabetical list contains a multitude of synonyms.

In Germany, the practicing physician is also legally responsible for documenting and coding patient charts that are seen in his/her office. A new trend is taking place for the practicing physician to attend and give care to his/her patients in the hospital.

Before August 2003, the depth of coding (to a fourth and fifth position as in other countries) in Germany was reduced in some cases to the third position with a hyphenation. An example of the third position coding would be Persons encountering health services for specific procedures not carried out (Z53. - and not Z53.0 to .9). This third position coding is largely seen in the External causes of morbidity and mortality (Chapter XX) and Factors influencing health status and contact with health services (Chapter XXI). The purpose of this coding reduction was because of the minimal standard definition (coding in doctors office) and diseases that are seldomly found in middle Europe (for example, Lungen pest A20. and not A20.2).2

The minimal standards was to be used when the doctor coded diseases outside of his speciality. The specialized practicing physicians need to code completely with the ICD-10-SGBV to the fourth and fifth position. Doctors in Radiology, Pathology, and Cytology, etc. can be exempted from the ICD-10 coding.3

Since August 15, 2003, the minimal standard coding (to the third position) was almost but not completely eliminated (for example, Z53. ) and more fourth and fifth digit coding from Factors influencing health status and contact with health services (Chapter XXI ) were added or allowed as acceptable coding practice.  

Other abstracted information from our documentation for billing includes localizations right (R), left (L), or both sides (B). The suspect of (V), status nach (Z), and ruled-out diagnoses (A) are abstracted for purposes used by the insurance companies. For example, this is necessary for those at the present time who cannot work.4 Length of stay, name of the admitting and discharge physician who documented the diagnose(s), newborn birth weight, admission weight for Pediatry children under one year of age, and the type of admission and discharge reason are examples of other information that needs to be entered/abstracted into our computerized health information system.5

For the purpose of billing and being compatible with the G-DRGs and DKR, the coding guidelines for chronic conditions or accompanying diseases that have no effect or relevance on the treatment should not be coded (see coding rule D003b). Should the doctor insist on documenting this condition in the discharge summary and in the coding program, we have the option to identify this code as a "not relevant DRG code" in the hospital's grouper.6

History of the German DRGs

On 27 June, 2000, an agreement was made with the Australian Refined Diagnosis Related Groups, Version 4.1 (AR-DRGs) for the foundation and development of the new German DRGs.   DIMDI was given the task from the BMG to revise the ICD-10.   The revised version 2.0 of the ICD-10 with the revised OPS version 2.0 was implemented in January 2001. In January 2002, DIMDI implemented the revised version 2.1 of the OPS coding book. The purpose of the revised versions was to have a complete standardized coding documentation to implement the DRGs at a federal level. Since January 2002, we have been coding with the DKR. Since September 2003, we were instructed to code inpatient admissions for the G-DRGs. For budgeting purposes in our hospital, January until August 2003, FP and SE calculations have been cross-mapped into the G-DRG.

The DKR was translated over from the Australian Coding Standards, First Edition. The coding guideline has two parts: general coding guidelines and special coding guidelines.

General Coding Guidelines and Special Coding Guidelines

  • General Coding Guidelines for Diseases indicated with a "D" before the rule (D001a)
  • General Coding Guidelines for Procedures indicated with a "P" before the rule (P001a)
  • Special Coding Guidelines include Chapter I to Chapter XIX:
    • Infectious and parasitic diseases (A00-B99)
    • Neoplasm's (C00-D48)
    • Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89)
    • Endocrine, nutritional, and metabolic diseases (E00-E90)
    • Mental and behavioural disorders (F00-F99)
    • Diseases of the nervous system (G00-G99)
    • Diseases of the eye and adnexa (H00-H59)
    • Diseases of the ear and mastoid process (H60-H95)
    • Diseases of the circulatory system (I00-I99)
    • Diseases of the respiratory (J00-J99)
    • Diseases of the digestive system (K00-K93)
    • Diseases of the skin and subcutaneous tissues (L00-L99)
    • Diseases of the musculoskeletal system and connective tissue (M00-M99)
    • Diseases of the genitourinary system (N00-N99)
    • Pregnancy, childbirth and the puerperium (O00-O99)
    • Certain conditions originating in the perinatal period (P00-P96)
    • Injury, poisoning and certain other consequences of external causes (S00-T98)

An alphabet description at the end of the DKR indicates the implementation date starting with "a" for Version 2002, "b" for changes or additions made to the coding guideline in Version 2003, and the alphabet "c" for changes or additions made in Version 2004.  

Should there be any discrepancies from the ICD-10-GM or OPS (§301) , the coding guidelines have the priority.7

Employment

Who in Germany had an interest for the international coding system more then 10 years ago? Kreiskrankenhaus Gummersbach8 was interested in the implementation of the DRGs.   Our department (Basis Dokumentation) was grounded in 1990. We currently consist of six employees and students searching for an apprenticeship or internship.

Working as a Coder in the Kreiskrankenhaus Gummersbach, our department is mainly responsible for ICD-10-GM coding plausibility. Our coding documentation consists of a computerized patient charting system: admission and discharge reports, operational reports, consultations, labor results, intensive documentation, hygiene, radiology reports, abstracted information, nursing documentation, quality management documentation, and diagnoses coded by the attending physicians. Other duties for which our department is responsible for; naming just a few, includes: DRG Grouping, teaching doctors the coding guidelines and usage of the computerized patient charting system, Quality Improvement (TQM), Certification for continual improvement of hospital quality (KTQ Certification), Risk Management, Project Co-ordination, Planning, trouble shooting computer problems, interacting between Medical Auditors and healthcare payers, and System/Network Administration.

Based on the statistics from Kreiskrankenhaus Gummersbach in 2003, we have 611 planned inpatient beds plus 140 inpatient beds in the Marienheide Clinic for Psychiatry. There are 1,600 employees and we continually train new students. The hospital belongs on the list of one the largest employers for the area of Gummersbach. The staff delivers care to–19,778 inpatients a year with a length of stay of 7,7 days. For the Psychiatric Clinic of Marienheide; there are 1,788 inpatients with a length of stay of 21,83 days. The medical departments include: Surgery, Orthopedics, Gynecology, Obstetrics, Pediatry, Ears-Nose-Throat, Ophthalmology, Neurology, Radiation Therapy, Psychiatry, Child and Young Adult Psychiatry, Intensive/Anesthesia, Inner Medicine, Dialysis, and Oncology.9 For each clinical department, there is one medical DRG representative who reports monthly to our departmental Medical Controller for educational instructions in coding and documentation. They are responsible for reporting back to their department for compliance.

Other known healthcare institutions where Medizinische Dokumentationsassistenten (MDA),10 are considered routine positions include:

  • Universitätsklinikum Charite´der Humboldt Universität (University Clinic Charite´- Humboldt University), Berlin
  • Klinken der Städt Köln (City Clinics of Cologne), Köln
  • Robert Bosch Krankenhaus (Hospital), Stuttgart
  • Klinikum der Stadt Ludwigshafen gGmbH (City Clinic of Ludwigshafen), Ludwigshafen

In 1998, the Charite´ (Center for Musculoskeletal Surgery) began a model-project with one MDA. The project ended in September 2002, with all stations occupying MDAs.11  The project was modelled after the Australian Clinical Coders work setting and is now routine with organised tasks for the MDAs. The concept of the Charite´ was to support the increasing documentation requirement and correct coding quality as well as to assist and motivate the medical staff.

Adapting Best Practice Solutions in Germany

Improving better coding practices for Germany would include the acknowledgment and recognition of international Coders. The physician is clearly, legally responsible for documenting the diagnosis on a patient's chart but a well-qualified Coder can advise, educate, comply, and optimise ICD-10-GM coding. To improve better coding practices and to further understand a coding compliance plan included areas of concern, risks, and future trends are as follows:

  1. Translations:   It should be mentioned that the coding guidelines are from the World Health Organization (WHO). There seems to be a semantic problem or a language barrier problem with the verbal interpretation for applying coding rules. Such interpretations as "secondary" may mean a secondary neoplasm to one person and not the secondary metastasis location. It should be mentioned that the international guidelines are; in general, the same rules. The same interpretation of the coding guidelines should be followed throughout all the countries.
  2. Full understanding of the coding books:   It is extremely important, that before we move onto the purpose of coding for DRGs that the Coders have a good understanding of the coding books (e.g. using the coding symbols and searching correctly in the Alphabetic and Tabular List books). They should be trained correctly when to apply the correct rules to a diagnosis (e.g. coronary heart disease with hypertension (I11.9) when related and hypertension (I10) plus coronary heart disease (I25.9 ) when they are unrelated).
  3. Identify encoder/automated coding discrepancies:   It is also very important for the Coder to understand the usage of the books, so they can identify encoder mistakes. This could possibly have an affect upon the DRG assignment when incorrectly coded. Is your institution using an automated coding system? "The automated coding system depends on two things: a) that whoever enters the information will enter it appropriately, and that whoever works with the information will be able to clarify and resolve questions."12
  4. Continuing education:   Provide ongoing educational opportunities, workshops, and training programs for the Coders (for example, a presentation on disease pathology such as Neoplasm's and special coding rules for neoplasm including oncology/morphology coding).   At the present time, we do not code morphology codes. It should be mentioned that continuing education enhances improved coding skills, networking outside of the hospital, and increases personal values.13
  5. Apprenticeships/internships:   Does your institution host internships for health information management students? If not, why not?
  6. Quality of documentation:   Address the quality of documentation: Are the Coders or physicians coding from the charts, computerized documentation, or even memory? What documentation is available to the Coder? Are there internal documentation standards or bylaws? Recommendation for coding from computerized documentation or charts includes: discharge summary , history and physical report, consultations, operational reports, pathology reports, etc.
  7. In-house continuing education:   Are attending hospital physicians required to participate on in-house seminars for improving medical record documentation? Are the Coders querying the attending physician on incomplete documentation for correct coding?   Querying the physicians for DRG relevance can also be a form of education.14 
  8. Recommended coding time per chart:   Because of the increasing awareness with coding time consumption, Ms. Elisabeth Bowman recommends 15 minutes as a standard for coding inpatient charts.15 According to the results of the AHIMA survey, "data captured for the average minutes per inpatient record type was 20 minutes."16  "Coders who specialize in certain types of records increase their productivity." 17 "Productivity rates should be based on what an average person can reasonably produce in a given time period--not the amount of work that needs to be completed."18
  9. Staffing: Is your hospital adequately staffed with Coders? According to the results of the AHIMA survey, "data captured 2.29 Coders per 100 hospital beds."19 In Germany, the Chief Executive Officer can decided with or without the Medical Staff decision, if he/she employees MDA/MD in their organization.  
  10. Internal/external audits and coding reviews:   Internal audits and coding reviews should be implemented. A coding compliance plan will protect your hospital in the future. Audits should include documentation assessment and operational assessment. Should your institution hire an outside audit company to do reviews? Who is reviewing and ensuring that correct coding and billing information has been transferred correctly to the insurer?20 Are the healthcare institutions in Germany participating on coding benchmarking practices? If not, why not? "Benchmarking is the process of improving performance by continuously identifying and adapting outstanding practices."21 Benchmarking does not mean you have to adopt the standards immediately.22
  11. Future trends:   At the fast and growing pace of technology, could your institution think of having at-home Coders/remote coding?   Remote coding can solve the problems and issues of space constraints, outsourcing, and overtime from vacation and illnesses.23  Could you imagine that your Coders will no longer be coding but "analyzing the coding data for quality control and maintain mappings from vocabularies to other classification systems? Their skills need to go beyond coding of the ICD. They will become information managers with focus on data and extracting clinical data."24 Are we assigning ICD codes to globalize international DRGs (IR-DRG) for assessment? According to Mr. Mullin, a healthcare research consultant for 3M, "native groupers assign the native (country specific) codes to the appropriate DRGs. Native groupers eliminate arguments with over mapping tables and are much more clinically and statistically accurate. AP-DRGs and APR-DRGs with refinement of the base DRG reflect the coding systems, clinical practice, and numerous refinements of the contents, form the basis of the IR-DRGs."25

In summary, a future vision for Germany by 2009, would be to expect Clinical Data Specialists (formerly known as Clinical Coders) in the hospital setting. They will be trained in depth with coding classes, workshops, and seminars regarding the usage the ICD-10-GM classification system for inpatient and outpatient coding. With increasing awareness, the Bundesministerium für Gesundheit (BMG) will acknowledge one or several Coding Centers in Germany. The future will present a new breed of professionals. Their knowledge and presence will expand into other European countries and they will participate in mapping other coding systems, collecting data, and analysing this data for international DRGs. We are now apart of that global team.

Endnotes

  1. DIMDI. ICD-10: Internationale Klassifikation der Krankheiten 10. Revision. Accessed 25.05.2003. < http://www.dimdi.de/klassi/diagnosen/icd10/index.htm >.
  2. DIMDI. ICD-10-SGBV: Besonderheiten der ICD-10-SGBV. Accessed 25.05.2003. < http://www.dimdi.de/klassi/diagnosen/icd10/icdsgbv13.htm >.
  3. Ibid.
  4. Ibid.
  5. For more information on iMedOne. < http://www.itb-ag.com/ >.
  6. Visasys Case mix Product, DrGroup 4.2 Dremsel AR-DRG Grouper. Accessed 18.01.2003. < http://www.visasys.de/Grouper_Flyer.htm >.
  7. Deutsche Kodierrichtlinien: Allgemeine und Spezielle Kodierrichtlinien für die Verschlüsselung von Krankheiten und Prozeduren. Version 2002, 2003, 2004. Copyright 2002.
  8. http:// www.kkh-gummersbach.de > Accessed 16.04.2003.
  9. Kreiskrankenhaus Gummersbach GmbH. Geschäftsberichts 2003 Kreiskrankenhaus Gummersbach/Klinik Marienheide: Daten, Zahlen, Fakten.
  10. For more information on the German Medical Documentationalists. <http://www.dvmd.de >.
  11. Linczak, Gerald, Marianne Duschek, Dr. Almut Tempka, PD Dr. Ursula Plöckinger, Prof. Dr. Manfred Dietel, Ärztlicher Direktor. "MDA auf jeder Station: Medizinische Dokumentationsassistent (inn)en zur Unterstützung stationärer Ablaufprozesse." Krankenhaus Umschau   6/2002. pg. 488 - 491.
  12. Beinborn, Julie RRA. "Automated Coding: The Next Step?" Journal of AHIMA July-August 1999 - 70/7 pg. 38-42
  13. Jeffries, Jane. "Writing a Coding Success Story." Journal of AHIMA July-August 2001 - 72/7 pg. 30-35.
  14. Ibid.
  15. Abdelhak, Mervat PhD, RHIA, Grostick, Sara MA, RHIA, Hanken, Mary Alice PhD, RHIA, Jacobs, Ellen MEd, RHIA. Health Information: Management of a Strategic Resource . Elisabeth D. Bowman, "Coding, Classification, and Reimbursement Systems." 2 nd Edition. Philadelphia: W. B. Saunders Co. Copyright 2001. Ch. 6. pg. 245.  
  16. Dunn, Rose T. RHIA, CPA, FACHE and Christina Mainord. "The Latest Look at Coding Trends."    Journal of AHIMA July-August 2001 - 72/7: 94-96.
  17. Dunn, Rose T. RHIA, CPA, FACHE. "Putting Productivity Plans to Work." Journal of AHIMA /October 2001 - 72/9: 96-100.
  18. Osborn, Carol E. PhD. RHIA "Practices and Productivity in Acute Care Facilities."   Journal of AHIMA /February 2000 - 71/2: 61-66.
  19. Dunn, Rose T. RHIA, CPA, FACHE and Christina Mainord. "The Latest Look at Coding Trends." Ibid.
  20. Jeffries, Jane. Ibid.
  21. Hughes, Gwen . "Using Benchmarking for Performance Improvement (AHIMA Practice Brief)." Journal of AHIMA 74, no. 2 (2003): 64A-D.
  22. Dunn, Rose CPA, RHIA, FACHE. "Developing Facility - Specific Productivity Measures." Journal of AHIMA April 2001 - 72/4: 73-74.
  23. Jeffries, Jane. Ibid.
  24. Johns, Merida . "Cover the future of coding." Journal of AHIMA /January 2000 - 71/1: 27-33.
  25. Mullin, Robert L. "International Refined DRGs Globalize Coding." Journal of AHIMA /July-August 2003 - 74/7: 70, 72, 74.

References

Kazmierczak, Dr. med. Krzystof and Gerald Linczak Dipl.- Kfm. "Wettbewerbsfaktor Medizinische Dokumentation: Wertschöpfungspotenzial durch Reorganisation strategisch and operativ nutzen." Krankenhaus Umschau 2/2003. pg. 102 - 106.

Linczak, Gerald Dipl. Kfm., Dr. med. Almut Tempka, Prof. Dr. med. Norbert Haas. Verwaltungsaufwand: Entlassung der knappen Ressource Arzt Deutsches Ärzteblatt (Sonderdruck) 03 October 2003; 100; A 2563 - 2566 (Heft 40).


Source: 2004 IFHRO Congress & AHIMA Convention Proceedings, October 2004