Health Information

Management (HIM) Program

Health Sciences Division
HIM 1203 – Health Information Coding I
(Introduction)
Monday, September 1, 2025
 HIM 1203
Health Information Coding

LO 1
Apply basic coding guidelines to accurately select and sequence
disease and procedure codes according to latest ICD conventions
 HIM 1203 – Health Information Coding I 3

Learning objective
• CLO1 - Apply basic coding guidelines to accurately select and sequence disease and procedure codes
according to latest ICD conventions
Define related terminology : coding & statistical classification system
Discuss the purpose and importance of coding
Discuss the role and responsibility of the health record professional for coding
Explain the importance of a complete and accurate source document for coding
Describe the history and development of ICD codes
Explain the format of ICD codes
Differentiate between coding versus reporting
Interpret and follow the disease classification conventions including instructional notes, abbreviations, cross-reference notes,
punctuation marks, relational terms, and symbols
Follow the basic steps in coding
Apply basic coding guidelines to accurately select and sequence disease codes
Define principal diagnosis and apply guidelines for its selection
Describe other reportable diagnoses and apply guidelines for their reporting
Interpret and follow the procedures classification conventions
Apply basic coding guidelines to accurately select and sequence procedure codes
Introduction to Clinical Coding
What do clinical Coder do?
• Coding is often seen as data entry, but it is really about creating data. As a clinical coder you have the challenge
of taking information about a patient’s stay in hospital, often from different sources, and creating a summary, which
is then translated into codes. It is like an abridged version of a story, only in a format that allows the story to be
analysed and manipulated in many ways for different purposes.
• As healthcare systems continues to move towards a digital future, the role of the clinical coder will need to adapt,
which is very exciting!
• Coders spend most of their days analysing coded data to ensure it is high quality and fit for purpose. It helps to make
sure that hospitals receive the funding they need, so it is vital they get it right!
• Some days coders undertake routine monitoring looking for any inaccuracies in the data before correcting them. They
may then carry out more in depth clinical coding audits which can help identify the root causes. They document their
findings and make recommendations of necessary actions to address problems.
• Some errors are due to mistakes made by clinical coders themselves so it is important that their supervisors (i.e.,
head of the coding unit) support their development to see how things can be improved.
• Other errors might come from data submitted by clinicians on hospital wards, in which case coders provide a
presentation or teaching session with clinical colleagues to try and sort those things out. Coders enjoy that part of
their job because they get to engage with different people across the hospitals.
• Knowing the data they create plays an important part in improving patient care is one of the best bit of the job!
(Jones, 2020) - https://www.healthcareers.nhs.uk/explore-roles/health-informatics/roles-health-informatics/information-
management-staff/real-life-story-michael-jones
Introduction to Clinical Coding

• Clinical coding is a method of organizing diseases and/or procedures into groups

or classes.

• This is done for data retrieval when reporting mortality & morbidity
Introduction to Clinical Coding

• Coding is accomplished by using an alphanumeric code that is used to

identify data components

• Diagnosis

• K80.60 Calculus of gallbladder & bile duct without

obstruction
Introduction to Clinical Coding

• From this, statistics can be collected regarding the frequency of the

occurrence of disease…

• Why is this so important to the Health Care Industry???

Introduction to Clinical Coding

• Coding allows us to collect valid morbidity and mortality statistics

• Helps to provide justification for the procedure, service, or treatment provided

• Facilitates the process of reimbursement

• Provides material for research, study & education

• Leads to standardization & conformity when referring to diseases & procedures

• Provides an adequate tool in management for measurement, comparison and planning

What is Clinical Coding

• Coding of health information

is a process that transforms
written descriptions of
diseases, injuries or
procedures into an
alphanumeric code or a
numeric code
What is Clinical Coding

• For example . . .

Hemiplegia G81.90
with involvement of
dominant side (right) G81.91
left G81.92
non-dominant side (left) G81.94
What is Clinical Coding

• Codes are ‘grouped’ together to allow statistical analysis and/or

comparisons to be made –

• Within a hospital

• Within the same city

• Within the same Emirate

• Within the same country

• Within the region

• Internationally . . .
What is Clinical Coding
• Coding has been defined in our text “Health Information: Management of a
Strategic Resource” as –

“Coding is a procedure which assigns an

(alpha)numeric code to diagnostic and procedural data
based on a medical classification system.”
What is Clinical Coding

• A “medical classification system” has been defined as –

“A medical classification system provides a method of

arranging related disease entities in groups for the
reporting of statistical data.”
Purpose of Coding
• Coding facilitates access to health information which can then be used for:

• Research
• Statistics
• Funding
• Education
• Quality management
• Utilization management
• Risk management
Purpose of Coding
• Coding health information is the very basis of
‘Health Information Management’

• Coding translates the bulky written word in

the patient’s record into a format that is
readily available for statistical analysis
Role of the HIM
• Required to have extensive knowledge of the
coding process

• Must be very familiar with the coding texts as

well as the patient’s records & other possible
sources of patient information

• Must know all coding conventions including

the meaning of various symbols and
abbreviations
HIM’s are responsible for . . .
• Coding Accuracy – selecting the correct,
most precise code to represent an individual
disease, injury or procedure

• Coding totality - selecting all the

necessary codes in order to completely and
accurately describe the patient’s encounter
at the hospital
HIM’s are responsible for . . .

• Coding Sequence - place codes in the correct and logical order

• This is important because of something called “casemix”

What is ICD-10-CM???

I International
C Classification
D Diseases Classify a wide range of
diseases, social
circumstances, injuries,
10 10th Revision cause of injuries,
abnormal findings,
signs, symptoms by
C Clinical assigning a ‘code’
M Modification
Development of ICD-10-CM

• International Classification of Diseases was created by the World

Health Organization

• They have developed the basic ICD-10 “edition”

• Various countries have then revised the basic edition to more accurately
address their specific healthcare needs. Thus, ICD-10-CM
Development of ICD-10-CM

• This edition has Draft stamped on every page as well as appearing on the
front cover…

• This has been designed by the United States but cannot be put into practice
until receiving formal approval from:

• WHO

• US Legislature
A little background . . .
• 1893 a doctor in Chicago designed a classification
system for reporting mortality

• Canada and Mexico began to use this system in

their healthcare systems

• Formed the American Public Health Association -

recommended revision of these codes every 10
years

• 1948 – WHO became responsible for ICD process

 References
Grebner, L. and Suarez, A. (2013) Medical Coding: Understanding ICD-10-CM and ICD-10-
PCS. McGraw-Hill Education: USA

Optum 360 (2019) The ICD-10-CM Expert for Physicians 2020: the complete official code set.
Optum 360: USA

Optum 360 (2019) The ICD-10-PCS Expert 2020: the complete official code set. Optum 360:
USA

Safian, S.C. and Johnson, M.A. (2019) Let’s Code It! McGraw-Hill Education: USA
 Thank You

800 MyHCT (800 www.hct.ac.ae

69428)