review of coding and indexing can be traced back from 16th century, with the work of John Graunt in the London Bill of Mortality (W. H. O., 2013). Their main aim was to allow systematic recording, analysis, interpretation, comparison of mortality and morbidity data collected in different countries and at different times. Coding and indexing is been reviewed every ten years and in 1989 the international conference on the 10th revision agreed that it is not feasible to hold revision conference frequently and was given an interval of 10 years (W.H.O., 2015). Coding and indexing has multi-axial structure and definition of terminology which permits specification of procedure and clinical coders with minimal efforts (Averill et al., (2019). Although, coding was perceived to have potentially jeopardized doctor-patient relationship, itwas said to be a difficult and often a tedious activity, it has been established that it has no equal in health data management and as such, healthcare systems at large. The essential element in making a correct clinical coding is the allocation of each diagnosis or procedure in the group category to which it belongs. A universal veritable tool that facilitates good clinical coding is the discharge summary which is a concise recapitulation of the patient course in the hospital, and it provides the information to support clinical documentation review process and clinical coding. Good clinical documentation enhances clinical coding as such ensures the availability of reliable information for the production of quality and accurate data for quality patient-care. Conversely, poor documentation and undermine analyses-based chart review affect clinical coding process and can reduce the quality of care. The coded data constitute the key component required for regulatory submission. Hence the function of coding is essential and the need to maintain high quality in the delivery of coded data should not be underestimated. Inaccurate or insufficient data inhibits health information exchange (HIE), and hinders clinical research, performance improvement and quality measurement initiatives.
Clinical coding is the process by which some clinical information about the patient are transformed into codes, to enable grouping of medical activities in a limited number of categories so that they are easy to process, store and analyzed (Alin et al., 2012).International statistical classification of disease and related health problem tenth revision (ICD -10) published by world health organization, is a veritable tool for the effectiveness of clinical coding practices and it helps to translate medical information relating to a patient’s encounter with the health facility into alpha-numeric codes and these codes enhance the analysis of health care activities by grouping diagnosis and procedures together according to recognized format. High quality coding allows for assessment of health care needs, the sharing between healthcare organization and clinicians of standardized records, effective resource management, medical and clinical audit to be carried out more easily and with ease even in epidemiological study.
The International Classification of Diseases (ICD) is the most important classification in medicine. It is used by all medical professionals (Svjetska, 2014). The basic concept of ICD is founded on the standardization of the nomenclature for the names of diseases and their basic systematization in the hierarchically structured category. The ICD is the international standard diagnostic classification for all general epidemiological, many health management purposes and clinical use. These include the analysis of the general health situation of population groups and monitoring of the incidence and prevalence of diseases and other health problems in relation to other variables such as the characteristics and circumstances of the individuals affected, reimbursement, resource allocation, quality and guidelines (Harris, 2018).
Health information managers (HIMs) and clinical coders (CCs) are responsible for the clinical coding of admitted patient records, thereby creating the bulk of these health data. The data are reported to state and federal government departments from where they are made available for use by multiple stakeholders, such as researchers, program managers and funding model developers. Within individual hospitals, researchers, funding managers and other stakeholders will also access these data to inform their work (Handley, 2020). #