Benefits Of Data Coding Standards

Coding systems are used in the inpatient and outpatient settings for the classification of patient morbidity and mortality information for statistical use. The World Health Organization (WHO) developed the Ninth Revision, International Classification of Diseases (ICD-9) in the 1970s to track mortality statistics across the world. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), is the adaptation the U.S. health system uses as a standard list of six-character alphanumeric codes to describe diagnoses. Globally utilizing a standardized system improves consistency in recording symptoms and diagnoses for payer claims reimbursement, as well as clinical research, and tracking purposes.

Uninformative codes can create confusion to what the code details. This language needs to be clear and detailed so that the health care organizations can provide the best health care as possible. When codes are

Medical coding, on the other hand, deals more closely with patient medical records. Medical coders work in the billing office, or “back office” of medical practices or hospitals. Alphanumeric codes are assigned to all illnesses, injuries and treatments. Medical procedures are coded for the purpose of classifying diseases in numerical sequences for identification and data collection purposes, similar to the Dewey Decimal System in libraries. Coding specialists review medical records and assign numeric codes for the diagnoses identified and procedures performed. Each medical procedure and patient encounter has a number (CPT code) associated with it which corresponds to an ICD code. These

One of the greatest milestones in the United States health system is the use of electronic health records codes to ensure consistency in diagnosis and treatment procedures provided by physicians (Romano & Stafford 2011). The purpose of the case scenario of the sixteen year old female who visits the emergency department is to show how electronic health record coding is done and its impact on health reimbursement. The International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT) codes are brought out well in the case study showing how they help in ensuring physician consistency in coding diagnosis and treatment procedures for the purpose of health reimbursement.

An accurate and specific documentation of universally accepted set of codes are important for the protection of healthcare providers as well as increased reimbursement for services received. These codes are for the validation of which services the patient received from their health care provider ( (Page, 2009). Having the correct codes in place insures the provider with the information needed by the health insurance carrier. Maintained by the AMA (American Medical Association), this universal numeric assignment is also used for developing guidelines for medical care review as well as data collection for medical education and research (Scott, 2013).

How data is captured varies from institution to institution. In order for data to be well understood, data should have a definition that is consistent and comprehensively understood by all users of the data. Standardization of how data is captured is critical to allow the production and export of data needed to support quality assessment, decision support, exchange of data for patients with multiple health care providers and public health surveillance. Patient safety and quality improvement are dependent upon embedded clinical guidelines that promote standardized, evidence-based practices. Unless we can achieve standardization with terminology, technologies, apps and devices, the goals of EHR implementation will not become a

The International Classification of Diseases, Tenth Revision (ICD-10) has been in development since 1983 to replace the outdated Ninth Revision (ICD-9) that has been in use in the U.S. for over 35 years (Giannangelo, 2015). Due to the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification regulation published in 2009, the Clinical Modification (ICD-10-CM) will replace ICD-9-CM Volumes 1 and 2, and the Procedure Coding System (ICD-10-PCS) will replace ICD-9-CM Volume 3 for all HIPAA transactions effective October 2015 (Giannangelo, 2015). These new code sets accommodate new procedures and diagnoses and allow for greater specificity in clinical documentation (Centers for Medicare & Medicaid Services [CMS],

The United States implemented the current version (ICD-9) in 1979. ICD-10- CM is the mandated code set for diagnoses under the HIPAA Electronic Health Care Transactions and Code Sets standard starting on October 1, 2014. While most countries moved to ICD-10 several years ago, the United States is just now transitioning into ICD-10 and has to be compliant by October 1, 2015. ICD has been revised a number of times since the coding system was first developed more than a hundred years ago.

Averill, Richard F. (1996). The Development of the ICD-10 procedure coding system (ICD-10-PCS): Draft. Wallingford, CT: 3M Health Information System.

Studies have found that coded data collected with a sole focus on reimbursement can poorly affect the use of the data for other purposes. Coded data goes farther and does more than ever before, making it imperative that professionals stay up to date of many rapid changes. One of the biggest changes is the expansion of coding from its traditional role of translating narrative clinical text into diagnosis and procedure codes. Coded data are now used for purposes such as severity adjustment, quality of care assessment, patient safety evaluation, public health surveillance, and decision support process development. Coding must meet an emerging need to capture healthcare data in a standard format that has universal meaning and can be applied both at the individual and aggregate levels. With this expansion come additional new responsibilities, such as entry of health information into a database and the need to understand how the quality and accuracy of the data are

MEDICAL CODING QUALIFICATIONS AND CERTIFICATION Medical Coding is a career in which professionals use numeric and alphabetic codes to help submit and process medical claims. The coder abstracts information from the patient records and combines that information with coding guidelines to assign the right code for the information provided by physicians, hospitals, and other healthcare professionals. Insurance companies look at these codes to understand the diagnosis, treatment, and prescriptions for proper payment of these services. Accordingly, the medical coding profession requires a worker to have a strong grasp of numbers and be detailed oriented. (AC Search & Media, Inc.)

What Importance might there be to the United States using the same reporting system?(ICD-10 ) as the rest of the world?. If the United States did not adopt this system how might this system impact the world?. The importance for ICD-10 is to track the codes for patients procedures, making sure you have those right codes identified for the insurance company. Because you must know the codes for that patients procedure. Otherwise you could messed up something by law .The Code are used to inform medical schemes about the conditions of the members were treated for. ICD-10 stands for International classification of diseases related to health problems. The ICD-10 translates the written description of medical, and health information. The information

The compliance date for implementation of the International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) was October 1, 2013 for all covered entities. Although, a number of countries that have already converted to ICD-10:

ICD-10, which is the tenth revision of the International Statistical Classification of Diseases and Related Health Problem, refers to a medical classification inventory for the coding of diseases, their signs, symptoms and causes (Center for Disease Control and Prevention 1). The use of this revised version in the United States is scheduled to begin officially on the first of October 2013. Currently, ICD-10 is being used for diagnosis coding, in procedure coding systems and for inpatient procedure coding.

There is an accentuation on the need for quality of coded data with the use of computer-assisted coding in healthcare organizations to assure compliance is being met with regards to the increasingly multifaceted quality reporting requirements.