Benefits Of Data Coding Standards

Apply accurate, complete, and consistent coding practices for the production of high-quality of healthcare data.

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

Common within each of these four categories is the need to collect, collate, format, and submit required data. Manual data collection is an expensive and time consuming endeavor that clinicians often outsource to billing companies or other third-party vendors. Electronic Health Records (EHR) and Anesthesia Information Systems (AIMS) are better solutions to data collection and submission. According to Dr. Emily Richardson, M.D., Chair of the Committee on Practice Quality Improvement for the ASA, there are three tiers of data categories (Emily Richardson, 2017):Tier 1: Administrative/Claims/Billing/DemographicTier 2: Registry/gross clinical (QR/ QCDR)Tier 3: AIMS/ granular

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).

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.

The majority of the time the use of HIM coders are involved in billing and reimbursements. However, coding specialists are important players within the healthcare industry.(Davis, 2014,2007,2002) They certify that providers maintain accuracy with coding procedures and government rules. (Davis, 2014,2007,2002) HIM functions and complex of regulatory requirements where coding can be very challenging. (AHIMA, 2016) The coders follow guidelines of the American Health Information Management Association AHIMA) Code of Ethics. (AHIMA, 2016) On the patient level, it is vitally important for the coder to code accurately because this information will trail the patient success throughout their course of treatment and beyond.

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

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 second standard of Ethical Coding is to report all healthcare data elements required for external reporting purposes completely and accurately, in accordance with regulatory and documentation standards and requirements and applicable official coding conventions, rules, and guidelines. Under this standard, a coding professional should first adhere to the ICD coding conventions, official coding guidelines approved by the American Health Information Management Association (AHIMA), American Hospital Association (AHA), Centers for Medicare and Medicaid Services (CMS), and National Center for Health Statistics (NCHS), the CPT rules established by the AHA, and any other official coding rules and guidelines established

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.