Icd-9-CM (ICD-10-PCS)

“Together, terminologies, such as SNOMED-CT, and classification systems, such as ICD-10-CM and ICD-10-PCS, provide the common medical language necessary for interoperability and the effective sharing of clinical data.” (Bowmen, 2005) Using common medical terminology in the electronic medical records, common standard format, and would be beneficial for this system. Making the information interoperable would help the automated clinical summary system. SNOMED-CT uses a mapping system to convert the codes to the ICD-10 codes. Mapping is used because it provides links to terminologies. “National Library of Medicine mappings offer several rules, groups, mapping priorities, and recommendations to be considered during the mapping process. Mapping rules are stored in a machine-readable Augmented Backus-Naur Form (ABNF) that evaluates the existence of one or more SNOMED CT concept instances (comorbid conditions) and/or one

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 second step is the major diagnostic category determination in which the principal diagnosis is assigned to an encounter for one of the 25 MDCs (Casto & Forrestal, 2015). The 3rd step is the medical/surgical determination to determine whether a procedure was performed and can be assigned a surgical status (Casto & Forrestal, 2015). The MS-DRG Definitions Manual and many of ICD codebooks verifies which procedures are valid or not valid (Casto & Forrestal, 2015). For example, minor procedures and testing do not qualify (Casto & Forrestal, 2015). Also, when a qualifying procedure is not performed, the case is assigned a medical status (Casto & Forrestal, 2015). The fourth step involves using different refinement questions to figure out the correct MS-DRG assignment (Casto & Forrestal, 2015). Therefore, once the medical and surgical classification groups for an MDC are formed, each class of patients is evaluated to determine if complications, comorbidities, the patient’s age or discharge status consistently affected the use of hospital resources (Design and Development,” n.d.).

In 1978, the World Health Organization published ICD-9. It was later modified by the US Public Health Service so that it could service the needs of American hospitals. This modification was named International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM). As of October 1, 2015, ICD-9-CM was replaced with ICD-10-CM. ICD-10-CM was considered an upgrade from ICD-9-CM because it was more specific and contained many more codes than its predecessor. Most of the categories contained in ICD-9-CM were completely full with no room for expansion. ICD-10-CM goes into a lot more detail than ICD-9-CM. ICD-10 has been upgraded to contain up to seven digits as opposed to the four to five that were associated with ICD-9.

while ICD-10-CM has many differences from ICD-9-CM; the new classification system does retain the traditional format and many of the same characteristics and conventions (AHIMA's 75th Anniversary National Convention and Exhibit Proceedings, 2003). Creating a data integration plan for Green Tree Healthcare starts with should be a unique code for all substantially different procedures.

The topic of transitioning to the ICD-10 coding system has become a very big issue within the medical practice field. In fact, as of October 1, 2015, all physicians, hospitals, and medical providers are required by the federal government to be in full compliance using ICD-10 coding. ICD-10-CM codes allow for medical providers to provide as much information as possible about the patients state of health and all treatment provided as such. In addition, "The CPT coding system offers doctors across the country a uniform process for coding medical services that streamlines reporting and increases accuracy and efficiency (Ama-assnorg, 2015)."

Before discussing the implementation process of ICD-10 it is imperative to understand the differences between ICD-9 and ICD-10 coding and the reason for the transition. The new ICD-10 coding has over 69,000 codes to identify diagnoses compared to 14,000 in the ICD-9 coding version. The increasing number of codes will aid in specificity of all diagnoses. Every diagnosis has a specific code identity. The code identity for the ICD-10 coding is made up of seven digits whereas ICD-9 coding has only three to five digits for each diagnosis. These digits are numbers used to explain a specific injury or procedure. Behind each diagnostic code is an exclusion wording. It gives the diagnosis code in specific detail of the exact diagnosis the physician

Standardized terminologies were created to be use within the electronic health record (EHR). “Standardized terminologies are

Two common medical coding classification systems are in use — the International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT). ICD is the standard

ICD-9-CM is the United States' alteration of the International Classification of Diseases, Ninth Revision, created by the World Health Organization. It is the most generally connected arrangement framework for coding analyze, explanations behind social insurance experiences, wellbeing status, and outside reasons for damage. The controls with respect to electronic exchanges and code set declared under HIPAA assign ICD-9-CM as the medicinal code set standard for sicknesses, wounds, or different experiences for social insurance administrations. In declaration before Congress in May 2002, Sue Prophet, AHIMA's executive of coding arrangement and consistency, affirmed that "AHIMA trusts that appropriation of a substitution for the ICD-9-CM analysis

- Terminology. For example, acute myocardial infarction was updated to 4 weeks instead of 8 weeks like in ICD-9 coding system.

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.

One cannot say that one level of equivalence is better than the other because they are intersecting and every level of them is important to the other one. The recent views of translation depend on the text to translate and concentrate on the purpose and ideas of that text rather than words such as Hatim and Mason (1990) who claim that we should never translate words, we translate sentences, ideas or messages. Nevertheless, Newmark (1988) asserts that who believes in translating texts rather than words will find himself dealing with words at the end. The emphasis on one level rather than the other might be affected by factors such as the method of translation, the type of text translated, the theory of language, etc, but still a translator has to keep each level in mind. Baker (1992) asserts that equivalences at word level and above word level are related to each other in order to have an equivalent translation. She asserts that a single word can have different meanings in different languages and cultures and there are different types of meaning included in lexical items: referential, connotative, associative, metaphorical, allusive, etc and the best way to find the suitable meaning is through looking at other

Two components were suggested for the architecture which uses data tacking protocol. They were “Local Conceptual Mapping