Introduction:. “Snomed-Ct Is A Comprehensive, Multilingual,

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.

A computerized clinical database consists of clinical data for storing, retrieving, analyzing, and reporting of information (McCartney, 2012).

Computer assisted coding has been adopted by most healthcare organizations in order for their overall applications to have enhanced production. This would improve the coding accuracy, Consistency, Transparency, and Compliance to create a smoother transition towards using CAC technology on a regular basis. Computer assisted coding provides a natural-language processing (NLP) that is used as a software scan towards medical documentation in the electronic health record (EHR) system. This can become an identifying key terminology that suggests certain codes for that particular treatment or service. The natural-language processing focuses on interpreting unstructured records by using special algorithms to support the codes. These unstructured applications

A current problem with SNOMED CT is concept ID. Concept IDs give a medical term (Patient or Scalpel) an ID. This language can be confusing, and when there is confusion, quality of care and higher costs of health care can occur. When concept IDs are created, there needs to be a hierarchy so that each version can be kept track of the specific relation. Commonalities in the concept IDs can create a problem with SNOMED CT; the new concept model was created to figure out how to solve the issue or make it explicit. In addition to Concept IDs, uninformative codes are another problem with SNOMED CT.

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.

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],

ICD-10 – CM is a three- to seven character alphanumeric representation of a disease or condition. The first digit is alpha; Digit 2 is numeric. There is a decimal placed after the third character. There are 69,000 codes to better capture specificity, tis also

The Centers for Medicare and Medicaid Services (CMS) requires all providers to implement ICD-10 coding system begin on October 1st, 2015 so the U.S. healthcare system can communicate in the same language as with other countries’ systems. The transition from ICD-9 to ICD-10 had big changes from 14,000 diagnostic codes to more than 68,000 and 4,000 procedure codes to 87,000. The transition affected the reimbursements of hospitals. Medicare requires all patients’ procedures and services to be coded using ICD-10 system while they are charged in CDM using CPT codes. However, there is no direct link between ICD and CPT codes (Jensen, Ward, & Starbuck, 2016). The CDM committee had to work together to prepare for this event. Switching from numerical

Many people get confused when they hear the terms inpatient and outpatient. An inpatient is a patient hospitalized for more than 24 hours, but the stay can be less, depending on doctor’s orders. An outpatient is a patient that does not stay overnight in a medical facility and goes home. ICD-9-CM diagnosis codes are 3 to 5 digits long (numeric) or can be a letter followed by up to 4 digits (alphanumeric). For example, the code for Hypertension is (401.9), examination of the breast is (V76.10), and struck accidentally by a falling object is (E916). ICD-10-CM diagnosis codes are three to seven digits or characters long. The first character is a letter, and the second to seventh characters are letters or numbers. For example, sprain of unspecified

The difference between theses two medical coding systems that medical practices rely on being financial stability.ICD-9 contains approximately 13,000 codes and ICD-10 will contain a totally 68,000 available codes. The ICD-10 structure code is greatly expanded and the new codes are capable of reporting data in much greater specific. When the CMS mandated the changes to be effective in 2014. The data ICD-10 codes contain is expected to improve the efficiency of healthcare reimbursement and reduce charges of fraud and abuse. The ICD-10 billing will involve an all encompassing alphanumeric systemization. The ICD-10 diagnosis code will always be a letter then numbers. The ICD-10CM/PCS has two consisted parts, ICD-10-CM diagnosed classification system developed by the centers for disease control and prevention for use in all U.S. health care treatment settings. Diagnosis coding under this system uses 3-7 alpha and numeric digit and full code titles. ICD-9-cm is very much the same. ICD-10-PCS procedure classification system developed by the centers for Medicare and Medicaid services CMS for use in the U.S. for inpatient hospital setting only. The new procedure coding system uses 7 alpha or numerical digits while the ICD-9-cm coding system uses 3or4 numbers that's the

The reason for the need of all these extra details is because not only does it increase accuracy in medical records but it also allows doctors to administer better patient care. Using ICD-10 for reimbursement purposes will also be a lot more efficient and cost-effective. With ICD-9’s broad classification system some procedures, associated with certain codes, would be unnecessary for specific patients. However, with ICD-10 because the codes are so specific, procedures associated with those codes will all be necessary for further diagnoses and no procedure will go to waste.

➤ Diagnosis classification system developed by the Centers for Disease Control and Prevention for use in all U.S. health care treatment settings. Diagnosis coding under this system uses 3–7 alpha and numeric digits and full code titles, but the format is very much the same as ICD-9-CM

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.

The outmoded coding professional’s role was to describe and apportion diagnosis, procedure, and other medicinal service codes using ICD-9-CM and HCPCS/CPT coding classifications while referencing the Coding Clinic for ICD-9-CM, Coding Clinic for HCPCS,