Podcast
Questions and Answers
What is the primary function of clinical coding in healthcare?
What is the primary function of clinical coding in healthcare?
- Converting narrative descriptions of diseases and procedures into alphanumeric codes for standardized data storage and analysis. (correct)
- Developing new pharmaceutical treatments based on genetic sequencing of pathogens.
- Creating diagnostic tests using biochemical markers to identify various disease states.
- Translating healthcare data into multiple languages for international collaboration.
Which factor most significantly contributes to the necessity of clinical coding in healthcare?
Which factor most significantly contributes to the necessity of clinical coding in healthcare?
- To create a billing process for patients, dependent on the diagnosis provided .
- To facilitate the detailed analysis of healthcare data for statistical and research purposes. (correct)
- To standardize medical vocabulary across different specialties.
- To train new medical staff.
What is the purpose of standardization in healthcare through coding systems?
What is the purpose of standardization in healthcare through coding systems?
- To ensure any and all healthcare data is transferable and can be utilized for statistical analysis. (correct)
- To allow international health agencies to accurately bill patients across different countries.
- To allow healthcare facilities to easily use supplies from other countries during shortages.
- To facilitate the sharing of patient medical records between providers.
In healthcare coding, what would be considered the most direct application of CPT codes?
In healthcare coding, what would be considered the most direct application of CPT codes?
Why is it essential for healthcare organizations to comply with coding systems as mandated by the federal government?
Why is it essential for healthcare organizations to comply with coding systems as mandated by the federal government?
What is the key distinction between ICD-10-CM and ICD-10-PCS?
What is the key distinction between ICD-10-CM and ICD-10-PCS?
How does the use of ICD-10-CM in the United States differ from the broader, international application of ICD-10?
How does the use of ICD-10-CM in the United States differ from the broader, international application of ICD-10?
What is the purpose of the seventh character in ICD-10-CM coding?
What is the purpose of the seventh character in ICD-10-CM coding?
How does the structure of ICD-9-CM codes differ significantly from that of ICD-10-CM codes?
How does the structure of ICD-9-CM codes differ significantly from that of ICD-10-CM codes?
What does the 'S' choice usually define in relation to the 7th character when coding for outpatient therapies in ICD-10-CM?
What does the 'S' choice usually define in relation to the 7th character when coding for outpatient therapies in ICD-10-CM?
What is the primary advantage of transitioning from ICD-9-CM to ICD-10?
What is the primary advantage of transitioning from ICD-9-CM to ICD-10?
What is required to code an inpatient procedure at a hospital?
What is required to code an inpatient procedure at a hospital?
Which of the following best describes the role of AHIMA in the context of ICD-10-PCS?
Which of the following best describes the role of AHIMA in the context of ICD-10-PCS?
Why are certain letters excluded from ICD-10-CM codes?
Why are certain letters excluded from ICD-10-CM codes?
What is a key consideration when converting ICD-10-CM codes to ICD-9-CM codes?
What is a key consideration when converting ICD-10-CM codes to ICD-9-CM codes?
Why is accurate clinical documentation important for efficient clinical data?
Why is accurate clinical documentation important for efficient clinical data?
A patient has a chronic condition, which coding set would be the correct initial choice?
A patient has a chronic condition, which coding set would be the correct initial choice?
Which of the following entities primarily uses ICD-10 codes for tracking public health?
Which of the following entities primarily uses ICD-10 codes for tracking public health?
A coder is working on a patient that has a history of smoking, which coding action would improve the outcome in the scenario?
A coder is working on a patient that has a history of smoking, which coding action would improve the outcome in the scenario?
What impact do both CPT and ICD-10-CM code updates have on the hospitals?
What impact do both CPT and ICD-10-CM code updates have on the hospitals?
Clinical coding involves translating diseases, health-related issues, and procedural information exclusively into visual representations for data archiving.
Clinical coding involves translating diseases, health-related issues, and procedural information exclusively into visual representations for data archiving.
One purpose of clinical coding is to hinder the retrieval of specific health information related to diseases for healthcare analysis.
One purpose of clinical coding is to hinder the retrieval of specific health information related to diseases for healthcare analysis.
According to the slide Healthcare Coding Systems, successful reimbursement does not depend on the use of coding systems recognised by the federal government.
According to the slide Healthcare Coding Systems, successful reimbursement does not depend on the use of coding systems recognised by the federal government.
According to the materials, Diagnosis/signs and symptoms, also known as 'Diseases' are exclusive to ICD11 and ICD12.
According to the materials, Diagnosis/signs and symptoms, also known as 'Diseases' are exclusive to ICD11 and ICD12.
According to the slides, the International Statistical Classification of Diseases, Tenth Revision, was developed by the United Nations to collect health insurance information.
According to the slides, the International Statistical Classification of Diseases, Tenth Revision, was developed by the United Nations to collect health insurance information.
The material states that ICD-11-CM, much like ICD-8-CM, is used in the United States to code various forms of payment information.
The material states that ICD-11-CM, much like ICD-8-CM, is used in the United States to code various forms of payment information.
In both ICD-9-CM and ICD-10-CM, the primary organization of codes is structured around a purely numerical sequence, disregarding alphabetical categorization.
In both ICD-9-CM and ICD-10-CM, the primary organization of codes is structured around a purely numerical sequence, disregarding alphabetical categorization.
The text says in ICD-10-CM, the number of codes is 140,000 codes.
The text says in ICD-10-CM, the number of codes is 140,000 codes.
In both ICD-9-CM and ICD-10-CM, special characters are not allowed in the strings.
In both ICD-9-CM and ICD-10-CM, special characters are not allowed in the strings.
In ICD-10-CM, the seventh String in a character does not hold any meaning.
In ICD-10-CM, the seventh String in a character does not hold any meaning.
Dysphagia has the same value in ICD-9-CM and ICD-10-CM, according to the presentation material.
Dysphagia has the same value in ICD-9-CM and ICD-10-CM, according to the presentation material.
In ICD-9-CM coding, the codes consist of 2 to 6 characters.
In ICD-9-CM coding, the codes consist of 2 to 6 characters.
ICD-10-CM codes always start with a numeric character.
ICD-10-CM codes always start with a numeric character.
According to slide 'ICD-9-CM STRUCTURE—FORMAT', categories are always numeric.
According to slide 'ICD-9-CM STRUCTURE—FORMAT', categories are always numeric.
Based on the information, 'ICD-10-CM STRUCTURE', extensions are never added to the code to explain external causes of injury.
Based on the information, 'ICD-10-CM STRUCTURE', extensions are never added to the code to explain external causes of injury.
For outpatient therapies, we will usually use one of 5 choices: the A, B, C, D and S.
For outpatient therapies, we will usually use one of 5 choices: the A, B, C, D and S.
According to the information given in the presentation, S = Initial encounter; tissue after burn.
According to the information given in the presentation, S = Initial encounter; tissue after burn.
The specificity of coding has decreased with ICD-10.
The specificity of coding has decreased with ICD-10.
Based on the slides, increased use of combination codes, is not due to the increase of ICD-10 to 70 K codes.
Based on the slides, increased use of combination codes, is not due to the increase of ICD-10 to 70 K codes.
For any in-patient procedures at a hospital, you are required to use code from ICD-9-PCS.
For any in-patient procedures at a hospital, you are required to use code from ICD-9-PCS.
Match the following coding systems with their primary purpose:
Match the following coding systems with their primary purpose:
Match the characteristic with the correct coding system
Match the characteristic with the correct coding system
Match the area with it's potential coding action:
Match the area with it's potential coding action:
Match the medical data with the correct description:
Match the medical data with the correct description:
Match the use case with it is potential goal:
Match the use case with it is potential goal:
Match the following term with a definition:
Match the following term with a definition:
Match each of the components listed with where they might be found:
Match each of the components listed with where they might be found:
Match common types of codes with what they do:
Match common types of codes with what they do:
Match the type of code and whether it includes additional information:
Match the type of code and whether it includes additional information:
Match the character with the code meaning:
Match the character with the code meaning:
Match the code with its descriptor
Match the code with its descriptor
Match the following disease to general symptoms:
Match the following disease to general symptoms:
Match the code to its function:
Match the code to its function:
Match the system to its properties:
Match the system to its properties:
Match the components listed to their descriptions:
Match the components listed to their descriptions:
Match the situation to the care provider responsible for the codings:
Match the situation to the care provider responsible for the codings:
Match the problem with the code used to report it:
Match the problem with the code used to report it:
Match the type of fracture with the code used to designate
Match the type of fracture with the code used to designate
Map the description to the acronym
Map the description to the acronym
Map the reason for the statistic to the type of care provided:
Map the reason for the statistic to the type of care provided:
Flashcards
Clinical Coding
Clinical Coding
Translating diseases and health-related problems into alphanumeric codes for data storage and analysis.
ICD (International Classification of Diseases)
ICD (International Classification of Diseases)
A system used for coding diagnoses, signs, and symptoms of diseases.
ICD-PCS (Procedure Coding System)
ICD-PCS (Procedure Coding System)
A system used for coding medical, surgical, and diagnostic procedures.
ICD-10-PCS Use
ICD-10-PCS Use
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ICD-9-CM Structure
ICD-9-CM Structure
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ICD-10-CM Structure
ICD-10-CM Structure
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ICD-10
ICD-10
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Learning objectives
Learning objectives
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Why Clinical Coding?
Why Clinical Coding?
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Healthcare Coding Systems
Healthcare Coding Systems
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ICD-10-CM: Purpose
ICD-10-CM: Purpose
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ICD-9-CM vs. ICD-10-CM
ICD-9-CM vs. ICD-10-CM
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CPT Codes: When to Use
CPT Codes: When to Use
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ICD-10-CM Outpatient Choices
ICD-10-CM Outpatient Choices
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ICD-10 Specificity
ICD-10 Specificity
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International Statistical Classification of Diseases
International Statistical Classification of Diseases
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Why is this Required?
Why is this Required?
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ICD-9-CM Code A
ICD-9-CM Code A
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ICD-9-CM Code B
ICD-9-CM Code B
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ICD-10-CM Code A
ICD-10-CM Code A
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ICD-10-CM Code B
ICD-10-CM Code B
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ICD-10-CM Code C
ICD-10-CM Code C
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ICD-10 Code Side of the body
ICD-10 Code Side of the body
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Reason for increased ICD-10 codes
Reason for increased ICD-10 codes
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Study Notes
- Clinical Documentation Improvement (CDI) presentation by Dr. Mohamed Azmi
Learning Objectives
- Define coding
- Recognise healthcare coding systems for diagnosis and procedures
- Define the concept of DRGs and its development
What is Coding?
- Clinical coding translates diseases, health problems, and procedural concepts from text into alphanumeric codes.
- These codes are used for storage, retrieval, and analysis of healthcare data.
Why Coding?
- Enables retrieval of information on diseases.
- Facilitates the collection of statistics on disease types and injuries.
- Aids in planning healthcare facilities.
- Helps compare the health status of countries
Healthcare Coding Systems
- Diagnosis/signs and symptoms (Diseases)
- ICD9, ICD10
- ICD9-CM, ICD10-CM
- Procedures
- CPT
- ICD-10-PCS
- The use of these systems is required by the federal government for reimbursement
- These systems are recognised by entities nationally and internationally
ICD-10
- International Statistical Classification of Diseases, Tenth Revision, developed by the World Health Organization for capturing disease data.
- ICD-10-CM (like ICD-9-CM) is used in the United States to code disease information.
- Procedure information is coded using the ICD-10-PCS.
- Includes updates to the ICD-10-CM and PCS
Comparison of ICD-9-CM and ICD-10-CM coding schemes
- ICD-9-CM consists of 14,000 codes with 3 to 5 characters, the first being alpha or numeric and characters 2-5 are numeric. An example code is 787.21 for Dysphagia, oral phase
- ICD-10-CM consists of 70,000 codes with 3 to 7 characters, the first character is alpha, and the second is always numeric. Example code is R13.11.
- Side of the body is embedded in the actual ICD-10 code, such as M24.551 for contracture of the right hip and M24.552 for contracture of the left hip.
- In ICD10, a 7th character can be used, with the section where it's used determining its meaning, such as the Cause of Injury.
- For outpatient therapies in ICD-10-CM, , 3 choices are commonly used to describe an encounter:
- A=Initial encounter active treatment
- D=After active treatment as routine care
- S=Sequella; scar tissue after burn
- The increase from ICD-10 to 70 K codes is due to:
- Updated medical terminology with modern medicine and expansion of procedures
- Increased use of combination codes such as code E11.311, Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema.
- Increased specificity
ICD10-PCS
- ICD-10-PCS is a medical classification system for procedural codes that track various health interventions carried out by medical professionals.
- If an inpatient procedure is being coded, the ICD-10-PCS code is required.
- Outpatient procedures are coded using CPT-4 coding.
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