Questions and Answers
What is a medical coding classification system?
Which two classification systems are widely recognized in medical coding?
What does ICD stand for?
International Classification of Diseases
What is the current version of the ICD system being used?
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What are the two components of ICD-10?
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What does CPT stand for?
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What does HCPCS stand for?
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What does DSM stand for?
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Which entities commonly have alternate classification systems?
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What can be traced back to the 16th century?
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ICD-9 is the abbreviation for __________.
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What is abstracting?
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How can data be collected in healthcare?
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What is automated abstracting?
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What aids in reducing billing delays?
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What are encoders?
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What does CAC stand for?
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What is the primary reason to abstract healthcare data?
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What is Big Data in healthcare?
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What influences data dependence and reliability in healthcare?
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Who are the most knowledgeable about gathering meaningful data?
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What is Information Technology (IT) in healthcare?
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HIM should check for record retention according to state and federal law.
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HIM and IT collaboration is not necessary during data mapping processes.
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What does AHA stand for?
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Study Notes
Medical Coding Classification Systems
- Medical coding classification systems capture clinical data for reporting and reimbursement, assist in disease statistical analyses, and support decision-making processes.
- Two widely recognized classification systems: International Classification of Diseases (ICD) and Current Procedural Terminology (CPT).
International Classification of Diseases (ICD)
- ICD is an international classification system that identifies morbidity and mortality.
- The current version in use is ICD-10, which has various modifications, including ICD-10-CM (clinical modification) and ICD-10-PCS (procedure coding system).
- ICD-10's origins can be traced back to the 16th century.
- ICD-9 was the 9th revision of this classification, used in the U.S. for 36 years.
Current Procedural Terminology (CPT)
- CPT was created for reporting care delivered by physicians.
Healthcare Common Procedure Coding System (HCPCS)
- HCPCS is another classification system used frequently in healthcare billing and coding processes.
Diagnostic and Statistical Manual of Mental Disorders (DSM)
- DSM is a key classification system for mental health disorders.
Alternate Classification Systems
- Other entities with alternate classification systems include home health, nursing, oncology, and pharmacotherapeutic fields.
Abstracting Process
- Abstracting involves extracting information from documents to summarize a patient's illness, treatment, and outcomes.
- Efficient abstracting software helps reduce billing delays and is commonly used.
Data Collection Methods
- Data can be collected manually through paper abstracts or inputted into computerized databases.
- Automated abstracting is a prevalent practice enhanced by tools such as encoders and computer-assisted coding (CAC).
Computer-Assisted Coding (CAC)
- CAC uses natural language processing (NLP) to extract relevant data from patient charts and complete predefined templates.
Importance of Abstracting
- Generating meaningful reports is a primary motivation for abstracting healthcare data, reflecting patient diagnoses and treatments.
Big Data in Healthcare
- Big data is becoming increasingly relevant as healthcare evolves.
Forces Driving Data Dependence
- Forces pushing for data use include meaningful use initiatives, population health management, clinical informatics algorithms, reimbursement models, and healthcare reforms.
Health Information Management (HIM) Professionals
- HIM professionals develop policies, ensure record compliance, and are experts in meaningful data collection and EHR technology manipulation.
- They must check for record retention in accordance with state and federal laws.
Collaboration Between HIM and IT
- Collaboration between HIM and IT is crucial during data mapping processes to identify and correct errors before implementation.
American Hospital Association (AHA)
- The AHA is a significant organization related to healthcare policies and practices (details not provided).
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Description
Test your knowledge on various medical coding classification systems, including ICD and CPT. Understand the implications of these systems in reporting, reimbursement, and decision-making in healthcare. Dive into the origins and nuances of ICD-10 and HCPCS.
