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Classification of Diseases Two related classification systems œInternational Classification of Diseases, Ninth Revision (ICD-9)  used to code & classify.

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Presentation on theme: "Classification of Diseases Two related classification systems œInternational Classification of Diseases, Ninth Revision (ICD-9)  used to code & classify."— Presentation transcript:

1 Classification of Diseases Two related classification systems œInternational Classification of Diseases, Ninth Revision (ICD-9)  used to code & classify mortality data from death certificates  Developed and revised by the World Health Organization (WHO) œInternational Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)  used to code & classify morbidity data from inpatient & outpatient records  Developed by the Health Care Financing Administration (HCFA)  Used in the U.S.

2 ICD-9-CM l Statistical classification system that arranges diseases and injuries into groups according to established criteria l Purpose  classification of mortality & morbidity information for statistical purposes  indexing of medical records by disease and operation  data storage and retrieval

3 ICD-9-CM l “Clinical” used to emphasize the modification’s intent…to classify morbidity data for indexing of medical records and other health care statistics l Numeric codes with descriptions l Annual updates published by Health Care Financing Administration (HCFA) l Medicare Catastrophic Coverage Act passed in 1988 required use of ICD-9 codes on Medicare Part B claim forms…other third party payers followed suit

4 ICD-9-CM l Volume 1 -- Numeric listing of diagnosis codes and descriptions l Volume 2 -- Alphabetical listing of diagnoses with codes and descriptions l A revision -- ICD-10-CM is in the works l Learn more about ICD-9-CM at the National Center for Health Statistics web siteNational Center for Health Statistics

5 Current Procedural Terminology (CPT) Codes l Classification of medical services and procedures l Purpose: to provide a uniform language that accurately describes medical, surgical, and diagnostic services l Provides reliable communication nationwide among providers, patients, and third parties

6 CPT Codes Developed by the American Medical Association in 1966 Annual updates made by CPT Panel of the AMA Each procedure/service has 5 digit code CPT codes must must be supported by diagnostic codes (ICD-9-CM) Learn more about CPT codes at the AMA web siteAMA

7 Documentation Guidelines for Evaluation and Management Services Jointly developed by AMA and HCFA Components of documentation  history  exam  complexity of medical decision-making  counseling  time Level of Service CPT Codes  Different CPT codes based on:  new vs. established patient  Type of history, exam, and decision-making

8 Documentation Guidelines CPT and ICD-9-CM codes must be supported by documentation To learn more about the Documentation Guidelines go to the HCFA web siteHCFA For a history of the documentation guidelines and to view a draft of new guidelines click on “Status Report” at the HCFA web siteStatus Report

9 Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM IV) l Purpose: to provide clear descriptions of diagnostic categories to enable clinicians and investigators to diagnose, communicate about, study and treat people with various mental disorders l Learn more about DSM IV at the American Psychiatric Association web site American Psychiatric Association


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