Question

why is it important to understand the different diagnostic code within medical records? provide example

Answer 1

**"""""****** important to understand the different diagnostic code within medical records? provide example*"*"*

ICD Codes, International Classification of Diseases codes, are found on patient paperwork, including hospital records, physician records, and death certificates. The tenth version of the code currently in use is called the ICD-10.

The United States has used the new ICD-10 codes since October 1, 2015, the classifications of which are provided by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS).

Purposes of ICD-10 Codes

ICD codes could be important to you for a variety of reasons, from the reimbursement of medical expenses to ensuring the standardized treatment is delivered among multiple providers.

Insurance Reimbursement...

When your doctor submits her bill to insurance for reimbursement, each service described by a CPT code must be matched to an ICD code. If those two codes don't align correctly with each other, payment may be rejected. In other words, if the service isn't one that would be typically provided for someone with that diagnosis, the doctor won't get paid.

For example, the doctor could not typically submit a bill for an X-ray if the patient's complaint was a rash.

Disease Management...

If you have a chronic disease, once an ICD code has been assigned, it may affect the treatment you receive if your provider looks at the code. That would most likely happen in a hospital where a doctor who is not the one who usually treats you (a hospitalist) or with a doctor who reviews your records before he sees you.

In a hospital setting, an ICD code can be a good or a bad thing. It could prevent you from getting contraindicated treatment or allow a hospital to provide (and bill for) an indicated treatment even if even if it is not needed.

Other Uses...

If you have a rare disease, then your ICD code may be used to admit you to a clinical trial.

An ICD code may also appear on a death certificate. ICD codes are used to track causes of death, but that coding more likely takes place after the death and is not always recorded on the death certificate.

Only 60% of the audited records met the benchmark for good quality medical records with regards to documentation and coding. A positive correlation between the accurate documentation and correct coding was noted, which supports the conclusion that high quality documentation enhances coding accuracy. These data, although encouraging, suggest room for improvement, which can be achieved through the collaboration of clinicians, who have extensive clinical experience, and coding professionals, who have comprehensive classification system expertise.

The core of the health information system in the hospital lies in the medical records

.1 As a primary means of communication between health care workers, a properly documented medical record is essential to good clinical care.

–5Coding is classifying data and assigning a representation for these data. Clinical coding is assigning numbers to diagnoses and procedures for retrieval, research and reimbursement purposes.

6 The most common coding system used to code hospital inpatients is the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) system.

7This will soon be replaced by the tenth revision (ICD-10-CM).

8 The coding process involves steps that include a review of the medical record, selection of items to code, assignment of the code, sequencing of the code, abstracting, entry, storage and retrieval of the coded data in a database.

Accurate diagnostic and procedural coding cannot be attained without clear and complete documentation.

9 Maintaining good standards of clinical documentation remains a problem in the health service. Little is known about the documentation and coding errors in the medical records at King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia (KFSHRC). We examined the frequency and sources of errors.

Coding also allows for uniform documentation between medical facilities. The code for streptococcal sore throat is the same in Arkansas as it is in Hawaii. Having uniform data allows for efficient research and analysis, which government and health agencies use to track health trends much more efficiently. If the CDC, for example, wants to analyze the prevalence of viral pneumonia, they can search for the number of recent pneumonia diagnoses by looking for the ICD-10-CM code.

Finally, coding allows administrations to look at the prevalence and effectiveness of treatment in their facility. This is especially important to large medical facilities like hospitals. Like government agencies tracking, say, the incidence of a certain disease, medical facilities can track the efficiency of their practice by analyzing

Now that we understand the importance of this practice, let’s take a look at the three types of code that you’ll have to become familiar with as a medical coder.