Medical coding nomenclatures and classifications have extreme importance when assessing the patients’ diagnosis, billing, and more. They also make it possible to standardize health information so there is interoperability, accurate health information exchange, and reliable secondary data usage. The common medical coding nomenclatures and classifications are SNOMED CT, ICD-10-CM and ICD-10-PCS, and CPT. The implementation of these have changed medical coding and impacted the workforce in many ways. Outpatient and inpatient healthcare settings had to adapt to the systems’ requirements necessary to meet clinical and billing objectives.
The Systematized Nomenclature of Medicine – Clinical Terms, SNOMED CT, according to Sayles and Gordon (2016),
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The tenth revision, Clinical Modification of ICD (ICD-10-CM) was implemented in the United States in 2015 to replace ICD-9-CM. ICD-10-CM is intended for billing purposes and enables a more comprehensive understanding of patients’ health conditions. ICD-10-Procedure Coding System (PCS), like CPT, it identifies the procedure performed by the provider. The purpose of ICD-10-PCS is to deliver a system for classifying procedures done on hospital inpatients. According to Sayles and Gordon (2016), “ it provides a unique code for all substantially different procedures, both currently known and those that may be identified at some future in date” (Sayles and Gordon …show more content…
It was a hard transition process and required a lot of training and preparation. While ICD-9 contained over 17,00 codes, ICD-10 has over 144,000 codes. Diagnosis codes increased from around 13,500 to 69,000, and hospital inpatient procedure codes increased from 4,000 codes to 71,000 codes (Centafont, 2015). The transition provided a more thorough understanding of patients’ health conditions and more precise billing of health services delivered. ICD-10-CM has up seven digits codes, while ICD-9 had up to 5. The codes in ICD-10 are more specified, with the additions of laterality, descriptions using anatomical, physiological, and disease process terminology, and episode of care. Those additions are believed to enable more specificity, and deliver more useful information for research, quality improvement, and public health initiatives. The Impact on the Workforce. The transition from ICD-9 to ICD-10 has impacted inpatient and outpatient settings in many ways. Some specialty clinics may have experienced a smooth transition due to the lower number of patients and perhaps staff. According to Cavit (2015), “in audiology, this should be a straightforward transition with the right training and the right tools” (Cavit, 2015). In the case of audiology practices, for example, the change was mostly because of in ICD-10 there is more specificity like ear distinction. Cavit also explained that “unless you have a
Generally, the development and adoption of Clinical Decision Support (CDS) systems is based on the necessity and essence of technical standards in enhancing healthcare. However, the various health IT tools must comply with some data interchange standards in order to enhance access to clinical records, lessen clinical errors and risks to patient safety, and promote innovation in “individual-based” care (Hammond, Jaffe & Kush, 2009, p.44). The need for compliance with standards is fueled by their role in enabling aggregation of informa...
The American Health Information Management Association provides guidelines of elements to be included in a health care organization’s policies of a coding compliance plan. (“Coding Compliance: Practical Strategies for Success,” ahima.org, 1998).
This is a critical review of the article entitled “Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care”. In this article, Lundberg, C.B. et al. review the different standardized terminology in electronic health records (EHR) used by nurses to share medical information to the rest of the care team. It aims at showing that due to the importance of nursing in patient care, there is a great need for a means to represent information in a way that all the members of the multidisciplinary medical team can accurately understand. This standardization varies from organization to organization as the terminologies change with respect to their specialized needs.
How would you define standardized terminologies and why are they important? Provide an example in your answer.
The ICD 10 codes are more detailed and on point whereas the ICD 9 codes were a little more generalized. This was done so the issue of accuracy would be improved and it helps organizations like the Center of Disease Control and Prevention to keep precise records. For example, the old codes would have wanted to know the patient broke his left wrist, but the new ICD 10 codes also need to know which bone in the wrist was broken. Understanding anatomy and physiology along with the ICD 10 codes will make the coders and billers more efficient and less likely to make
Medical billers often communicate with physicians and other health care professionals to explain diagnoses or to attain further information by means of phones, email, fax, etc. The biller must know how to read a medical record and be familiar with CPT®, HCPCS Level II and ICD-9-CM codes.
This technology assist the nurse in confirming patients identify by confirming the patients’ dose, time and form of medication (Helmons, Wargel, & Daniels, 2009). Having an EHR also comes with a program that allows the medical staff to scan medications so medication errors can be prevented. According to Helmons, Wargel, and Daniels (2009) they conducted an observational study in two medical –surgical units one in the medical intensive care (ICU) and one in the surgical ICU. The researchers watched 386 nurses within the two hospitals use bar code scanning before they administrated patients’ medications. The results of the research found a 58 % decrease in medication errors between the two hospitals because of the EHR containing a bar code assisted medication administration
When assessing where the industry will go over the next ten years, there is one area that stands out. Government involvement in healthcare has become a major player in how this industry is changing. New regulations are being introduced at a rapid rate and have pushed hospitals into constant change management (Arab Kash, Spaulding, Johnson, & Gamm, 2014).
“Current Procedural Terminology codes otherwise known as CPT codes are a classification of diagnostic and therapeutic procedures performed by physicians and other health care providers”. Each procedure is assigned a 5 digit code (Centers for Disease Control and Prevention, 2013). “CPT codes are numbers assigned to every procedure and service a medical professional may provide to a patient. These include medical, surgical and diagnostic services” ("5 thoroughly explain," 2014). They are then used by insurers to determine the amount of reimbursement a physician will receive from the insurer. Since everyone uses the same codes to mean the same thing, they ensure uniformity ("5 thoroughly explain," 2014).
Clinical Documentation Improvement ensures that their health care system provides the accurate recording of medical records. The health information management industry (HIM) thrives over the improvements towards clinical documentation as medical assistance validates healthcare and optimizes their medical processing system. Clinical documentation specialist (CDS) is essential in order to alter the medical landscape in a positive measure as they provide detailed documentation and medical coding. Documentation requirements for Health Information Management (HIM) professionals intend on making the healthcare data obtainable from the additional diagnoses, which will require an enhancement of the documentation system. Thus, the ICD-10 is a new tool
Health Information Management (HIM) professional: Will expect that the healthcare providers are honest, accurate in their diagnoses, and the charges are legal, fair, and correspond to services rendered on the given day. All inaccuracies must be corrected as soon as discovered to inspire confidence in the HIM professional, the facility, and all the organization’s employees. All stakeholders depend upon the HIM professional to maintain the accuracy, privacy and security of the patient’s medical charts, and thereby secure the reputation of the facility and welfare of the patients.
After ICPMs creation, other countries decided to translate, adapt, and use the ICPM as well. The main purposes of ICD-9-CM were to help organizations bill for health services, assist with record keeping, and to help gather data on health statistics throughout the United States. In the midst of creating ICD-9 WHO realized that more specificity in classification would need to be implemented, so they began working on ICD-10 (1999-present) before ICD-9 was
Our clinical knowledge is expanding. The researcher has first proposed the concept of electronic health record (EHR) to gather and analyze every clinical outcome. By late 1990s computer-based patient record (CPR) replaced with the term EHR (Wager et al., 2009). The process of implementing EHR occurs over a number of years. An electronic record of health-related information on individual conforms interoperability standards can create, manage and consult with the authorized health professionals (Wager et al., 2009). This information technology system electronically gather and store patient data, and supply that information as needed to the healthcare professionals, as well as a caregiver can also access, edit or input new information; this system function as a decision support tools to the health professionals. Every healthcare organization is increasingly aware of the importance of adopting EHR to improve the patient satisfaction, safety, and lowering the medical costs.
Venes, Donald, and Clarence Wilbur Taber. Taber's Cyclopedic Medical Dictionary. 16th ed. Philadelphia: F.A. Davis, 2013. 1372-373. Print.
...d procedures are now being monitored to improve clinical processes. Ensuring that these processes are implemented in a timely, effective manner can also improve the quality of care given to patients. Management of the processes ensures accountability of the effectiveness of care, which, as mentioned earlier, improves outcomes. Lastly, providing reimbursements based on the quality of care and not the quantity also decreases the “wasting” and overuse of supplies. Providers previously felt the need to do more than necessary to meet a certain quota based on a quantity of supplies or other interventions used. Changing this goal can significantly decrease the cost of care due to using on the supplies necessary to provide effective, high-quality care. I look forward to this implementation of change and hope to see others encouraging an increase in high-quality healthcare.