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Codes based on ICD-10 (WHO, 1992) structure for information exchange promoting interoperability. Uses a coding structure of five alphanumeric digits to link the two CCC System terminologies to each other and to map to other EHR/HIT systems. Designed for determining workload (productivity), resources (needs), outcomes (quality), and care costs.
An example to highlight clinical coding experience would be the standard within the Australian Coding Standards 0010 General Abstraction Guidelines. [9] These guidelines indicate that a coder must seek further detail within a record in order to correctly assign the correct diagnoses code.
The Major Diagnostic Categories (MDC) are formed by dividing all possible principal diagnoses (from ICD-9-CM) into 25 mutually exclusive diagnosis areas. MDC codes, like diagnosis-related group (DRG) codes, are primarily a claims and administrative data element unique to the United States medical care reimbursement system. DRG codes also are ...
The Eating Disorder Examination Questionnaire (EDE-Q) is a 28-item self-report questionnaire, adapted from the semi-structured interview, the Eating Disorder Examination (EDE). The questionnaire is designed to assess the range, frequency and severity of behaviours associated with a diagnosis of an eating disorder.
A medical classification is used to transform descriptions of medical diagnoses or procedures into standardized statistical code in a process known as clinical coding. Diagnosis classifications list diagnosis codes, which are used to track diseases and other health conditions, inclusive of chronic diseases such as diabetes mellitus and heart ...
SNOMED started in 1965 as a Systematized Nomenclature of Pathology (SNOP) and was further developed into a logic-based health care terminology. [6] [7]SNOMED CT was created in 1999 by the merger, expansion and restructuring of two large-scale terminologies: SNOMED Reference Terminology (SNOMED RT), developed by the College of American Pathologists (CAP); and the Clinical Terms Version 3 (CTV3 ...
The ICPC-3 includes codes for the four key elements of healthcare encounters: the reason for the encounter (RFE); the diagnosis and/or health problem; functioning (i.e. information about activities/participation, physiological functions and about personal and environmental factors related to the health problem); processes of care.
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