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HCPCS includes three levels of codes: Level I consists of the American Medical Association's Current Procedural Terminology (CPT) and is numeric.; Level II codes are alphanumeric and primarily include non-physician services such as ambulance services and prosthetic devices, and represent items and supplies and non-physician services, not covered by CPT-4 codes (Level I).
The CPT code revisions in 2013 were part of a periodic five-year review of codes. Some psychotherapy codes changed numbers, for example 90806 changed to 90834 for individual psychotherapy of a similar duration. Add-on codes were created for the complexity of communication about procedures.
In health care, diagnosis codes are used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnostic coding is the translation of written descriptions of diseases, illnesses and injuries into codes from a particular classification.
In a nomenclature there is a separate listing and code for every clinical concept. So, in the previous example, each of the tachycardia listed would have its own code. This makes nomenclatures unwieldy for compiling health statistics. Types of coding systems specific to health care include: Diagnostic codes
Medical billing, a payment process in the United States healthcare system, is the process of reviewing a patient's medical records and using information about their diagnoses and procedures to determine which services are billable and to whom they are billed.
For example, a clinical coder may use a set of published codes on medical diagnoses and procedures, such as the International Classification of Diseases (ICD), the Healthcare Common procedural Coding System (HCPCS), and Current Procedural Terminology (CPT) for reporting to the health insurance provider of the recipient of the care.
Procedure codes are a sub-type of medical classification used to identify specific surgical, medical, or diagnostic interventions. The structure of the codes will depend on the classification; for example some use a numerical system, others alphanumeric.
A nursing care component is defined as a cluster of elements that represents a unique pattern of clinical care nursing practice; namely, Health Behavioral, Functional, Physiological, and Psychological. Nursing Diagnoses: A clinical judgment about the healthcare consumer's response to actual or potential health conditions or needs.