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Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance ...
A nosologist (medical coding expert) in the U.S. will usually be certified by either AHIMA or the AAPC (often both) at their highest level of certification and speciality inpatient and/or outpatient certification (pediatrics, obstetrics/gynecology, gerontology, oncology are among those offered by AHIMA and/or the AAPC), have at least 3–5 ...
Whilst the ICD-10-PCS codes also contains procedure codes, those are only used in the inpatient setting. [5] CPT is identified by the Centers for Medicare and Medicaid Services (CMS) as Level 1 of the Healthcare Common Procedure Coding System. Although its use has become federally regulated, the CPT's copyright has not entered the public domain ...
The ICD-10 Procedure Coding System (ICD-10-PCS) is a US system of medical classification used for procedural coding.The Centers for Medicare and Medicaid Services, the agency responsible for maintaining the inpatient procedure code set in the U.S., contracted with 3M Health Information Systems in 1995 to design and then develop a procedure classification system to replace Volume 3 of ICD-9-CM.
Diagnostic coding is the translation of written descriptions of diseases, illnesses and injuries into codes from a particular classification. In medical classification, diagnosis codes are used as part of the clinical coding process alongside intervention codes. Both diagnosis and intervention codes are assigned by a health professional trained ...
ICD has a hierarchical structure, and coding in this context, is the term applied when representations are assigned to the words they represent. [30] Coding diagnoses and procedures is the assignment of codes from a code set that follows the rules of the underlying classification or other coding guidelines.
Following an extensive, years-long revision process involving nearly 15,000 clinicians from 155 countries, [31] the WHO developed the ICD-11 CDDG (Clinical Descriptions and Diagnostic Guidelines), [33] [34] [35] later renamed the ICD-11 CDDR (Clinical Descriptions and Diagnostic Requirements). [36]
Healthcare Common Procedure Coding System (including Current Procedural Terminology) (for outpatient use; used in United States) ICD-10 Procedure Coding System (ICD-10-PCS) (for inpatient use; used in United States) ICD-9-CM Volume 3 (subset of ICD-9-CM) (formerly used in United States prior to the introduction of the ICD-10-PCS)
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