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Evaluation and management coding (commonly known as E/M coding or E&M coding) is a medical coding process in support of medical billing. Practicing health care providers in the United States must use E/M coding to be reimbursed by Medicare , Medicaid programs, or private insurance for patient encounters.
The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings. [1]
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. The current version of the ICD, ICD-10, was endorsed by WHO in 1990. WHO Member states began using the ICD-10 classification system from 1994 for both morbidity and mortality reporting.
The first version was developed in the early 1980s by Dr James Read, a Loughborough general medical practitioner. [2] The scheme was structured similarly to ICD-9: . each code was composed of four consecutive characters: first character 0-9, A-Z (excepting I and O), remaining three characters 0-9, A-Z/a-z (excepting i,I,o and O) plus up to three trailing period '.' characters
A subsequent revision which was published in the 1993 publication The International Classification of Primary Care in the European Community: With a Multi-Language Layer is known as ICPC-E. The 1998 publication, of version 2, is referred to as ICPC-2. The acronym ICPC-2-E, refers to a revised electronic version, which was released in 2000.
As the AMA decided in April 1960, the Current Medical Terminology (CMT) handbook was first published in June 1962 – 1963 to standardize terminology of the Standard Nomenclature of Diseases and Operations (SNDO) and International Classification of Diseases (ICD), and for the analysis of patient records, and was aided by an IBM computer. [22]
A statistical classification, such as ICD-10 or DSM-5, will bring together similar clinical concepts, and group them into one category. This allows the number of categories to be limited so that the classification does not become too big, but still allows statistical analysis. An example of this is in ICD-10 at code I47.1.
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 ...