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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 ...
The ICD-10 Clinical Modification (ICD-10-CM) is a set of diagnosis codes used in the United States of America. [1] It was developed by a component of the U.S. Department of Health and Human services, [2] as an adaption of the ICD-10 with authorization from the World Health Organization.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) instructed CMS to adopt a standard coding systems for reporting medical transactions. The use of Level III codes was discontinued on December 31, 2003, in order to adhere to consistent coding standards.
The CCC System was one of the standards in the first set of 55 national standards approved for use in the EHR, by the Department of Health and Human Services (AHIC, 2006) and the only national nursing terminology standard. In 2020, HCA Healthcare became the new custodian of Dr. Virginia Saba's Clinical Care Classification (CCC) System.
The Physician Quality Reporting System ... is a health care quality improvement incentive program initiated by the Centers for Medicare and Medicaid Services ...
reimbursement (e.g., to process claims in medical billing based on diagnosis-related groups) knowledge-based and decision support systems; direct surveillance of epidemic or pandemic outbreaks; In forensic science and judiciary settings; There are country specific standards and international classification systems.
The principal diagnosis, additional diagnoses alongside intervention codes essentially depict a patient's admission to a hospital. [4] Diagnoses codes are subjected to ethical considerations as they contribute to the total coded medical record in health services areas such as a hospital.
Barriers to the widespread adoption of effective data standards include: inconsistency in and poor understanding of the concepts and language used in clinical practice, for example compared to those in chemistry or accounting; rival systems of standards; the cost of implementation or change to better standards; avoidance of commercial competition.