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In particular the paper medical record standard 'AS 2828' created by Standards Australia focuses on a few key areas that are critical to maintaining a legible paper medical record. [7] The following criteria should be used as a guideline when creating a medical record specific to the aid of providing clear documentation for diagnostic coding.
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.
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]
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 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.
Some medical coders elect to be certified by more than one society. The AAPC offers the following entry-level certifications in the U.S.: Certified Professional Coder (CPC); which tests on most areas of medical coding, and also the Certified Inpatient Coder (CIC) and Certified Outpatient Coder (COC). Both the CPC and COC have apprentice ...
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