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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 .
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 ...
The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.
The ICD-10 Clinical Modification (ICD-10-CM) is a set of diagnosis codes used in the United States of America. It was developed by a component of the U.S. Department of Health and Human services, as an adaption of the ICD-10 with authorization from the World Health Organization.
The classification system allows more than 55,000 different codes and permits tracking of many new diagnoses and procedures, a significant expansion on the 17,000 codes available in ICD-9. Adoption was relatively swift in most of the world.
The Healthcare Common Procedure Coding System (HCPCS, often pronounced by its acronym as "hick picks") is a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (CPT).
Clinical Coder. A clinical coder —also known as clinical coding officer, diagnostic coder, medical coder, or nosologist —is a health information professional whose main duties are to analyse clinical statements and assign standardized codes using a classification system. The health data produced are an integral part of health information ...
A medical classification is used to transform descriptions of medical diagnoses or procedures into standardized statistical code in a process known as clinical coding. Diagnosis classifications list diagnosis codes, which are used to track diseases and other health conditions, inclusive of chronic diseases such as diabetes mellitus and heart ...
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.
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. [1]