Introduction to ICD Classification - Classification Systems (U2IP&DB) - Essay Example

Introduction to ICD ification ification Systems Part I “ The International ification of Diseases, Clinical Modification (ICD-9-CM) isused to code and classify morbidity data from the inpatient and outpatient records, physician offices, and most National Center for Health Statistics (NCHS) surveys. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), are overseen by The National Center for Health Statistics (NCHS), and the Medicare and Medicaid Services. These U.S.

governmental agencies are in charge of all changes and alterations to the ICD-9-CM. ICD-9-CM is the United States official system for assigning codes to procedures and diagnoses based on the World Health Organizations Ninth Revision, International Classification of Diseases (ICD-9)” (MediLexicon, 2008, pg. 1). Four main steps are involved in the process of selecting the proper ICD-9-CM codes. These must be followed in detail in order to ensure that the diagnosis is accurately described by the code.

The steps described in the following paragraph are necessary in order to establish the proper ICD-9-CM code (Pelaia, 2003, pg. 7). The first step in assigning the proper ICD-9-CM code is to “review the medical record documentation in order to properly identify the terms that best describe the patient’s diagnosis” (Pelaia, 2003, pg. 8). The second step in assigning the proper code is to “look up the terms that best describe the patient’s diagnosis in Volume 2 (the alphabetic index) and identify the ICD-9 code that best matches the diagnosis” (Pelaia, 2003, pg. 9). The third step in assigning the proper ICD-9-CM code is to “look up the selected code in Volume 1 (the tabular list) to make the code selection.

Careful attention should be paid to ‘includes’ and ‘excludes’ notes and other instructions in Volume 1” (Pelaia, 2003, pg. 10). Finally, all information should be carefully reviewed and verified.ReferencesICD-9 and ICDCM codes search. (2008). MediLexicon. Retrieved June 19, 2008, from http://www.medilexicon.com/icd9codes.phpPelaia, R.A. (2003). The fundamentals of coding for non-coders and potential compliance issues related to coding activities. University of Florida Health Science Center.

Part IIIt is extremely important for a medical coder or for a medical professional responsible for ensuring that the correct diagnostic codes are being recorded for the procedures performed at a medical facility is using an up-to-date code book. Failing to use a current code book can result in a variety of mishaps that can easily be avoided. If a person loses his or her current code book, it should be replaced immediately.First of all, it is essential that medical personnel keep proper records in order to stay compliant with legal regulations.

Using an old code book could result in the wrong diagnosis being recorded for a patient which could have disastrous results. It could also harm the medical facility seriously in the financial department in the form of fines and lawsuits. This must be avoided at all costs in order to ensure a safe and accurate account of patient medical records at the facility.Inaccurate coding can also result in denied claims to a physician’s office, which can also harm the facility financially. “Physician practices of all sizes struggle with accurate, timely coding and billing services.

Payers, in turn, scrutinize claims to minimize costs and prevent unauthorized payments or fraud. This dynamic will certainly intensify with CMS’s recent implementation of recovery audit contractors (RAC) focused on ensuring accurate payments. By effectively streamlining coding and billing through electronic CBR solutions, the complexities a physician practice faces can be simplified, while generating additional capital” (Ingenix, 2008, pg. 1).ReferencesTechnological vigilance ensures tomorrow’s success. (2008). Ingenix.

Retrieved June 19, 2008, from http://209.85.215.104/search?q=cache:QLdR1BX0snIJ:www.ingenix.com/content/attachments/Provider_white_paper-final.pdf+%22medical+coding%22+outdated+code+book&hl=en&ct=clnk&cd=9&gl=usOptimize Physician Practices’ Reimbursement