223:
responsible for its reflected funding. These decisions also affect clinical documentation by physicians as recommendations from a Health
Information Service can directly affect how a clinician may document a condition that a patient may have. The difference between the codes assigned for confusion and delirium can alter a hospitals DRG assignment as delirium is considered a higher level code than confusion within the ICD-10 coding hierarchy in terms of severity. A clinical coder or Health Information Manager may feel obliged to maximize funding above the ethical requirement to be honest within their diagnostic coding; this highlights the ethical standpoint of diagnoses codes as they should be reflective of a patient's admission.
241:
documentation, handwriting legibility, compilation of forms, duplication and inaccurate patient data. For example, if a clinical coder or Health
Information Manager was extracting data from a medical record in which the principal diagnoses was unclear due to illegible handwriting, the health professional would have to contact the physician responsible for documenting the diagnoses in order to correctly assign the code. In Australia, the legibility of records has been sufficiently maintained due to the implementation of highly detailed standards and guidelines which aim to improve the legibility of medical records. In particular the paper medical record standard 'AS 2828' created by
269:
semi-electronic. The diagnoses codes selected from the extraction are generally compiled and sequenced in order to represent the admission. An experienced coder may incorrectly assign codes due a lack of application of a classification systems relevant standards. An example to highlight clinical coding experience would be the standard within the
268:
The experience of the health professional coding a medical record is an essential variable that must be accounted for when analysing the accuracy of coding. Generally a coder with years of experience is able to extract all the relevant information from a medical record whether it is paper, scanned or
293:
Hence, the result of coding is a reduction to the scope of representation as far as possible to be depicted with the chosen modeling technology. There will never be an escape, but choosing more than one model to serve more than one purpose. That led to various code derivatives, all of them using one
320:
Hierarchical ordering of more than one code system may be seen as appropriate, as the human body is principally invariant to coding. But the dependency implied with such hierarchies decrease the cross referencing between the code levels down to unintelligibility. The escape is with hyper maps that
301:
Focusing a code on one purpose lets other purposes unsatisfied. This has to be taken into account when advertising for any coding concept. The operability of coding is generally bound to purpose. Inter-referring must be subject of evolutionary development, as code structures are subject of frequent
231:
Accuracy is a major component in diagnoses codes. The accurate assignment of diagnoses codes in clinical coding is essential in order to effectively depict a patient's stay within a typical health service area. A number of factors can contribute to the overall accuracy coding which includes medical
336:
Intelligibility of results of coding is achieved by semantic design principles and with ontologies to support navigating in the codes. One major aspect despite the fuzziness of language is the bijectivity of coding. Escape is with explaining the code structure to avoid misinterpreting and various
218:
Classification systems are often subjected to high end decision making that could affect the outcome of funding. It's important to look at the scope of diagnoses codes in terms of their application in finance. The diagnoses codes in particular the
Principal Diagnoses and Additional Diagnoses can
82:
coding to correspond to the codes in ICD. In 2005, for example, DSM changed the diagnostic codes for circadian rhythm sleep disorders from the 307-group to the 327-group; the new codes reflect the moving of these disorders from the Mental
Disorders section to the Neurological section in the ICD
81:
As the knowledge of health and medical advances arise, the diagnostic codes are generally revised and updated to match the most up to date current body of knowledge in the field of health. The codes may be quite frequently revised as new knowledge is attained. DSM (see below) changes some of its
328:
Purpose of documenting will be seen as essential just for the validation of a code system in aspects of correctness. However this purpose is timely subordinate to the generating of the respective information. Hence some code system shall support the process of medical diagnosis and of medical
312:
Projections of code spaces as flattened graphs may ease the depiction of a code, but generally reduce the contained information with the flattening. There is no explanation given with many of the codes for transforming from one code system to another. That leads to specialized usage and to
222:
Ethically, this highlights the fact that the assignment of the diagnoses code can be influenced by a decision to maximize reimbursement of funding. For example, when looking at the activity based funding model used in the public hospital system in
Victoria the total coded medical record is
308:
Spatial depictions of n-dimensional code spaces as coding scheme trees on flat screens may enhance imagination, but still leave the dimensionality of image limited to intelligibility of sketching, mostly as a 3D object on a 2D screen. Pivoting such image does not solve the intelligibility
240:
The legibility of a medical record is a contributing factor in the accuracy of diagnostic coding. The assigned proxy that is extracting information from the medical record is dependent on the quality of the medical record. Factors that contribute to a medical records quality are physician
65:
Several diagnosis classification systems have been implemented to various degrees of success across the world. The various classifications have a focus towards a particular patient encounter type such as emergency, inpatient, outpatient, mental health as well as surgical care. The
280:
and may not use the correct detail which could be further found within the details of the medical record. This directly relates to the accuracy of diagnoses codes as the experience of the health professional coder is significant in its accuracy and contribution to finance.
96:
A number of diagnostic coding systems are implemented across the world to code the stay of patients within a typical health setting, such as a hospital. The following table provides a basic list of the coding systems in use as of approximately 2010:
54:, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnostic coding is the translation of written descriptions of diseases, illnesses and injuries into codes from a particular classification. In
1038:
111:
67:
276:. These guidelines indicate that a coder must seek further detail within a record in order to correctly assign the correct diagnoses code. An inexperienced coder may simply just use the description from the discharge summary such as
248:
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. In particular the legibility of a medical record is dependent on —
209:
Diagnosis codes are generally used as a representation of admitted episodes in health care settings. The principal diagnosis, additional diagnoses alongside intervention codes essentially depict a patient's admission to a hospital.
611:
Cheng, Ping; Gilchrist, Annette; Robinson, Kevin M; Paul, Lindsay (March 2009). "The Risk and
Consequences of Clinical Miscoding Due to Inadequate Medical Documentation: A Case Study of the Impact on Health Services Funding".
213:
Diagnoses codes are subjected to ethical considerations as they contribute to the total coded medical record in health services areas such as a hospital. Hospitals that are based on
Activity Based Funding and
1002:
305:
Unambiguous coding requires strict restriction to hierarchical tree structures possibly enhanced with multiple links, but no parallel branching for contemporary coding whilst maintaining bijectivity.
837:
992:
1107:
975:
955:
162:
1053:
970:
656:
965:
376:
432:"International classification of diseases, 10th edition, clinical modification and procedure coding system: descriptive overview of the next generation HIPAA code sets"
62:. Both diagnosis and intervention codes are assigned by a health professional trained in medical classification such as a clinical coder or Health Information Manager.
812:
253:
Durability: If a medical record wasn't durable, overtime if a coder was to revisit the record and it wasn't legible it wouldn't be feasible to code from that record.
960:
144:
480:
1084:
915:
134:
397:
232:
record legibility, physician documentation, clinical coder experience, financial decision making, miscoding, as well as classification system limitations.
997:
1024:
893:
920:
1117:
1065:
935:
859:
351:
192:
1060:
805:
688:
172:
329:
treatment of any kind. Escape is with a specialised coding for the processes of working on diagnosis as on working with treatment (as
663:
526:
Uzkuraitis, C; Hastings, K.; Torney, B. (2010). "Casemix funding optimisation: working together to make the most of every episode".
259:
Reproducible: A coder would need to make sure that the record is reproducible in that copies can be made to aid in effective coding.
256:
Ready
Identification: A coder must be able to identify the exact record being coded in order to effectively extract diagnoses codes.
1138:
798:
1043:
1028:
763:
70:(ICD) is one of the most widely used classification systems for diagnosis coding as it allows comparability and use of
1122:
298:, with ICD-10 coding. However, concurrent depiction of several models in one image remains principally impossible.
852:
406:
366:
270:
1159:
864:
847:
356:
215:
27:
This article is about codes used in medical classification. For codes used in man-made digital systems, see
842:
821:
361:
91:
55:
405:. United States of America: American Health Information Management Association. p. 2. Archived from
32:
1099:
289:
Generally, coding is a concept of modeling reality with reduced effort, but with physical copying.
242:
501:
1112:
829:
637:
551:
570:
1048:
745:
692:
629:
543:
461:
313:
limitations in communication between codes. The escape is with code reference structures (as
219:
significantly affect the total funding that a hospital may receive for any patient admitted.
735:
727:
621:
586:
535:
451:
443:
245:
focuses on a few key areas that are critical to maintaining a legible paper medical record.
1016:
740:
715:
456:
431:
117:
59:
1153:
1032:
731:
641:
555:
980:
321:
exceed planar views (as e.g. with SNOMED3) and their referring to other codes (as
571:"Casemix accounting systems and medical coding Organisational actors balanced on
399:
ICD-9-CM Diagnostic Coding and
Reimbursement for Physician Services 2006 Edition
68:
International
Statistical Classification of Diseases and Related Health Problems
39:
770:
625:
539:
139:
Also includes reasons for encounter (RFE), procedure codes and process of care
17:
590:
447:
28:
714:
O'Malley, K; Cook, K.; Price, M.; Wildes, K.; Hurdle, J.; Ashton, C. (2005).
1075:
930:
182:
58:, diagnosis codes are used as part of the clinical coding process alongside
749:
633:
547:
465:
790:
1070:
75:
51:
47:
1079:
903:
898:
371:
187:
Used throughout United Kingdom General Practice computerised records
124:
1089:
985:
925:
908:
153:
71:
794:
436:
Journal of the American Medical Informatics Association
163:
Diagnostic and Statistical Manual of Mental Disorders
1131:
1098:
1015:
944:
882:
873:
828:
377:American Health Information Management Association
764:"Towards Semantic Interoperability in Healthcare"
227:Factors affecting accuracy in diagnostic coding
145:International Classification of Sleep Disorders
806:
31:. For codes used in automotive industry, see
8:
129:The international standard since about 1998
579:Journal of Organizational Change Management
879:
813:
799:
791:
691:. University of Wollongong. Archived from
481:"New Diagnostic Codes for Sleep Disorders"
739:
455:
46:are used as a tool to group and identify
716:"Measuring Diagnoses: ICD Code Accuracy"
116:Volumes 1 and 2 only. Volume 3 contains
99:
388:
341:, yet not served at all with SNOMED3).
337:codes for the very same condition (as
294:basic reference code for ordering, as
205:Financial aspects of diagnostic coding
662:. Standards Australia. Archived from
614:Health Information Management Journal
528:Health Information Management Journal
502:"Victorian Hospital Admission Policy"
352:Systematized Nomenclature of Medicine
193:Systematized Nomenclature of Medicine
7:
274:0010 General Abstraction Guidelines
173:Online Mendelian Inheritance in Man
483:. American Psychiatric Association
25:
325:, yet not existing with SNOMED3).
732:10.1111/j.1475-6773.2005.00444.x
689:"OVERVIEW OF ICD-10-AM/ACHI/ACS"
167:Primarily psychiatric disorders
285:Weaknesses in diagnostic coding
1:
333:, not intended with SNOMED3).
317:, not existing with SNOMED3).
657:"Paper-based Health Record"
430:Steindel, S (20 May 2010).
271:Australian Coding Standards
1176:
626:10.1177/183335830903800105
540:10.1177/183335831003900309
89:
26:
591:10.1108/09534810110367110
448:10.1136/jamia.2009.001230
367:Major Diagnostic Category
264:Clinical coder experience
236:Medical record legibility
86:Diagnostic coding systems
720:Health Services Research
357:Diagnosis-related group
216:Diagnoses-Related Group
822:Medical classification
655:Standards, Australia.
507:. Department of Health
362:Medical classification
92:Medical classification
56:medical classification
396:Hazelwood, A (2005).
103:Classification System
1100:Pharmaceutical codes
33:On-board diagnostics
830:Topographical codes
243:Standards Australia
60:intervention codes
1147:
1146:
1011:
1010:
573:leaky black boxes
479:First, M (2005).
202:
201:
177:Genetic diseases
16:(Redirected from
1167:
1017:Procedural codes
949:
887:
880:
875:Diagnostic codes
815:
808:
801:
792:
785:
784:
782:
781:
775:
769:. Archived from
768:
760:
754:
753:
743:
726:(5): 1620–1639.
711:
705:
704:
702:
700:
695:on 29 April 2013
685:
679:
678:
676:
674:
669:on March 5, 2016
668:
661:
652:
646:
645:
608:
602:
601:
599:
597:
569:Lowe, A (2001).
566:
560:
559:
523:
517:
516:
514:
512:
506:
498:
492:
491:
489:
488:
476:
470:
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459:
427:
421:
420:
418:
417:
411:
404:
393:
100:
21:
1175:
1174:
1170:
1169:
1168:
1166:
1165:
1164:
1160:Diagnosis codes
1150:
1149:
1148:
1143:
1127:
1094:
1007:
945:
940:
883:
869:
824:
819:
789:
788:
779:
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773:
766:
762:
761:
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713:
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708:
698:
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687:
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672:
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659:
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649:
610:
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605:
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568:
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563:
525:
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504:
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486:
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473:
429:
428:
424:
415:
413:
409:
402:
395:
394:
390:
385:
348:
287:
229:
207:
118:Procedure codes
94:
88:
44:diagnosis codes
36:
23:
22:
18:Diagnosis codes
15:
12:
11:
5:
1173:
1171:
1163:
1162:
1152:
1151:
1145:
1144:
1142:
1141:
1135:
1133:
1132:Outcomes codes
1129:
1128:
1126:
1125:
1120:
1115:
1110:
1104:
1102:
1096:
1095:
1093:
1092:
1087:
1082:
1073:
1068:
1063:
1058:
1057:
1056:
1051:
1046:
1036:
1021:
1019:
1013:
1012:
1009:
1008:
1006:
1005:
1000:
995:
990:
989:
988:
983:
973:
968:
963:
958:
952:
950:
942:
941:
939:
938:
933:
928:
923:
918:
913:
912:
911:
906:
901:
890:
888:
877:
871:
870:
868:
867:
862:
857:
856:
855:
850:
845:
834:
832:
826:
825:
820:
818:
817:
810:
803:
795:
787:
786:
755:
706:
680:
647:
603:
561:
518:
493:
471:
442:(3): 274–282.
422:
387:
386:
384:
381:
380:
379:
374:
369:
364:
359:
354:
347:
344:
343:
342:
334:
326:
318:
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306:
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299:
286:
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266:
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261:
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257:
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238:
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228:
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206:
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199:
196:
189:
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185:
179:
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169:
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165:
159:
158:
156:
150:
149:
147:
141:
140:
137:
131:
130:
127:
121:
120:
114:
108:
107:
104:
87:
84:
24:
14:
13:
10:
9:
6:
4:
3:
2:
1172:
1161:
1158:
1157:
1155:
1140:
1137:
1136:
1134:
1130:
1124:
1121:
1119:
1118:SNOMED C axis
1116:
1114:
1111:
1109:
1106:
1105:
1103:
1101:
1097:
1091:
1088:
1086:
1083:
1081:
1077:
1074:
1072:
1069:
1067:
1066:SNOMED P axis
1064:
1062:
1059:
1055:
1052:
1050:
1049:9-CM Volume 3
1047:
1045:
1042:
1041:
1040:
1037:
1034:
1030:
1026:
1023:
1022:
1020:
1018:
1014:
1004:
1001:
999:
996:
994:
991:
987:
984:
982:
979:
978:
977:
974:
972:
969:
967:
964:
962:
959:
957:
954:
953:
951:
948:
943:
937:
936:SNOMED D axis
934:
932:
929:
927:
924:
922:
919:
917:
914:
910:
907:
905:
902:
900:
897:
896:
895:
892:
891:
889:
886:
881:
878:
876:
872:
866:
863:
861:
860:SNOMED T axis
858:
854:
851:
849:
846:
844:
841:
840:
839:
836:
835:
833:
831:
827:
823:
816:
811:
809:
804:
802:
797:
796:
793:
776:on 2011-07-18
772:
765:
759:
756:
751:
747:
742:
737:
733:
729:
725:
721:
717:
710:
707:
694:
690:
684:
681:
665:
658:
651:
648:
643:
639:
635:
631:
627:
623:
619:
615:
607:
604:
592:
588:
585:(1): 79–100.
584:
580:
576:
574:
565:
562:
557:
553:
549:
545:
541:
537:
533:
529:
522:
519:
503:
497:
494:
482:
475:
472:
467:
463:
458:
453:
449:
445:
441:
437:
433:
426:
423:
412:on 2013-07-18
408:
401:
400:
392:
389:
382:
378:
375:
373:
370:
368:
365:
363:
360:
358:
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148:
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128:
126:
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119:
115:
113:
110:
109:
105:
102:
101:
98:
93:
85:
83:
79:
77:
73:
69:
63:
61:
57:
53:
50:, disorders,
49:
45:
41:
34:
30:
19:
947:specialized:
946:
884:
874:
838:Terminologia
778:. Retrieved
771:the original
758:
723:
719:
709:
697:. Retrieved
693:the original
683:
671:. Retrieved
664:the original
650:
620:(1): 35–46.
617:
613:
606:
594:. Retrieved
582:
578:
572:
564:
534:(3): 47–49.
531:
527:
521:
509:. Retrieved
496:
485:. Retrieved
474:
439:
435:
425:
414:. Retrieved
407:the original
398:
391:
338:
330:
322:
314:
295:
288:
277:
273:
267:
247:
239:
230:
221:
212:
208:
95:
80:
64:
43:
37:
865:MeSH A axis
40:health care
1076:Read codes
931:Read codes
780:2010-04-07
487:2008-08-08
416:2013-05-27
383:References
278:Infarction
90:See also:
29:Error code
183:Read code
76:morbidity
72:mortality
1154:Category
885:general:
750:16178999
642:16646334
634:19293434
556:21319807
548:28683680
466:20442144
346:See also
309:problem.
195:(SNOMED)
112:ICD-9-CM
52:symptoms
48:diseases
1071:OPS-301
1033:Level 2
741:1361216
457:2995704
302:change.
198:D Axis
106:Detail
1080:OPCS-4
1044:10 PCS
1003:OSIICS
998:CCMD-3
916:ICPC-2
748:
738:
699:29 May
673:30 May
640:
632:
596:25 May
554:
546:
511:25 May
464:
454:
372:MedDRA
135:ICPC-2
125:ICD-10
78:data.
1090:LOINC
1025:HCPCS
956:ICD-O
926:NANDA
774:(PDF)
767:(PDF)
667:(PDF)
660:(PDF)
638:S2CID
552:S2CID
505:(PDF)
410:(PDF)
403:(PDF)
154:NANDA
1085:CCAM
1054:ICHI
971:ILDS
966:ICHD
961:ICSD
746:PMID
701:2013
675:2013
630:PMID
598:2013
544:PMID
513:2013
462:PMID
339:e.g.
331:e.g.
323:e.g.
315:e.g.
296:e.g.
74:and
1139:NOC
1123:DIN
1113:NDC
1108:ATC
1061:NIC
1039:ICD
1029:CPT
993:BPA
976:DSM
921:DRC
894:ICD
736:PMC
728:doi
622:doi
587:doi
536:doi
452:PMC
444:doi
38:In
1156::
1031:,
981:IV
904:10
899:11
853:TE
848:TH
843:TA
744:.
734:.
724:40
722:.
718:.
636:.
628:.
618:38
616:.
583:14
581:.
577:.
550:.
542:.
532:39
530:.
460:.
450:.
440:17
438:.
434:.
42:,
1078:/
1035:)
1027:(
986:5
909:9
814:e
807:t
800:v
783:.
752:.
730::
703:.
677:.
644:.
624::
600:.
589::
575:"
558:.
538::
515:.
490:.
468:.
446::
419:.
35:.
20:)
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