Diagnosis code

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In health care, diagnosis codes are used as a tool to group and identify diseases, disorders, symptoms, 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 medical classification, diagnosis codes are used as part of the clinical coding process alongside intervention codes. Both diagnosis and intervention codes are assigned by a health professional trained in medical classification such as a clinical coder or Health Information Manager. [1]

Contents

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 International Statistical Classification of Diseases and Related Health Problems (ICD) is one of the most widely used classification systems for diagnosis coding as it allows comparability and use of mortality and morbidity data. [2]

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 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 [3]

Diagnostic coding systems

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:[ needs update? ]

Classification SystemDetail
ICD-9-CM Volumes 1 and 2 only. Volume 3 contains Procedure codes
ICD-10 The international standard since about 1998
ICPC-2 Also includes reasons for encounter (RFE), procedure codes and process of care
International Classification of Sleep Disorders
NANDA
Diagnostic and Statistical Manual of Mental Disorders Primarily psychiatric disorders
Online Mendelian Inheritance in Man Genetic diseases
Read code Used throughout United Kingdom General Practice computerised records
Systematized Nomenclature of Medicine (SNOMED)D Axis

Financial aspects of diagnostic coding

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. [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. Hospitals that are based on Activity Based Funding and Diagnoses-Related Group 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 significantly affect the total funding that a hospital may receive for any patient admitted. [5]

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 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. [6]

Factors affecting accuracy in diagnostic coding

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 record legibility, physician documentation, clinical coder experience, financial decision making, miscoding, as well as classification system limitations.

Medical record legibility

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 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 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. In particular the legibility of a medical record is dependent on —

  1. 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.
  2. Ready Identification: A coder must be able to identify the exact record being coded in order to effectively extract diagnoses codes.
  3. Reproducible: A coder would need to make sure that the record is reproducible in that copies can be made to aid in effective coding. [8]
Clinical coder experience

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 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 Australian Coding Standards 0010 General Abstraction Guidelines. [9] 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 Infarction 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. [10]

Weaknesses in diagnostic coding

Generally, coding is a concept of modeling reality with reduced effort, but with physical copying.

See also

Related Research Articles

<i>Diagnostic and Statistical Manual of Mental Disorders</i> American psychiatric classification

The Diagnostic and Statistical Manual of Mental Disorders is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common language and standard criteria. It is the main book for the diagnosis and treatment of mental disorders in the United States and Australia, while in other countries it may be used in conjunction with other documents. The DSM-5 is considered one of the principal guides of psychiatry, along with the International Classification of Diseases ICD, CCMD, and the Psychodynamic Diagnostic Manual. However, not all providers rely on the DSM-5 as a guide, since the ICD's mental disorder diagnoses are used around the world and scientific studies often measure changes in symptom scale scores rather than changes in DSM-5 criteria to determine the real-world effects of mental health interventions.

The International Classification of Diseases (ICD) is a globally used medical classification used in epidemiology, health management and for clinical purposes. The ICD is maintained by the World Health Organization (WHO), which is the directing and coordinating authority for health within the United Nations System. The ICD is originally designed as a health care classification system, providing a system of diagnostic codes for classifying diseases, including nuanced classifications of a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease. This system is designed to map health conditions to corresponding generic categories together with specific variations, assigning for these a designated code, up to six characters long. Thus, major categories are designed to include a set of similar diseases.

Diagnosis-related group (DRG) is a system to classify hospital cases into one of originally 467 groups, with the last group being "Ungroupable". This system of classification was developed as a collaborative project by Robert B Fetter, PhD, of the Yale School of Management, and John D. Thompson, MPH, of the Yale School of Public Health. The system is also referred to as "the DRGs", and its intent was to identify the "products" that a hospital provides. One example of a "product" is an appendectomy. The system was developed in anticipation of convincing Congress to use it for reimbursement, to replace "cost based" reimbursement that had been used up to that point. DRGs are assigned by a "grouper" program based on ICD diagnoses, procedures, age, sex, discharge status, and the presence of complications or comorbidities. DRGs have been used in the US since 1982 to determine how much Medicare pays the hospital for each "product", since patients within each category are clinically similar and are expected to use the same level of hospital resources. DRGs may be further grouped into Major Diagnostic Categories (MDCs). DRGs are also standard practice for establishing reimbursements for other Medicare related reimbursements such as to home healthcare providers.

Case mix, also casemix and patient mix, is a term used within healthcare as a synonym for cohort; essentially, a case mix groups statistically related patients. An example case mix might be male patients under the age of 50, who present with a myocardial infarction and also undergo emergency coronary artery bypass surgery.

A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice compared to dependent interventions driven by physician's orders. Nursing diagnoses are developed based on data obtained during the nursing assessment. A problem-based nursing diagnosis presents a problem response present at time of assessment. Risk diagnoses represent vulnerabilities to potential problems, and health promotion diagnoses identify areas which can be enhanced to improve health. Whereas a medical diagnosis identifies a disorder, a nursing diagnosis identifies the unique ways in which individuals respond to health or life processes or crises. The nursing diagnostic process is unique among others. A nursing diagnosis integrates patient involvement, when possible, throughout the process. NANDA International (NANDA-I) is body of professionals that develops, researches and refines an official taxonomy of nursing diagnosis.

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 disease, and infectious diseases such as norovirus, the flu, and athlete's foot. Procedure classifications list procedure code, which are used to capture interventional data. These diagnosis and procedure codes are used by health care providers, government health programs, private health insurance companies, workers' compensation carriers, software developers, and others for a variety of applications in medicine, public health and medical informatics, including:

<span class="mw-page-title-main">SNOMED CT</span> System for medical classification

SNOMED CT or SNOMED Clinical Terms is a systematically organized computer-processable collection of medical terms providing codes, terms, synonyms and definitions used in clinical documentation and reporting. SNOMED CT is considered to be the most comprehensive, multilingual clinical healthcare terminology in the world. The primary purpose of SNOMED CT is to encode the meanings that are used in health information and to support the effective clinical recording of data with the aim of improving patient care. SNOMED CT provides the core general terminology for electronic health records. SNOMED CT comprehensive coverage includes: clinical findings, symptoms, diagnoses, procedures, body structures, organisms and other etiologies, substances, pharmaceuticals, devices and specimens.

Medcin, is a system of standardized medical terminology, a proprietary medical vocabulary and was developed by Medicomp Systems, Inc. MEDCIN is a point-of-care terminology, intended for use in Electronic Health Record (EHR) systems, and it includes over 280,000 clinical data elements encompassing symptoms, history, physical examination, tests, diagnoses and therapy. This clinical vocabulary contains over 38 years of research and development as well as the capability to cross map to leading codification systems such as SNOMED CT, CPT, ICD-9-CM/ICD-10-CM, DSM, LOINC, CDT, CVX, and the Clinical Care Classification (CCC) System for nursing and allied health.

The classification of mental disorders, also known as psychiatric nosology or psychiatric taxonomy, is central to the practice of psychiatry and other mental health professions.

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 management, and are used by local and national governments, private healthcare organizations and international agencies for various purposes, including medical and health services research, epidemiological studies, health resource allocation, case mix management, public health programming, medical billing, and public education.

<span class="mw-page-title-main">ICD-10</span> World Health Organization medical codes

ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. Work on ICD-10 began in 1983, became endorsed by the Forty-third World Health Assembly in 1990, and was first used by member states in 1994. It was replaced by ICD-11 on January 1, 2022.

<span class="mw-page-title-main">Medical diagnosis</span> Process to identify a disease or disorder

Medical diagnosis is the process of determining which disease or condition explains a person's symptoms and signs. It is most often referred to as a diagnosis with the medical context being implicit. The information required for a diagnosis is typically collected from a history and physical examination of the person seeking medical care. Often, one or more diagnostic procedures, such as medical tests, are also done during the process. Sometimes the posthumous diagnosis is considered a kind of medical diagnosis.

Personality disorders (PD) are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual's culture. These patterns develop early, are inflexible, and are associated with significant distress or disability. The definitions vary by source and remain a matter of controversy. Official criteria for diagnosing personality disorders are listed in the sixth chapter of the International Classification of Diseases (ICD) and in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).

<span class="mw-page-title-main">Healthcare Cost and Utilization Project</span>

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The ICD-11 is the eleventh revision of the International Classification of Diseases (ICD). It replaces the ICD-10 as the global standard for recording health information and causes of death. The ICD is developed and annually updated by the World Health Organization (WHO). Development of the ICD-11 started in 2007 and spanned over a decade of work, involving over 300 specialists from 55 countries divided into 30 work groups, with an additional 10,000 proposals from people all over the world. Following an alpha version in May 2011 and a beta draft in May 2012, a stable version of the ICD-11 was released on 18 June 2018, and officially endorsed by all WHO members during the 72nd World Health Assembly on 25 May 2019.

In medicine, Not Otherwise Specified (NOS) is a subcategory in systems of disease/disorder classification such as ICD-9, ICD-10, or DSM-IV. It is generally used to note the presence of an illness where the symptoms presented were sufficient to make a general diagnosis, but where a specific diagnosis was not made. The DSM-IV, for example, "applies the term not otherwise specified (NOS) to a disorder or disturbance that does not meet the criteria for the specific disorders already discussed". The term was introduced because "it is sometimes impossible for the practitioner completing the diagnostic assessment to categorize all the symptoms that a client is experiencing into one diagnostic category". In the context of mental health diagnoses, four situations have been outlined for which such a diagnosis may be considered appropriate:

  1. Client meets the general guidelines for a disorder, yet not all of the criteria are met, or the ones present are not considered clinically significant.
  2. Significant behaviors are noted affecting social and occupational functioning, but are not considered part of the usual presentation for a disorder.
  3. Uncertainty about etiology or the cause of the disorder exists. This is especially important when it is suspected that the disorder may be related to a general medical condition.
  4. Insufficient information exists to fully support assigning behaviors to a particular mental disorder in the category, but the general criteria for the category of disorders are evident.

The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings.

OPS, the Operationen- und Prozedurenschlüssel is the German modification of the International Classification of Procedures in Medicine (ICPM). For German hospitals it is currently the official coding system for medical procedures. Apart from its use for clinical controlling and performance statistics it is a basis for inpatient claims processing within the German Diagnosis-related Groups (G-DRG) system. Yearly OPS releases are produced by DIMDI. Besides OPS, G-DRG also requires disease codes based on ICD-10-GM is.

Bouffée délirante (BD) is an acute and transient psychotic disorder. It is a uniquely French psychiatric diagnostic term with a long history in France and various French speaking nations: Caribbean, e.g., Haiti, Guadeloupe, Antilles and Francophone Africa. The term BD was originally coined and described by Valentin Magnan (1835–1916), fell into relative disuse and was later revived by Henri Ey (1900–1977).

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 sanctioned by the Health Insurance Portability and Accountability Act in the United States.

References

  1. ↑ Hazelwood, A (2005). ICD-9-CM Diagnostic Coding and Reimbursement for Physician Services 2006 Edition (PDF). United States of America: American Health Information Management Association. p. 2. Archived from the original (PDF) on 2013-07-18. Retrieved 2013-05-27.
  2. ↑ Steindel, S (20 May 2010). "International classification of diseases, 10th edition, clinical modification and procedure coding system: descriptive overview of the next generation HIPAA code sets". Journal of the American Medical Informatics Association. 17 (3): 274–282. doi:10.1136/jamia.2009.001230. PMC   2995704 . PMID   20442144.
  3. ↑ First, M (2005). "New Diagnostic Codes for Sleep Disorders". American Psychiatric Association. Retrieved 2008-08-08.
  4. ↑ "Victorian Hospital Admission Policy" (PDF). Department of Health. Retrieved 25 May 2013.[ permanent dead link ]
  5. ↑ Uzkuraitis, C; Hastings, K.; Torney, B. (2010). "Casemix funding optimisation: working together to make the most of every episode". Health Information Management Journal. 39 (3): 47–49. doi:10.1177/183335831003900309. PMID   28683680. S2CID   21319807.
  6. ↑ Lowe, A (2001). "Casemix accounting systems and medical coding Organisational actors balanced on leaky black boxes". Journal of Organizational Change Management. 14 (1): 79–100. doi:10.1108/09534810110367110 . Retrieved 25 May 2013.
  7. ↑ 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". Health Information Management Journal. 38 (1): 35–46. doi:10.1177/183335830903800105. PMID   19293434. S2CID   16646334.
  8. ↑ Standards, Australia. "Paper-based Health Record" (PDF). Standards Australia. Archived from the original (PDF) on March 5, 2016. Retrieved 30 May 2013.
  9. ↑ "OVERVIEW OF ICD-10-AM/ACHI/ACS". University of Wollongong. Archived from the original on 29 April 2013. Retrieved 29 May 2013.
  10. ↑ O'Malley, K; Cook, K.; Price, M.; Wildes, K.; Hurdle, J.; Ashton, C. (2005). "Measuring Diagnoses: ICD Code Accuracy". Health Services Research. 40 (5): 1620–1639. doi:10.1111/j.1475-6773.2005.00444.x. PMC   1361216 . PMID   16178999.
  11. ↑ "Towards Semantic Interoperability in Healthcare" (PDF). Archived from the original (PDF) on 2011-07-18. Retrieved 2010-04-07.
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