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The International Classification of Diseases (ICD) is a globally used diagnostic tool for epidemiology, health management and 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.
Resource-based relative value scale (RBRVS) is a schema used to determine how much money medical providers should be paid. It is partially used by Medicare in the United States and by nearly all health maintenance organizations (HMOs).
A Federally Qualified Health Center (FQHC) is a reimbursement designation from the Bureau of Primary Health Care and the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services. This designation is significant for several health programs funded under the Health Center Consolidation Act.
Medical billing is a payment practice within the United States health system. The process involves a healthcare provider obtaining insurance information from a patient, filing a claim, following up on, and appealing claims with health insurance companies in order to receive payment for services rendered; such as testing, treatments, and procedures. The same process is used for most insurance companies, whether they are private companies or government sponsored programs: Medical coding reports what the diagnosis and treatment were, and prices are applied accordingly. Medical billers are encouraged, but not required by law, to become certified by taking an exam such as the CMRS Exam, RHIA Exam, CPB Exam and others. Certification schools are intended to provide a theoretical grounding for students entering the medical billing field. Some community colleges in the United States offer certificates, or even associate degrees, in the field. Those seeking advancement may be cross-trained in medical coding or transcription or auditing, and may earn a bachelor's or graduate degree in medical information science and technology.
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:
The Current Procedural Terminology (CPT) code set is a medical code set maintained by the American Medical Association through the CPT Editorial Panel. 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 Procedure Coding System (ICD-10-PCS) is an international 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. ICD-9-CM contains a procedure classification; ICD-10-CM does not. ICD-10-PCS is the result. ICD-10-PCS was initially released in 1998. It has been updated annually since that time.
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.
A clinical coder – also known as clinical coding officer, diagnostic coder, or medical coder – is a health information professional whose main duties are to analyse clinical statements and assign standard codes using a classification system. The 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.
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 will be replaced by ICD-11 on January 1, 2022.
Split billing is the division of a bill for service into two or more parts. Bills may be split to divide work between clients, payers or for reimbursement to different service providers for performing a shared service.
A hospital-acquired condition (HAC) is an undesirable situation or condition that affects a patient and that arose during a stay in a hospital or medical facility. It is a designation used by Medicare/Medicaid in the US for determining MS-DRG reimbursement beginning with version 26. Not only hospital-acquired infections but also any other situation or condition, such as pressure ulcers, blood type mismatch, or iatrogenic injury, can be a HAC.
A Medically Unlikely Edit (MUE) is a US Medicare unit of service claim edit applied to Medical claims against a procedure code for medical services rendered by one provider/supplier to one patient on one day. Claim edits compare different values on medical claim to a set of defined criteria to check for irregularities, often in an automated claims processing system. MUE are designed to limit fraud and/or coding errors. They represent an upper limit that unquestionably requires further documentation to support. The ideal MUE is the maximum unit of service for a code on the majority of medical claims. MUE is part of the National Correct Coding Initiative (NCCI) to address coding methodologies. The NCCI policies are based on coding conventions by nationally recognized organizations and are updated annually or quarterly.
The Healthcare Common Procedure Coding System is a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (CPT).
The Expanding Medical and Behavioral Resources with Access to Care for Everyone (EMBRACE) plan is a healthcare system reform proposal introduced by a group called Healthcare Professionals for Healthcare Reform (HPfHR). The plan incorporates elements of private health insurance, single-payer and fee-for-service models in one comprehensive system. It has been referred to as a "Single System" healthcare system. First published in the Annals of Internal Medicine in April 2009, the plan got some early discussion in the healthcare community, but appeared to have come out too late to have had any impact in the development of the Patient Protection and Affordable Care Act (PPACA), the 111th Congress’ landmark health insurance reform legislation. A book outlining the EMBRACE plan in more detail was authored in 2016 by Dr. Gilead Lancaster, a cofounder of HPfHR.
The Specialty Society Relative Value Scale Update Committee or Relative Value Update Committee is a volunteer group of 31 physicians who have made highly influential recommendations on how to value a physician's work when computing health care prices in the United States' public health insurance program Medicare.
A prospective payment system (PPS) is a term used to refer to several payment methodologies for which means of determining insurance reimbursement is based on a predetermined payment regardless of the intensity of the actual service provided.
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.
The ICD-10 Clinical Modification (ICD-10-CM) is a modification of the ICD-10, authorized by the World Health Organization, used as a source for diagnosis codes in the United States of America. It replaces the earlier ICD-9-CM.
References
- ↑ ADA (2010). "Current Dental Terminology (CDT)". product description. American Dental Association. Archived from the original (web) on November 19, 2010. Retrieved October 17, 2010.
- ↑ Nield-Gehrig; Jill S. Nield-Gehrig; Donald E. Willmann (2007). Foundations of Periodontics for the Dental Hygienist. Lippincott Williams & Wilkins. p. 414. ISBN 978-0-7817-8487-0.
- ↑ Green; Michelle A. Green; Jo Ann C. Rowell (10 December 2007). Understanding Health Insurance: A Guide to Billing and Reimbursement. Cengage Learning. p. 263. ISBN 978-1-4180-6706-9.
- ↑ CMS_323 (October 22, 2004). "CMS Manual System - Pub. 100-04 Medicare Claims Processing - Transmittal 323" (PDF). Update Regarding the Use of American Dental Association’s (ADA) Current Dental Terminology (CDT) Codes on Medicare Contractors’ Web Sites and Other Electronic Media. Centers for Medicare & Medicaid Services . Retrieved February 18, 2010.
- ↑ "D-CODES" (web). Glossary. Centers for Medicare & Medicaid Services. 2006. Retrieved February 18, 2010.
- ↑ American Dental Association. "Purchase the CDT Manual" (Web). American Dental Association. Retrieved December 25, 2011.
- ↑ Davis, James (2013). CDT PLUS! 2014. Practice Management Information Corporation. p. 185. ISBN 978-1-939852-39-7. Archived from the original on 2013-06-17. Retrieved 2013-08-22.
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