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Electronic Medical Record
Electronic Medical Record
Electronic Medical Record

 

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The International Classification of Diseases (ICD) is the standard diagnostic tool for epidemiology, health management and clinical purposes. ICD is used worldwide by physicians, nurses, other providers, researchers, health information technology workers and coders, to classify diseases and other health problems recorded on many types of health and vital records.

The current method of diagnosis coding, International Classification of Diseases 9th Edition, Clinical Modification/Procedure Coding System (ICD-9), has been used in the United States since approximately 1978. However, it contains outdated terminology and does not allow for updates in healthcare that have occurred in the 21st century. Due to these limitations, it has been mandated that all healthcare providers in the United States comply with the International Classification of Diseases 10th Edition, Clinical Modification/Procedure Coding System (ICD-10 CM/PCS) at least one year to October 1, 2015. ICD-10 will fully replace ICD-9 as of this date.

There are advantages to the use of ICD-10, which include:

 

  • Increased specificity of diagnosis and procedures

  • Enhanced ability to conduct public health tracking and surveillance

  • Improved ability to measure health care services

  • Increased accuracy in claims processing

  • Decreased need to include supporting documentation with claims

  • Updated medical terminology and classification of diseases

  • Enhance accurate payment for services rendered

  • Facilitate evaluation of medical processes and outcomes

 

The new classification system provides significant improvements through greater detailed information and expansion capabilities in order to capture additional advancements in clinical medicine. It can describe diagnoses and inpatient procedures delivered in the 21st century accurately.  ICD-10-CM/PCS consists of two parts:

 

ICD-10-CM

 

ICD-10 CM better reflects current medical practice and captures more detailed and specific data from clinical documentation. The diagnosis classification system was developed by the Centers for Disease Control and Prevention for use in all U.S. health care treatment settings. Diagnosis coding under this system uses 3 to 7 alpha and numeric digits and full code titles. In the case of fracture, for example, the new coding captures left vs. right side of body, initial vs. subsequent encounter, routine vs. delayed healing, and nonunion vs. malunion.

 

ICD-10-PCS

 

The procedure classification system has been developed by the Centers for Medicare & Medicaid Services (CMS) for the exclusive use in U.S. inpatient hospital settings. The new procedure coding system uses 7 alpha or numeric digits while the ICD-9-CM coding system uses 3 or 4 numeric digits. ICD-10-PCS provides detailed information on procedures and distinct codes for all types of devices.