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Services include therapeutic group homes, super- vised apartment living, monitoring the person’s compliance with prescribed mental and medical treatment plans, and job placement. Intake Screening An interview conducted by health service providers when a patient is admitted to a hospital or treatment program. International Classification of Diseases (ICD-10):
The World Health Organization lists international standards used to diagnose and classify diseases. The listing is used by the healthcare system so clinicians can assign an ICD code to submit claims to insurers for reimbursement for services for treating various medical and mental health conditions in patients. The code is periodically updated to reflect changes in classifications of disease or to add new disorders. | 2 | 6 |
Intake Screening An interview conducted by health service providers when a patient is admitted to a hospital or treatment program. International Classification of Diseases (ICD-10):
The World Health Organization lists international standards used to diagnose and classify diseases. The listing is used by the healthcare system so clinicians can assign an ICD code to submit claims to insurers for reimbursement for services for treating various medical and mental health conditions in patients. The code is periodically updated to reflect changes in classifications of disease or to add new disorders. Interpersonal Therapy (IPT):
Also called interpersonal psychotherapy, IPT is designed to help people identify and address their interpersonal problems, specifically those involving grief, interpersonal role conflicts, role transitions, and interpersonal deficits. | 2 | 7 |
Distribution of Injuries
It is important to catalog injuries by severity and nature. There are several systems available for cataloguing injuries by nature and severity. ICD-10 codes are important in cataloguing the various injuries and their nature. Death certificate data is the best way to identify injury-related deaths. There can be variations in the way that these injuries are presented. | 2 | 38 |
|Classification and external resources|
|ICD-9||307.42, 307.41, 327.0, 780.51, 780.52|
Insomnia, or sleeplessness, is a sleep disorder in which there is an inability to fall asleep or to stay asleep as long as desired. While the term is sometimes used to describe a disorder demonstrated by polysomnographic or actigraphic evidence of disturbed sleep, this sleep disorder is often practically defined as a positive response to either of two questions: "Do you experience difficulty sleeping?" or "Do you have difficulty falling or staying asleep?" | 2 | 92 |
- American Family Physician: Chronic Insomnia: A Practical Review. Aafp.org (1999-10-01). Retrieved on 2011-11-20. - Athens Insomnia Scale: validation of an instrument based on ICD-10 criteria
- Passarella, S, Duong, M. "Diagnosis and treatment of insomnia." 2008. | 2 | 199 |
Shapes include fusiform and saccular. Fusiform is when the aneurysm is enlarged equally in all directions; saccular is when the bulge or sac occurs on only one side of the aorta. Possible locations of an aortic aneurysm are as follows:
• Ascending (441.2); if ruptured, use 441.1;
• Arch (441.2); if ruptured, use 441.1;
• Descending, not otherwise specified (NOS) (441.9); if ruptured, use 441.5;
• Thoracic descending (441.2); if ruptured, use 441.1;
• Abdominal descending (441.4); if ruptured, use 441.3;
• Thoracoabdominal (441.7); if ruptured, use 441.6;
• Abdominal (441.4); if ruptured, use 441.3. An abdominal aortic aneurysm is the most common type. If an aortic aneurysm is documented but not specified as to site, assign code 441.9. | 4 | 327 |
Possible locations of an aortic aneurysm are as follows:
• Ascending (441.2); if ruptured, use 441.1;
• Arch (441.2); if ruptured, use 441.1;
• Descending, not otherwise specified (NOS) (441.9); if ruptured, use 441.5;
• Thoracic descending (441.2); if ruptured, use 441.1;
• Abdominal descending (441.4); if ruptured, use 441.3;
• Thoracoabdominal (441.7); if ruptured, use 441.6;
• Abdominal (441.4); if ruptured, use 441.3. An abdominal aortic aneurysm is the most common type. If an aortic aneurysm is documented but not specified as to site, assign code 441.9. A ruptured aortic aneurysm, NOS is classified to code 441.5. A pseudoaneurysm (false aneurysm) is an aneurysm that does not have some or all of the aortic wall layers. | 3 | 328 |
An abdominal aortic aneurysm is the most common type. If an aortic aneurysm is documented but not specified as to site, assign code 441.9. A ruptured aortic aneurysm, NOS is classified to code 441.5. A pseudoaneurysm (false aneurysm) is an aneurysm that does not have some or all of the aortic wall layers. Often due to an injury of inner aortic wall and an infection, a pseudoaneurysm is unpredictable and may rupture at smaller sizes. | 3 | 329 |
This life-threatening condition usually occurs in the ascending or descending part of the thoracic aorta but may also occur in the abdominal aorta. The physician may document this condition as dissecting aneurysm. Dissecting aortic aneurysm or aortic dissection is classified to ICD-9-CM code 441.0x. The following fifth-digit subclassifications identify the site of the dissection:
• 441.00, Unspecified site;
• 441.01, Thoracic;
• 441.02, Abdominal; and
• 441.03, Thoracoabdominal. Aortic dissections may be classified as type A or B. | 3 | 330 |
The physician may document this condition as dissecting aneurysm. Dissecting aortic aneurysm or aortic dissection is classified to ICD-9-CM code 441.0x. The following fifth-digit subclassifications identify the site of the dissection:
• 441.00, Unspecified site;
• 441.01, Thoracic;
• 441.02, Abdominal; and
• 441.03, Thoracoabdominal. Aortic dissections may be classified as type A or B. Type A is defined as involving the ascending aorta and usually requires surgical treatment. | 3 | 331 |
Type B does not involve the ascending aorta and may be managed medically. The type of aortic dissection does not affect code assignment. The code assignment is only based on the site of the dissecting aneurysm (AHA Coding Clinic for ICD-9-CM, 1989, fourth quarter, page 10). Diagnosis and Treatment
Aortic diseases are diagnosed using echocardiogram, transthoracic echocardiogram, transesophageal cardiogram, a CT scan, or MRI. The treatment for aortic aneurysm and dissection depends on the location, size, and type. | 3 | 332 |
An endovascular repair may also treat aneurysms. Coding and sequencing for aortic conditions are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding. — This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 5,000 healthcare providers. | 2 | 333 |
Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding. — This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447. | 2 | 334 |
3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447. ICD-10-CM Coding for Aortic Aneurysm and Dissection
The index and tabular list for aortic aneurysm and dissection is very similar in ICD-10-CM as in ICD-9-CM. The ICD-10-CM code assignments are as follows:
• I71.00, Dissection of unspecified site of aorta;
• I71.01, Dissection of thoracic aorta;
• I71.02, Dissection of abdominal aorta;
• I71.03, Dissection of thoracoabdominal aorta;
• I71.1, Thoracic aortic aneurysm, ruptured;
• I71.2, Thoracic aortic aneurysm, without rupture;
• I71.3, Abdominal aortic aneurysm, ruptured;
• I71.4, Abdominal aortic aneurysm, without rupture;
• I71.5, Thoracoabdominal aortic aneurysm, ruptured;
• I71.6, Thoracoabdominal aortic aneurysm, without rupture;
• I71.8, Aortic aneurysm of unspecified site, ruptured; and
• I71.9, Aortic aneurysm of unspecified site, without rupture. | 3 | 335 |
The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447. ICD-10-CM Coding for Aortic Aneurysm and Dissection
The index and tabular list for aortic aneurysm and dissection is very similar in ICD-10-CM as in ICD-9-CM. The ICD-10-CM code assignments are as follows:
• I71.00, Dissection of unspecified site of aorta;
• I71.01, Dissection of thoracic aorta;
• I71.02, Dissection of abdominal aorta;
• I71.03, Dissection of thoracoabdominal aorta;
• I71.1, Thoracic aortic aneurysm, ruptured;
• I71.2, Thoracic aortic aneurysm, without rupture;
• I71.3, Abdominal aortic aneurysm, ruptured;
• I71.4, Abdominal aortic aneurysm, without rupture;
• I71.5, Thoracoabdominal aortic aneurysm, ruptured;
• I71.6, Thoracoabdominal aortic aneurysm, without rupture;
• I71.8, Aortic aneurysm of unspecified site, ruptured; and
• I71.9, Aortic aneurysm of unspecified site, without rupture. The only difference is that “dissecting” is no longer a subterm under aneurysm in the ICD-10-CM index. | 3 | 336 |
More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447. ICD-10-CM Coding for Aortic Aneurysm and Dissection
The index and tabular list for aortic aneurysm and dissection is very similar in ICD-10-CM as in ICD-9-CM. The ICD-10-CM code assignments are as follows:
• I71.00, Dissection of unspecified site of aorta;
• I71.01, Dissection of thoracic aorta;
• I71.02, Dissection of abdominal aorta;
• I71.03, Dissection of thoracoabdominal aorta;
• I71.1, Thoracic aortic aneurysm, ruptured;
• I71.2, Thoracic aortic aneurysm, without rupture;
• I71.3, Abdominal aortic aneurysm, ruptured;
• I71.4, Abdominal aortic aneurysm, without rupture;
• I71.5, Thoracoabdominal aortic aneurysm, ruptured;
• I71.6, Thoracoabdominal aortic aneurysm, without rupture;
• I71.8, Aortic aneurysm of unspecified site, ruptured; and
• I71.9, Aortic aneurysm of unspecified site, without rupture. The only difference is that “dissecting” is no longer a subterm under aneurysm in the ICD-10-CM index. Therefore, it would stand to reason that if a patient experienced a dissecting aortic aneurysm, two codes should be assigned to identify the entire diagnosis: one for the dissection and one for the aneurysm. | 3 | 337 |
ICD-10-CM Coding for Aortic Aneurysm and Dissection
The index and tabular list for aortic aneurysm and dissection is very similar in ICD-10-CM as in ICD-9-CM. The ICD-10-CM code assignments are as follows:
• I71.00, Dissection of unspecified site of aorta;
• I71.01, Dissection of thoracic aorta;
• I71.02, Dissection of abdominal aorta;
• I71.03, Dissection of thoracoabdominal aorta;
• I71.1, Thoracic aortic aneurysm, ruptured;
• I71.2, Thoracic aortic aneurysm, without rupture;
• I71.3, Abdominal aortic aneurysm, ruptured;
• I71.4, Abdominal aortic aneurysm, without rupture;
• I71.5, Thoracoabdominal aortic aneurysm, ruptured;
• I71.6, Thoracoabdominal aortic aneurysm, without rupture;
• I71.8, Aortic aneurysm of unspecified site, ruptured; and
• I71.9, Aortic aneurysm of unspecified site, without rupture. The only difference is that “dissecting” is no longer a subterm under aneurysm in the ICD-10-CM index. Therefore, it would stand to reason that if a patient experienced a dissecting aortic aneurysm, two codes should be assigned to identify the entire diagnosis: one for the dissection and one for the aneurysm. — Audrey Howard | 3 | 338 |
Both professionals are involved in the reimbursement cycle that assures the fact that health care providers are paid according to their services. It is crucial to review the primary and responsibilities these professions carry out in the healthcare industry. The work of medical coding requires reviewing clinical statements and issues standard codes such as CPT, ICD-10-CM MAD HCPCS LEVEL II. It is an essential part of medical coding to translate medical reports in form code that can be utilized within the premises of healthcare. In simple words, medical code summarizes reports and medical services. | 2 | 339 |
New penalties were also applied – as dictated by HITECH – to covered outfits that fell afoul of the HIPAA Enforcement Rule. Amendments were also included to take in to account changing work practices brought about by technological advances, covering the use of mobile devices in particular. A major number of healthcare professionals are now using their own mobile devices to view and share ePHI, and the Final Omnibus Rule included new administrative procedures and policies to account for this, and to include scenarios which could not have been predicted in 1996. The complete text of the Final Omnibus Rule can be found here. After a number of delays, the deadline for the United States to use Clinical Modification ICD-10-CM for diagnosis coding and Procedure Coding System ICD-10-PCA for inpatient hospital procedure coding was finally established as October 1, 2015. | 2 | 353 |
A major number of healthcare professionals are now using their own mobile devices to view and share ePHI, and the Final Omnibus Rule included new administrative procedures and policies to account for this, and to include scenarios which could not have been predicted in 1996. The complete text of the Final Omnibus Rule can be found here. After a number of delays, the deadline for the United States to use Clinical Modification ICD-10-CM for diagnosis coding and Procedure Coding System ICD-10-PCA for inpatient hospital procedure coding was finally established as October 1, 2015. All HIPAA covered outfits must use ICD-10-CM. Another requirement is these of EDI Version 5010. | 2 | 354 |
The complete text of the Final Omnibus Rule can be found here. After a number of delays, the deadline for the United States to use Clinical Modification ICD-10-CM for diagnosis coding and Procedure Coding System ICD-10-PCA for inpatient hospital procedure coding was finally established as October 1, 2015. All HIPAA covered outfits must use ICD-10-CM. Another requirement is these of EDI Version 5010. HIPAA History Significant Dates
- August 1996 – HIPAA Enacted by President Bill Clinton. | 2 | 355 |
All HIPAA covered outfits must use ICD-10-CM. Another requirement is these of EDI Version 5010. HIPAA History Significant Dates
- August 1996 – HIPAA Enacted by President Bill Clinton. - April 2003 – Effective Date of the HIPAA Privacy Rule. - April 2005 – Effective Date of the HIPAA Security Rule. | 2 | 356 |
[Ejection Fraction] What is an ejection fraction? Can I code an ejection fraction of 0% as with occlusion? A: Now, ejection fraction just happens to be part of a cardiology aspect as well. You have ejection fractions for your gallbladder but you also have ejection fraction as most commonly known for cardiology. | 3 | 362 |
You need to go look it up). Maybe a former MI (meaning they’d had a heart attack). Just a little tidbit in ICD-9, it was like six week’s out, I think, they will be considered an old MI. In ICD-10, it’s only four weeks; so there’s a big change there. It might be a heart valve disease. | 2 | 368 |
Maybe a former MI (meaning they’d had a heart attack). Just a little tidbit in ICD-9, it was like six week’s out, I think, they will be considered an old MI. In ICD-10, it’s only four weeks; so there’s a big change there. It might be a heart valve disease. As that goes through, the valve isn’t working properly, so that ejection of blood up into the atrium may not be a good amount that it should be. | 2 | 369 |
Chronic tic disorder was either single or multiple, motor or phonic tics (but not both), which were present for more than a year. Tourette's is diagnosed when multiple motor tics, and at least one phonic tic, are present for more than a year. The fifth version of the DSM (DSM-5), published in May 2013, reclassified Tourette's and tic disorders as motor disorders listed in the neurodevelopmental disorder category, and replaced transient tic disorder with provisional tic disorder, but made few other significant changes. Tic disorders are defined only slightly differently by the World Health Organization International Statistical Classification of Diseases and Related Health Problems, ICD-10; code F95.2 is for combined vocal and multiple motor tic disorder [de la Tourette]. Although Tourette's is the more severe expression of the spectrum of tic disorders, most cases are mild. | 2 | 377 |
Tourette's is diagnosed when multiple motor tics, and at least one phonic tic, are present for more than a year. The fifth version of the DSM (DSM-5), published in May 2013, reclassified Tourette's and tic disorders as motor disorders listed in the neurodevelopmental disorder category, and replaced transient tic disorder with provisional tic disorder, but made few other significant changes. Tic disorders are defined only slightly differently by the World Health Organization International Statistical Classification of Diseases and Related Health Problems, ICD-10; code F95.2 is for combined vocal and multiple motor tic disorder [de la Tourette]. Although Tourette's is the more severe expression of the spectrum of tic disorders, most cases are mild. The severity of symptoms varies widely among people with Tourette's, and mild cases may be undetected. | 2 | 378 |
doi:10.1016/S1875-9572(10)60050-2 PMID 20951354
- Leckman JF, Bloch MH, King RA, Scahill L. "Phenomenology of tics and natural history of tic disorders". Adv Neurol. 2006;99:1–16. PMID 16536348
- "Tourette's Disorder, 307.23 (F95.2)". Diagnostic and Statistical Manual of Mental Disorders, 2013, Fifth edition. | 2 | 421 |
Adv Neurol. 2006;99:1–16. PMID 16536348
- "Tourette's Disorder, 307.23 (F95.2)". Diagnostic and Statistical Manual of Mental Disorders, 2013, Fifth edition. American Psychiatric Association, p. 81. | 2 | 422 |
2006;99:1–16. PMID 16536348
- "Tourette's Disorder, 307.23 (F95.2)". Diagnostic and Statistical Manual of Mental Disorders, 2013, Fifth edition. American Psychiatric Association, p. 81. - Neurodevelopmental disorders. | 2 | 423 |
PMID 16536348
- "Tourette's Disorder, 307.23 (F95.2)". Diagnostic and Statistical Manual of Mental Disorders, 2013, Fifth edition. American Psychiatric Association, p. 81. - Neurodevelopmental disorders. American Psychiatric Association. | 2 | 424 |
Coding for Burns
Approximately every minute, someone in the United States sustains a burn injury serious enough to require treatment. According to the American Burn Association, an estimated 486,000 hospital admissions and visits to hospital emergency departments occur annually for burn evaluation and treatment in the United States. The likelihood for a medical coder to have to code a burn case is extremely high. Here’s what you need to know. | 2 | 595 |
A burn is tissue damage with partial or complete destruction of the skin caused by heat, chemicals, electricity, sunlight, or nuclear radiation. Proper selection of burn codes requires consideration of the location of the burn, severity, extent, and external cause in addition to laterality and encounter. ICD-10 makes a distinction between burns and corrosions:
- Burn codes apply to thermal burns (except sunburns) that come from a heat source, such as fire, hot appliance, electricity, and radiation. - Corrosions are burns due to chemicals. Burn severity is classified based on the depth of the burn. | 2 | 596 |
- Corrosions are burns due to chemicals. Burn severity is classified based on the depth of the burn. There are six degrees of burns:
- First-degree burns damage the outer layer (epidermis) of the skin; erythema
- Second-degree burns indicate blistering with damage extending beyond the epidermis partially into the layer beneath it (dermis)
- Third-degree burns indicate full-thickness tissue loss with damage or complete destruction of both layers of skin (including hair follicles, oil glands, & sweat glands)
ICD-10 Coding Using the “Rules of Nines”
You need at least three codes to properly report burn diagnoses:
First-listed code(s): S/S for site and severity (categories T20-T25)
- Your first-listed code will be a combination code that reports both the site and severity of the injury. The descriptions of codes in the T20-T28 range are first defined by an anatomical location of the body affected by burn or corrosion. - The fourth character for each category identifies the severity (except categories T26-T28). | 3 | 597 |
- The fifth character reports additional details regarding the anatomical site of the burn. - The sixth character represents laterality. Next listed code: E for extent (categories T31/32)
- Burns and corrosions are classified according to the extent, or percentage, of the total body surface area involved (TBSA). - Code T31 to report a burn and T32 to report corrosion, based on the classic “rule of nines.”
- The rule of nines, for adult patients, assigns 1% of TBSA to the genitalia, and multiples of 9% to other body areas (9% head, 9% per arm, 18% per leg, etc.). - A modified rule of nines is applied for infants, to account for their relatively larger head (18%) and smaller legs (14%, each). | 3 | 598 |
- The sixth character represents laterality. Next listed code: E for extent (categories T31/32)
- Burns and corrosions are classified according to the extent, or percentage, of the total body surface area involved (TBSA). - Code T31 to report a burn and T32 to report corrosion, based on the classic “rule of nines.”
- The rule of nines, for adult patients, assigns 1% of TBSA to the genitalia, and multiples of 9% to other body areas (9% head, 9% per arm, 18% per leg, etc.). - A modified rule of nines is applied for infants, to account for their relatively larger head (18%) and smaller legs (14%, each). - The required fourth character identifies the percentage of the patient’s entire body affected by burns. | 3 | 599 |
Next listed code: E for extent (categories T31/32)
- Burns and corrosions are classified according to the extent, or percentage, of the total body surface area involved (TBSA). - Code T31 to report a burn and T32 to report corrosion, based on the classic “rule of nines.”
- The rule of nines, for adult patients, assigns 1% of TBSA to the genitalia, and multiples of 9% to other body areas (9% head, 9% per arm, 18% per leg, etc.). - A modified rule of nines is applied for infants, to account for their relatively larger head (18%) and smaller legs (14%, each). - The required fourth character identifies the percentage of the patient’s entire body affected by burns. The fifth character identifies the percentage of the patient’s body that is suffering from third-degree burns or corrosions only. | 3 | 600 |
Lastly, code(s): E for external cause code(s)
- External Cause – To identify the source, place, and intent of the burn. - Agent – To identify the chemical substance of the corrosion. ICD-10-CM guidelines recommend reporting appropriate external cause codes for burn patients. Not all payers accept these codes, however. CPT Coding Using the Lund-Browder Classification
CPT codes to report local treatment of burns and many skin grafting procedure codes, specify the surface area (TBSA) treated. | 3 | 601 |
ICD-10-CM guidelines recommend reporting appropriate external cause codes for burn patients. Not all payers accept these codes, however. CPT Coding Using the Lund-Browder Classification
CPT codes to report local treatment of burns and many skin grafting procedure codes, specify the surface area (TBSA) treated. CPT® utilizes the more precise Lund-Browder classification method to calculate TBSA for burns and grafts. Lund-Browder divides the body into 19 distinct areas and specifies six different age groups to account for the changes in body composition during development into adulthood. | 3 | 602 |
Not all payers accept these codes, however. CPT Coding Using the Lund-Browder Classification
CPT codes to report local treatment of burns and many skin grafting procedure codes, specify the surface area (TBSA) treated. CPT® utilizes the more precise Lund-Browder classification method to calculate TBSA for burns and grafts. Lund-Browder divides the body into 19 distinct areas and specifies six different age groups to account for the changes in body composition during development into adulthood. The CPT® code book contains a Lund-Browder classification method chart for easy TBSA calculation by body area and patient age. | 3 | 603 |
CPT Coding Using the Lund-Browder Classification
CPT codes to report local treatment of burns and many skin grafting procedure codes, specify the surface area (TBSA) treated. CPT® utilizes the more precise Lund-Browder classification method to calculate TBSA for burns and grafts. Lund-Browder divides the body into 19 distinct areas and specifies six different age groups to account for the changes in body composition during development into adulthood. The CPT® code book contains a Lund-Browder classification method chart for easy TBSA calculation by body area and patient age. | 3 | 604 |
CPT® utilizes the more precise Lund-Browder classification method to calculate TBSA for burns and grafts. Lund-Browder divides the body into 19 distinct areas and specifies six different age groups to account for the changes in body composition during development into adulthood. The CPT® code book contains a Lund-Browder classification method chart for easy TBSA calculation by body area and patient age. | 2 | 605 |
Cysticercosis Classification and external resources
Magnetic resonance image of a patient with neurocysticercosis demonstrating multiple cysticerci within the brain. ICD-10 B69 ICD-9 123.1 DiseasesDB 3341 MedlinePlus 000627 eMedicine emerg/119 med/494 ped/537 MeSH D003551
Cysticercosis refers to tissue infection after exposure to eggs of Taenia solium, the pork tapeworm. The disease is spread via the fecal-oral route through contaminated food and water, and is primarily a food borne disease. After ingestion the eggs pass through the lumen of the intestine into the tissues and migrate preferentially to the brain and muscles. | 3 | 606 |
Dysplastic nevus Classification and external resources ICD-10 D48.5 (ILDS D48.540) ICD-9 238.2 ICD-O: M8727/0 OMIM 155600 MeSH D004416
A dysplastic nevus (also known as a: Atypical mole, Atypical nevus, B-K mole, Clark's nevus, Dysplastic melanocytic nevus, Nevus with architectural disorder) is an atypical melanocytic nevus; a mole whose appearance is different from that of common moles. Dysplastic nevi are generally larger than ordinary moles and have irregular and indistinct borders. Their color frequently is not uniform and ranges from pink to dark brown; they usually are flat, but parts may be raised above the skin surface. | 3 | 688 |
In 40-50% of cases, the disorder has been linked with germline mutations in the CDKN2A gene, which codes for p16 (a regulator of cell division). - ^ Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. pp. | 2 | 696 |
J Natl Cancer Inst. 83 (23): 1726–33. doi:10.1093/jnci/83.23.1726. PMID 1770551. http://jnci.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=1770551. Gonadal tumors, paraganglioma, and glomus (ICD-O 8590-8719) Gonadal/
sex cord-gonadal stromal (8590-8679)
Glomus tumors (8680-8719)
tumr, epon, para
Tumors: Skin neoplasm, Nevi and melanomas (C43/D22, 172/216, ICD-O 8720-8799) MelanomaMucosal melanoma · Superficial spreading melanoma · Nodular melanoma · lentigo (Lentigo maligna/Lentigo maligna melanoma, Acral lentiginous melanoma)Amelanotic melanoma · Desmoplastic melanoma · Melanoma with features of a Spitz nevus · Melanoma with small nevus-like cells · Polypoid melanoma · Soft-tissue melanoma Nevus/
Balloon cell nevus · Dysplastic nevus/Dysplastic nevus syndrome
Wikimedia Foundation. | 2 | 710 |
doi:10.1093/jnci/83.23.1726. PMID 1770551. http://jnci.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=1770551. Gonadal tumors, paraganglioma, and glomus (ICD-O 8590-8719) Gonadal/
sex cord-gonadal stromal (8590-8679)
Glomus tumors (8680-8719)
tumr, epon, para
Tumors: Skin neoplasm, Nevi and melanomas (C43/D22, 172/216, ICD-O 8720-8799) MelanomaMucosal melanoma · Superficial spreading melanoma · Nodular melanoma · lentigo (Lentigo maligna/Lentigo maligna melanoma, Acral lentiginous melanoma)Amelanotic melanoma · Desmoplastic melanoma · Melanoma with features of a Spitz nevus · Melanoma with small nevus-like cells · Polypoid melanoma · Soft-tissue melanoma Nevus/
Balloon cell nevus · Dysplastic nevus/Dysplastic nevus syndrome
Wikimedia Foundation. 2010. Look at other dictionaries:
dysplastic nevus — dysplastic melanocytic nevus a type of acquired, atypical melanocytic nevus with an irregular border, indistinct margin, and mixed coloring, characterized by dysplastic melanocytes in the epidermis. | 2 | 711 |
PMID 1770551. http://jnci.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=1770551. Gonadal tumors, paraganglioma, and glomus (ICD-O 8590-8719) Gonadal/
sex cord-gonadal stromal (8590-8679)
Glomus tumors (8680-8719)
tumr, epon, para
Tumors: Skin neoplasm, Nevi and melanomas (C43/D22, 172/216, ICD-O 8720-8799) MelanomaMucosal melanoma · Superficial spreading melanoma · Nodular melanoma · lentigo (Lentigo maligna/Lentigo maligna melanoma, Acral lentiginous melanoma)Amelanotic melanoma · Desmoplastic melanoma · Melanoma with features of a Spitz nevus · Melanoma with small nevus-like cells · Polypoid melanoma · Soft-tissue melanoma Nevus/
Balloon cell nevus · Dysplastic nevus/Dysplastic nevus syndrome
Wikimedia Foundation. 2010. Look at other dictionaries:
dysplastic nevus — dysplastic melanocytic nevus a type of acquired, atypical melanocytic nevus with an irregular border, indistinct margin, and mixed coloring, characterized by dysplastic melanocytes in the epidermis. Particularly in patients with other family who… … Medical dictionary
dysplastic nevus — An atypical mole; a mole whose appearance is different from that of a common mole. | 2 | 712 |
Nevus… … Wikipedia
nevus with architectural disorder — new name proposed for dysplastic nevus … Medical dictionary
Nevus — A pigmented spot on the skin, such as a mole. The plural of nevus is nevi. * * * 1. A circumscribed malformation of the skin, especially if colored by hyperpigmentation or increased vascularity; a n. may be predominantly epidermal, adnexal,… … Medical dictionary
Melanocytic nevus — Classification and external resources Mole, more specifically an intradermal nevus ICD 10 D22 … Wikipedia
Congenital melanocytic nevus — Classification and external resources Congenital nevus ICD 10 D22 (ILDS D22.L60) The congenital melanocytic nevus is a type of … Wikipedia
Blue nevus — Classification and external resources Micrograph of a blue nevus showing the characteristic pigmented melanocytes between bundles of collagen. H E stain … Wikipedia | 3 | 714 |
The plural of nevus is nevi. * * * 1. A circumscribed malformation of the skin, especially if colored by hyperpigmentation or increased vascularity; a n. may be predominantly epidermal, adnexal,… … Medical dictionary
Melanocytic nevus — Classification and external resources Mole, more specifically an intradermal nevus ICD 10 D22 … Wikipedia
Congenital melanocytic nevus — Classification and external resources Congenital nevus ICD 10 D22 (ILDS D22.L60) The congenital melanocytic nevus is a type of … Wikipedia
Blue nevus — Classification and external resources Micrograph of a blue nevus showing the characteristic pigmented melanocytes between bundles of collagen. H E stain … Wikipedia | 3 | 715 |
Types and Diagnosis of Cardiosclerosis
ICD-10( International Classification of Tenth Revision) includes all types of cardiosclerosis in the class of diseases of the heart and blood vessels( I20.0-I20.9).The terms used in Russia are adapted to ICD-10, but sometimes they do not coincide with it. By the amount of damage to the heart muscle, 2 types are distinguished:
- focal cardiosclerosis - connective tissue appears in small patches, does not germinate the muscle through, is characteristic of acute myocarditis in children or adults, may not show any symptoms at all, is revealed during preventive examination;
- diffuse - the replacement of muscle tissue with scar tissue occurs intensively, captures large surfaces and the entire depth of the muscle. It often occurs against the background of coronary heart disease. | 3 | 716 |
Types and Diagnosis of Cardiosclerosis
ICD-10( International Classification of Tenth Revision) includes all types of cardiosclerosis in the class of diseases of the heart and blood vessels( I20.0-I20.9).The terms used in Russia are adapted to ICD-10, but sometimes they do not coincide with it. By the amount of damage to the heart muscle, 2 types are distinguished:
- focal cardiosclerosis - connective tissue appears in small patches, does not germinate the muscle through, is characteristic of acute myocarditis in children or adults, may not show any symptoms at all, is revealed during preventive examination;
- diffuse - the replacement of muscle tissue with scar tissue occurs intensively, captures large surfaces and the entire depth of the muscle. It often occurs against the background of coronary heart disease. Progression of the disease complicates the patient's condition. | 3 | 717 |
Treats mild-to-moderate microbial infections. [emedicine.medscape.com]
A case of neonatal sepsis and meningitis resulting from horizontal transmission of P. multocida is described. [ncbi.nlm.nih.gov]
[…] multocida A28.0 ICD-10-CM Codes Adjacent To A28.0 A26.7 Erysipelothrix sepsis A26.8 Other forms of erysipeloid A26.9 Erysipeloid, unspecified A27 Leptospirosis A27.0 Leptospirosis icterohemorrhagica A27.8 Other forms of leptospirosis A27.81 Aseptic meningitis [icd10data.com]
The diagnosis of P. multocida infection should be made early on, as this bacterial pathogen is highly susceptible to antimicrobial therapy, but also because more severe forms may be life-threatening . One of the most important parts of the workup is a thoroughly obtained patient history that will confirm recent or previous close animal contact . Additionally, physicians must inquire about the presence of underlying diseases and comorbidities that could serve as risk factors for respiratory and systemic infections by P. multocida, whereas a complete physical examination is also important in identifying the site of infection. | 3 | 731 |
anxiety, or depression
The International Statistical Classification of Diseases and Related Health Problems (ICD-10) and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders have set out criteria for PCS and postconcussional disorder (PCD), respectively. The ICD-10 established a set of diagnostic criteria for PCS in 1992. In order to meet these criteria, a patient has had a head injury "usually sufficiently severe to result in loss of consciousness" and then develop at least three of the eight symptoms marked with a check mark in the table at right under "ICD-10" within four weeks. About 38% of people who suffer a head injury with symptoms of concussion and no radiological evidence of brain lesions meet these criteria. In addition to these symptoms, people that meet the ICD-10 criteria for PCS may fear that they will have permanent brain damage, which may worsen the original symptoms. | 2 | 802 |
"Diagnostic criteria for postconcussional syndrome after mild to moderate traumatic brain injury". Journal of Neuropsychiatry and Clinical Neurosciences 17 (3): 350–6. doi:10.1176/appi.neuropsych.17.3.350. PMID 16179657. - ICD-10, International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) Version for 2010, F07.2 Postconcussional syndrome, World Health Organization. | 2 | 887 |
doi:10.1176/appi.neuropsych.17.3.350. PMID 16179657. - ICD-10, International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) Version for 2010, F07.2 Postconcussional syndrome, World Health Organization. - Sivák S, Kurca E, Jancovic D, Petriscák S, Kucera P (2005). "[Contemporary view on mild brain injuries in adult population]" (PDF). | 2 | 888 |
Deaths from 1980 to 1998 were classified according to the International Statistical Classification of Diseases Ninth Edition (ICD-9), while deaths from 1999 were classified according to the Tenth Edition (ICD-10). The drug-induced deaths from these different classifications have been matched to facilitate comparisons over time. In this article, drug-induced deaths include the following categories from the ICD-10:
accidental drug-induced deaths, which include two components: accidental poisoning by drugs (X40-X44) and mental and behavioral disorders due to drug use (F11-F16, F19 & F55)
drug deaths where the intent of the poisoning was undetermined (Y10-Y14). This page last updated 17 September 2008 | 3 | 983 |
The drug-induced deaths from these different classifications have been matched to facilitate comparisons over time. In this article, drug-induced deaths include the following categories from the ICD-10:
accidental drug-induced deaths, which include two components: accidental poisoning by drugs (X40-X44) and mental and behavioral disorders due to drug use (F11-F16, F19 & F55)
drug deaths where the intent of the poisoning was undetermined (Y10-Y14). This page last updated 17 September 2008 | 3 | 984 |
Methods | Statistics | Clinical | Educational | Industrial | Professional items | World psychology |
|ICD-10||A83-A86, B941, G05|
Encephalitis is a brain disorder due to an acute inflammation of the brain. It can be caused by a bacterial infection such as bacterial meningitis spreading directly to the brain (primary encephalitis), or may be a complication of a current infectious disease like rabies or syphilis (secondary encephalitis). Certain parasitic or protozoal infestations, such as toxoplasmosis, malaria, or primary amoebic meningoencephalitis, can also cause encephalitis in people with compromised immune systems. | 2 | 985 |
|ICD-10||J00, J30, J31.0|
|eMedicine||ent/194 med/104, ped/2560|
Rhinitis // or coryza is irritation and inflammation of the mucous membrane inside the nose. Common symptoms of rhinitis are a stuffy nose, runny nose, and post-nasal drip. The most common kind of rhinitis is allergic rhinitis, which is usually triggered by airborne allergens such as pollen and dander. | 2 | 991 |
Comparison and conditions
Specific developmental disorders of speech and language (F80):
Specific developmental disorders of scholastic skills (F81):
- Ahuja Vyas: Textbook of Postgraduate Psychiatry (2 Vols. ), 2nd ed. 1999
- Dennis Cantwell & Lorian Baker: Developmental Speech and Language Disorders, 1987, page 4
- Sir Michael Rutter, Eric A. Taylor: Child and Adolescent Psychiatry, 4th ed. 2005
- Robert Jean Campbell, III: Campbell's Psychiatric Dictionary, 2003, page 184
- http://apps.who.int/classifications/icd10/browse/2010/en#/F80 Reference for all ICD-10 disorders mentioned in the table. - http://behavenet.com/apa-diagnostic-classification-dsm-iv-tr#301 Reference for all DSM-IV-TR disorders mentioned in the table. | 2 | 1,025 |
International Statistical Classification of Diseases and Related Health Problems. 10th ed. (ICD-10). 2006 [cited 2007-06-25]. F84. | 2 | 1,037 |
10th ed. (ICD-10). 2006 [cited 2007-06-25]. F84. Pervasive developmental disorders. | 2 | 1,038 |
4th ed., text revision (DSM-IV-TR). 2000. ISBN 0-89042-025-4. Diagnostic criteria for 299.80 Asperger's Disorder (AD). - National Institute of Mental Health. | 2 | 1,041 |
2000. ISBN 0-89042-025-4. Diagnostic criteria for 299.80 Asperger's Disorder (AD). - National Institute of Mental Health. Autism spectrum disorders (pervasive developmental disorders); 2009 [cited 2009-04-23]. | 2 | 1,042 |
|Classification and external resources|
|ICD-10||M62.8, T79.5, T79.6|
Rhabdomyolysis // is a condition in which damaged skeletal muscle tissue (Greek: ραβδω rhabdo- striped μυς myo- muscle) breaks down (Greek: λύσις –lysis) rapidly. Breakdown products of damaged muscle cells are released into the bloodstream; some of these, such as the protein myoglobin, are harmful to the kidneys and may lead to kidney failure. The severity of the symptoms, which may include muscle pains, vomiting, and confusion, depends on the extent of muscle damage and whether kidney failure develops. | 2 | 1,092 |
|Classification and external resources|
|ICD-10||C62.9 (ILDS C62.930)|
|DiseasesDB||3604 12952 12966|
A teratoma is a tumor with tissue or organ components resembling normal derivatives of more than one germ layer. Although the teratoma may be monodermal or polydermal (originating from one or more germ layers), its cells may differentiate in ways suggesting other germ layers. The tissues of a teratoma, although normal in themselves, may be quite different from surrounding tissues and may be highly disparate; teratomas have been reported to contain hair, teeth, bone and, very rarely, more complex organs or processes such as eyes, torso, and hands, feet, or other limbs. | 2 | 1,328 |
Most mental health professionals recommend therapy for internal conflicts about gender identity or discomfort in an assigned gender role, especially if one desires to transition. People who experience discord between their gender and the expectations of others or whose gender identity conflicts with their body may benefit by talking through their feelings in depth; however, research on gender identity with regard to psychology, and scientific understanding of the phenomenon and its related issues, are relatively new. The terms transsexualism, dual-role transvestism, gender identity disorder in adolescents or adults and gender identity disorder not otherwise specified are listed as such in the International Statistical Classification of Diseases (ICD) or the American Diagnostic and Statistical Manual of Mental Disorders (DSM) under codes F64.0, F64.1, 302.85 and 302.6 respectively. The DSM-5 refers to the topic as gender dysphoria. Transgender people may meet the criteria for a diagnosis of gender identity disorder (GID) "only if [being transgender] causes distress or disability." | 2 | 1,454 |
Resources. Human Rights Campaign. Retrieved 2013-09-17.
should be identified with their preferred pronoun
- APA task force (1994) "...There must be evidence of a strong and persistent cross-gender identification, which is the desire to be, or the insistence that one is of the other sex..." in DSM-IV: Sections 302.6 and 302.85 published by the American Psychiatric Association. Retrieved via Mental Health Matters on 2007-04-08. - World Health Organisation (1992) "...The desire to live and be accepted as a member of the opposite sex..." in ICD-10, Gender Identity Disorder, category F64.0 published by the World Health Organisation. | 2 | 1,477 |
Retrieved 2013-09-17.
should be identified with their preferred pronoun
- APA task force (1994) "...There must be evidence of a strong and persistent cross-gender identification, which is the desire to be, or the insistence that one is of the other sex..." in DSM-IV: Sections 302.6 and 302.85 published by the American Psychiatric Association. Retrieved via Mental Health Matters on 2007-04-08. - World Health Organisation (1992) "...The desire to live and be accepted as a member of the opposite sex..." in ICD-10, Gender Identity Disorder, category F64.0 published by the World Health Organisation. Retrieved on 2007-04-09. - Author and date unknown. | 2 | 1,478 |
Retrieved via Mental Health Matters on 2007-04-08. - World Health Organisation (1992) "...The desire to live and be accepted as a member of the opposite sex..." in ICD-10, Gender Identity Disorder, category F64.0 published by the World Health Organisation. Retrieved on 2007-04-09. - Author and date unknown. "... For some, maintaining a link to their transness or their otherly-gendered past is highly significant, while for others, they view themselves as no longer trans, but now fully as a man or woman..." Post transition identification as a man or ftm or other[dead link] from FORGE (For Ourselves: Reworking Gender Expression), an American education, advocacy and support umbrella organization supporting FTMs and others. | 2 | 1,479 |
Retrieved on 2007-09-06. - APA task force (1994) "...preoccupation with getting rid of primary and secondary sex characteristics..." in DSM-IV: Sections 302.6 and 302.85 published by the American Psychiatric Association. Retrieved via Mental Health Matters on 2007-04-06. - Committee on Health Care for Underserved Women (December 2011). "Health Care for Transgender Individuals: Committee Opinion No. | 2 | 1,491 |
- APA task force (1994) "...preoccupation with getting rid of primary and secondary sex characteristics..." in DSM-IV: Sections 302.6 and 302.85 published by the American Psychiatric Association. Retrieved via Mental Health Matters on 2007-04-06. - Committee on Health Care for Underserved Women (December 2011). "Health Care for Transgender Individuals: Committee Opinion No. 512". | 2 | 1,492 |
Defining newborns and stillbirths
A baby in its first 28 days of life is referred to as a newborn. When a baby dies during the first 27 completed days after birth, it is referred to as a neonatal death. A fetal death or stillbirth is defined as a baby born with no signs of life at or after 28 weeks’ gestation. The definition is taken from the International Classification of Diseases (ICD-10)1 which also provides thresholds to classify a stillbirth as either a late fetal death, early fetal death, or a miscarriage. Figure 1 demonstrates the timeline for pregnancies, including definitions of the type of death by the stage at which they occur. | 2 | 1,527 |
It is responsible for filtering excess fluids and waste products from our blood and eliminated in the urine. The chronic kidney disease is progressive loss in the kidney function over a period of months or even years. ICD-10 code for chronic kidney disease is N18. You may have known the term of ICD already. It is the global health information standard that is used in clinical care and research to define diseases as well as chronic kidney. | 2 | 1,532 |
The chronic kidney disease is progressive loss in the kidney function over a period of months or even years. ICD-10 code for chronic kidney disease is N18. You may have known the term of ICD already. It is the global health information standard that is used in clinical care and research to define diseases as well as chronic kidney. The ICD-10 code for chronic kidney disease is listed in Section C15-C26. | 3 | 1,533 |
You may have known the term of ICD already. It is the global health information standard that is used in clinical care and research to define diseases as well as chronic kidney. The ICD-10 code for chronic kidney disease is listed in Section C15-C26. This disease occurs due to many factors such as diabetes and high blood pressure. It can also be caused by kidney infection or inflammation, congenital kidney diseases, obstruction of the urinary tract and autoimmune disorders. | 2 | 1,534 |
Total 100 patients diagnosed as schizophrenia as per International Classification of Diseases–10th revision of WHO (ICD-10) diagnostic criteria fulfilling the inclusion and exclusion criteria between Jan to Apr 2013 were included in the study. The majority of the physical illnesses were diagnosed by medical specialists within our hospital setup and documented in the medical records of the patients. Patients in the age group of more than 18 and less than 55 years of age (due to increase risk of cognitive deficits in the patients). Patients diagnosed to be suffering from Schizophrenia according to ICD 10 criteria. Patients who were stable on medications since at least past three months. | 2 | 1,538 |
The creation of a specific diagnosis for children reflects the lesser ability of children to have insight into what they are experiencing, or ability to express it in the event that they have insight. Other specified gender dysphoria or unspecified gender dysphoria can be diagnosed if a person doesn't meet the criteria for gender dysphoria but still has clinically significant distress or impairment. The International Classification of Diseases (ICD-10) list three diagnostic criteria for "transsexualism" (F64.0):[not in citation given] Uncertainty about gender identity which causes anxiety or stress is diagnosed as sexual maturation disorder, according to the ICD-10. Treatment for a person diagnosed with GID may include psychotherapy or to support the individual's preferred gender through hormone therapy, gender expression and role, or surgery. This may include psychological counseling, resulting in lifestyle changes, or physical changes, resulting from medical interventions such as hormonal treatment, genital surgery, electrolysis or laser hair removal, chest/breast surgery, or other reconstructive surgeries. | 2 | 1,567 |
- "Denmark will become first country to no longer define being transgender as a mental illness". The Independent. 2016-05-14. - "ICD-11 Beta Draft (Mortality and Morbidity Statistics) - Gender incongruence". World Health Organization. | 2 | 1,643 |
The Independent. 2016-05-14. - "ICD-11 Beta Draft (Mortality and Morbidity Statistics) - Gender incongruence". World Health Organization. Retrieved December 23, 2016. | 2 | 1,644 |
ICD-10-CM Coding: Cholesteatoma
Cholesteatoma is an abnormal skin growth in the middle ear, behind the eardrum. These develop as cysts or pouches that fill with old skin cells and other waste material. Typically, a cholesteatoma occurs because of Eustachian tube dysfunction, as well as infection in the middle ear, and can lead to deafness. | 2 | 1,672 |
Congenital cholesteatoma are most commonly found in the anterior aspect of the eardrum. Good clinical documentation should include the specific site or location of the Cholesteatoma (such as attic, tympanum, mastoid, and external ear). ICD-10-CM introduces the concept of laterality, and complete documentation should detail whether the Cholesteatoma is left, right, or bilateral. If laterality is not documented, you must use an unspecified code. Example: The patient was brought to the OR and placed supine on the operating table. | 3 | 1,673 |
Findings: Small cholesteatoma pearl, fairly encapsulated and attached to chorda, and was removed along with the chorda. This example contains documentation of the location of the cholesteatoma as tympanum, and the laterality as left ear. H71.0 Cholesteatoma of attic
H71.1 Cholesteatoma of tympanum
H71.2 Cholesteatoma of mastoid
H71.3 Diffuse cholesteatoma
H71.9 Unspecified cholesteatoma
Additionally, category H71 contains an Excludes II note, which indicates that you may separate report the presence of additional conditions, when present:
Cholesteatoma of external ear (H60.4-)
Recurrent cholesteatoma of postmastiodectomy cavity (H95.0-)
Example: A twenty-two-year-old male presented with complaints of decreased hearing. Video otoscopic examination revealed keratin debris and “attic cerumen” in the right ear. CT scan indicated attic cholesteatoma with the beginnings of bone erosion. | 3 | 1,675 |
Diagnostic testing confirms cholesteatoma in the right ear. The location is documented as “attic.” The correct code is H72.01. Latest posts by John Verhovshek (see all)
- 90 Day Global: The Meaning of a Major Surgery - April 25, 2018
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- Reporting Anesthesia Time Units - April 25, 2018 | 3 | 1,676 |
This creates an environment where the disparate systems must exchange as well as understand information to provide an effective, integrated healthcare system. Terms related to terminology include:
Administrative code sets are designed to support administrative functions of healthcare, such as reimbursement and other secondary data aggregation. Common examples are the International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT).1 Each system is fundamentally different; ICD's purpose is to aggregate, group, and classify conditions, whereas CPT is used for reporting medical services and procedures. - Administrative code sets
- Clinical code sets
- Reference terminologies
- Interface terminologies
Clinical code sets have been developed to encode specific clinical entities involved in clinical work flow, such as LOINC and RxNorm. Clinical code sets have been developed to allow for meaningful electronic exchange and aggregation of clinical data for better patient care. | 2 | 1,704 |
Example of SNOMED CT Hierarchy Relationship
SNOMED CT is an example of a reference terminology, a concept-based kind of terminology. Below is an example of the aortic valve hierarchical relationship in SNOMED CT. Many clinicians are forced to use administrative coding sets (CPT, HCPCS, and ICD-9-CM codes) to capture clinical data. However, administrative code sets were designed to either group diagnoses and procedures or to contain broad categories with administrative technical terms with complex rules and guidelines. Examples of this are time durations or vascular branch orders directly stated in various terms. | 2 | 1,706 |
Examples of this are time durations or vascular branch orders directly stated in various terms. Administrative codes and terms typically use language that is not natural or familiar for clinicians. For example, in ICD-10-PCS the root operation term "extirpation" is not routinely stated by surgeons. Administrative codes and descriptors also do not contain the different clinical, administrative, and colloquial terms used in healthcare, making it difficult for clinicians, information management professionals, and patients to find the terms they need when performing simple text searches. This disconnect between clinician language and coding sets creates concern over losing clinical intent in the documentation. | 2 | 1,707 |
Forcing a physician to document in administrative terms is uncomfortable and disruptive. Interface terminology "bridges the gap between information that is in the physician's mind and information that can be interpreted by computer applications. "3 Interface terminology helps clinicians find the right diagnosis and procedure terms to document and code more comprehensively and accurately within their normal workflow. Interface Terminology Architecture
Clinicians interact with interface terminology when documenting diagnoses and procedures in the patient's electronic record. The physician performs searches using the search functionality in designated locations in the EHR, which returns terms to the provider to select the appropriate problem or procedure. | 2 | 1,708 |
The physician selects the appropriate term to capture the clinical intent. The term(s) populate predetermined fields in the electronic record. The selected term contains mappings to one or more industry standard terminologies, such as ICD or SNOMED CT. The "behind-the-scenes" mappings allow the physician to focus on patient care while at the same time capturing the necessary administrative and reference codes. Each EHR vendor determines which codes are actually stored in the patient's record. | 2 | 1,709 |
With interface terminology in place within an EHR, physicians find a number of beneficial impacts to their clinical workflow:
- Improved diagnostic search results for physicians to locate problems
- More clinically meaningful physician documentation
- Better and more complete problem lists are created
- Improved coding accuracy and reliability
The Problem List
Interface terminologies are important for problem lists. In practice, clinicians use many different synonyms, acronyms, eponyms, abbreviations, and other terms to describe the same diseases and problems. These alternate forms are often more familiar and frequently used in the clinical domain rather than the standard ICD-9-CM or ICD-10-CM terms. Interface terminology provides an interface to the standard ICD-9-CM-driven terminology in the EHR search. If the diagnosis was in standard ICD language, the clinician might have to alter the description or, depending upon the term, might even be unable to initially locate the diagnosis for selection. | 2 | 1,710 |
In practice, clinicians use many different synonyms, acronyms, eponyms, abbreviations, and other terms to describe the same diseases and problems. These alternate forms are often more familiar and frequently used in the clinical domain rather than the standard ICD-9-CM or ICD-10-CM terms. Interface terminology provides an interface to the standard ICD-9-CM-driven terminology in the EHR search. If the diagnosis was in standard ICD language, the clinician might have to alter the description or, depending upon the term, might even be unable to initially locate the diagnosis for selection. The physician selects an interface terminology diagnosis. | 2 | 1,711 |
These alternate forms are often more familiar and frequently used in the clinical domain rather than the standard ICD-9-CM or ICD-10-CM terms. Interface terminology provides an interface to the standard ICD-9-CM-driven terminology in the EHR search. If the diagnosis was in standard ICD language, the clinician might have to alter the description or, depending upon the term, might even be unable to initially locate the diagnosis for selection. The physician selects an interface terminology diagnosis. The selected diagnosis populates the patient's problem list. | 2 | 1,712 |
The physician selects an interface terminology diagnosis. The selected diagnosis populates the patient's problem list. The associated ICD-9-CM mappings populate the organization's billing system for review and claims generation to increase efficiency and accuracy in the revenue cycle. Clinical Interface to the Standards
Importance of Interface Terminology
The goal of interface terminology is to facilitate clinical documentation while streamlining other administrative functions of healthcare. Clinician-friendly terms with associated industry standard terminologies facilitate this goal. | 2 | 1,713 |
Clinician-friendly terms with associated industry standard terminologies facilitate this goal. Interface terminology also supports the "capture once, use many times" philosophy of electronic health information. For example, if the term "CHF (congestive heart failure)" is captured with an associated ICD-9-CM code (428.0) or ICD-10-CM code (I50.9) and SNOMED CT code (42343007), the ICD code is routed to the financial system for review and claims generation, while the SNOMED CT code is available for other reporting. ICD-10-CM/PCS codes may also be associated with the terms in an interface terminology. Having both ICD-9-CM and ICD-10-CM/PCS codes available for the terms frequently documented by an organization's providers can facilitate ICD-10-CM/PCS preparation. | 3 | 1,714 |
Interface terminology also supports the "capture once, use many times" philosophy of electronic health information. For example, if the term "CHF (congestive heart failure)" is captured with an associated ICD-9-CM code (428.0) or ICD-10-CM code (I50.9) and SNOMED CT code (42343007), the ICD code is routed to the financial system for review and claims generation, while the SNOMED CT code is available for other reporting. ICD-10-CM/PCS codes may also be associated with the terms in an interface terminology. Having both ICD-9-CM and ICD-10-CM/PCS codes available for the terms frequently documented by an organization's providers can facilitate ICD-10-CM/PCS preparation. Interface terminology provides a stable and constant pivot point to meet the changing coding requirements of the healthcare industry. | 3 | 1,715 |
For example, if the term "CHF (congestive heart failure)" is captured with an associated ICD-9-CM code (428.0) or ICD-10-CM code (I50.9) and SNOMED CT code (42343007), the ICD code is routed to the financial system for review and claims generation, while the SNOMED CT code is available for other reporting. ICD-10-CM/PCS codes may also be associated with the terms in an interface terminology. Having both ICD-9-CM and ICD-10-CM/PCS codes available for the terms frequently documented by an organization's providers can facilitate ICD-10-CM/PCS preparation. Interface terminology provides a stable and constant pivot point to meet the changing coding requirements of the healthcare industry. Depending upon the EHR functionality, organizations can extract the terms and associated codes for analysis. | 3 | 1,716 |
As industry standard terminologies are updated, organizations engage in a maintenance process. Interface terminology eases the maintenance process for organizations. What happens if a diagnosis appears in a medical record, but the ICD code for that diagnosis is replaced? Interface terminology has the ability to have the diagnostic term remain active while the associated ICD code is updated to reflect the new code. No longer can physicians select diagnoses linked to out-of-date, incorrect, or non-billable codes. | 2 | 1,717 |
Interface terminology eases the maintenance process for organizations. What happens if a diagnosis appears in a medical record, but the ICD code for that diagnosis is replaced? Interface terminology has the ability to have the diagnostic term remain active while the associated ICD code is updated to reflect the new code. No longer can physicians select diagnoses linked to out-of-date, incorrect, or non-billable codes. This helps reduce the amount of running back-and-forth between billing and clinicians to determine clinical intent and adjudicate coding discrepancies. | 2 | 1,718 |
No longer can physicians select diagnoses linked to out-of-date, incorrect, or non-billable codes. This helps reduce the amount of running back-and-forth between billing and clinicians to determine clinical intent and adjudicate coding discrepancies. The historical tags between the term and the prior ICD code stay intact for historical purposes. Benefits of Interface Terminology
While there are many benefits of interface terminology, the most notable are:
- Uses familiar medical terms, which reduces search time and increases precision
- Improves charge capture as a result of accurate diagnostic codes
- Minimizes maintenance, which saves the expense of creating and maintaining a term dictionary and complicated term-to-code mappings
- Provides meaningful use compliance
- Enables accurate data capture at the point of care
- Increases patient safety through clarity of diagnosis, problem, and procedure descriptions
Health information management (HIM) professionals need to recognize the role of interface terminology in the EHR. Knowing how the terminology works in the EHR will help to ensure the organization is reaping all the benefits of the system. | 2 | 1,719 |
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