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Medical Classification
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: * statistical analysis of diseases and therapeutic actions * reimbursement (e.g., to process claims in medical billing based on diagnosis-related groups) * knowledge-based and decisi ...
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Medical Diagnosis
Medical diagnosis (abbreviated Dx, Dx, or Ds) is the process of determining which disease or condition explains a person's symptoms and signs. It is most often referred to as diagnosis with the medical context being implicit. The information required for 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 posthumous diagnosis is considered a kind of medical diagnosis. Diagnosis is often challenging because many signs and symptoms are nonspecific. For example, redness of the skin ( erythema), by itself, is a sign of many disorders and thus does not tell the healthcare professional what is wrong. Thus differential diagnosis, in which several possible explanations are compared and contrasted, must be performed. This involves the correlation of various pieces of information followed by the recognition and different ...
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Rubric
A rubric is a word or section of text that is traditionally written or printed in red ink for emphasis. The word derives from the la, rubrica, meaning red ochre or red chalk, and originates in Medieval illuminated manuscripts from the 13th century or earlier. In these, red letters were used to highlight initial capitals (particularly of psalms), section headings and names of religious significance, a practice known as rubrication, which was a separate stage in the production of a manuscript. Rubric can also mean the red ink or paint used to make rubrics, or the pigment used to make it. Although red was most often used, other colours came into use from the late Middle Ages onwards, and the word rubric was used for these also. Medievalists can use patterns of rubrication to help identify textual traditions. Various figurative senses of the word have been extended from its original meaning. Usually these senses are used within the set phrase "under hateverrubric", for example, " ...
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International Classification Of Health Interventions
The International Classification of Health Interventions (ICHI) is a system of classifying procedure codes being developed by the World Health Organization (WHO). It is currently available as a beta 3 release. The components for clinical documentation are stable. The component on public health interventions is in the process of being finalized. Updates on development and status of the classification are listed on WHO home page. History The WHO began development of ICHI in 2012 as a replacement for ''International Classification of Procedures in Medicine'' (ICPM), which was a system of classifying procedure codes published from 1978. ICPM, however, never received the same international acceptance as ICD-9. Due to difficulties in the consultation processes, development of the ICPM effectively stopped in 1989. As a result, nations would go on to develop their own individual classifications for procedures and interventions incompatible with the ICPM approach. Germany's OPS-301 is based ...
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International Classification Of Procedures In Medicine
The International Classification of Health Interventions (ICHI) is a system of classifying procedure codes being developed by the World Health Organization (WHO). It is currently available as a beta 3 release. The components for clinical documentation are stable. The component on public health interventions is in the process of being finalized. Updates on development and status of the classification are listed on WHO home page. History The WHO began development of ICHI in 2012 as a replacement for ''International Classification of Procedures in Medicine'' (ICPM), which was a system of classifying procedure codes published from 1978. ICPM, however, never received the same international acceptance as ICD-9. Due to difficulties in the consultation processes, development of the ICPM effectively stopped in 1989. As a result, nations would go on to develop their own individual classifications for procedures and interventions incompatible with the ICPM approach. Germany's OPS-301 is based ...
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HCPCS
The Healthcare Common Procedure Coding System (HCPCS, often pronounced by its acronym as "hick picks") is a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (CPT). History The acronym ''HCPCS'' originally stood for ''HCFA Common Procedure Coding System'', a medical billing process used by the Centers for Medicare and Medicaid Services (CMS). Prior to 2001, CMS was known as the Health Care Financing Administration (HCFA). HCPCS was established in 1978 to provide a standardized coding system for describing the specific items and services provided in the delivery of health care. Such coding is necessary for Medicare, Medicaid, and other health insurance programs to ensure that insurance claims are processed in an orderly and consistent manner. Initially, use of the codes was voluntary, but with the implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) use of the HCPCS for transactions in ...
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Current Procedural Terminology
The Current Procedural Terminology (CPT) code set is a procedural code set developed by the American Medical Association (AMA). It is maintained by 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. New editions are released each October, with CPT 2021 being in use since October 2021. It is available in both a standard edition and a professional edition. CPT coding is similar to ICD-10-CM coding, except that it identifies the services rendered, rather than the diagnosis on the claim. Whilst the ICD-10-PCS codes also contains procedure codes, those are only used in the inpatient setting. CPT is identified by the Centers for Medicare and Medicaid Services (CMS) as Level 1 of the Healthcare Common Procedure Coding Syst ...
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Procedure Code
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. Examples of procedure codes International * International Classification of Primary Care (ICPC-2), as well as procedure codes; ICPC-2 also contains diagnosis codes, reasons for encounter (RFE), and process of care. * International Classification of Procedures in Medicine (ICPM) and International Classification of Health Interventions (ICHI) * SNOMED CT North American * Canadian Classification of Health Interventions (CCI) (used in Canada. Replaced CCP.) * Current Dental Terminology (CDT) * Healthcare Common Procedure Coding System (including Current Procedural Terminology) (for outpatient use; used in United States) * ICD-10 Procedure Coding System (ICD-10-PCS) (for inpatient use; used in United States) * ICD-9-CM Volume 3 ...
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ICD-11
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. The ICD-11 is a large ontology consisting of about 85,000 entities, also called classes or nodes. An entity can be anything that is relevant to health care. It usually represents a disease or a pathogen, but it can also be an isolated symptom or (developmental) anomaly ...
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ICD-10
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. While WHO manages and publishes the base version of the ICD, several member states have modified it to better suit their needs. In the base classification, the code set allows for more than 14,000 different codes and permits the tracking of many new diagnoses compared to the preceding ICD-9. Through the use of optional sub-classifications, ICD-10 allows for specificity regarding the cause, manifestation, location, severity, and type of injury or disease. Th ...
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ICD-9-CM
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. The ICD is published by the WHO and used worldwide for morbidity and mortality statistics, reimbursement systems, and automated ...
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Diagnosis Code
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. 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 Probl ...
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Medical Terminology
Medical terminology is a language used to precisely describe the human body including all its components, processes, conditions affecting it, and procedures performed upon it. Medical terminology is used in the field of medicine Medical terminology has quite regular morphology, the same prefixes and suffixes are used to add meanings to different roots. The root of a term often refers to an organ, tissue, or condition. For example, in the disorder known as hypertension, the prefix "hyper-" means "high" or "over", and the root word "tension" refers to pressure, so the word "hypertension" refers to abnormally high blood pressure. The roots, prefixes and suffixes are often derived from Greek or Latin, and often quite dissimilar from their English-language variants. This regular morphology means that once a reasonable number of morphemes are learnt it becomes easy to understand very precise terms assembled from these morphemes. Much medical language is anatomical terminology, conc ...
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