transition was a difficult process because ICD-10 contains nearly 10 times as many codes as ICD-9. ICD-10-CM (clinical modifications) is a morbidity classification developed by the Centers for Disease and Control and Prevention (CDC) for classifying diagnoses and reason for doctor visits in the American healthcare setting. ICD-10-CM diagnosis codes are composed of codes with 3-7 alpha and numeric digits and full code titles. The ICD-10-CM includes more than 68,000 diagnostic codes, compared to 13,000 in ICD-9-CM. Also ICD-10-CM codes include twice as many categories. ICD-10- PCS (the procedure classification system) was developed by the CMS for use in the U.S. for inpatient hospital settings only. The new procedure coding system uses 7 alpha or numeric digits while the ICD- 9-CM coding system uses 3 or 4 numeric digits (CMS, n.d.). The Current Procedural Terminology (CPT) a uniform code set is developed and maintained by the American Medical Association (AMA). The CPT code set classifies and describes various healthcare services to allow communication among the participants in the healthcare process, such as clinicians, coders, regulatory authorities, insurers, payers, patients, and others. CPT coding is similar to ICD-10 coding, except that it identifies the services rendered rather than the diagnosis on the claim (Moisio, 2009). CPT codes are used in conjunction with ICD-10-CM codes in the electronic medical billing process. Updated CPT codes are published annually. The types of codes include evaluation and
management, anesthesia, surgery, radiology, pathology and laboratory, and medicine (category I), performance measurement (category II) and emerging technology (category III). An example of CPT codes is shown in Table 9.4. Table 9.4 Representative CPT codes that are used in clinical neuropychology. From Boake (2008) CPT code Description Service 96116 Clinical interview and mental status examination by psychologist, per hour, including interpretation and record preparation Neurobehavioral status exam 96118 Administration of formal tests, interpretation, and report preparation by psychologist, per hour Neuropsychological testing 96119 Test administration by technician, per hour 96120 Test administration by computer, per hour 97532 Training to improve cognitive skills (e.g. teaching compensatory strategies), per 15 minutes of direct contact Cognitive rehabilitation Code sets include tables of terms, definitions of medical concepts, and codes for medical diagnosis or medical procedures. Medical-data code sets include coding systems for: 1. Problems • Diseases • Impairments • Other health related problems and their manifestations • Causes of injury 2. Treatment and prevention • Actions taken to prevent, diagnose, treat, or manage diseases, injuries, and impairments 3. Therapy • Substances • Equipment • Supplies, or other items used to deliver therapy 4. Administrative and financial health care transaction standards • Diagnoses • Procedures • Drugs The International Classification of Diseases ICD-10 and their Clinical Modification ICD-10-CM provides guidelines for coding and reporting the following items reported by hospitals: • Prevention • Diagnosis
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