Chapter two medical coding, code assignment and reimbursement

of Diseases, or ICD, codes, which correspond to a patient’s injury or sickness, and Current

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of Diseases, or ICD, codes, which correspond to a patient’s injury or sickness, and Current
Procedure Terminology, or CPT, codes, which relate to what functions and services the healthcare provider performed on or for the patient. These codes act as the universal language between doctors, hospitals, insurance companies, insurance clearinghouses, government agencies, and other health-specific organizations. The coder reads the healthcare provider’s report of the patient’s visit and then translates each bit of information into a code. There is a specific code for what kind of visit this is, the symptoms that patient is showing, what tests the doctor does, and what the doctor diagnoses the patient with. Every code set has its own set of guidelines and rules. Certain codes, like ones that signify a preexisting condition, need to be placed in a very particular order. Coding accurately and within the specific guidelines for each code will affect the status of a claim. The coding process ends when the medical coder enters the appropriate codes into a form or software program. Once the report is coded, it is passed onto the medical biller.
Diagnosis Codes The International Classification of Diseases (most commonly known by the abbreviation ICD) is the standard for designating diseases plus a wide variety of signs, symptoms, and external causes of injury. Published by the World Health Organization, ICD codes are used internationally to

3 record many types of health events, including hospital inpatient stays and death certificates. (ICD codes were first used into report death statistics) The codes are periodically revised the most recent version is 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 allover the world. Following an alpha version in May 2011 and a beta draft in Maya 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 taxonomy consisting of about 85,000 entities, also called classes or nodes. An entity can be anything that is relevant to healthcare. It usually represents a disease or a pathogen, but it can also bean isolated symptom or (developmental) anomaly of the body. There are also classes for reasons for contact with health services, social circumstances of the patient, and external causes of injury or death. The ICD-11 is part of the WHO-FIC (WHO-Family of International Classification, a family of medical classifications. The WHO-FIC contains the Foundation Component, which comprises all entities of all classifications endorsed by the WHO. The Foundation is the common core from which all classifications are derived. For example, the ICD-O is a derivative classification optimized for use in oncology. The primary derivative of the Foundation is called the ICD-11 MMS, and it is this system that is commonly referred to as simply "the ICD-11".
MMS stands for Mortality and Morbidity Statistics. The ICD-11 is distributed under a Creative Commons BY-ND license.

4 The ICD-11 officially came into effect on 1 January 2022. On 11 February, the WHO claimed that
35 countries were using the ICD-11. In the United States, an expected implementation year of
2025 has been given, but if a clinical modification is determined to be needed (similar to the ICD-
10-CM), ICD-11 implementation might not begin until 2027. The ICD-11 MMS can be viewed online on the WHO's website. Aside from this, the site offers two maintenance platforms the ICD-11 Maintenance Platform, and the WHO-FIC Foundation Maintenance Platform. Users can submit evidence-based suggestions for the improvement of the
WHO-FIC, i.e. the ICD-11, the ICF, and the ICHI. In practice, the application of ICD codes to diagnoses is complicated and technical. Hospital coders have to understand the coding system and the medical terminology and abbreviations used by clinicians. Because of this complexity, and because proper coding can mean higher reimbursement from third-party payers, ICD coders require a great deal of training and experience to be most effective.

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