What is ICD-10?
The International Statistical Classification of Disease and Related Health Problems - 10th Edition.
Who made ICD-10 and ICD-10-CA?
ICD-10 was made by WHO, but the Canadian version was implemented by CIHI.
What does CCI stand for and who made it?
It stands for the Canadian Classification of Health Interventions and was made by CIHI as well.
What is coding?
A system of assigning numbers to diseases, condition, operations and other encounters. It is the process of turning medical diagnoses and procedures into universal medical code numbers.
What are the 2 components of the coding process?
1. Interpretation of the source documents: reviewing records to obtain a complete view of the episode of care, and to get the most accurate code.
2. Code assignment: the process of assigning a code to a condition following the interpretation of the records, guidelines and instructions.
What are some purposes of coding?
- Reimbursement
- Education
- Research
What are some factors that may affect the quality of coded data?
- Adequate training
- Adequate references and resources (up to date)
- Accurate and complete documentation that has all the pertinent information to the patient
- Continuous quality improvement processes
How is the quality of coded data evaluated? What are some elements?
- How reliable it is.
- Its validity.
- Completeness
- Timeliness
What is the most challenging component of the coding process and why?
Interpretation of the source documents because it really requires a thorough review of the record, and even one mistake can change the code.
Name 3 statistical uses of encoded health care data?
- Resource allocation and management
- Managing quality of care
- Establishing funding rates
What are source documents?
Documents within a patient's chart that describe their episode of care/encounter. Ex: inpatient records and day surgery records.