Alliyah Evangelista-
What is ICD-10?
The International Statistical Classification of Disease and Related Health Problems - 10th Edition.
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Who made ICD-10 and ICD-10-CA?
ICD-10 was made by WHO, but the Canadian version was implemented by CIHI.
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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.
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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.
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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.
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What are some purposes of coding?
- Reimbursement
- Education
- Research
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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
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How is the quality of coded data evaluated? What are some elements?
- How reliable it is.
- Its validity.
- Completeness
- Timeliness
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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.
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Name 3 statistical uses of encoded health care data?
- Resource allocation and management
- Managing quality of care
- Establishing funding rates
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What are source documents?
Documents within a patient's chart that describe their episode of care/encounter. Ex: inpatient records and day surgery records.
