The Rationale for and History of Coding



The Rationale for and History of Coding



Learning Objectives



1. Describe the application of coding


2. Define nomenclature and classification


3. Identify the historical timeline of coding


4. Explain the difference between ICD-9-CM and ICD-10-CM


5. Delineate coder training needs for transitioning to ICD-10-CM


6. Describe different coding organizations and credentials


7. Recognize the importance of the Standards of Ethical Coding


8. Define compliance as it relates to coding


9. Explain confidentiality as it applies to coding



Abbreviations/Acronyms


























Background of Coding


What Is Coding and What Are Its Applications?


As a student in this field, you will often be asked these questions. Why does one study this subject? What type of work does a “coder” do? Basically, medical coding consists of translating diagnoses and procedures into numbers for the purpose of statistically capturing data. This process is done for us every day in all aspects of daily life. If you buy a banana at the grocery store, the cash register captures that banana as a number, which, in turn, provides data on the number of bananas sold in that store or by that grocery chain; it also yields data of importance to the store on replenishing their inventory, details regarding what time of year the greatest number of bananas are sold, and so forth.


Translation of a disease and/or a procedure into an ICD-9 code is not as simple as it may seem. This process requires a thorough knowledge of anatomy and physiology, disease processes, medical terminology, laboratory values, pharmacology, surgical procedures, and last but not least, a myriad of coding rules and guidelines. Diseases and procedures are translated into a coding system known as the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). This classification system has been used worldwide and has been clinically modified for the United States.


Coded data are used for many purposes. Prior to the advent of diagnosis-related groups (DRGs), which are used by Medicare and other payers as the basis for hospital reimbursement (payment), coding was used for research and planning. A healthcare provider or facility could use these data to find out how many cases of appendicitis were treated in a year. This information could be used by a healthcare facility in decisions about the possible purchase of more equipment, the addition of an operating room, or the hiring of additional staff, or by the provider to gain additional skills. Since the implementation of DRGs—now known as MS-DRGs—coded data are also used for reimbursement purposes, and they are increasingly used for risk management and quality improvement, as well as in nursing clinical pathways. Coded data were important from the start, but use of these data for reimbursement has elevated the importance of accurate coding to new heights.


Capture of health data through ICD-9 and ICD-10 codes that are used worldwide has proved useful for the study of patterns of disease, disease epidemics, causes of mortality, and treatment modalities. Without the use of a classification system, comparison of data would be impossible.



Nomenclature and Classification


A nomenclature and a classification of diseases are required for development of a coding system. A nomenclature is a system of names that are used as preferred terminology, in this case, for diseases and procedures. Often, diseases in different areas of the country or in different countries are identified by dissimilar terminology, which makes the capture of comparative statistical data next to impossible. For example, another name for “amyotrophic lateral sclerosis” is “Lou Gehrig’s disease,” which is also known as a “motor neuron disease.” Nomenclatures of disease were first developed in the United States around 1928. The Systematized Nomenclature of Medicine (SNOMED), published by the College of American Pathologists, is the most up-to-date system in current use.


Classification systems group together similar items for easy storage and retrieval. Within a classification system, items are arranged into groups according to specific criteria. The history of classification systems goes back as far as Hippocrates. During the 17th century, London Bills of Mortality represented the first attempts of scientists to gather statistical data on disease. The ICD-9-CM classification system is a closed system that comprises diseases, injuries, surgeries, and procedures. In a closed classification system a disease, condition, or procedure can be classified in only one place.



History of Coding


ICD-9-CM is the coding classification system that is currently in use in the United States. This classification system dates back to Bertillon’s Classification of Causes of Death, which was developed in 1893. This system was adopted by the United States in 1898 under the recommendation of the American Public Health Association. System revisions were scheduled to take place every 10 years, and the classification was maintained by the World Health Organization (WHO). Revisions became known as the International Classification of Causes of Death. Over the years, this system has been changed to allow its use not only in mortality reporting but in morbidity reporting as well. Since its inception, this classification has been revised 10 times. The Clinical Modification (CM) was developed in 1977 by the United States to more accurately capture morbidity data for study within the United States, as well as information on operative and diagnostic procedures that were not included in the original publication of ICD. ICD-9-CM, a publication of the U.S. Department of Health and Human Services, consists of three volumes.


Currently, many countries are using ICD-10, which was published in 1993 by the WHO. ICD-10 has also been clinically modified for use in the United States with implementation proposed for October 1, 2014. ICD-10-CM will replace the 30-year-old ICD-9-CM. The final rule for adoption of ICD-10-CM and ICD-10-PCS was released in January of 2009.


Work on ICD-10 was begun in 1983. The tabular volume was published in 1992, and the instructional volume followed in 1993; the Alphabetic Index was published in 1994. In 1994, the United States began the process of determining whether a clinical modification (CM) would be necessary. A draft version was made available in 2002, updated in July 2007, and updated again in 2009. This version can be found at the National Center for Health Statistics website.


Clinical modifications made to ICD-10 allow a higher level of specificity. Since 1999, ICD-10 has been used in the United States for the reporting of mortality data. A total of 90 countries, including Canada and Australia, are currently using ICD-10.


ICD-9-CM may be updated biannually in April and October. Updates contain additional codes, revised codes, and codes that are deleted. These updates are published in the Federal Register (the official daily publication for rules, proposed rules, and notices of U.S. federal agencies and organizations) as a proposed rule and then as a final rule. They are available at the Centers for Medicare and Medicaid Services (CMS) website (www.cms.gov). It is of the utmost importance that code books and coding software (encoder) be updated to ensure that coding is accurate and to facilitate accurate reimbursement.


The ICD-9-CM Coordination and Maintenance Committee meets twice a year and is used as a forum for proposals to update ICD-9-CM. This Committee serves in an advisory capacity. Two Federal agencies are responsible for maintenance of ICD-9-CM. The classification of diagnoses is the responsibility of the NCHS (National Center for Health Statistics) and the classification of procedures is the responsibility of CMS (Centers for Medicare and Medicaid Services). The Coordination and Maintenance Committee meetings are open to the public and comments are encouraged. All comments and recommendations are evaluated before a final decision on new codes is issued.


The development and maintenance of the guidelines of ICD-9-CM is the responsibility of the National Center for Health Statistics (NCHS), CMS, the American Hospital Association (AHA), and the American Health Information Management Association (AHIMA), which are also known as the Cooperating Parties. Many publications provide coding advice and information, but only one publication is official. This publication, AHA Coding Clinic for ICD-9-CM (referred to as Coding Clinic), which is published quarterly by the AHA, provides coding advice and guidelines that have been approved by the Cooperating Parties and must be followed by coders.


Coding Clinic references will be used throughout the text with specific issue information provided, such as 2002:4Q:p126-130. This reference alerts the student of information contained in the fourth quarter 2002 issue and the associated page numbers. The Coding Clinic references used throughout this text may be referred to for more detailed information about the subject being referenced. Coding Clinic has publications dating back to 1985. Unless superseded or clarified by additional Coding Clinic references, the original publication of any advice remains in effect. Although reference may be made to advice in an issue from 1994, this may be the most current advice available. A date of 1994 for a given source does not mean that the publication is outdated. As the transition to ICD-10-CM/PCS begins, this textbook will have all examples and exercises coded using ICD-9 and ICD-10.

Related posts:

  1. Diseases of the Skin and Subcutaneous Tissue: (ICD-9-CM Chapter 12, Codes 680-709, and ICD-10-CM Chapter 12, Codes L00-L99)
  2. Diseases of the Blood and Blood-Forming Organs: (ICD-9-CM Chapter 4, Codes 280-289, and ICD-10-CM Chapter 3, Codes D50-D89)
  3. Diseases of the Circulatory System: (ICD-9-CM Chapter 7, Codes 390-459, and ICD-10-CM Chapter 9, Codes I00-I99)
  4. Introduction to ICD-10-PCS

Stay updated, free articles. Join our Telegram channel
Tags:
Jun 14, 2017 | Posted by in GENERAL SURGERY | Comments Off on The Rationale for and History of Coding

Full access? Get Clinical Tree
Get Clinical Tree app for offline access