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The ICD-10 Clinical Modification ( ICD-10-CM) is a set of diagnosis codes used in the United States of America. [ 1] It was developed by a component of the U.S. Department of Health and Human services, [ 2] as an adaption of the ICD-10 with authorization from the World Health Organization. In 2015, ICD-10-CM replaced ICD-9-CM as the federally ...
ICD-10 is the 10th revision of the International Classification of Diseases (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. [ 1] Work on ICD-10 began in 1983, [ 2 ...
The International Classification of Diseases, Clinical Modification (ICD-9-CM) was an adaptation created by the US National Center for Health Statistics (NCHS) and used in assigning diagnostic and procedure codes associated with inpatient, outpatient, and physician office utilization in the United States. The ICD-9-CM is based on the ICD-9 but ...
Major Diagnostic Category. The Major Diagnostic Categories (MDC) are formed by dividing all possible principal diagnoses (from ICD-9-CM) into 25 mutually exclusive diagnosis areas. MDC codes, like diagnosis-related group (DRG) codes, are primarily a claims and administrative data element unique to the United States medical care reimbursement ...
Clinical Care Classification System. The Clinical Care Classification ( CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings. [ 1]
Medical classification. A medical classification is used to transform descriptions of medical diagnoses or procedures into standardized statistical code in a process known as clinical coding. Diagnosis classifications list diagnosis codes, which are used to track diseases and other health conditions, inclusive of chronic diseases such as ...
Where available, ICD-10 codes are listed. When codes are available both as a sign/symptom (R code) and as an underlying condition, the code for the sign is used. When there is no symptoms for a disease that a patient has, the patient is said to be asymptomatic.
Nursing diagnosis. A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions ...