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Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance ...
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 ...
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 diabetes mellitus and heart ...
Optum ICD-10 Training Curriculum Helps Hospitals Prepare for the New Coding Standard Optum ICD-10 Core Education delivers comprehensive training to prepare physicians, coders and other staff ...
Preparticipation physical evaluation. In sports medicine, a preparticipation physical evaluation ( PPE) is a physical examination of an athlete. [ 1] PPEs screen for a variety of conditions, including athletic heart syndrome [ 2] and risk of sudden cardiac death. [ 3][ 4] PPEs are required for athletic participation according to the laws of ...
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 ...
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 ...
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]