Classification of Diseases Two related classification systems International Classification of Diseases, Ninth Revision (ICD-9) used to code & classify mortality data from death certificates Developed and revised by the World Health Organization (WHO) International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) used to code & classify morbidity data from inpatient & outpatient records Developed by the Health Care Financing Administration (HCFA) Used in the U.S.

ICD-9-CM Statistical classification system that arranges diseases and injuries into groups according to established criteria Purpose classification of mortality & morbidity information for statistical purposes indexing of medical records by disease and operation data storage and retrieval

ICD-9-CM “Clinical” used to emphasize the modification’s intent…to classify morbidity data for indexing of medical records and other health care statistics Numeric codes with descriptions Annual updates published by Health Care Financing Administration (HCFA) Medicare Catastrophic Coverage Act passed in 1988 required use of ICD-9 codes on Medicare Part B claim forms…other third party payers followed suit

ICD-9-CM Volume 1 -- Numeric listing of diagnosis codes and descriptions Volume 2 -- Alphabetical listing of diagnoses with codes and descriptions A revision -- ICD-10-CM is in the works Learn more about ICD-9-CM at the National Center for Health Statistics web site

Current Procedural Terminology (CPT) Codes Classification of medical services and procedures Purpose: to provide a uniform language that accurately describes medical, surgical, and diagnostic services Provides reliable communication nationwide among providers, patients, and third parties

CPT Codes Developed by the American Medical Association in 1966 Annual updates made by CPT Panel of the AMA Each procedure/service has 5 digit code CPT codes must must be supported by diagnostic codes (ICD-9-CM) Learn more about CPT codes at the AMA web site

Documentation Guidelines for Evaluation and Management Services Jointly developed by AMA and HCFA Components of documentation history exam complexity of medical decision-making counseling time Level of Service CPT Codes Different CPT codes based on: new vs. established patient Type of history, exam, and decision-making

Documentation Guidelines CPT and ICD-9-CM codes must be supported by documentation To learn more about the Documentation Guidelines go to the HCFA web site For a history of the documentation guidelines and to view a draft of new guidelines click on “Status Report” at the HCFA web site

Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM IV) Purpose: to provide clear descriptions of diagnostic categories to enable clinicians and investigators to diagnose, communicate about, study and treat people with various mental disorders Learn more about DSM IV at the American Psychiatric Association web site