1. 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.

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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