Classification of DiseasesTwo 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

ServicesJointly developed by

AMA and HCFAComponents 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