Classification Primer/ICD-10-CA/CCI 7th edition,Capter 1&2 Questions With 100% Correct Answers.

classification system - is a systematic arrangement of elements within a subject into groups or categories according to the pre-established criteria,based on a particular point of view. 2 classification systems are used for data collection within the acute care system - ICD-10-CA and CCI ICD-10-CA - It's a statistical classification system.Modified for use in Canada by CIHI. Elements that are included here are diseases, injuries and other reasons for contact with Health care System cci - modified for use in Canada by CIHI. Contains: diagnostic/therapeutic procedures. coding process contains - pretation of the source documents assignment accurate code assignment requires interpretation and application of - ification systems coding instructions,guidelines,conventions 2. standarts, rules,policies ssional ethics purpose of coding - provide health care data that can be stored,indexed and easily retrieved.The info is used by Statistics Canada,PHAC,Health Canada,CIHI(RESEARCH,determine special needs, making decisions, education) Statistic canada and provincial vital statistics agencies use ICD-10 FOR - MORTALITY APPLICATION ICD-10-CA IS USED - to collect morbidity dataCIHI - USES ICD-10-CA INDEPENDENT,NOT-FOR PROFIT ORGANIZATION MANDATED BY FEDERAL AND PROVINCIAL TERRITORIAL MINISTERS. pURPOSE: TO PROVIDE RELEVANT, OBJECTIVE, ACCURATE AND TIMELY HEALTH INFO. ICD-10-CA AND CCI - HAVE BEEN ADOPTED AS THE EXCLUSIVE NATIONAL STANDARDS FOR DIAGNOSIS AND INTERVENTION CLASSIFICATION SINCE April 1,2001 diseases - conditions numenclature - it's a terminology list, provides a separate category for each and every known disease/health related problem axis - is the criterion on which the classification is based. primary axes includes - epidemic diseases constitutional/general diseases local diseases developmental injuries 2 major components of ICD-10-CA - 1. Alphabetical index 2.Tabular list Alphabetical index - it's alphabetical listing of diseases, injuries, factors influencing health status or other reasons for contact with the health care system leading to the codes in the tabular list. must always be referenced first before proceeding to the tabular list organized by lead terms with secondary terms lead term - indicate the noun expressed as the name of disease, injury, factor influencing health status or reason for contact with health servicessecondary terms - also called sub terms are adjectives and are described as modifiers -modify the lead term by providing additional details(site,type,etiology) tabular list - 1. classification itself. 2. consist of numeric listing in alphanumeric order of diagnosis codes,injury codes and codes describing factors influencing health status or other reasons for contact with the health care system. 3. consists of chapters, blocks and categories. chapter - 23 most correspond to the primary axes(neoplasia,respiratory system,nervous system) a condition should be preferably classified to the special group chapter each letter is associated with a particular chapter important info is provided in the beginning of all chapters- to ensure accurate code assignments. subdivided into blocks of 3 character categories blocks - categories of a related group of diseases /health related problems(D50-D53) 3 character category(D50) - represent a group of closely related conditions or a single disease. IS USED WHEN THE CATEGORY has not been further subdivided. RESIDUAL CATEGORIES -other and unspecified categories are referred to this category(N32- OTHER DISORDERS OF BLADDER) .8-is used for other conditions within the 3-character category.(N64.8-other specified disorders of breast) .9-is used to represent the unspecified conditions within the 3-character category(N64.9- DISORDERS OF BREAST UNSPECIFIED) .- - INCOMPLETE CODEHYPERLINKS - the alphabetical index leads to the codes in the tabular list ----- - more specifity essential modifiers - secondary terms affect the code selection nonessential modifiers - appear before the code in parentheses do not affect code selection specified NEC - not elsewhere classified-when a condition is described specifically,but not secondary term can be located. indicators for using: 1.a specific term used in documentation is not listed as a secondary term term used fits the axis of the category/subcategory term can't be assigned to a synonymous term unspecified NOS - not otherwise specified- documentation does not provide the specific information concerning the condition to permit assignment of a more specific code (*)asterisk - indicates that both codes must be assigned inclusion terms - synonyms,examples exclusion notes(terms) - are not classified to that category,are classified elsewhere