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digital.ahrq.gov/sites/default/files/docs/page/improved-accuracy-of-coding-quick-reference-guide.pdf
September 01, 2009 - of Coding
Improved Accuracy of
Coding
Monitoring the use of current procedural
terminology (CPT) codes … lead
to enhanced revenue because visits could be coded
with higher complexity level-of-service billing codes … Current Findings in the Literature: Billing in
health care organizations is based primarily on CPT
codes … However, coding guidelines are
complicated and substantial disagreement often
exists over assigning codes … Evaluation: Examine the change in the percent-
age of categories of CPT codes.
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digital.ahrq.gov/loinc
January 01, 2023 - LOINC codes are based on a six-part name, which means that codes are unique not just to the component … During a 12-month period, 4,000 codes accounted for almost 49 million clinical results. … Of the total codes identified, 80 (2 percent) codes accounted for 80 percent of the results, and 784 … (19 percent) codes account for 99 percent of the results. … LOINC by initially focusing on a subset of high-volume transaction codes.
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digital.ahrq.gov/ahrq-funded-projects/improving-health-data-quality-assessing-and-enhancing-semantic-integrity
January 01, 2023 - These changes include adding refinement to existing codes, the addition of new codes, and major version … With the growing use of large electronic health record (EHR) data sets for research, having multiple codes … or combinations of codes that represent the same phenotype creates issues in the identification of desired … cohorts based on these codes. … Contexts of codes will be analyzed over time and across data sources.
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digital.ahrq.gov/cpt
January 01, 2023 - The CPT standard consists of three categories:
Category I - codes that describe common medical, surgical … Category II - codes that describe performance measurement variables designed to facilitate data collection … Category III - temporary codes that describe emerging technology, services, and procedures. … CPT codes are used in electronic transaction messages and electronic medical records (EMRs) to accurately … The 2007 version of CPT contains 8,611 codes and descriptors. The standard is updated annually.
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digital.ahrq.gov/sites/default/files/docs/resource/Dataform_3_Medication_Error_and_Near_Miss_Classification_Form.pdf
June 16, 2021 - Reviewer ID Number: ____ ____
See below for codes
3.
Case #
4.
Script #
5. … Near miss
Codes for Question 6 and 8
1. … LMR
Codes for question 11 (Choose all that apply)
1. … None
Codes for Question 12 (Choose all that apply)
1. Physician order
2. … Can’t tell
Codes for Question 13
1. No
2.
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digital.ahrq.gov/icd
January 01, 2023 - The latest version (2001) of ICD-CM is ICD-9-CM , which is the official system of assigning codes to … A draft of ICD-10-CM has been produced; however, the ICD-10-CM codes are not currently valid for any … Expanded injury codes. … Combination diagnosis/symptom codes to reduce the number of codes needed to fully describe a condition
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digital.ahrq.gov/sites/default/files/docs/citation/cds-artifact-enhancement.pdf
December 01, 2018 - Logical
Object Identifier Names and
Codes (LOINC) codes do not
currently exist. … MITRE submitted applications for
LOINC codes to be assigned. … standard codes are not
currently available. … with the standard codes. … If codes are not available for the express need of a concept, developers are
forced to use local codes
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017094-mccolm-final-report-2009.pdf
January 01, 2009 - measure population and
submit those codes to CMS on claims for payment. … Measure 3 is
the systolic and diastolic blood pressure (while two CPT codes are applied, both codes … Four codes could have been assigned to each case. … for this indicator 1244
Total codes assigned by coders 201 16%
Codes not assigned by coders 1043 … Populations based on ICD9 and CPT codes are not standardized.
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digital.ahrq.gov/ahrq-funded-projects/using-precision-performance-measurement-conduct-focused-quality-improvement/annual-summary/2010
January 01, 2010 - Exception codes are being introduced into the EHR for 18 national quality measures. … reasons or medical reasons for why quality measures are not met and assess the use of these exception codes … , the impact of exception reporting on measured levels of quality, and the impact of using these codes … on physician satisfaction and self-reported efficiency. ( Ongoing )
Use the exception codes (patient … intervention increases provision of recommended therapies and tests and documentation of exclusion codes
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digital.ahrq.gov/ahrq-funded-projects/using-precision-performance-measurement-conduct-focused-quality-improvement/annual-summary/2011
January 01, 2011 - Exception codes for 18 national quality measures were introduced into the EHR. … reasons or medical reasons for why quality measures are not met and assess the use of these exception codes … , the impact of exception reporting on measured levels of quality, and the impact of using these codes … (Achieved)
Use the exception codes (patient reasons and medical reasons) that clinicians enter to target … intervention increases provision of recommended therapies and tests and documentation of exclusion codes
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digital.ahrq.gov/standards-0
January 01, 2023 - Summary: The Logical Observation Identifier Names and Codes (LOINC) database provides a universal code … LOINC codes are being used by large reference laboratories and federal agencies, and are part of the … Laboratories should include LOINC codes in their outbound HL7 messages so that clinical and research … CPT)
International Classification of Diseases (ICD)
Logical Observation Identifiers, Names, and Codes … (LOINC)
National Drug Codes (NDC)
Systematized Nomenclature of Medicine (SNOMED-CT)
Standards
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017048-schneider-final-report-2011.pdf
January 01, 2011 - Time
Window
Enc-
ounter
Codes
Clin-
ical
Note
Diag-
nosis
Codes
Med
Codes
Lab
Codes … Lab
Res-
ults
Proc-
edure/
Imag-
ing
Codes
Path/
Imag-
ing
Res-
ults
Use of
Appropriate … Time
Window
Enc-
ounter
Codes
Clin-
ical
Note
Diag-
nosis
Codes
Med
Codes
Lab
Codes … Time
Window
Enc-
ounter
Codes
Clin-
ical
Note
Diag-
nosis
Codes
Med
Codes
Lab
Codes … Time
Window
Enc-
ounter
Codes
Clin-
ical
Note
Diag-
nosis
Codes
Med
Codes
Lab
Codes
-
digital.ahrq.gov/ndc
January 01, 2023 - Background
The National Drug Codes (NDCs) are standards for reporting drugs and biological products … The product and package codes are assigned by the manufacturer.
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digital.ahrq.gov/ahrq-funded-projects/design-toolkit-add-electronic-clinical-data-statewide-hospital-administrative
January 01, 2023 - The addition of clinical data to administrative data—especially present-on-admission (POA) codes and … help data organizations increase effectiveness and efficiency when adding laboratory values or POA codes
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digital.ahrq.gov/sites/default/files/docs/page/08-0085_bcma.pdf
August 01, 2008 - AHRQ-funded projects reported that scanners they tested were unable to
accurately interpret all of the bar codes … Before purchasing bar
code scanners, hospitals should test for compatibility with the bar codes they … Nurses and other caregivers using BCMA
scanners must be able to scan bar codes on medication containers … In-house
repackaging of medications is often necessary to improve the usability of bar codes and to
comply
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digital.ahrq.gov/ahrq-funded-projects/automating-assessment-obesity-care-quality/annual-summary/2010
January 01, 2010 - The study team will use reasons for visit, orders, referrals, diagnosis codes, laboratory test values … working draft of the OCQ Measure Set developed, have begun to identify the content-specific rules and codes … required to identify the relevant clinical events, such as the order codes used at each site, that indicate
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digital.ahrq.gov/ahrq-funded-projects/design-toolkit-add-electronic-clinical-data-statewide-hospital-administrative/annual-summary/2010
January 01, 2010 - Adding clinical data, especially "present-on-admission" (POA) codes and laboratory results, to existing … help data organizations increase effectiveness and efficiency when adding laboratory values or POA codes … Statewide data organizations also expressed uncertainty about the quality of POA codes collected.
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digital.ahrq.gov/sites/default/files/docs/page/2006King_051611comp.pdf
June 16, 2021 - Data Elements currently received
Core Entity Patient ID Data Lab Results Encounter Data
Diagnostic
Codes … (working on the project) identified a
subset of laboratory test results to begin
• A list of ~40 codes … standardized to LOINC across sites
• Send LOINC mappings back to sites to load in their LIS
• Select next 50 codes … to map
• Define process to do annual review and update of LOINC
codes
http://www.volunteer-ehealth.org
-
digital.ahrq.gov/ahrq-funded-projects/automating-assessment-obesity-care-quality/annual-summary/2011
January 01, 2011 - Measures to evaluate the association include: reasons for visit; orders; referrals; diagnosis codes; … (Ongoing)
2011 Activities: Study staff identified the content-specific rules and codes required … to distinguish the relevant clinical events (e.g., the order codes used at each site that indicate "obesity
-
digital.ahrq.gov/sites/default/files/docs/page/2006Levett_051711comp.pdf
June 16, 2021 - Reporting Variables: Service Line, DRG, Physician, Diagnosis,
Procedure, Trending
– Including ICD-9 codes … – Reporting Variables: Major Practice Category, ETG, Physician,
Trends, Office Processes, CPT-4 Codes … , NDC Codes
Tools: Anticoagulation Clinic
Process patient flow chart: This flow chart documents