Medical Coding

Topics

• Medical Coding
• ICD-9
• Knowledge Base
• Thresholds
• Sample Claim

Medical Coding

Whenever you go to the hospital (emergency room, doctor's appointment, or lengthy stay), the hospital needs to file claims with your insurance company so that they can get paid, and you can be covered. As in most situations where vagaries can cause major problems, certain systems have been created to ensure that communications are accurate. In the case of medical reimbursement, there are a number of different coding systems in place which map diagnoses and medicial procedures to a system of numbers and letters. This mapping is essential for the communications between hospitals and insurance companies so that the hospital, and the patient, can be correctly reimbursed and covered.

ICD-9

ICD-9, or International Classification of Diseases, Ninth Revision, is a government regulated standard for medical coding. It was originally intended to be used for mortality statistics, established in 1900. Essentially, it provided a simple mechanism for determining what cause of death should be reported on a death certificate. The medical community revised the classifications to create ICD-9-CM, or ICD-9 Clinical Modification. The modifications added codes for inpatient medical procedures. More information can be found at http://www.cdc.gov/nchs/about/major/dvs/icd9des.htm. For this project, I will be using a coding structure similar to ICD-9-CM, but it will be entirely made up as the intricacies of the rules pertaining to using ICD-9-CM codes is beyond the scope of this project.

Knowledge Base

The purpose of my project is to assist medical coders in making their claims as accurate as possible. To do this, I plan to use a knowledge base which will be updated with every claim put through the system. The goal of the knowledge base is to suggest codes that are likely to appear with the codes already entered, but which were left out. It is not uncommon for doctors to forget to write down everything they do, and this program will allow the coders to question the doctors concerning common procedures that they may have forgotten to take note of.

Thresholds

To make sure that the suggestions offered by the program are meaningful, a series of threshold values will be put in place, possibly modifiable by the user. These values would require a code be present with another code on X number of claims, or appear with another code at least X% of the time before being suggested to the coder. It will also be possible to use a combination of the two threshold types so that a code must appear with another code at least X times and at least X% of the time. This ensures that the codes being offered have a significant chance of actually being needed.

Sample Claim

Main Project Page