Free Electronic Health Records And Procedures Essay Sample

Type of paper: Essay

Topic: Health, Medicine, Change Management, Diagnosis, Information, Health Care, Patient, Nursing

Pages: 2

Words: 550

Published: 2020/10/16


An Electronic Health Record (EHR) is a digital record of patient health information that is generally compiled in any hospital setting. The patient’s record includes demographics, progress notes, problems, medications and vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR refers to the software platform that is used to manage these records.
The ICD-9-CM is the modification of the International classification of diseases, ninth revision that was developed by the WHO. It is a universally applied system for coding diagnoses, healthcare encounters and health status. The regulations regarding electronic transactions and codes get promulgated under the ICD-9-CM. However, this has become outdated and obsolete. However, the WHO developed the tenth revision of this system in order to expand the content, include ambulatory care services, increase clinical detail, capture risk factors in primary care and include group diagnoses for epidemiological purposes (Hillestad,2005).
These codes will help improve efficiency and effectiveness of the health care system and lead to improved health benefits from EHR. These code sets would meet the needs of the health data standards of the user community, especially health care providers. It also aims to provide timely development, testing, implementation and updating procedures in order to simplify administrative benefits faster. It would also be technologically independent of computer platforms and transmission proto used in EHR. It would help in being flexible and adapt easily (Sidorov,2006).
In order to be considered medically necessary, the service has to be reasonable and has to be diagnosed or treated for a medical condition. When submitting claims for payment, diagnosis codes reported with the service helps in telling the patient as to why the medical procedure was necessary. For instance, when a patient is ordered to get an ECG done by a doctor, it is performed in the office and interpreted by the doctor with a CPT code. The ECG is being done as the patient had complained of chest pain. There is a code for unspecified chest pain. The provider should document the diagnosis for all procedures that are performed and also include the diagnosis for each diagnostic test ordered. A common mistake while reviewing medical documentations is that the provider will document a diagnosis and tests ordered but it would be unclear if all the tests ordered were for the diagnosis documented for the particular assessment. Apart from the ECG if any other test had been ordered, like an arthrocentesis for knee pain and a chest X-ray, the only diagnosis documented is the knee pain and it supports the medical necessity for the arthrocentesis but not for a chest X-ray. The provider can now be questioned as to why the X-ray was ordered so that the right diagnosis can be reported (Hillestad,2005).
Not all diagnoses for procedures are considered medical necessity. Medicare and commercial payers specify diagnostic codes that support medical necessity for certain procedures. It also includes documentation requirements, which will include diagnostic test values that should be met and less invasive treatments should be attempted before the service is deemed medically necessary.


The ICD-10-CM will provide payers, policy makers and providers with detailed information to establish proper reimbursement rates, improving patient care, efficiency in healthcare delivery, reducing healthcare costs and monitoring service and resource utilization. The ICD-10-CM has been significantly improved when compared to ICD-9-CM (Hillestad,2005).
The ICD-10-CM is specific with clinical data and information that are relevant to ambulatory and managed care encounters. The structure of the ICD-1—CM is such that it allows for greater expansion of code numbers. The new system also includes diseases that were discovered since the recent revision of ICD-9-CM. The disease classification has been updated in order to be consistent with the current clinical practice. Being more specific will help providers and policy makers in improving delivery of health care
and evaluating the quality of patient care and monitoring service and resource utilization (Sidorov,2006).
The ICD-10-CM codes are alphanumeric and include all letters except U to provide a lot of code numbers. The ICD-9-CM’s V and E have also been included. The length of codes in ICD-9-CM was 5 digits but the ICD-10-CM has seven characters in digits and letters. Those conditions that were not identified in ICD-9-CM have been assigned code numbers in ICD-10-CM. These changes are expected to benefit various health care settings.
The ICD-9-CM codes are different than the ICD-10-CM/PCS code sets. These revisions show the changes in the medical and health care field. The ICD-10-CM/PCS codes will improve the quality of data while tracking public health conditions. It will also help in improving data for epidemiological research. These codes will help in measuring outcomes and care provided and in making clinical decisions. It will also assist in spotting fraud and abuse. Designing payment systems and processing claims will become easier (Sidorov, 2006).
However, there is a difference in format for these 2 coding systems. There are nearly 19 times as many procedure codes in ICD-10-PCS than in ICD-9-CM and five times as many diagnosis codes in ICD-10-PCS. While transition to these new code sets will bring about a major change there are significant benefits to this ne coding system over the ICD-9-CM. Some of the important benefits are, it would be easier to compare the mortality and morbidity data. In each and every area there would be improved quality of data. Concepts that did not exist in ICD-9-CM like, dosing, blood type and alcohol level are present in the ICD-10-CM. The transition to ICD-10-CM/PCS code sets have been effective since October 2014 and data received by secondary users coded in ICD-10-CM/PCS (Hillestad,2005).


Hillestad, R., Bigelow, J., Bower, A., Girosi, F., Meili, R., Scoville, R., & Taylor, R. (2005). Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Affairs, 24(5), 1103-1117.
Sidorov, J. (2006). It ain’t necessarily so: the electronic health record and the unlikely prospect of reducing health care costs. Health Affairs, 25(4), 1079-1085.

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Free Electronic Health Records And Procedures Essay Sample. Free Essay Examples - Published Oct 16, 2020. Accessed June 18, 2024.

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