LESSON 2
DIAGNOSTIC AND OPERATIVE CODING
Section I. GENERAL
2-1. INTRODUCTION
Statistical information is used for research, training, manpower requirements,
budget requirements, and future planning for the medical community. One of the
elements of statistical information is the numerical classification of diseases, injuries,
and operative procedures. Medical terminology does not blend into the computerized
statistical reports required by the Army, so a numerical classification is used. You may
recall from the lesson you had in admission and disposition procedures the use of the
ICD-9-CM code number on the imprinting plate which was initiated at the time of
admission. In this lesson, you will learn the process of coding diseases, injuries, and
operative procedures and put that knowledge to practical use in your work in the Patient
Administration Division (PAD).
2-2. CLASSIFICATION OF DISEASES AND PROCEDURES
a. The resource used in the classification of diseases and medical procedures is
the International Classification of Diseases-9th Revision Clinical Modification
(ICD-9-CM). The ICD-9-CM consists of three volumes which are based on the
International Classification of Diseases, 9th Revision (ICD-9) published by the World
Health Organization. These references provide for classification of morbidity and
mortality information for statistical purposes and for indexing of hospital records by
disease and by medical operation to facilitate data storage and retrieval.
b. History and Development of the ICD-9-CM. In February 1977, a steering
committee was convened by the National Center for Health Statistics to provide advice
and counsel to the development of a clinical modification of the International
Classification of Diseases, 9th Revision. As a result of this steering committee's efforts,
the ICD-9-CM was published in 1979. The second edition that you are using is probably
dated September 1980. The term "clinical" is used to emphasize the modification's
intent; to serve as a useful tool in the area of classification of morbidity data for indexing
of medical records, medical care review, ambulatory and other medical care programs,
as well as for basic health statistics. To describe the clinical picture of the patient, the
codes must be more precise than those needed only for statistical grouping and trend
analysis.
c. The ICD-9-CM is totally compatible with its parent system, the ICD-9, thus
meeting the need for comparability of morbidity and mortality statistics at the
international level.
MD0753
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