Abstract:
Objective: Diagnosis coding is a core clinical competency. A basic understanding of the structure of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), the conventions and rules for diagnosis coding, and what constitutes accurate coding, is fundamental to the clinician\'s knowledge base. This commentary seeks to provide a practical framework for clinicians to perform accurate diagnosis coding of neurocognitive disorders. Method: This paper: (1) summarizes the structure of the ICD-10-CM, (2) describes the rules and conventions of diagnosis coding for diagnostic categories relevant to neurocognitive disorders, (3) presents clinical examples and pragmatic recommendations to help readers improve their day-to-day use of diagnosis codes, and (4) describes limitations and discrepancies in the diagnosis coding advice for neurocognitive disorders presented within the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) and the DSM-5-TR Neurocognitive Disorders Supplement. Its content originates from the ICD-10-CM itself and its companion document, the ICD-10-CM Official Guidelines for Coding and Reporting. Conclusion: The ICD-10-CM classification scheme is logically organized and easy to navigate for users who understand its structure and rules. Many neuropsychologists rely on the DSM-5-TR diagnosis coding advice, however that advice is limited with respect to the range of diagnosis codes relevant to neurocognitive disorders and their underlying causes. Relying on the ICD-10-CM directly for diagnosis coding of neurocognitive disorders, rather than the DSM-5-TR or other secondary sources, is therefore preferable and aids clinicians in accurate diagnosis coding.
摘要:
目的:诊断编码是临床核心能力。对国际疾病分类的结构有基本的了解,第十次修订,临床修改(ICD-10-CM),诊断编码的惯例和规则,什么构成了准确的编码,是临床医生知识库的基础。本评论旨在为临床医生提供一个实用的框架,以对神经认知障碍进行准确的诊断编码。研究方法:(1)总结了ICD-10-CM的结构,(2)描述了与神经认知障碍相关的诊断类别的诊断编码规则和惯例,(3)提供临床实例和务实的建议,以帮助读者改善他们的诊断代码的日常使用,和(4)描述了在精神疾病诊断和统计手册中提出的神经认知障碍的诊断编码建议的局限性和差异,第五版,文本修订(DSM-5-TR)和DSM-5-TR神经认知障碍补充。其内容来源于ICD-10-CM本身及其配套文件,ICD-10-CM编码和报告官方指南。结论:ICD-10-CM分类方案在逻辑上是有组织的,对于了解其结构和规则的用户来说,易于导航。许多神经心理学家依赖于DSM-5-TR诊断编码建议,然而,关于与神经认知障碍相关的诊断代码范围及其根本原因的建议是有限的。直接依靠ICD-10-CM进行神经认知障碍的诊断编码,而不是DSM-5-TR或其他次要来源,因此是优选的,并帮助临床医生进行准确的诊断编码。