Unit II Assessment QUESTION 1 Explain the differences in structure between ICD-10-CM and ICD-10-PCS and give an example of each. Your response must be at least 75 words in length. QUESTION 2 Explai

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Introduction:
As a medical professor in charge of creating college assignments and answers for medical college students, it is imperative to equip students with in-depth knowledge and understanding of medical coding. In this assessment, we will explore the differences in structure and examples of ICD-10-CM and ICD-10-PCS, the meaning and appropriate response to NOS and NEC abbreviations, outline the steps in ICD-10-CM coding, and the benefits of medical coding in the healthcare industry.

Question 1:
ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) is a coding system used for representing medical diagnoses and reasons for health care encounters. It is alphanumeric and has a hierarchical structure with three to seven characters. For example, S82.091A is used to represent a closed fracture of the lower end of the right tibia, initial encounter, which has the structure of an initial character, body system or anatomical region, etiology, severity, and extension. On the other hand, ICD-10-PCS (International Classification of Diseases, Tenth Revision, Procedure Coding System) is used to code medical procedures or surgeries. It is also alphanumeric and has a seven-character structure that includes specific details such as body system, type of procedure, approach, and device. For example, 0DQMXZZ is used to represent the insertion of an external ventricular drainage device, percutaneous approach, which has the structure of a body system, root operation, approach, device, qualifier, and value.

Question 2:
NOS (Not Otherwise Specified) and NEC (Not Elsewhere Classified) are abbreviations used in medical coding to indicate a lack of information or an unspecified diagnosis. NOS is used when there is not enough information to code a specific diagnosis, while NEC is used when a diagnosis does not fall into any of the specific categories available. Therefore, it is essential to avoid the use of NOS and NEC in medical coding and instead consult with the provider or medical records for further clarification. The appropriate response to seeing these abbreviations is to query the provider or seek further documentation to ensure accuracy and specificity in coding.

Question 3:
The process of ICD-10-CM coding involves several steps that include reviewing the medical documentation, assigning and sequencing diagnosis codes using the Index to Diseases and Injuries and the Tabular List of Diseases and Injuries, and verifying code assignment. The Index to Diseases and Injuries serves as an alphabetical index to locate diagnoses, while the Tabular List of Diseases and Injuries is a chapter-wise listing of codes with definitions, instructional notes, and code first, and includes tables used to expand code choices. These two tools add to the level of specificity in medical coding by providing a comprehensive list of the available codes, allowing for more detailed descriptions of diagnoses, and ensuring accuracy and consistency in coding.

Question 4:
Other than reimbursement, medical coding has other benefits in the healthcare industry. Proper medical coding plays an essential role in public health research and surveillance, population health management, and quality improvement. Organizations such as the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) can use coding data to track diseases, identify trends, and develop public health interventions. Medical coding also enables healthcare organizations to streamline billing processes, monitor patient outcomes, and ensure compliance with legal and regulatory requirements. Overall, medical coding is an integral part of the healthcare system and plays a crucial role in improving patient care, population health, and healthcare management.