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Acta Inform Med. 2010; 18(1): 34-36


Code Wars

Ilir,Akshija,,Elizana,Petrela,Zaimi.

Abstract
The electronic patient record (EPR), being the new paradigm shift at the end of paper based era, is not being accepted easily. From many issues that obstacle its implementation, the codification of diagnoses is one of them. Also, the expected code change from ICD-9-CM to ICD-10 is another issue that has to be addressed correctly. Is the first time that diagnoses codes are being used to justify payment for care. For decades coding served for multiple purposes, but two critical issues as quality of coding and their use from insurance companies were not taken in consideration. The regulatory procedures as the first step coders charge doctors and the revision of them is the daily job of medical record department. But not practical methodology is offered till now for use of the EPR as useful and trusted source for the many of its purposes, including payment for health care. The paper starts with a short descriptive analysis of the actual coding methodology in quality of coding and proposes the necessary improvements in methodology, suggesting the job description for people which will be the trusted coders.

Key words: Electronic Patient Record, ICD-9-CM, ICD-10, Code Wars






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