Health Information Management Technology: An Applied Approach Ch. 5

Nonmenclature

A recognized system that lists preferred medical terminology.

Classification Systems

Group together similar diseases and procedures.

Clinical Vocabularies

List of clinical words or phrases with their meanings.

Standard Nomenclature of Disease and Operations

First medical nonmenclature to be universally accepted in the United States which was developed by the New York Academy.

World Health Organization (WHO)

The United Nations specialized agency for health, established on April 7, 1948, with the objective, as set out in its constitution, of the attainment by all peoples of the highest possible levels of health; responsible for the International Statistical Classification of Diseases & Related Health Problems (ICD-10)

Morbidity

State of being diseased (including illness, injury, or deviation from normal health); the number of sick persons or cases of disease in relationship to a specific population.

Mortality

Term referring to the incidence of death in a specific population. The loss of subjects during the course of a clinical research study.

Clinical Users

Providers who use clinical vocabularies and classifications to collect, process, and retrieve data for clinical purposes. Use the vocabularies to support activities such as clinical research, disease prevention, and patient care.

Administrative Users

Healthcare facilities, professional organizations, and government agencies. These groups use clinical vocabularies and classifications to support administrative, statistical, and reimbursement functions.

Current Procedural Terminology (CPT)

Codes used to report physician services to the Medicare program to determine reimbursement.

Healthcare Common Procedure Coding System (HCPCS)

System used for reporting physician and other healthcare services, including non-inpatient procedures.

Cooperating Parties

ICD-9-CM is maintained by four organizations: The National Center for Health Statistics (NCHS), the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), and the Centers for Medicare and Medicaid Services (CMS).

Responsibilities of the Cooperating Parties

Serve as a clearinghouse to answer questions on ICD-9-CM, develop educational materials and programs on ICD-9-CM, to work cooperatively in maintaining the integrity of ICD-9-CM, to recommend revisions and modifications to current and future revisions of ICD.

Uses of ICD-9-CM

Classifying morbidity and mortality information for statistical purposes.

Indexing hospital records by disease and operations.

Reporting diagnosis by physicians.

Storing and retrieving data.

Reporting national morbidity and mortality data.

Serving as the basis of diagnosis-related group (DRG) assignment for hospital reimbursement.

Reporting and compiling healthcare data to assist in the evaluation of medical care planning for healthcare delivery systems.

Determining patterns of care among healthcare providers.

Analyzing payments for health services.

Conducting epidemiological and clinical research.

Volume 1

Tabular List. It contains the numerical listing of codes that represent diseases and injuries. Divided into three subdivisions: classification of diseases and injuries, supplementary classifications, and appendixes. Divided into 17 chapters organized by type of condition and anatomical system. Chapters are further divided into sections. Sections of three-digit code numbers.

Categories

Represent a group of closely related conditions or a single disease entity. Divided into subcategories (four-digit code numbers are used)

V Codes

Used to classify occasions when circumstances other than disease or injury are recorded as the reason for the patient's encounter with the healthcare provider.

E Codes

Classify environmental events, circumstances, and conditions as the cause of injury, poisoning, and other adverse effect.

Volume 2

Index to Diseases and Injuries. Main terms appear alphabetically in the index by type of disease, injury, or illness. Subterms are indented under the main term.

Volume 3

Contains the tabular and alphabetic lists of procedures. Chapters are organized by anatomical system, except for the last chapter, Miscellaneous Diagnostic and Therapeutic Procedures.

ICD-10

Used in the U.S. since 1999 to capture mortality statistics.

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)

Planned replacement for ICD-9-CM, volumes 1 and 2, developed to contain more codes and allow greater specificity.

Include combination codes for conditions and common symptoms or manifestation, decreasing cross-referencing by writing out the full code title for all codes, Providing codes for laterality, providing expanded codes to capture more detail in several sections.

International Classification of Diseases , Tenth Revision, Procedure Coding System (ICD-10-PCS)

Separate procedure coding system that would replace ICD-9-CM, volume 3, intended to improve coding accuracy and efficiency, reduce training effort, and improve communication with physicians. Consists of a multiaxial seven-character alphanumeric code structure. The 10 digits 0-9 and the 24 letters A-H, J-N, P-Z. All have seven characters. The first character specifies the section where the procedure is indexed. The second through the seventh characters have a meaning within each section.

International Classification of Functioning, Disability, and Health (ICF)

Provides unifying frameworks for classifying the consequences of disease. It is structured around the following broad components: body functions and structure, activities (related to tasks and actions by an individual) and participation (involvement in a life situation), additional information on severity and environmental factors.

International Classification of Diseases for Oncology, Third Edition (ICD-O-3)

First edition was published in 1976. System used for classifying incidences of malignant disease. Hospitals use this only for severe purposes, for example, to develop cancer registries.

Oncology

Study of neoplasms (new tissue), or tumors.

Morphology

Structure

Topography

Site

Morphology Codes

Identify the type of tumor found and its behavior. It consists of the letter M followed by five digits. The first four digits identify the histological type of neoplasm. The fifth digit identifies the behavior of the tumor.

Behavior code/0

Benign

/1

Uncertain whether benign or malignant, borderline malignancy

Behavior code/2

Carcinoma in situ

Intraepithelial

Noninfiltrating

Non-invasive

Behavior code/3

Malignant, primary site

Behavior code/6

Malignant, metastatic site

Secondary site

Behavior code /9

Malignant, uncertain whether primary or metastatic site

Healthcare Common Procedure Coding System (HCPCS) pronounced Hick Picks

Used to report physicians' services to Medicare for reimbursement. Collection of codes and descriptors used to represent healthcare procedures, supplies, products, and services.

Level I HCPCS

AMA's CPT codes. These five-digit codes and two-digit modifiers are copyrighted by the AMA. Modify or change code description.

Level II HCPCS

Also called National Codes, are maintained by CMS. Developed to code medical services, equipment, and supplies that are not included in CPT.

Current Procedural Terminology, Version 4 (CPT-4)

Comprehensive descriptive listing of terms and codes for reporting diagnostic and therapeutic procedures and medical services. System for standard terminology and coding to report medical procedures and services.

CPT Introduction

Contains a list of the codebook section numbers and their sequences and instructions for use.

CPT Sections

Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and Laboratory, Medicine, Category II Codes, Category III Codes.

Category II Codes

Designed as "supplemental tracking codes that can be used for performance measurements"

Category III Codes

Allow for temporary coding assignment for new technology and services that do not meet rigorous requirements necessary to be added to the main section of the CPT book.

CPT Appendix A

Provides a complete list of modifiers and their descriptions. Modifiers are written as two-digit codes that follow the main CPT codes.

CPT Appendix B

Summary of the additions, deletions, and revisions that have been implemented for the current CPT edition.

CPT Appendix C

Provides clinical examples for codes found in the evaluation and management section (E/M) of the book.

CPT Appendix D

Listing of CPT add-on codes.

CPT Appendix E

Summary of CPT codes that are exempt from modifier 51.

CPT Appendix F

Summary of CPT codes that are exempt from modifier 63.

CPT Appendix G

Contains codes that include conscious/moderate sedation.

CPT Appendix H

Alphabetic index of performance measures by clinical condition or type but was removed from CPT.

CPT Appendix I

Contains genetic testing code modifiers used for reporting with lab procedures related to genetic testing.

CPT Appendix J

Listing of sensory, motor, and mixed nerves that are useful for nerve condition studies.

CPT Appendix K

Lists procedures included in the CPT code book that are not yet approved by the FDA.

CPT Appendix L

Reference of the vascular families including which are considered first-, second-, and third-order vessels.

CPT Appendix M

Displays a table of deleted CPT codes and crosswalks to current codes.

CPT Appendix N

Listing of codes that have been resequenced.

CPT Index

Lists main terms alphabetically:

Procedure or service

Organ or other anatomic site

Condition

Synonym, eponym, or abbreviation

The Systematized Nomenclature of Medicine Clinical Terminology (SNOMED CT)

Standardized vocabulary, sometimes referred to as a controlled reference terminology.

Read Codes

The former name of the United Kingdom's CTV3 codes; named for James Read, the physician who originally devised the system to organize computer-based patient data in his primary care practice.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV)

Tool for providing a set of codes that could be used to aid in the collection of clinical data using stand-alone personal computers. Provide a means to record data on patients treated for substance abuse and mental disorders.

Nursing Vocabularies

Used to classify nursing diagnosis, interventions, and outcomes in various healthcare settings. Developed to aid in the collection of data about nursing care. Used to determine the appropriate plan of care for the patient.

Reliability in coding

Degree to which the same results are achieved consistently (that is, when different individuals code the same health record, they assign the same code)

Validity in coding

Degree to which codes accurately reflect the patient's diagnoses and procedures.

Completeness in coding

Degree to which the codes capture all the diagnoses and procedures documented in the health record.

Timeliness in coding

Time frame in which the health records are coded.

Encoder

Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system.

Natural Language Processing (NLP)

Field of computer science and linguistics concerned with the interactions between computers and human (natural) languages that converts information from computer databases into readable human language.

Logic based encoders

As the coder answers questions, the encoder leads the coder to codes for diagnosis and procedures.

Knowledge based encoders

Utilize more of an electronic code book by automating a look-up function similar to the manual index in ICD or other coding classifications.

Interface

Zone between different computer systems across which users want to pass information (for example, a computer program written to exchange information between systems or the graphic display of an application program designed to make the program easier to use)

Computer-assisted coding (CAC)

Utilizes natural language processing (NLP) and algorithmic software to electronically analyze entire medical charts to pre-code with both CPT procedure and ICD-9 diagnostic nomenclatures.

National Library of Medicine UMLS Project

Purpose is to aid in the development of systems that help healthcare professionals retrieve and integrate electronical biomedical information from a variety of sources.

Metathesaurus

Provides a uniform collection of more than one hundred biomedical/health-related vocabularies, coding systems, and classifications and links the different names used in the various vocabularies and classifications.

Specialist lexicon

Contains syntactic information for many terms.

Semantic Network

Provides a system for categorizing objects and identifying the relationship among various concepts.

Nosology

Branch of medical science that deals with classification systems.

Nosologist

Person who works with using and developing classification systems.