Chapter 6: Nomenclatures and Classification Systems
Eponyms
Words that are based on the personal names of people
Medical language
Words, their pronunciations, and the methods of combining them that have been established by long period of usage and are understood by the medical profession
International Classification of Diseases (ICD)
authoritative index of mental and physical diseases, including infectious diseases, and the criteria for their diagnosis; published by the World Health Organization (WHO)
Vocabulary
List of words or phrases and their associated meanings that have been accepted by a discipline, group, or organization to express, organize, and index concepts and phenomena of interest
Health care fraud and abuse
The false misrepresentation or intentional deception of fact that is a departure from reasonable use that could result in unauthorized payment
Case mix
Type and volume of patients a health care organization treats
ICD-10-CM
Used by numerous health care entities in different types of health care settings to code and classify diseases
DSM-V
Used by psychiatric institutions and psychiatric units within health care facilities as a source of diagnostic info
Alternative Billing Codes (ABC codes)
Used to classify services, supplies, or therapies provided in outpatient settings and not ordinarily found in CPT
Clinical vocabulary
Vocabulary that specializes in words or phrases of a clinical or medical nature
Case mix index
A formula wherein a relative value is assigned after adding MS-DRG weights for a group of patients discharged during a certain period and dividing it by the total number of patients discharged
Case mix management
An organization analyzes the patient case mix as it relates to reimbursement and the organization's financial health
Evaluation
Assessment of info to reach a specific conclusion
General equivalency mappings (GEMs)
Attempts to include all valid relationships between the National Centers for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS)
International Classification of Health Interventions (ICHI)
Tool for reporting and analyzing the distribution and evolution of health internet ions for statistical purposes
Physician query process
Contacting the physician responsible for the patient's care to request clarification about the documentation in the patient's health record so that the appropriate code can be assigned
Semantic Network
Contains info about the types or categories to which all Metathesaurus concepts have been assigned and the permissible relationships among these types
Lexicon
Contains syntactic info and tools for many terms, component words, and English words that don't appear in the Metathesaurus
Diagnosis-related group (DRG)
Classification system that groups patients who are medically related by diagnosis, treatment, length of stay, age, and sex
Classification of Diseases for Oncology (ICD-O-3)
Classification system that used a 10-digit code to describe a tumor's primary site topology, histology, behavior, and aggression
International Classification of Injuries, Disabilities, and Handicaps (ICIDH)/International Classification of Functioning, Disability, and Health (ICF)
Classifies health and health-related domains that describe body functions and structure, activities, and participation
International Classification of Primary Care (ICPC-2)
Classifies patient data and clinical activity in the domains of general, family, and primary care practices
Systemized Nomenclature of Medicine (SNOMED)
Comprehensive nomenclature that was first published by American College of Pathologists in 1977 and classifies terminology in order of localization and etiology and also classifies terminology by morphology, function, disease, and procedures
Resource-Based Relative Value Scale (RBRVS)
DRG-type system for reimbursement of physician services
ICD-10-PCS
Designed solely for use in inpatient hospital settings only to classify procedure data from inpatient health records
International Classification of External Causes of Injury (ICECI)
Designed to describe, measure, and monitor the occurrence of injury
Compliance
Efforts made to establish a culture that promotes prevention, detection, and resolution of instances of conduct that don't conform to applicable local, state, and federal laws and regulations
Coding compliance program
Ensures the establishment of effective internal controls that detect, correct, and prevent coding errors and promote adherence to the applicable local, state, and federal laws and regulations and the program requirements of federal, state, and private health plans
Healthcare Common Procedure Coding System (HCPCS)
Expanded version of CPT that includes codes for non physician services, including NPs, clinical social workers, nurse midwives, and PAs
Unified Medical Language System (UMLS)
Goal is to enable computer systems to understand medical meaning, thereby allowing disparate EHR systems to communicate with each other and health professionals and researchers to retrieve and integrate electronic biomedical info from various sources
Major diagnostic category (MDC)
Grouping based on the organ or system involved
Classification systems/taxonomies
Groupings of similar items that have 1+ common denominators serving as a way to organize related entities for easy retrieval
Systematized Nomenclature of Pathology (SNOP)
Nomenclature published by the American College of Pathologists that is useful in classifying pathological specimens
Nosologist
Persons who are responsible for the development, maintenance, and management of vocabularies and classification systems
Upcoding
Practice of selecting a code and submitting a bill for a higher level of reimbursement that's actually rendered in order to receive a higher reimbursement
Coding
Process by which a numeric or alphanumeric code listed in a classification system is assigned to data found in the health record
Data mapping
Process of linking terminology between two different schemes, a target and source, for a given purpose
Management
Process of working within a framework to achieve a goal
Metathesaurus
Provides a uniform, integrated distribution format for more than 100 biomedical vocabularies and classifications, linking many different names for the same concepts
Data set
Provides structure and context to the data needed for a given purpose by forming a list of recommended data elements with uniform definitions
Current Dental Terminology (CDT)
Published by American Dental Association and classifies dental procedures and services
National Drug Codes (NDC)
Published by a variety of vendors and managed by the US FDA, and serves as a universal product identifier for prescription drugs and select OTC products
Current Procedural Terminology (CPT)
Published by the AMA and is a comprehensive listing of medical terms and codes used to designate diagnostic and therapeutic procedures
Standard Classified Nomenclature of Disease (SNDO)
Published in 1993 by the AMA and classified diagnostic terminology in order of localization and ecology
Clinical terminology
Recognized system of preferred clinical or medical terminology
Optimizing programs
Seek the highest-paying MS-DRG based on the codes assigned and in compliance with prevailing regulations
Natural language processing encoding systems
Software programs can read and interpret digital text from online documents and automatically assign appropriate codes
Groupers
Software programs that use branching logic to arrive at the most accurate MS-DRG
Encoders
Software tools that incorporate the text and logic of coding systems into an automated form
Prospective payment system (PPS)
System for Medicare patients by which a predetermined level of reimbursement is established before services are provided
Nomenclature/terminology
Systematic listing of proper names for concepts, items, actions, and other aspects of a particular area of interest or knowledge
Clinical data representation
The way in which clinical data are presented using classification systems, clinical vocabularies, other forms of data, and standards
