HIM Chapter 5 - Clinical Terminologies, Classifications, Code Systems

ICD-O-3 use

-planning and evaluating patient case -administrative info for facility planners, cancer committess, and practitioners -developing and evaluating cancer control programs -cancer research

ICF classification levels

1- chapter 2- branches are the tiered levels

LOINC Fully specified name includes 6 parts:

1. component analyte 2. kind of property 3. time aspect 4. system 5. scale 6. method ( used when different methodolgoies significantly change the interpretation)

ICD-O-3 five main sections

1. instructions 2. topography numerical list 3. morphology numerical list 4. alphabetic index 5. differences in morphology codes between second and third edition

ICD-10-CM is divided into how many chapters?

21 chapters within each chapter are blocks of conditions related in some manner, such as a single disease entity, categories and subcategories

ICD-11-MMS content and structure

26 chapters one supplemental section one extension code chapter WHO includes ancient Chinese Medicine disorders

ICDM-10-CM content and structure

3-7 character codes and descriptions for patient conditions symptoms syndromes diseases other reasons for patient heatlhcare instructions known as 'conventions' are included as part of the classification

Nursing Outcomes Classification (NOC)

A classification system that defines and describes patient outcomes to nursing interventions.

HCPCS levell II is divided into chapters:

A codes: transportation B codes: therapy C codes: outpatient prospective payment system D: dental E: medical equipment G: procedures/services H: alcohol and drug abuse treatment J: drugs administered K: temporary L: orthotic and prosthetic M: medical services P: pathology and laboratory Q: temporary R: diagnostic radiology S: temporary national (non medicare) T: Temporary national V: vision and hearing

LOINC

A common language (set of identifiers, names, and codes) for identifying health measurements, observations, and documents. If you think of an observation as a "question" and the observation result value as an "answer."

Clinical terminologies

A set of standardized terms and their synonyms that record patient findings, circumstances, events, and interventions with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement

Nursing Terminologies

A systematic standardized way of describing nursing practice and includes data sets, taxonomies, nomenclatures, and classification systems. American Nursing Association(ANA) has specific criteria

SNOMED CT Identifier

A unique integer assigned to each SNOMED CT component item indentifier partition identifier check-digit

code system

An accumulation of terms and codes for exchanging or storing information

ICD-10-CM Index to Diseases and Injuries ICD-10CM Index to External Causes

An alphabetical listing of terms and their corresponding codes, which include specific illnesses, injuries, eponyms, abbreviations, and other descriptive diagnostic terms. Two tables - neoplasm/drugs and chemicals Main terms - the condition of the patient Modifying terms - further explain the condition

ICD-10-PCS updates are available when?

April 1 - address new technologies and October 1 - update happens yearly

Umbrella terms - functioning

Body functions Body structures and activities Participation

As a classification; ICF four code components

Body structures Body functions activities and participation environmental factors

Unified Medical Language System (UMLS)

Centralized location of health and biomedical terminologies and standards having access to terminologies, classifications, and code systems from a signle source is made possible by NLM via UMLS

CCDS

Common Clinical Data Set combination of common sets of data types and elements and associated standards used across several certification criteria used across inpaitent and ambulatory

ICD-10-PCS tables

Composed of grids specifying the valid combinations of characters that make up a procedure code alphanumeric order

ICD-10-CM Coordination and Maintenance Committee

Composed of representatives from the National Center for Health Statistics (NCHS) and Centers for Medicare and Medicaid Services (CMS) that is responsible for maintaining the US clinical modification version of the ICD-10-CM/PCS code sets.

Diagnostic and Statistical Manual of Mental Disorders (DSM) 5th Edition

Developed by American Psychiatric Association (APA)

ICF purposes

Four primary purposes: 1. to provide scientific basis for understanding and studying health realted states/ outcomes 2. to establish common language for describing health and health related states to improve communciation between different users 3. permit comparison of data across countries, healthcare disciplines, services, time 4. provide a systematic coding scheme for health information systems

SNOMED CT allows for what level of collection?

Granular level of clinical data (Drop down option of clinical terms, clinical terms have unseen identifiers attached)

CPT divided into three categories:

I - major terminology II - performance measurement III - emerging technologies, procedures, services

CPT Category I

I - major terminology : description along with 5 digit code for each service (2 digit modifiers 6 main sections: Evaluation and Management (E/M) Anasthesia Surgery Radiology Pathology and Laboratory Medicine

APA updates

ICD-10-CM codes for DSM-5 dianosesyearly and issues other revisions as needed to address advances in the science of mental disorders

Tumor or cancer registries consider what as their system?

ICD-O-3 for classifying topography and morphology of neoplasms

ICD-11-MMS

International Classification of Diseases 11th Revision for Mortality and Morbidity Statistics linearization of the ICD-11 foundation component continuously updated because of the collaborative open development and maintenance process

ICD-10-CM

International Classification of Diseases, 10th Revision, Clinical Modification National Center for Health Statistics (NCHS) governmental body responsible for maintenance it originates from the World Health Organization's (WHO) International Statistical Classification of Diseases and Related Health Problems 10th Revision

ICD-11

International Classification of Diseases, Eleventh Revision

ICF

International Classification of Functioning, Disability, and Health

Logical Observation Identifiers Names and Codes

LOINC

SNOMED Clinical Terms (CT) is the

Most comprehensive, multilingual clinical healthcare terminology in the world

UHDDS was developed thru

National Committee on Vital Health and Statistics (NCVHS)

ICD-10-PCS - Medical/Surgical Section

Obstetrics placement administration measurement and monitoring extracorporeal or systemic assistance extracorporeal or systemic therapies osteopathic chiropractic

ONC

Office of the National Coordinator for Health Information Technology

Common Clinical Data Set

Office of the National Coordinator for Health Information Technology (ONC) established a common set of data types and elements and associated standards for use across several certification criteria

How many meanings does a concept have?

Only one, even though more than one term may be associated

Regenstrief LOING Mapping Assistant

RELMA assist in the mapping of local items to the universal LOINC codes

Purpose of nursing terminologies?

Represent clinical information generated and used by nursing staff to communicate consistent information about nursing services for a variety of reasons including directing patient care, measuring progress of treatment, administrative functions, education, and analytical purposes

CPT Category III

Represent emerging technologies. 5-digit alphanumeric code ending with T.

SNOMED CT extension occurs when?

SNOMED CT International release does not contain content needed at the national, local, or organization level

Code systems are used for what level of data?

Some used for granular level when details are key some used for aggregate level when the combination of data provides information that is sufficient

RxNorm

Standardized nomenclature for clinical drugs semantic interoperability tool

ICD-O-3

The International Classification of Diseases for Oncology. used for coding diagnoses of neoplasms in tumor and cancer registries and in pathology laboratories.

RxNorm concept unique identifier (RXCUI)

The drug name and all of its synonyms, which represent a single concept

When is the ICD-10-CM updated?

Twice a year October always occurs April occurs when it is neccesary for improving timeliness of data

UHDDS CMS-1450

Uniform Bill UB-40 used for paper UHDDS claims

ICD-O-3 is a derived classification of what?

WHO Family of International Classifications and is based on ICD

ICD-11 Foundation Component

WHO revised ICD-11 in 2000 with the goal to procude a classification that relfects scientific and medical advances can be integrated with electronic health applications makes it significantly easier for healthcare organizations to implement

DSM-5 fills the need for

a clear and concise description of each mental disorder it standardizes clinician's diagnostic process for patients

SNOMED CT defines a concept as_____

a clinical idea to which a unique identifier has been assigned example of clinical concepts are: diagnoses and procedures

Classification

a clinical vocabulary, terminology, or nomenclature that lists words or phrases and their meanings

What would be used by the hopsital to explain the reason for a patient being admitted and dischared for care and the inpatient procedures performed?

a diagnosis coded in ICD-10-CM code combined with a procedure coded in ICD-10-PCS

SNOMED CT concept definition

a set of one or more axioms(true statements) that serve as a starting point for further reasoning and arguments

A code system is the______

accumulation of terms and codes for the exchange or storing of information

RxNorm purpose

allow computer systems to efficiently and unambiguously communicate drug related information between hospitals pharmacies and other organizations normalize names of generic and trade name drugs and attach unique identifier to that name

Semantic tag

allows differentiation among concept domains ulcer (disorder) vs ulcer (morphologic abnormality)

ICD-10-PCS Index

alphabetic organized by two types of main terms 1. common procedure names 2. based on the value of the third character of 7 character code

Stem code + extension code : what combines the two

ampersand &

code set

any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes; includes both the codes and their descriptions

In LOINC each lab test

assigned a permanent code

Derived classification

based on a reference classification such as ICD or ICF by adopting the reference classification structure, categories, and providing additional details

LOINC is one of several standards to____

be chosen for the entry of structured data in certified EHR systems

ICF conent and structure:

both a model and classification

ICD-11 Tabular List

built for a cuse case, such as reporting mortality and morbidity or primary care

ICF is updated?

by WHO once a year October

EHR

can capture the detail of clinical data, observations about the patient

If the objective is aggregate data then,

classifications are a better choice

ICF uses:

clinical practice population based census survey data education systems policy making advocacy

If data granularity is the goal of collecting the data,

clinical terminologies is the best choice

ONC's interoperability building blocks?

clinical terminologies, classifications, code systems they support by providing mutual understandinf of the meaning of data exchanged

UMLS Metathesaurus

codes and terms from over 200 terminology, classification and coding standards

semantic clinical drug term type

combination of ingredients plus strength plust dose form

UHDDS defines and lists a set of

common data elements for the purpose of facilitating the collection of uniform and comparable health information from hospitals

SNOMED CT is made up of three main components____

concepts discriptions relationships each assigned a unique numeric and machine readble SNOMED CT identifier (SCTID)

DSM-5 may be used to

conduct clinical assessments develop comprehensive treatment plan standard language for communicating between healthcare providers about mental health

HCPCS level II content and structure

contains products, supplies, services ambulance services drugs durable medical equipment prosthetics orthotics supplies

Granular level of clinical data

data consisting of small components or details at lowest level (SNOMED CT)

Aggregate data is what?

data extracted from individual health records and may be combined to form deidentified information about groups of patients that can be analyzed

Aggregation of clinical data

data used for secondary data purposes (ICD-10-CM)

Electronic Health Record Standards and Certification Criteria Rule

defines the standards that must be used for the EKR technology to be certified by the authorized Certification Bodies

Sufficiently defined concept

defining characteristics are enough to define the concept in the contextr of its hierarchy

DSM-5 contains diagnostic criteria for

depressive, anxiety, feeding and eating, and personality disorders

ICD-O-3 morphology code

describes charactertistics of the tumor cell type biologic activity

ICD-10-CM is named as the standard for what?

diseases injuries impairments other health related problems, their manifestations and causes of injuries healthcare providers must report dianogses to public as well as private insurers using ICD-10-CM

Partially defined (primitive concept)

does not have the required characteristics to distinguish it from similar concepts

ICD-O-3 content and structure

dual classification contains a set of codes for topography and morphology of tumors site of origin - topography characteristics of tumor - morphology

LOINC faciliatates the

exchange of data between diverse electronic systems including the clinical laboratory ifnormation management and the EHR it also uses clinical data to study the outcomes and improve care

Clinical terminologies, classifications, and code systems

exist to name and arrange medical content so it can be used for patient care, monitor outcomes, research, administrative activities

CPT codes

five character identifiers two character identifiers indicate the service or procedure performed has been altered in circumstance but not changed in definition

Stem code + stem codes : what combines

forward slash /

ICF is the WHO

framework for measuring health and disability at both individual and population levels

SNOMED CT Description types

fully specified name (FSN) - unique text assigned to a concept that completely describes it synonym - alternative way to describe the meaning of the concept in a specific language (preferred term) preferred term - synonym that is the description assiged to a concept that is the most commonly used in a clincal record for a specific language

ICD classifies

health conditions

NCQA collects the data from

health plans healthcare organizations government agencies the data collected form the basis of performance improvement (PI) efforts for health plans

SNOMED CT Descriptions

human readble representations of concepts there may be multiple each designated a description type

code

identifier of data

DSM-5 codes are used to

identify mental health disorders ICD-10-CM codes are incorporated into the classification

ICD-10-PCS ancillary sections

imaging nuclear medicine radiation therapy physical rehabilitation mental health substance abuse treatment new technology

Umbrella terms - disability

impairments activity limitations participation restrictions

HCPCS level I

includes (5) five-digit CPT codes developed and published by the American Medical Association (AMA).

Nursing Intervention Classification (NIC)

includes a label, name, definition, number code, set of activities to carry out the intervention

CPT content and structure

includes codes, descriptions, guidelines and covers the breadth of health services physicians provide new patient visit anesthetic services surigcal procedures radiology services pathology and lab tests medical care

RxNorm normalized drug name is the

ingredient strength dose form updated weekly

ICD-11-MMS conventions

instructions such as code also or use additional code Reference guide contains info on conventions and instructions on how to apply them

Classifications are

key to secondary data use because they aggregate data for healthcare statistics, design payment systems, and determine correct payment provide data that are used in monitoring public health risks

ICD-11 is a network of

knowledge placed into a database from the foundation componenet that a linearization and county specific modifications are built

LOINC laboratory

laboratory tests such as chemistry urinalysis serology toxicology

ICF provides standard

language terms concepts organized data structure for health and disability information

ICD-10 Procedure Coding System (ICD-10-PCS)

like CPT identifies the procedure performed by the provider created as a companion to ICD-10-CM and not as a replacement for CPT

UMLS Uses

linking health info across different computer systems coordination patient care among different hospitals search engine retrieval data mining reporting public health statistics researching terminology

Vocabulary

list of collection of clinical words or phrases and their meanings

Data set is a

list of recommended data elements with uniform definitions used to collect statistical data for national and state registries gather data for clinical decision support and for reporting clinical quality measures

Merit Based Incentive Payment System e-prescribing measure

lists RxNorm as the standard

Observation

measurement, test, or simple assertion

HCPCS level II purpose

meet operational needs of Medicare and Medicaid reimbursement programs required for reimbursement of ambulatory services provided in healthcare settings

UMLS contains

metathesaurus semantic network specialist lexicon lexical tools make up UMLS knowledge resources

ICD-11-MMS codes have

minimum of four character first character: number or letter, signifies the chapter number second character: is a letter, to not confuse ICD-10 and ICD-11-MMS third character: number to prohibit spelling of undersirable words

LOINC provides

names and code for identifying labratory and clinical variables

LOINC Clinical

names and codes for observations like vital signs obstetric ultrasound radiology respiratory therapy nursing clinical documents patient assessment

LOINC Committee determined

no code system available was granular enough for observation identifiers LOINC was created to fill this gap

SCTID is nonsemantic meaning what?

no meaning is inferrable from the numerical value of the identifier or from the sequence of digits

ICF model

nonlinear systemic, biopsychosocial model with multiple components health condition body functions and structures activities and participation contextual factors umbrella terms

RxNorm does what?

normalizes names and unique identifiers for clinical drugs and links its names to they varying names of drugs present in many different vocabularies within the Unified Medical Language System (UMLS) Metathesaurus

International Classification of Functioning, Disability, and Health

one of three reference classifications approved by the WHO Family of International Classification Network (WHO-FIC)

Regenstrief Institute

organization responsible for the development and maintenance of LOINC

SNOMED CT purpose and use?

overall purpose is to standardize clinical phrases, making it easier to produce accurate electronic health information. doing so enables automatic interpretation and sharing of clinical information. semantic interoperability is also possible. with SNOMED CT encoded data sent securely during the transfer of care to other providers or to pts, the barriers to the electronic exchange are reduced resulting in improve quality of the information. Combining SNOMED CT coded data w/other encoded data such as medication and lab results has a number of uses including clinical decison support, clinical quality measures and registries SNOMED CT is also one of several standards chosen for the entry of structured data in certified electronic health record systems. This includes pt problems, encounter diagnosis, procedures, family health history, and smoking status.

CPT Cateogory II

performance measurement: support data collection about the quality of care by coding services and test results that support nationally established performance measures alphanumeric codes, 4 numbers followed by F

WHO reference classification

product of international agreements and is broadly accepted for international reporting on health may be used as a model for the development or revision of other classifications

ICD-10-CM purpose and use

provide a classification of diseases for morbidity morbidity is the state of being diseased including illness, injury, or deviation from normal health classify diagnoses established by physicians at the conclusion of the paient encounter

ICD-10-PCS purpose and use

provide a system for classifying procedures performed on hopsital inpatients

Current Procedural Terminology Purposes

provide a uniform language that allows for accurate descriptions of medical, surgical, and diagnostic services designed to communicate consisten information about medical services and procedures

UMLS Terminology Services (UTS)

provides UMLS access

ICD-10-PCS is the standard for what?

prventive, diagnostic, therapeutic, or other management procedures taken for diseases, injuries, and impairements on hopsital inpatients reported by hospitals

CMS updates HCPCS level II

quarterly Jan 1 April 1 July 1 Oct 1

Nomenclature

recognized system of terms that follows a pre-established naming conventions

SNOMED CT hierarchies

relationships between concepts structured to logic-based representations of meanings At the top - root concept descended down - specific domain hierarchies

RxNorm is the standard for medication and medication allergy___

reporting per the Common Clinical Data Set

Uniform Hospital Discharge Data Set (UHDDS)

required by the Department of Health and Human Services (HHS) data elements collected by acute-care, short-term stay hospitals to report inpatient data lements in a standardized manner

NLM; national institute of Medicine

responsible for the maintenance of RxNorm

ICD-O-3 topography code

same four character category code as in the malignant neoplasm section of second chapter of ICD-10 topography for specific types of tumors

An interoperable Health IT environment is one where____

seamless health information exchange is possible across different EHR systems and the information is understood and shared when needed with those in need

HCPCS level II; Dental Codes or D codes

seperate category and published by American Dental Associate

ICD-10-PCS Content and structure

seven character codes and descriptions for procedures describe medical and surgical procedures

OASIS data items address

sociodemographic, environmental, support system, health status, function status, and health service utlization of the patient core data item set for collection on all adult home health patients whose skilled care is reimbursed by Medicare and Medicaid

SNOMED CT is implemented by what?

software applications where healthcare providers record clinical information using identifiers that refer to concepts formally designed as part of the terminology during the process of care

CCDS data types

some but not all have a standard attached an example is smoking status (data element with specified standard) must be reports with SNOMED CT identifiers

The axioms may either partially or sufficiently _______

specify the SNOMED CT concept's meaning

Healthcare Effectiveness Data and Information Set (HEDIS)

sponsored by the National Committee for Quality Assurance (NCQA) designed to collect administrative, claims, and health record review data more than 90 standard performance measured related to patient outcomes and data about treatment process

ICD-11-MMS stem code

standalone code and can be a single entity or a combination of clinical detail

RxNorm nomenclature

standard for exchanging clinical drug information

RxNorm has been named as the

standard for government programs this includes medications for the entry of structured data in certified EHR systems under the Meaningful Use (promoting interoperability program)

UHDDS 8371

standard healthcare claim format for electronic health transactions

DSM-5

standard medical classification for mental disorders provides a reliable source of clinical criteria for mental health and medical professionals when establishing a diagnosis

LOINC purpose

standardize names and codes for the identification of laboratory and clincial variables settings: clinical institutions health institutions information technology research projects government agencies Professional societies insurance agencies

Outcome and Assessment Information Set (OASIS)

standardized data set designed to provide necessary data items to measure outcomes and patient rick factors of Medicare beneficiaries who are receiving skilled services from a medicare-certified home health agency

Clinical Terminology is a set of what?

standardized terms and codes for the healthcare industry for use in encoding clinical data Examples include: SNOMED CT Current Procedural Terminology Nursing Technologies

HCPCS Level II

standardizes the reporting of professional services, procedures, products and supplies. CMS publishes and maintains

ICD-11-MMS extension code

starts with X adds detail to stem code must be used with the stem code

ICF classifies

states of function, disability, and health

ICD-11 linearization

subset of the foundation componenet; once created the subset becomes the Tabular list

Common RxNorm uses:

support interoperability during e-prescribing and formulary management communication between hospital, pharmacy, and other systems for order entry and analytics for a medication list development of an allergy value set to support effecter and interoperable health information exchange

CPT Editorial Panel

supports revision of CPT codes. supported by the CPT Advisory committee, reps from 90 medical specialities. CPT revised yearly, January 1. must be planned for.

ICD-10-PCS is made up of

tables an index definitions

Upon discharge of the patient from the hospital, a professional coder assigns_____

the ICD-10-PCS code based on physician documentation

ICD-10-CM identifies what?

the diagnosis established by the provider

HIPPA named CPT as what?

the procedure cod set for all but hospital inpatient procedures

CPT identifies what

the services rendered rather than the diagnosis on the claim CPT and ICD form units of information about a patient visit in that the diagnosis represented by ICD supports the medical neccesity of the services represented in CPT

Current Procedural Terminology (CPT)

the standardized classification system for reporting medical procedures and services American Medical Associate owns copyrights most widely accepted nomenclature for reporting physician procedures and services under government and private health insurance programs

DSM-5 Content and Structure

three sections, appendix, index 1. DSM-5 Basics : introduction along with instruction 2. diagnostic criteria and codes : diagnostic criteria, descriptive text, ICD-10-CM codes 3. Emerging measures and models : content that is not required but could be helpful

ICD-10-PCS definitions

tied to the values of characters 3-7 of the seven-character code

ICD-O-3 purpose

to classify diseases for oncology, a branch of medicine that focuses on tumors data is reported to state, national and north american cancer registries

CMS requires physicians to use HCPCS level II

to report services provided to Medicare and Medicaid patients hospitals must report ambulatory surgery services, radiology, and other diagnostic services using HCPCS level II

LOINC is updated

twice a year June December No book of LOINC codes is produce web based search application

Healthcare Common Procedure Coding System (HCPCS)

two code systems: level I level II

LOINC conent and structure

two major groups: clinical laboratory

Foundation Component

underpinning database of all ICD entities

ICD-11-MMS foundation component includes

uniform resource indentifier (URI) allows for an entity to be classified in more than one place, that is an entity to have more than one parent

Uniform Resource Identifier (URI)

unique character string for each entity

Concepts

unique unit of knowledge or thought created by a unique combination of characteristics

observation identifier

universal indentifiers(names and codes) for the observation

HCPCS Level II modifiers

used to enhance code narrative to describe the circumstances of each procedure or service and how it applies to an individual patient

UTS

web based applications that serve as the gateway to UMLS Knowledge sources and the site to downloand UMLS data files

SNOMED namespace Identifier

when the component originates in an extension