Sayles Chapter 5 (Clinical Terminologies, Classification, and Code Systems MODIFIED

CPT CATEGORY III CODES

0345T Transcatheter mitral valve repair percutaneous approach via the coronary sinus Is an example of

clinical terminologies examples

1. SNOMED CT used in EHR for clinical terms 2. CPT is a terminology and a code systems 3. Nursing terminology

CPT CATEGORY II CODES

1065F Ischemic stroke symptom onset of less than 3 hours prior to arrival Is an example of

Data Set

A list of recommended data elements with uniform definitions

Clinical terminology*******

A set of terms representing the system of concepts for the medical field purpose is to have 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.

Relationships

A type of connection between two concepts

Clinical terminologies

Also known as reference terminology a reference terminology in HIT domain is a set of concepts and relationships that provide a mutual understanding for clinical decision support and for exchanging data with meaning about the health care course

code system

An accumulation of numeric or alphanumeric representations or codes for exchanging or storing information is known as a(n) _________.

CPT CATEGORY I CODES

Are examples of

3

CPT is divided into how many categories?

Nomenclature

Consists of a system of terms that follows pre-established naming conventions. They include clinical terminologies, classification, and coding systems

Are examples of Common Clinical Data Set

Data Element: Patient name DOB Ethnicity Smoking Status Medications Laboratory test(s) Vital Signs (body height and weight, blood pressure, heart rate, etc.) Procedures Immunizations Assessment and plan of treatment Health concerns Sex Race Preferred language Problems Medication allergies Laboratory value(s)/result(s) Care plan fields, including goals and instructions Care team member(s) Unique device identifier(s) for a patient's implantable device Goals

Aggregate data

Data that is extracted from an individual health records and combined to form deidentified Information about groups of patients that can be compared and analyzed

EHR data granular

Detailed clinical content real time encounters & interactions assessments & problems observations orders charges vitals follow up appt lab results EHR data enhances risk algorthyms & informs outcome- based measures

Twice a year.

How often does the ICD-10-CM update by the National Center for Health Statistics (NCHS)

Twice (April 1 and October 1)

How often does the ICD-10-PCS update?

Twice a year (June and December)

How often does the LOINC update

Once a year

How often is ICF updated

classification examples

ICD 10 PCS - hospital in patients procedures ICD 10 CM - classification for morbidity CMS ICD 03 classify diseases for oncology (tumors) ICF functioning, disability & health DSM 5 mental disorder

Classifications

If the objective is aggregate data then ________ are the better choice

Clinical terminologies

If the objective is granular data than then ________ are used

Aggregate data

Is needed when the combination of data provides information about related entities is sufficient

Category II codes

Is used for performance measurement. This category was created to support data collection about the quality of care rendered by coding certain services and test results that support nationally established performance measures and have an evidence base as contributing to quality of care

Category I codes

It includes six main sections that are listed in the photo and contains a description along with a five digit code. What CPT category is this?

UHDDS

Lists and define a set of common data elements for the purpose of facilitating the collection of uniform and comparable health information from hospitals.

semantic interoperability

Mutual understanding of the meaning of data exchanged between information systems

SNOMED-CT

Overall purpose is to standardize clinical phases, making it easier to produce accurate electronic health information. Doing so enables automatic interpretation and sharing of clinical information

code set examples

RxNORM LOINC HCPCS CPT = cpt - code sets & terminologies

STOPPED

STOPPED

claims data

Surface clinical content is easy to come by but delayed and short on details

Data Capture

Term for the various methods by which data can be entered into the computer so that it can be processed.

Semantic interoperability= building block

The mutual understanding of the meaning of data exchanged between information systems (EHR) which are: clinical term classifications code systems

Coding

The process of assigning numeric or alphanumeric representations to clinical documentation

Logical Observation Identifiers Names and Codes (LOINC)

The purpose of the ________ is to standardize names and codes for the identification of laboratory and clinical test results or observation

Nursing Terminologies

The purpose of this is to represent clinical information generated and used by nursing staff. They are designed to communicate consistent information about nursing services for a variety of reasons including direct patient care, measuring progress of treatment, as well as for administrative functions, education, and analytical purposes.

HEDIS

They are important in the creation of physician profiles for use in positively shaping physician practice patterns by showing comparative clinical performance information to encourage quality improvement or utilization adjustments

The International Classification of Diseases (ICD)

They identify the diagnosis

CPT

They identify the services rendered rather than the diagnosis on the claim

HEDIS

They survey data and protocols standardize data about specific health-related conditions or issues in order to evaluate and compare the success of various treatment plans

Outcomes and Assessment Information Set (OASIS)

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

Classification

This is also a system where related entities are organized together a clinical vocabulary terminology or nomenclature that lists words or phrases with their meanings, provides for the proper use of clinical words as names or symbols facilitates mapping standardized terms to broader classifications for: administrative regulatory oversight fiscal requirements

Healthcare Effectiveness Data and Information Set (HEDIS)

This is designed to collect administrative, claims, and health record review data. It contains more than 80 standard performance measures. Included are data related to patient outcomes and data about the treatment process

Category III codes

This is for emerging technologies, services, and procedures. They are considered temporary codes

Granular data

This is needed when the details are key to use if the data is granularity, or detail is the goal, then clinical terminologies are the best option

Uniform Hospital Discharge Data Set (UHDDS)

This is required by department of health and human services (HHS). This set is controlled by acute care, short-term stay (less than 30 days) hospitals to report inpatient data elements in a standardized manner.

Health information exchange= interoperability

This is when health information is electronically traded between providers and others with the same level of interoperability

Concepts

Unique units of knowledge or thoughts created by a unique combination of characteristics

SNOMED-CT CPT various nursing terminologies

What are some examples of clinical terminologies

Concepts, descriptions, and relationships

What are the 3 main components that make up SNOMED-CT

Modifying terms

What further explains the condition of a patient? (Ex: congestive heart is the what for the diagnosis of congestive heart failure)

Clinical drugs and a semantic interoperability tool

What is RxNorm used for

Semantic Tag

What is SNOMED-CT preferred term includes the _________.

It standardizes the clinician's diagnostic process for patients with mental disorders

What is the purpose for Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5)

To provide a uniform language that allows for accurately descriptions of medical, surgical, and diagnostic services.

What is the purpose of CPT?

To provide a classification of diseases for morbidity (is the state of being diseased including illness, injury, or deviation from normal health)

What is the purpose of ICD-10-CM

Provide a system for classifying procedures performed on hospital inpatients

What is the purpose of ICD-10-PCS?

To classify diseases for oncology, a branch of medication that focuses on tumors.

What is the purpose of International Classification of Diseases for Oncology Third edition (ICD-O-3)

Main terms

What represents the condition of the patient (ex: failure is the what for congestive heart)

Annually

When is CPT published

World Health Organization (WHO)

Who approves the International Classification of Functioning, Disability and Health (ICF)

HIPAA (Health Insurance Portability and Accountability Act)

Who mandates the use of CPT in healthcare data electronic transactions

The American Medical Association (AMA)

Who owns and copyrights Current Procedural Terminology (CPT)

National Committee for Quality Assurance (NCQA)

Who sponsors HEDIS

clinical terminology provide the data structure

and from the basis for coded data and provide the data structure required for semantic interoperability and HIM exchange ie CPT codes start with a form of terminology ie tonsilectomy = tonsil

code system examples

broad term CPT can be called a code system & clinical terminology

interoperability building block

clinical term classifications coding systems are one of the interoperability building blocks. they support system interoperability by providing the mutual understanding of the meaning of data exchanged between information systems

SNOMED CT (clinical terminology)

clinical terminology used for documentation & reporting most comprehensive multilingual clinical terminology in the world no book of codes or assignment by a coding professional implemented in software applications that use identifiers that refer to concepts that are formally defined as part of the terminology during the process of care granular level of clinical data capture

aggregate data capture

combination of data is sufficient use: classification code system do a summary report or hip replacement

Granularity (granular) data capture EHR

details need to be very precise details are key use: clinical terminology codes systems

one that aggregates the data will work for secondary data use

example of secondary use: is the identification & procedures for the purpose of billing & payment

SNOMED CT

example: the point of care a physician using an EHR uses a drop-down list to view the clinical terms relevant to their practice & patient's problem. by selecting the clinical term, the identifier is captured & thereby provides the primary source of information about the patient

code system importance

historical = name & arrange medical content now= expanded to uses for pt. care measuring patient outcomes research claim submission for reimbursement

health information exchange HIM exchange

is when health info is electronically traded between providers and others with the same level of interoperability

nomenclature that allows for collection of clinical data at a granular level is needed for primary data use such as for clinical decision support

primary & secondary data uses are relevant to understanding clinical term, classifications & code systems

the determination of which clinical terminologies classifications coding systems

regulation driven by the ONC selection of a standard for reporting by the ONC content standards represent EHR information