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AB103118_Ch05_PPT1.pptxHealth Information Management Technology: An Applied Approach, Sixth Edition
Chapter 5: Clinical Terminologies, Classifications, and Code Systems
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Definitions
Vocabulary/terminology: A set of terms specific to a domain
Nomenclature: A system of names that follows preestablished conventions
Classification: A mono-hierarchical method of organizing related terms together
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Definitions
Code: An identifier
Code set: An accumulation of numeric or alphanumeric codes
Code system: An accumulation of terms and codes for exchanging or storing information
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Definitions
Clinical Terminology: A set of standardized terms and codes used in the healthcare industry to encode clinical data
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History and Importance
Name and arrange medical content
Historically to identify causes of death
Expanded to uses for patient care, measuring patient outcomes, research and claim submission for reimbursement
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Expanded Uses and Data Capture
Claims data
Surface clinical content
EHR data
Detailed clinical content
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Data Capture
Details are key to use: granular
Clinical terminologies
Code systems
Combination of data is sufficient: aggregate
Classifications
Code systems
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Primary and Secondary Data Use
Primary use: granular
Example—clinical decision support
Secondary use: aggregate
Example—billing and payment
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Clinical Terminologies, Classifications, and Code Systems
Selection of a standard for reporting
Primarily regulation driven
Content standards for representing electronic health information
Interoperability building block
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Clinical Terminologies
Form the basis for coded data
Provide the data structure
Semantic interoperability
Health information exchange
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Clinical Terminologies
Reference terminologies
Provide common semantics
Supports meaning-based retrieval
Example
SNOMED CT
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SNOMED CT
Clinical terminology used for documentation and reporting
No book of codes and no assignment by a coding professional
Implemented in software applications
Granular level of clinical data capture
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SNOMED CT (continued)
Purpose is to standardize clinical phrases
Used for sharing of clinical information
Standard for certified EHR systems
Structure
Concepts
Descriptions
Relationships
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SNOMED CT (continued)
SNOMED CT identifier
Unique integer
Includes
Item identifier
Partition identifier
Check-digit
Namespace identifier when component originates in an extension
Nonsemantic
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SNOMED CT (continued)
Concepts
Concept definition
Sufficiently defined
Partially defined (primitive)
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SNOMED CT (continued)
Descriptions
Types
Fully specified name
Synonym
Preferred term
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SNOMED CT (continued)
Relationships
Connection between a source and destination concept
Form the polyhierarchical structure of SNOMED CT
Is a relationship type
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Current Procedural Terminology (CPT)
Nomenclature used for reporting procedures
Print, e-book, and in software applications
Assignment by a professional coder
Standard for certified EHR systems
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CPT (continued)
Provides uniform language for services and procedures
Reports services and procedures on healthcare claims
Excludes inpatient claims
Structure
Codes, descriptions and guidelines
Category I, Category II, and Category III
Modifiers
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Nursing Terminologies
Terminology used to report nursing care
Multiple terminologies available
Content, structure, and purpose varies
Examples
Nursing Interventions Classification (NIC)
Interventions
Nursing Outcomes Classification (NOC)
Outcomes
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Classifications
Key to secondary data use
Aggregate clinical data
Healthcare statistics
Determine payment
Monitor public health
Improve financial performance
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International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)
Developed and maintained by National Center for Health Statistics
ICD-10 Coordination and Maintenance (C & M) Committee
Updated in October and when necessary, April
Print, online, and in software applications
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ICD-10-CM
Assignment by a professional coder
Used to report diagnoses on healthcare claims
Structure
3–7 characters
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ICD-10 Procedure Coding System (ICD-10-PCS)
Created by 3M Health Information Systems
Maintained by Centers for Medicare and Medicaid Services
Reports procedures for inpatient claims
Updated in October and when necessary, April
Print, online, and in software applications
Assignment by a professional coder
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ICD-10-PCS
7-character code
Sections
Medical and surgical procedures
Medical and surgical-related procedures
Ancillary procedures
Tables, index, and definitions
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ICD-11
Foundation component
Linearization
ICD-11-MMS
Collaborative and open development and maintenance process
Development version continuously updated
Annual official release
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ICD-11
Reflects scientific and medical advances
Can be integrated with electronic health applications
Easy to implement
Accessible and easy to use
Improved links to terminologies and derived and related classifications
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ICD-11
New content
Chinese medicine disorders and patterns
Supplementary section for functioning assessment
New chapters
Sleep-wake disorders
Conditions related to sexual health
Extension codes
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ICD-11
Foundation component
URI
Multiple parents
Stem codes and extension codes
Code combinations
Conventions
Alphabetic index
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International Classification of Functioning, Disability and Health (ICF)
Used to measure health and disability
Print and online
Assignment by a health professional
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ICF
Components
Body functions
Activities and participation
Environmental factors
Body structures
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International Classification of Diseases for Oncology, Third Edition (ICD-O-3)
Derived classification
Used by tumor or cancer registries
Reports topography and morphology of neoplasm
Print and online
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ICD-O-3
Used to report cancers to state and national registries
Dual classification
Greater detail of the histology than ICD-10
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Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
Classification for mental disorder
Print, online, and in software applications
Determination of a mental disorder by a clinician
ICD-10-CM codes incorporated into DSM-5
Used for
Clinical assessments
Developing treatment plans
Communicating between healthcare providers
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Code System
An accumulation of terms and codes for exchanging or storing information
Broad term
Characteristics of a terminology or a classification
Primary or secondary data use
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Logical Observation Identifiers, Names, and Codes (LOINC)
System for identifying health measurements observations, and documents
No book of codes or no assignment by a coding professional
Implemented in software applications
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LOINC
Standardizes names and codes for the identification of laboratory and clinical variables
Fully specified name made up of five or six parts
Facilitates sharing of data
Standard for certified EHR systems
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Healthcare Common Procedure Coding System (HCPCS) Level II
Two code systems
Level I: CPT
Level II: professional services, procedures, products, and supplies
Level II published by CMS
Updated quarterly
Print, online, and in software applications
Standard for certified EHR systems
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HCPCS Level II
Assignment by a professional coder
Used for reimbursement of ambulatory care
Modifiers
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RxNorm
Standardized nomenclature for clinical drugs
No book of codes or no assignment by a coding professional
Implemented in software applications
Interim updates: weekly and full update monthly
Standard for certified EHR systems
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RxNorm
Used to communicate drug related information
Standard for certified EHR systems
Concept unique identifier
Semantic clinical drug term type
Ingredient
Strength
Dose form
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Health Data and Information Sets
Data set: list of recommended data elements with uniform definitions
Data collected used for
National and state statistics
Clinical decision support
Clinical quality measures
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Outcomes and Assessment Information Set (OASIS)
Collected on Medicare beneficiaries receiving skilled services from a Medicare-certified home health agency
RN and therapists collect the data
Home health agency process and improvement outcome measures based on OASIS data
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Healthcare Effectiveness Data and Information Set (HEDIS)
Sponsored by NCQA
Designed to collect administrative, claims, and health record review data
Form the basis for performance improvement
Use by healthcare purchasers and consumers to compare performance
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Uniform Hospital Discharge Data Set (UHDDS)
Data collected by acute care, short-term stay hospitals
Core data elements incorporated into IPPS
Example: principal diagnosis
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Common Clinical Data Set
Established by the ONC
Originated from federal reporting requirements tied to certification criteria
Some but not all have a standard attached
Example: SNOMED CT attached to the data element smoking status
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Database of Clinical Terminologies, Classifications, and Code Systems
Unified Medical Language System (UMLS)
Centralized location of health and biomedical terminologies and standards
UMLS Knowledge Resources
Metathesaurus
Semantic Network
SPECIALIST Lexicon and Lexical Tools
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Metathesaurus
Contains codes and terms from over 200 terminology, classification, and code systems
Examples: SNOMED CT, ICD-10-CM, and LOINC
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