Standardization is going to help speed up any process. In my last
coding class, we talked about data dictionaries and vocabulary. I
think that fits into this discussion. Anytime you are able to define a
specific term and use it over the course of each chart, it is going to
help the next person understand the chart. I think it also helps a
medical provider be more specific when there are more codes for a
specific diagnosis. For instance, appendicitis, the doctor might just
put that in the past, but now we have codes to specify gangrene with
that. I think it helps to have those options now so we can narrow
down the type. When we have synonyms that can be used to locate
terms as well as the actual name that helps as well. In a medical
chart, it is important for the documentation to be specific. That's why
coding is nice. We have CPT, PCS, E/M levels, clinic codes, ICD-10
codes, and HCPCS codes. All of those sets already have the terms
defined. If you look at a CPT code, it is going to give you a
description and idea of what you need to use that particular code. In
diagnosis codes on ICD-10, you also have a code definition. Those
help us narrow down what a diagnosis should be vs. just having a
symptom. I think the hard part of standardization is when there is not
a specific code. It is almost frustrating when you have to code a NEC
or an unlisted procedure. From my experience, insurance companies
do not like that either.
However, it is getting clearer with additions each year. According to
Kaufmann, "the advantages of standardizing healthcare terms
outweigh the major efforts to combat the issue around unstructured
data and interoperability." Being able to use specific language helps
to be able to extract data when it comes to interoperability. This also
helps transfer the data between different systems. If everyone uses
the same language, everyone can understand it. Meaningful use is a
big deal for driving more standardization to promote interoperability.
It encourages the use of EHRs, which are trying "to improve quality,
safety, efficiency, and reduce health disparities, improve care
coordination, improve population and public health, engage patients
and their families in their own health care, and ensuring that patient
privacy and security is maintained according to the Health Insurance
Portability and Accountability Act (HIPAA) Privacy Rule" (aanem).
In inpatient coding, they use ICD-10-PCS for procedures while
outpatient is going to use CPT. ICD-10-CM is used for both inpatient
and outpatient for diagnosis. HCPCS 2 can be used for outpatient
codes for medical equipment. There is a coding format for all
different types of services. I never coded the system before 10, but
from what I gather, it was not very specific. Now we have
specifications of right vs left in fractures, leg pain, and cellulitis.
There are also codes now to specify what type of stage a kidney
failure is happening. It even goes down to stage 3a and b. I think
what they are trying to do is great. Coding and extracting data can
really help us in the future. We can look at certain treatments and
see how they worked on a wide variety of patients. I think medical
research is amazing. It's also nice for a provider to have access to
records faster and be able to understand what the other doctor said
based on him having that diagnosis code. I think it also helps the
patient understand. From reading surgeries, myself... I think reading
the description of the code is so much more simplified.
Kaufmann, K. (2019, June 18). Standardizing healthcare terms:
Challenges, benefits, and future -. Perficient Blogs. Retrieved January
20, 2022,
from https://blogs.perficient.com/2019/07/09/standardizing-
healthcare-terms-challenges-benefits-future/
(n.d) Electronic Health Records (EHRs) and Meaningful Use
(MU). Retrieved January 20, 2022, from EHR-and-Meaningful-
Use.pdf.aspx (aanem.org)
