Clinical Terminology and Classification Systems
The medical arena consists of a world of terminology that can sound much
like an unknown language. It does not matter how long one has studied,
practiced, or worked in the medical field, there is always something new to
learn. The United States began using the ICD-9-CM system around 1987;
the ICD-10-CM/PCS system was required to go into effect on October 1,
2015. This system contains terminology that most are not familiar with, and
many are not looking forward to using the system. This is just one of the
many systems that medical staff must be familiar with and understand. The
World Health Organization has developed an updated ICD classification,
ICD-11. This classification system has not been adopted by the United
States at this time.
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is
a very important regulation for the healthcare industry. The HIPAA security
standards identify three separate types of safeguards that healthcare
facilities must have in place. These are administrative, technical, and
physical safeguards. These safeguards involve assigning responsibility, and
developing and establishing safety standards for the human resources of the
organization. The safeguards must also establish access controls for the
EHR system and verify encryption of data in the system. And the safeguards
must also establish physical safeguards for the equipment and data
associated with the EHR system (Department of Health and Human
Services, 2014).
Accreditation standards also involve a variety of different organizations.
Most of the organizations in the accreditation field are voluntary and these
organizations cover very specific areas of the facility. The Accreditation
Association for Ambulatory Health Care (AAAHC) focuses on the
ambulatory settings. The standards that the AAAHC enforces are published
in the Accreditation Handbook for Ambulatory Health Care and they cover
areas such as healthcare clinics, surgery centers, community health centers,
diagnostic imaging centers, pain management centers, and several other
ambulatory centers (Maki & Petterson, 2014).
There are many requirements for facilities trying to obtain various
certification standards. Some of these standards are required for the facility
to participate in different payer programs. One of the more important payer
programs is the Medicare and Medicaid program. While Medicaid programs
are state-based, the Medicare program is a federally based program. To
participate in this program, the facility must meet the Conditions of
Participation (CoP) or Conditions of Coverage (CoC). The regulations for
these are found in the Code of Federal Regulations (Centers for Medicaid
and Medicare Services, 2014).
There are a variety of areas that require standards in order to meet all
regulations. One of these areas includes data sets collected in ambulatory
settings. The Uniform Ambulatory Care Data Set (UACDS) was developed
by the U.S. Department of Health and Human Services and approved by the
National Committee on Vital and Health Statistics. This group developed
the information that should be collected by healthcare providers for the
health records of their patients. This provides a standard for types of
information that should be transferred from one provider to another, should
there be a need to transfer the care of a patient. These standards cover
items such as personal identification information, demographic information,
patient history, diagnoses, laboratory and other diagnostic testing results,
progress notes, discharge summaries, and other vital information (Maki &
Petterson, 2014).
There are also organizations that cover areas such as documentation and
policies standards. Other organizations cover forms that are used for billing
within a healthcare facility. There are many organizations that provide
licensures for the healthcare facilities, both federal and state. These controls
are used to help ensure the safety of the patient and healthcare workers. In
using standardized forms and regulations, the continuity of patient care is
far easier to achieve, making the success rate of patient treatment much
greater.
In Module Eight, students will explore the care of the patients in the mental
health community, which offers a challenging set of circumstances for the
healthcare world.
References
Centers for Medicare & Medicaid Services. (2014). Medicare learning
network. Retrieved from www.cms.gov
Department of Health and Human Services. (2014). Medicare fraud &
abuse. Medicare Learning Network. Retrieved from
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNProducts/downloads/Fraud_and_Abuse.pdf
Maki, S. E., & Petterson, B. (2014). Using the electronic health records in the
health care provider practice (2nd ed.). Clifton Park, NY: Delmar.
