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Clinical Vocabularies and Classification Systems

Nomenclature:

A recognized system of terms used in science or art that follows pre-established naming conventions; a disease nomenclature is a listing of the proper name for each disease entity with its specific code number.

How is a nomenclature used in medicine?

It's a recognized system that lists preferred medical terminology.
Nomenclatures, or "naming" systems, such as CPT, also are referred to as clinical terminology.

Classification systems

1. Group together similar diseases and procedures. They also organize related entities for retrieval.
2. A system for grouping similar diseases and procedures and organizing related information for easy retrieval.
3. A system for assigning numeric or alphanumeric code numbers to represent specific diseases and/or procedures.

Example of a classification systems: International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM):

A classification system used in the United States to report morbidity and mortality information

Clinical vocabularies

1. A formally recognized list of preferred medical term
2. Have been developed to create a list of clinical words or phrases with their meanings

What do the International Classification of Diseases do?

1. Systems that facilitate the organization, storage, and retrieval of healthcare diagnostic and procedural data
2. Aid in the development and implementation of computerized patient record systems

Some of the physicians who are using standardized lists provided on software are doing what?

Selecting codes that are not substantiated by the clinical documentation in the patients' health record

What is the end result of selecting codes that are not substantiated by the clinical documentation in the patients' health record:

1. The end result is incorrect code assignment, denied reimbursement, and erroneous database entries
2. Clearly, policies and procedures are needed to control the coding process especially when creating standardization with an electronic health record system

What was the first medical nomenclature to be universally accepted in the United States?

1. Was developed by the New York Academy of Medicine and titled the Standard Nomenclature of Disease and Operations
2. In 1937, the American Medical Association (AMA) assumed the copyright and editing responsibility for this work and expanded it to include a nomenclature for procedures as well as diseases.
3. The expanded work was published in one volume titled Standard Nomenclature of Disease and Standard Nomenclature of Operations

What is the most recognized classification system used today in the U.S.? How did it evolve?

1. ICD-9-CM
2. It evolved from a classification developed by Dr. Jacques Bertillon

What was published by Dr. Jacques Bertillon in 1893

A system was published in 1893 as the Bertillon Classification of Causes of Death

What did the American Public Health Association recommend in 1898?

That registrars in the United States, Canada, and Mexico use the Bertillon classification.

How was the Bertillon classification revised? What were the versions?

1. This classification system was revised throughout the early 1900s
2. In 1948, the World Health Organization (WHO) published the sixth revision of the system
3. The sixth revision included a classification for morbidity and mortality data

What happened in classification throughout the 1900s?

Various healthcare associations and public health organizations representing numerous countries worked to create a standardized classification system for healthcare

Why did representatives from numerous countries meet in Geneva, Switzerland in 1975?

To develop the International Classification of Diseases under the direction of WHO

Today, the ICD classification system is used throughout the world and is undergoing which revision?

11th revision

What does the United Status use for ICD? When is a new revision planned?

A modification of ICD (ICD-9-CM) is used in the United States with a new revision (ICD-10-CM) planned for implementation by October 31, 2013

What has the development of the systems such as the ICD-9-CM helped to standardize?

Development of these systems has helped to standardize terminology for the collection, processing, and retrieval of medical information

Clinical Vocabularies, Classifications, and Nomenclatures: Users of clinical vocabularies and classifications can be divided into two main groups, what are they?

Clinical and administrative

Define clinical users of clinical vocabularies and classifications and how the vocabularies are used. Give an example of a clinical user.

1. Clinical users are providers who use clinical vocabularies and classifications to collect, process, and retrieve data for clinical purposes.
2. They use the vocabularies to support activities such as clinical research, disease prevention, and patient care
3. An example of a clinical user would be a physician who uses ICD-9-CM codes to track a patient's diagnostic history.

Who are administrative users of clinical vocabularies and classifications?

1. Administrative users include healthcare facilities, professional organizations, and government agencies.
2. These groups use clinical vocabularies and classifications to support administrative, statistical, and reimbursement functions
3. An example of this is when Current Procedural Terminology (CPT) codes are used to report physician services to the Medicare program to determine reimbursement.

What did HIPAA require establishment of?

The Health Insurance Portability and Accountability Act (HIPAA) required the establishment of electronic transactions and coding standards

In 2000, the Department of Health and Human Services (HHS), in accordance with HIPAA, established what?

Official medical coding set standards

What official medical coding sets were all covered entities required to use to be in compliance with the HIPAA law?

1. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), including the Official ICD-9-CM Guidelines for Coding and Reporting: Volumes 1 and 2 are used for reporting all diseases, injuries, impairments, other health problems and causes of such, and Volume 3 is used to report procedures performed on hospital inpatients. (ICD-10-CM and ICD-10-PCS will replace ICD-9-CM in 2013.)
2. Healthcare Common Procedure Coding System (NCPCS), which includes Current Procedural Terminology (CPT): This system is used for reporting physician and other healthcare services, including all non-inpatient procedures
3. Current Dental Terminology, Code on Dental Procedures and Nomenclatures (CDT): This system is used for reporting dental services
4. National Drug Codes (NDC): In the original ruling from Medicare, the NDC was designated as the official data set for reporting drugs used by pharmacies. However, this adoption was repealed in 2003. Currently, there is no official standard for reporting medications on pharmacy transactions

International Classification of Diseases, Ninth Revision, Clinical Modification:

The International Classification of Diseases (ICD) is a classification system for reporting medical diagnoses and procedures

The International Classification of Diseases (ICD)

1. ICD-9-CM is one of the most common classification systems used in the United States today
2. It is an adaptation of the International Classification of Diseases, Ninth Revision (ICD-9), published by WHO in Geneva, Switzerland
3. In the United States, the federal government, through the National Center for Health Statistics (NCHS), modified ICD-9 to create ICD-9-CM

When was the ICD-9 issued in the U.S., and what was its intent?

1. ICD-9-CM was issued for use in the United States in 1978
2. The intent of this modification was to provide a classification system for morbidity data

ICD-9-CM is maintained by four organizations known as:

The cooperating parties:
1. NCHS
2. The American Hospital Association (AHA)
3. The American Health Information Management Association (AHIMA)
4. Centers for Medicare and Medicaid Services (CMS)

The four cooperating parties of the ICD-9-CM assume the following responsibilities:

1. To serve as a clearinghouse to answer questions on ICD-9-CM
2. To develop educational materials and programs on ICD-9-CM
3. To work cooperatively in maintaining the integrity of ICD-9-CM
4. To recommend revisions and modifications to current and future revisions of ICD

The work of the four cooperating parties is supplemented by:

AHA's Editorial Advisory Board for Coding Clinic, which is composed of representatives of hospitals, health data systems, and the federal government.

What are NCHS and cms responsible for updating? What does AHIMA help with?

1. Primarily, NCHS is responsible for updating the diagnosis classification (Volumes 1 and 2), and
2. CMS is responsible for updating the procedure classification (Volume 3)
3. AHIMA works to help provide training and certification, and the AHA maintains the central office on ICD-9-CM and publishes Coding Clinic for ICD-9-CM, which contains the official coding guidelines and official guidance on the usage of ICD-9-CM codes

What was established in 1985? Who was it made up of and what did it do?

1. In 1985, the ICD-9-CM Coordination and Maintenance Committee was established
2. Cochaired by representatives of NCHS and CMS, the committee is made up of advisors and representatives of all the cooperating parties
3. It meets twice a year to provide a public forum for discussing possible revisions and updates to ICD-9-CM
4. Discussions at these meetings are advisory only

Who determines all final revisions to the ICD?

The director of NCHS and the administrator of CMS determine all final revisions

According to the Central Office on ICD-9-CM, ICD-9-CM has the following uses:

1. Classifying morbidity and mortality information for statistical purposes
2. Indexing hospital records by disease and operations
3. Reporting diagnoses by physicians
4. Storing and retrieving data
5. Reporting national morbidity and mortality data
6. Serving as the basis of diagnosis-related group (DRG) assignment for hospital reimbursement
7. Reporting and compiling healthcare data to assist in the evaluation of medical care planning for healthcare delivery systems
8. Determining patterns of care among healthcare providers
9. Analyzing payments for health services
10. Conducting epidemiological and clinical research

ICD-9-CM is published in how many volumes?

ICD-9-CM is published in three volumes

Volume 1 of the ICD-9-CM is known as what? What does it contain?

1. Volume 1 is known as the Tabular List
2. It contains the numerical listing of codes that represent diseases and injuries

Volume 2 of the ICD-9-CM is known as what? What does it contain?

1. Volume 2 is the Alphabetic Index
2. It consists of an alphabetic index for all the codes listed in Volume 1.

Volume 3 of the ICD-9-CM is known as what? What does it contain? How is it used?

1. The Tabular List and Alphabetic Index for Procedures are published as Volume 3
2. Volume 3 is not part of the international version of ICD-9
3. It is used only in the United States to report procedures performed on hospital inpatients

Volume 1 of ICD-9-CM is divided into three subdivisions:

1. Classification of diseases and injuries
2. Supplementary classifications
3. Appendixes

The first subdivision of volume 1 of ICD-9-CM is divided into how many chapters? How are they organized, examples of this organization?

1. The classification of diseases and injuries is divided into 17 chapters (figure 6.1)
2. The chapters are organized by type of condition and anatomical system. 3. For example, chapter 5, Mental Disorders, represents a chapter that groups diseases by type of condition. 4. Chapter 6, Diseases of the Nervous System and Sense Organs, represents a chapter that groups diseases by anatomical system

Figure 6.1: Chapter titles in the ICD-9-CM Classification of Diseases and Injuries:

1. Infectious and Parasitic Diseases
2. Neoplasms
3. Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders
4. Diseases of the Blood and Blood-Forming Organs
5. Mental Disorders
6. Diseases of the Nervous System and Sense Organs
7. Diseases of the Circulatory System
8. Diseases of the Respiratory System
9. Diseases of the Digestive System
10. Diseases of the Genitourinary System
11. Complications of Pregnancy, Childbirth, and the Puerperium
12. Diseases of the Skin and Subcutaneous Tissue
13. Diseases of the Musculoskeletal System and Connective Tissue
14. Congenital Anomalies
15. Certain Conditions Originating in the Perinatal Period
16. Symptoms, Signs, and Ill-Defined Conditions
17. Injury and Poisoning

Chapters in the ICD-9-CM are further divided into sections, how are they grouped?

1. Sections are groups of three-digit code numbers
2. An example of a section in chapter 5 is the disease classification for organic psychotic conditions (290-294) (see figure 6.2)

Figure 6.2 shows an Example of an ICD-9-CM section:

Organic psychotic conditions (290-294)
Includes: psychotic organic brain syndrome
Excludes: nonpsychotic syndromes of organic etiology (310.0-310.9) psychoses classifiable to 295-298 and without
impairment of orientation, comprehension, calculation, learning capacity, and judgment, but associate with physical disease, injury, or condition affecting the brain [e.g., following childbirth]
290 Senile and presenile organic psychotic conditions

How are sections of the ICD-9-CM further divided?

1. Sections are subdivided into categories
2. Categories represent a group of closely related conditions or a single disease entity
3. Category 290, Senile and presenile organic psychotic conditions, is an example of a category found in chapter 5
4. Categories are further divided into subcategories. At this level, four-digit code numbers are used. 5. Figure 6.2 provides an example of a subcategory: code number 290.1, Presenile dementia

Where are the most specific codes in the ICD-9-CM? What kinds of codes represent this level?

1. The most specific codes in the ICD-9-CM system are found at the sub-classification level
2. Five-digit code numbers represent this level
3. In figure 6.2, code 290.10 represents a code at the sub-classification level

Which two supplementary classifications are part of Volume 1:

1. The Supplementary Classification of Factors Influencing Health Status Contact with Health Services (V codes) and the
2. Supplementary Classification of External Causes of Injury and Poisoning (E codes)

What are V Codes?

A set of ICD-9-CM codes used to classify occasions when circumstances other than disease or injury are recorded as the reason for the patient's encounter with healthcare providers

Such circumstances generally occur in one of the following three ways:

1. When a person who is not currently sick encounters a health service provider for some specific reason, such as to act as an organ or tissue donor, to receive prophylactic vaccination, or to discuss a problem that in itself is not a disease or injury (for example, when a patient sees a physician for a measles vaccination)
2. When a person with a known disease or injury, whether current or resolving, encounters the healthcare system for a specific treatment of that disease or injury (for example, when a patient seeks follow-up care for a previously applied cast)
3. When some circumstance or problem influences the person's health status but is not in itself a current injury or illness (for example, when a patient has a personal history of smoking)

Why are V codes always alphanumeric? What is an example?

1. They are easy to identify because they begin with the alpha character V and are followed by numerical digits. 2. An example is V15.04, Allergy to seafood

What are E Codes?

E codes provide a means to classify environmental events, circumstances, and conditions as the cause of injury, poisoning, and other adverse effect.

How are they used?

E codes provide a means to classify environmental events, circumstances, and conditions as the cause of injury, poisoning, and other adverse effect.

E codes must be used in addition to what? What do E codes provide?

1. These codes must be used in addition to codes from the main chapters of ICD-9-CM
2. E codes provide additional information used by insurance companies, safety programs, and public health agencies to determine the causes of injuries, poisonings, or other adverse situation

Even though use of many E codes is optional, many facilities use them as what? In what circumstances might some states mandate reporting of E codes?

1. Secondary codes to identify the cause of accidents and injuries
2. Some states have mandated reporting of E codes in certain circumstances, such as in reporting head trauma

E codes begin with the alpha character E and are followed by:

1. Numerical characters
2. E925.0 represents the code for an accident caused by an electric current in domestic wiring and appliances

The last subdivision of Volume 1 consists of what?

The appendixes

CD-9-CM includes two appendixes, however most publishers include references to all five previously existing appendixes:

1. Appendix A: Morphology of Neoplasms
2. Appendix B: Glossary of Mental Disorders (removed in 2004)
3. Appendix C: Classification of Drugs by American Hospital Formulary Service List Number
4. Appendix D: Classification of Industrial Accidents According to Agency (removed in 2009)
5. Appendix E: List of Three-Digit Categories (removed in 2007)

Volume 2of ICD-9-CM: How do main terms and subterms appear?

1. The Index to Diseases and Injuries is printed as Volume 2 of ICD-9-CM. 2. Main terms appear alphabetically in the index by type of disease, injury, or illness
3. Subterms are indented under the main term: For example, the main term bradycardia and the subterms for bradycardia appear as shown in figure 6.3.

Figure 6.3. Example of index entries for main terms and subterms in ICD-9-CM:

Brachycephaly 756.0
Brachymorphism and ectopia lentis 759.89
Bradley's disease (epidemic vomiting) 078.82
Bradycardia 427.89
chronic (sinus) 427.81
newborn 763.83
nodal 427.89
postoperative 997.1
reflex 337.0
sinoatrial 427.89
with paroxysmal tachyarrhythmia
or tachycardia 427.81
chronic 427.81
sinus 427.89
with paroxysmal
tachyarrhythmia or tachycardia
427.81
chronic 427.81
persistent 427.81
severe 427.81
tachycardia syndrome 427.81
vagal 427.89
Bradypnea 786.09
Brailsford's disease 732.3
radial head 732.3
tarsal scaphoid 732.5

The third volume of ICD-9-CM contains:

1. The tabular and alphabetic lists of procedures
2. The Tabular List of Procedures contains chapters organized according to anatomical system, except for the last chapter, Miscellaneous Diagnostic and Therapeutic Procedures
3. Figure 6.4 shows the procedure chapter titles
4. According to the HIPAA regulations, these codes are to be used only for inpatient hospital billing

Figure 6.4. Chapter titles in the ICD-9-CM tabular list of procedures:

1. Operations on the Nervous System
2. Operations on the Endocrine System
3. Operations on the Eye
4. Operations on the Ear
5. Operations on the Nose, Mouth, and Pharynx
6. Operations on the Respiratory System
7. Operations on the Cardiovascular System
8. Operations on the Hemic and Lymphatic System
9. Operations on the Digestive System
10. Operations on the Urinary System
11. Operations on the Male Genital Organs
12. Operations on the Female Genital Organs
13. Obstetrical Procedures
14. Operations on the Musculoskeletal System
15. Operations on the Integumentary System
16. Miscellaneous Diagnostic and Therapeutic Procedures

How are ICD-9-CM procedure codes organized?

1. ICD-9-CM procedure codes are organized according to these 16 chapters, and then
2. The chapters are divided into two-, three-, and sometimes four-digit code numbers
3. All procedure codes are written with two digits to the left of the decimal point
4. Figure 6.5 provides an example of a tabular listing from the beginning of chapter 2, Operations on the Endocrine System

Figure 6.5. Example from the ICD-9-CM tabular list of procedures

06 Operations on thyroid and parathyroid glands
Includes: incidental resection of hyoid bone

06.0 Incision of thyroid field
Excludes: division of isthmus (06.91)
06.01 Aspiration of thyroid field
Percutaneous or needle drainage of thyroid field
Excludes: aspiration biopsy of thyroid (06.11)

How is the Alphabetic Index to Procedures organized?

In the same manner as the Alphabetic Index to Diseases. Figure 6.6 shows an example of the alphabetic organization of procedures.

Figure 6.6. Example of alphabetic entries in the ICD-9-CM index to procedures

Acromioplasty 81.83
for recurrent dislocation of shoulder 81.82
partial replacement 81.81
total replacement 81.80
Actinotherapy 99.82
Activities of daily living (ADL)
therapy 93.83
training for the blind 93.78
Acupuncture 99.92
with smouldering moxa 93.35
for anesthesia 99.91
Adams operation
advancement of round ligament 69.22
crushing of nasal septum 21.88
excision of palmar fascia 82.35

Instructions: Use the following excerpt from the Alphabetic Index to complete the questions below.

Bacillary—see condition
Bacilluria 791.9
asymptomatic, in pregnancy or puerperium 646.5
tuberculous (see also Tuberculosis) 016.9
Bacillus—see also Infection, bacillus
abortus infection 023.1
anthracis infection 022.9
coli
infection 041.4
generalized 038.42
intestinal 008.00
pyemia 038.42
septicemia 038.42
Flexner's 004.1
fusiformis infestation 101
mallei infection 024
Shiga's 004.0
suipestifer infection (see also Infection, Salmonella) 003.9
Back—see condition
Backache (postural) 724.5
psychogenic 307.89
sacroiliac 724.6

List the first four main terms that appear in the excerpt

Bacillary, Bacilluria, Bacillus, Back

List the first four subterms that appear under Bacillus.

abortus infection, anthracis infection, coli, Flexner's

Indicate whether each of the following codes represents a disease (D) or a procedure (P).
a. ____ 99.82

b. ____ 098.0

c. ____ 301.51

d. ____ 73.4

e. ____ 844.0

f. ____ 45.24

a. P

b. D

c. D

d. P

e. D

f. P

International Classification of Diseases, Tenth Revision, Clinical Modification

Established by WHO, the ICD system was designed to be totally revised at 10-year intervals.

What was ICD-10? When was it published? What does it capture?

In the mid-1990s, WHO published the newest version of ICD: International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, known as ICD-10
•This revision is currently in use by many countries throughout the world and has been used in the United States to capture mortality statistics since 1999

What did studies in the U.S. determine about ICD-10?

•Studies in the United States determined that ICD-10 needed to be modified to capture data that would support our reimbursement system prior to implementation
•At the date of this writing, ICD-10-CM and ICD-10-PCS are scheduled to be implemented in the United States on October 1, 2013

What 4 main enhancements does ICD-10-CM provide? What are these enhancements anticipated to improve?

•ICD-10-CM provides several enhancements that are anticipated to improve coding accuracy (Zeisset 2009):
1. Including combination codes for conditions and common symptoms or manifestations.
•A single code may be used to classify two diagnoses, a diagnosis with an associated sign or symptom, or a diagnosis with an associated complication
•This allows one code to be assigned, resulting in fewer cases requiring more than one code and reducing sequencing problems.

2. Decreasing cross-referencing by writing out the full code title for all codes.

3. Providing codes for laterality such as codes for left side, right side, and in some cases bilateral as available in appropriate chapters.

4. Providing expanded codes to capture more detail in several sections such as injury, diabetes, postoperative complications, and others
•Adding code alpha character extensions (seventh character) in appropriate sections to provide specific information about the characteristics of the encounter such as initial encounter, subsequent encounter, or sequelae

In addition to the 4 main enhancements, what else does ICD-10-CM provide? What are the results?

ICD-10-CM provides flexibility and expandability, which allow more specificity in the coding of many conditions
•This should result in improved usefulness of the data in many areas such as measuring quality of patient care, conducting research, establishing health policy, designing payment systems and processes for reimbursement, tracking public health risks, and monitoring resource utilization to name a few (Zeisset 2009)

The Clinical Modification of ICD-10 is known as the:

The Clinical Modification of ICD-10 is known as the International Classification of Diseases, Tenth Revision, Clinical Modification

According to NCHS, what is the ICD-10-CM the planned replacement for? What is the revision considered to be?

•ICD-10-CM is the planned replacement for ICD-9-CM, Volumes 1 and 2
•This revision is considered to be an improvement over both ICD-9-CM and ICD-10, and was developed to contain a great many more codes and allow greater specificity than existing ICD code sets

Overview of Structure of the ICD: what was the former supplementary classification information? What additions does the ICD-10 contain?

•The traditional ICD structure remains, ICD-10-CM is a complete alphanumeric coding scheme
•The former supplementary classification information (V and E codes) was incorporated into the main classification system with different letters preceding the numerical portions of the codes
•ICD-10 contains new chapters and several categories have been restructured and new features added to maintain consistency with modern medicine
•The disease classification has been expanded to provide greater specificity at the sixth-digit level and with a seventh-digit extension.

•Similarities in structure and terms between ICD-10-CM and ICD-9-CM are shown and explained in figure 6.7.

Figure 6.7. Similarities in structure and terms between ICD-10-CM and ICD-9-CM:

ICD-10CM:
•Has the same type of hierarchy in its structure as ICD-9CM. All codes have the same first three digits describing common traits, with each character beyond the first three providing more specificity.
•Has the same organization and use of notes and instructions. When a note appears under a three-character code, it applies to all codes within that category, and notes under specific code apply to the single code.
•Codes must be at least three characters, with a decimal point used after the third character. The additional characters following the decimal point describe the etiology, anatomic site, or severity
•Consists of an alphabetic index formatted by main terms listed in alphabetic order with indentations for any applicable qualifies or descriptors. Familiar punctuation such as brackets, parentheses, colons, and commas are used in ICD-10-CM, as are terms such as Not Elsewhere Classified (NEC), Not Otherwise Specified (NOS), "code first," "Use additional code," and "code also" notes familiar to coding professionals
•Uses cross-references to provide instructions to reference other or additional terms. The tabular list is present in code number order and used like ICD-9-CM

Examples of ICD-10-CM codes include the following:

•Malignant Neoplasm
— C34.1 Malignant neoplasm of upper lobe, bronchus or lung
— C34.10 Malignant neoplasm of upper lobe, bronchus or lung, unspecified side
— C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
— C34.12 Malignant neoplasm of upper lobe, left bronchus or lung

Examples of ICD-10-CM codes include the following:

•Diabetes
— E10.2 Type 1 diabetes mellitus with kidney complications
— E10.21 Type 1 diabetes mellitus with diabetic nephropathy
Type 1 diabetes mellitus with intercapillary glomerulosclerosis
Type 1 diabetes with intracapillary glomerulonephritis
Type 1 diabetes mellitus with Kimmelstiel-Wilson disease
— E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease
Type 1 diabetes mellitus with chronic kidney disease due to conditions classified to .21 and .22
Use additional code to identify stage of chronic kidney disease (N18.1-N18.6)
— E10.29 Type 1 diabetes mellitus with other diabetic kidney complication
Type 1 diabetes mellitus with renal tubular degeneration

International Classification of Diseases, Tenth Revision, Procedure Coding System: What does ICD-10-CM not include?

•ICD-10-CM does not include a procedure volume

Bc the ICD-10-CM does not include a procedure volume, when the US began planning to clinically modify WHO's ICD-10, what was determined? What is the result of this?

•Thus, when the U.S. began planning to clinically modify WHO's ICD-10, it was determined that creating a separate volume for procedures would be insufficient
•As a result, CMS contracted with 3M Health Information Systems to develop a separate procedure code system that would serve as a replacement for ICD-9-CM, Volume 3

3M Health Information Systems to developed a separate procedure code system that would serve as a replacement for ICD-9-CM, Volume 3, what is this coding system known as?

•This coding system is known as the International Classification of Diseases, Tenth Revision, Procedure Coding System, or ICD-10-PCS.

Definition International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS):

A separate procedure coding system that would replace ICD-9-CM, volume 3, intended to improve coding accuracy and efficiency, reduce training effort, and improve communication with physicians

Purpose and Use: What agency is responsible for updating the procedure section of ICD-9-CM?

The CMS, the agency responsible for updating the procedure section of ICD-9-CM

According to CMS, the design of ICD-10-PCS included what goals?

•To improve accuracy and efficiency of coding
•To reduce training effort
•To improve communication with physicians

Overview of Structure: ICD-10-PCS, what is the correlation in structure to ICD-10-CM? What is the ICD-10-PCS code structure, and what characters are used?

•ICD-10-PCS has no correlation to the ICD-10-CM structure
•It consists of a multiaxial seven-character alphanumeric code structure
•The 10 digits 0-9 and the 24 letters A-H, J-N, and P-Z are characters used in ICD-10-PCS

What replacement capability does the ICD-10-PCS system have? And what will it replace?

•Although this system has the capability and flexibility to replace all existing procedural coding systems, it is only going to replace ICD-9-CM procedure codes

The ICD-10-PCS is considered complete and expandable due to what?

Because of its unique structure, ICD-10-PCS is considered to be both complete and expandable.

Why has each root procedure has been defined in ICD-10-PCS? What does this help to clarify?

Because many different and confusing names of procedures are in use in the medical field, each root procedure has been defined in ICD-10-PCS
•This helps to clarify terms that currently have overlapping meaning, such as excision, resection, or removal

How are procedures divided in the ICD-10-PCS? How many characters do procedure codes have?

•Procedures are divided into 16 sections related to general type of procedure (medical and surgical, imaging, and so on)
•All procedure codes have seven characters

What does the first character of the procedure code in the ICD-10-PCS specify? What do the rest of the characters mean?

•The first character of the procedure code always specifies the section where the procedure is indexed. •The second through seventh characters have a standard meaning within each section

How are the seven characters defined in medical and surgical procedures?

1 = Section of the ICD-10-PCS system where the code resides
2 = The body system
3 = Root operation (such as excision, incision)
4 = Specific body part
5 = Approach used, such as intraluminal or open
6 = Device used to perform the procedure
7 =Qualifier to provide additional information about the procedure (for example, diagnostic versus therapeutic)

An example of an ICD-10-PCS code is:

An example of an ICD-10-PCS code is 097F7DZ, Dilation Eustachian Tube, Right, Transorifice Intraluminal.
0 Surgical Section
9 Body System—Ear, nose, sinus
7 Procedure is a dilation
F Eustachian tube, right
7 Via natural or artificial opening
D Intraluminal
Z No qualifier

Implementation of ICD-10 in the United States: The department of Health and Human Services published what in the Federal Register on January 16, 2009?

•A final rule to establish a timeline for implementation of ICD-10-CM and ICD-10-PCS.
•The effective date for this rule is October 1, 2013. This final rule can be reviewed at http://edocket.access.gpo.gov/2009/pdf/E9-743.pdf
•The transition from ICD-9-CM to ICD-10-CM and ICD-10-PCS will be a tremendous effort.

The two coding systems ICD-10-CM and ICD-10-PCS will be adopted as what?

•These two coding systems will be adopted as the national standards under the HIPAA electronic transactions and coding standards rule to replace the current uses of ICD-9-CM.

The Journal of American Health Information Management Association and other publications are publishing preparation articles that will do what? What is also being developed for this transition?

•Enable coders to stay current and be prepared for the changes as they take effect
•Extensive training sessions and coding materials are being developed to assist coders and facilities with this transition.

ICD-9-CM to ICD-10-CM Transition Issues: What is important in transition, what staff should be included? What type of approaches to training should be developed?

•Planning for education at all levels in the organization is important
•Examples of staff that should be included in a training program include coding, billing, quality management, information systems, and researchers to name a few
•Different approaches to training should be developed depending on the level and type of training required
•For example, coding staff will require different training than, say, billing or quality management staff
•Figure 6.8 provides a checklist of training considerations for coding staff

Historically, change to a new classification system has proven what? What should organizations do, and what is needed?

•That advance preparation is essential
•Organizations should put in place a detailed implementation plan that identifies key tasks to be performed and assigns responsibilities and timelines for completion
•An adequate budget needs to be allocated to cover the costs of implementation.

What is the first training consideration for coding staff in transition? 6.8 ICD-10 training checklist for coding staff:

• Evaluate coding personnel's baseline knowledge in skills to identify knowledge gaps in the areas of medical terminology, anatomy and physiology, pathophysiology, and pharmacology. •Measuring coding professionals' baseline knowledge will shorten the learning curve, improve coding accuracy and productivity, prepare for educational needs, and accelerate the realization of benefits of the new coding systems
•AHIMA plans to provide self-assessment tools and other resources suitable for skill assessment

What is the second training consideration for coding staff in transition? 6.8 ICD-10 training checklist for coding staff:

•Review ICD-10-CM coding guidelines, ICD-10-PCS reference manual, and other ICD-10 educational materials to identify areas where increased clinical knowledge will be needed

What is the third training consideration for coding staff in transition? 6.8 ICD-10 training checklist for coding staff:

•Use information from coding professional knowledge gap assessment to develop individualized education plans for improving clinical knowledge to ensure it meets the requirements of ICD-10-CM and ICD-10-PCS

What is the fourth training consideration for coding staff in transition? 6.8 ICD-10 training checklist for coding staff:

•If outsourced staff are used for coding, communicate with the companies that provide these services concerning their plans for ICD-10 related training

What is the fifth training consideration for coding staff in transition? 6.8 ICD-10 training checklist for coding staff:

Consider having the coding personnel practice coding a few records using ICD-10-CM and ICD-10-PCS to increase familiarity with the new coding systems
—Download ICD-10-CM information at http://www.cdc.gov/nchs/icd/icd10cm.htm
—Download ICD-10-PCS information at http://www.cms.gov/ICD10/11b_2011_ICD10PCS.asp

Implementation of ICD-10 will also require that changes to be made to what? What is an example?

•Changes need to be made in the organization's information systems and a detailed plan to handle the transition needs to be developed
•For example, it would be important to conduct an inventory to identify what databases and applications currently use ICD-9-CM codes and how these systems need to be changed to accommodate the new ICD-10 codes
•Software changes that may need to be done might include expanding field sizes, accommodating longer code descriptions, making modifications to table structures, and building new system interfaces.

Because the ICD-10 requires a greater level of detail, what should happen?

•A medical record documentation assessment should be performed
•The assessment should identify documentation deficiencies result in a documentation improvement program
•Education of physicians in documentation practices will be key to more precise data capture

What is the International Classification of Diseases for Oncology, Third Edition?

•The International Classification of Diseases for Oncology, Third Edition (ICD-O-3) is a system used for classifying incidences of malignant disease

Why do hospitals use ICD-O-3?

•Hospitals use ICD-O-3 for several purposes, for example, to develop cancer registries
•Cancer registries list all the cases of cancer diagnosed and treated in the facility

History of ICD-O-3:

•WHO published the first edition of the International Classification of Diseases for Oncology (ICD-O) in 1976
•It was developed jointly by the United States Cancer Institute and WHO's International Agency for Research on Cancer

In 1968, the American Cancer Society published what Manual?

•Manual of Tumor Nomenclature and Coding (MOTNAC)

Also in 1968, WHO asked the International Agency for Research on Cancer to develop what?

•Also in 1968, WHO asked the International Agency for Research on Cancer to develop a chapter on neoplasms for the ninth revision of ICD.
•WHO decided to publish a supplemental neoplasm classification based on MOTNAC for ICD-9

ICD-O-3 was published for use in what?

•ICD-O-3 was published for use in coding cancers diagnosed in the United States after January 1, 2001, and is updated on an annual basis.

Originally, ICD-O was developed to aid in what? What was it's purpose?

•Originally, ICD-O was developed to aid in the collection of information in the field of oncology
(Oncology is the study of neoplasms [new tissue], or tumors.)
•Its purpose is to provide a detailed classification system for coding the histology (morphology [structure]), topography (site), and behavior of neoplasms

The current version of ICD-O provides a detailed classification used by who?

Pathology departments, cancer registries, and healthcare providers who treat cancer patients

What kind of classification is used in ICD-O-3? What are these codes compatible with?

•A dual-axis classification is used in ICD-O-3 to code the topography and morphology of the neoplasm
•These codes are identical or compatible with other coding classifications and nomenclatures. •For example, the topography codes used in ICD-10 for malignant neoplasms are the same codes used in ICD-O-3.

What do the morphology codes in ICD-O-3 identify?

The morphology codes identify the type of tumor found and its behavior

What do the morphology codes in ICD-O-3 consist of?

•The morphology code numbers consist of the letter M followed by five digits
•The first four digits identify the histological type of the neoplasm
•The fifth digit identifies the behavior of the tumor

The following morphology codes for some leukemias provide an example:

Leukemias
M9891/3
Acute monocytic leukemia
M9895/3
Acute myeloid leukemia with multilineage dysplasia
M9896/3
Acute myeloid leukemia, AML1
M9897/3
Acute myeloid leukemia, MLL

The fifth-digit (behavior) codes that appear after the slash are used to indicate the following:

/0
Benign
/1
Uncertain whether benign or malignant, borderline malignancy
/2
Carcinoma in situ
Intraepithelial
Noninfiltrating
Non-invasive
/3
Malignant, primary site
/6
Malignant, metastatic site
Secondary site
/9

Check your understanding 6.2:
List the type of behavior for the tumors represented by the following codes:

1. __benign______ M8140/0

2. __malignant metastatic site__ M8490/6

3. _malignant primary site__ M8331/3

4. __carcinoma in situ___ M8120/2

Healthcare Common Procedure Coding System (HCPCS):

•HCPCS was originally called the HCFA Common Procedure Coding System
•The name of the system was changed in 2001, when the Health Care Financing Administration (the agency that administered the Medicare and Medicaid programs) changed its name to the Centers for Medicare and Medicaid Services (CMS)
•HCPCS is used to report physicians' services to Medicare for reimbursement.

History of HCPCS, what is HCPCS?

•HCPCS (pronounced "Hick Picks") is a collection of codes and descriptors used to represent healthcare procedures, supplies, products, and services

When the HCPCS Medicare program was first implemented in the early 1980s, the Health Care Financing Administration (HCFA) found it necessary to expand what? Why was it expanded?

•To expand the HCPCS system because not all supplies, procedures, and services could be coded using the CPT system
•An example of this shortcoming is durable medical equipment (DME)
•CPT does not contain codes for DME
•Therefore, HCFA developed an additional level of codes to report supplies and services that are not in CPT (for example, DME)

Why did Medicare introduce HCPCS?

•In 1983, Medicare introduced HCPCS to promote uniform reporting and statistical data collection of medical procedures, supplies, products, and services.
•Most state Medicaid programs and other insurance companies recognize portions of the HCPCS coding system

Who uses HCPCS codes?

Physicians and providers use HCPCS codes to report the services and procedures they deliver.

Overview of structure: How is HCPCS divided?

HCPCS is divided into two code levels or groups: I and II

HCPCS Level I codes:

•Level I codes are the AMA's CPT codes
•These five-digit codes and two-digit modifiers are copyrighted by the AMA
•CPT codes primarily cover physicians' services but are used for hospital outpatient coding as well
•CPT codes are updated annually, effective January 1

HCPCS Level II codes:

•Level II codes, also called National Codes, are maintained by CMS
•With the exception of temporary codes, level II codes are updated annually on January 1

HCPCS Level II temporary codes:

•Temporary codes begin with the letters G, K, or Q
•Temporary codes are updated throughout the year
•Level II also contains modifiers in the form of letters and alphanumeric characters

Why were level II HCPCS codes developed?

•Level II codes were developed to code medical services, equipment, and supplies that are not included in CPT

Today, when people refer to HCPCS codes, they are often referring to what kind of codes?

•Today, when people refer to HCPCS codes, they are often referring to level II codes
•Level I codes are most often referred to merely as CPT
• Technically, HCPCS includes both level I (CPT) and level II codes

HCPCS codes are listed by:

•The codes are alphanumeric and start with an alphabetic character from A to V
•The alphabetic character is followed by four numeric characters
•The alphabetic character identifies the code section and type of service or supply coded

At times, level II codes were designed to reflect code assignment based on what?

At times, level II codes were designed to reflect code assignment based on Medicare payment regulations.

Figure 6.9 shows the different code choices for patients undergoing a colonoscopy based on their medical necessity

Figure 6.9. CPT/HCPCS code choices for colonoscopy
Example:
Reason for Colonoscopy | Appropriate code
•Problem, such as bleeding or polyps | CPT codes 45378-45392
•Colorectal cancer screening, patient does not meet Medicare definition of high risk | G0121
•Colorectal cancer screening, patient meets definition of high risk | G0105

Figure 6.10 provides a list of the major sections in level II:

Figure 6.10. HCPCS Level II section titles

A0000-A0999 | Transport Services Including Ambulance
A4000-A4899 | Medical and Surgical Supplies
A9000-A9999 | Administrative, Miscellaneous, and Investigational
B4000-B9999 | Enteral and Parenteral Therapy
D0000-D9999 | Dental Procedures
E0100-E9999 | Durable Medical Equipment
G0000-G9999 | Procedures/Professional Services (Temporary)
J0000-J8999 | Drugs Other Than Chemotherapy
J9000-J9999 | Chemotherapy Drugs
K0000-K9999 | Orthotic Procedures
L5000-L9999 | Prosthetic Procedures
M0000-M0009 | Medical Services
P2000-P2999 | Laboratory Tests
Q0000-Q9999 | Temporary Codes
R0000-R5999 | Domestic Radiology Services
S0009-S9999 | Temporary National Codes
V0000-V2999 | Vision Services
V5000-V5299 | Hearing Services

Level II also contains modifiers that can be used how? What do the modifiers permit?

•Level II also contains modifiers that can be used with all levels of HCPCS codes, including CPT codes
•The modifiers permit greater reporting specificity in reference to the main code
•Sample level II modifiers appear in figure 6.11

Figure 6.11. Sample HCPCS Level II modifiers

-AA | Anesthesia services performed personally by anesthesiologist
-E1 | Upper left eyelid
-E2 | Lower left eyelid
-E3 | Upper right eyelid
-E4 | Lower right eyelid
-NU | New equipment
-QC | Single channel monitoring

Current Procedural Terminology, Version 4: Who copyrights and maintains the CPT system? When was the original edition published? What has been done since then?

•As mentioned earlier, the CPT system is copyrighted and maintained by the AMA.
•There have been several major updates to the system since the original edition was published in 1966
•Code updates are published annually and take effect every January 1.

History of CPT-4: What is CPT? How often is it updated and who updates?

•CPT is a comprehensive descriptive listing of terms and codes for reporting diagnostic and therapeutic procedures and medical services. •Currently, it is updated annually by the AMA's CPT Editorial Panel

Who makes up the AMA's CPT Editorial Panel? Who advises the editorial panel on revisions?

•This panel is composed of physicians and other healthcare professionals who revise, modify, and update the publication.
•The Editorial Panel gets advice on revisions from the

Who nominates the CPT Advisory Committee? Who makes up the committee?

This committee is nominated by the AMA House of Delegates and is composed of representatives from more than 90 medical specialties and healthcare providers.

As defined by the AMA, the CPT Advisory committee has three objectives:

1. To serve as a resource to the Editorial Panel by giving advice on procedure coding and nomenclature as relevant to the member's specialty
2. To provide documentation to staff and the Editorial Panel regarding the medical appropriateness of various medical and surgical procedures
3. To suggest revisions to CPT

What is the purpose of CPT?

The purpose of CPT is to provide a system for standard terminology and coding to report medical procedures and services.

Use of CPT:

•CPT is one of the most widely used systems for reporting medical services to health insurance carriers
•It is used for other administrative purposes, such as developing guidelines for medical care review •Organizations that collect data for medical education and research purposes also use CPT

What does CMS require CPT codes be used for?

•CMS requires that CPT codes be used to report medical services provided to patients in specific settings
•Starting in 1983, HCFA (now called the CMS) required that CPT be used to report services provided to Medicare Part B beneficiaries

In October 1986, HCFA required state Medicaid agencies use what?

•Use CPT as part of the Medicaid Management Information System

What did HCFA require in July 1987 as part of the Omnibus Budget Reconciliation act?

As part of the Omnibus Budget Reconciliation Act, HCFA required in July 1987 that CPT be used for reporting outpatient hospital surgical procedures and ambulatory surgery center procedures

The most recent mandate for CPT use occurred with what final rule?

•The most recent mandate for CPT use occurred with the final rule of the Health Insurance Portability and Accountability Act (HIPAA).
•HIPAA mandates that CPT be used as the required code set for physicians' services and other medical services such as physical therapy and most laboratory procedures.

HCFA is now called:

CMS

The CPT codebook consists of what? What codes are used?

•The CPT codebook consists of an introduction, eight sections containing the codes, appendixes, and an index. •Five digit codes are used—most are numeric, although specific sections include an alpha character
•The eight sections include: evaluation and management services, anesthesia, surgery, radiology (including nuclear medicine and diagnostic ultrasound), pathology and laboratory, medicine, Category II and Category III codes.

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