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Health Information Chapter 6

Clinical Vocabularies and Classification Systems
STUDY
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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.
What does the introduction of the CPT codebook contain? What does this apply to?
•The introduction contains a list of the codebook section numbers and their sequences and instructions for use. •Information that appears in the introduction applies to all sections of the codebook.
•A coder who is unfamiliar with CPT coding should read the introduction
What is used to assist coders in correct usage of CPT codes? Where are these explained in the codebook? Where are they found? What does a bullet listed to the left of the code signify?
•Symbols and punctuation marks are used to assist coders in correct usage of CPT codes
•The symbols used in the CPT codebook are explained in the introduction and are found at the bottom of each page of the coding section of the book
•For example, a bullet listed to the left of a code signifies that the code is new for that year's updated book.
The sections of the CPT codebooks are as follows:
Evaluation and Management | 99201-99499
Anesthesia | 00100-01999
Surgery | 10021-69990
Radiology | 70010-79999
Pathology and Laboratory | 80047-89398
Medicine | 90281-99607
Category II Codes | 0001F-7025F
Category III Codes | 0016T-0207T
Each of these sections of the CPT begins with guidelines containing what?
•Each of these sections begins with guidelines containing specific instructions and definitions that are unique to the section
•Coders must understand the information in the guidelines in order to code correctly from each section
What were Category II Codes in the CPT designed as? What can they be used to provide? Are they optional or not optional?
•According to CPT, Category II codes were designed as "supplemental tracking codes that can be used for performance measurement."
•Although these codes are optional, they can be used to provide greater specificity regarding a patient's visit and treatment details
Why were Category III Codes added to the CPT book? Are they optional or not optional? How often are they evaluated?
•Category III codes were added to the CPT book to allow for temporary coding assignment for new technology and services that do not meet the rigorous requirements necessary to be added to the main section of the CPT book
•The codes are not optional and should be used to report procedures performed
•Codes in the Category III section are evaluated and added every six months
As Category I codes (codes ranging from 00100 to 99499) are created to describe new procedures, what will happen to the corresponding temporary category III codes?
•Category III codes will be deleted from the CPT system. •After approximately five years, if Category III codes have not been utilized, CPT may remove them from the CPT book and "archive" them
Appendixes: B
•Appendixes follow the last section of code
•The appendixes provide information to help the coder in the coding process
•Appendix A provides a complete list of modifiers and their descriptions
•Modifiers are written as two-digit codes that follow the main CPT codes
•For example, the two-digit modifier for bilateral procedures is modifier 50
Appendixes: B
•Appendix B is a summary of the additions, deletions, and revisions that have been implemented for the current CPT edition
•This appendix can be used to update information and data that contain CPT codes.
Appendix C
•Appendix C provides clinical examples for codes found in the evaluation and management section (E/M) of the book
•These examples can be used as a tool to assist the coder in reporting an E/M code
Appendix D
•Appendix D is a listing of CPT add-on codes
•These codes must be preceded by a primary procedure code and would never be reported alone
Appendix E
Appendix E is a summary of CPT codes that are exempt from modifier 51, and appendix F is a summary of CPT codes that are exempt from modifier 63.
Appendix G
Appendix G contains codes that include conscious/moderate sedation.
Appendix H
Appendix H is an alphabetic index of performance measures by clinical condition or type but was removed from CPT.
Appendix I
Appendix I contains genetic testing code modifiers used for reporting with lab procedures related to genetic testing.
Appendix J
Appendix J includes a listing of sensory, motor and mixed nerves that are useful for nerve conduction studies.
Appendix K
Appendix K lists procedures included in the CPT code book that are not yet approved by the FDA.
Appendix L
Appendix L is a reference of the vascular families including which are considered "first" "second" and "third" order vessels.
Appendix M
Appendix M displays a table of deleted CPT codes and crosswalks to current codes. Appendix N is a listing of codes that have been resequenced.
How does the index of the CPT codebook list terms?
The index of the CPT codebook lists main terms alphabetically.
Main term entries are of four types:
Main terms entries of the CPT index are of what four types?
Procedure or service
Organ or other anatomic site
Condition
Synonym, eponym, or abbreviation
Main terms of the CPT index are followed by:
•Main terms are followed by subterms
•The subterms modify the main terms and are indented under them
How do coders begin their search for the correct CPT code?
•Coders begin their search for the correct CPT code by checking the alphabetic index in the above order until finding a likely code to describe the procedure performed
•The coder should then verify the code(s) selected in the main section of the codebook to be certain the code best describes the procedure(s) performed
Figure 6.12 shows a portion of the CPT index
Face
CT Scan | 70486-70488
Lesion Destruction | 17000-17004, 17280-17286
Magnetic Resonance Imaging (MRI) | 70540-70543
Tumor Resection | 21015
Face Lift |15824-15828
Facial Asymmetries
See Hemifacial Microsomia
Check your understanding 6.3: Instructions: List the section of the CPT codebook in which each of the following codes is located
1. ___Evaluation and Management____ 99311

2. ___Medicine______ 90807

3. ___Surgery___ 33470

4. __Anesthesia___ 01200

5. __Pathology and Laboratory__ 87551

6. __Radiology____ 77295

7. __Category II codes___ 0071T
Systematized Nomenclature of Human and Veterinary Medicine (SNOMED CT):
A comprehensive clinical vocabulary developed by the College of American Pathologists that is the most promising set of clinical terms available for a controlled vocabulary for health-care; now known as SNOMED International
The Systematized Nomenclature of Medicine Clinical Terminology (SNOMED CT) is a controlled reference terminology: The American College of Pathologists (ACP) defines SNOMED CT as:
The American College of Pathologists (ACP) defines SNOMED CT as a systematized, multiaxial, and hierarchically organized nomenclature of medically useful terms.
"SNOMED CT (Systematized Nomenclature of Medicine—Clinical Terms) is:
•A comprehensive clinical terminology, originally created by the College of American Pathologists (CAP) and, as of April 2007, owned, maintained, and distributed by the International Health Terminology Standards Development Organisation (IHTSDO), a non-for-profit association in Denmark
•The CAP continues to support SNOMED CT operations under contract to the IHTSDO and provides SNOMED-related products and services as a licensee of the terminology" (NLM 2009)
Who published the first edition of SNOMED? What is SNOMED based on?
•ACP published the first edition of SNOMED in 1977
•SNOMED is based on the Systematized Nomenclature of Pathology (SNOP), which was published by ACP in 1965 to organize information from surgical pathology reports
SNOP
Because SNOP was widely used and accepted in the medical community, it was expanded as a nomenclature for other specialties.
Numerous versions of SNOMED have been published since 1977. The current version includes what?
•More than 150,000 terms that are used in countries throughout the world
•SNOMED CT is the most comprehensive controlled vocabulary developed to date
•The updated version of SNOMED is SNOMED CT (clinical terms), which is a "comprehensive multilingual clinical terminology tool providing the information framework for clinical decision making for electronic medical record" (Brouch 2003)
•This version is an adaptation of earlier versions of SNOMED and also contains the United Kingdom's National Health Service's Clinical Terms (previously known as Read Codes). Read Codes users are being migrated over to SNOMED CT
In 2007, the Health and Human Services (HHS) Secretary announced that the United States would participate in an international effort to do what?
To encourage more rapid development and worldwide adoption of standard clinical terminology for electronic health records.
International Health Terminology Standards Development Organisation (IHTSDO):
The United States is one of nine charter members of the new International Health Terminology Standards Development Organisation (IHTSDO), which has acquired Systemized Nomenclature of Medicine (SNOMED) Clinical Terms (SNOMED CT) from the College of American Pathologists (CAP). Other charter members are from Australia, Canada, Denmark, Lithuania, the Netherlands, New Zealand, Sweden, and the United Kingdom. Membership is open to all countries.
What was international implementation of SNOWMED CT said to be good for?
"International implementation of SNOMED CT is good for everyone engaged in developing electronic health records, and it will open up new opportunities for international collaboration in research and public health surveillance," Secretary Leavitt said. "This use of a standard terminology will enable the use of health information across borders, facilitate public health surveillance and support evidence-based research."
Purpose and Use of SNOWMED: What makes it difficult to gather and retrieve information in the field of medicine? And what is needed?
•Two physicians may use two different terms for the same medical condition, making it difficult to gather and retrieve information
•Standardized vocabulary is needed to facilitate the indexing, storage, and retrieval of patient information in an EHR
•SNOMED CT creates a standardized vocabulary.
The Computer-based Patient Record Institute (CPRI)
•The Computer-based Patient Record Institute (CPRI) has studied the ability of current nomenclatures to capture information for EHRs
•The institute has determined that SNOMED CT is the most comprehensive controlled vocabulary for coding the contents of the health record and facilitating the development of computerized records
Using SNOMED as a foundation, SNOMED CT presents:
Data in a completely machine-readable format
According to SNOMED International, the core content data of SNOMED CT include the following tables:
Concepts
Descriptions
Relationships
History
SNOMED CT has been mapped to ICD-9-CM as well as other commonly used vocabularies such as:
ICD-O3, ICD-10, and LOINC
Core tables; concepts table
•The core tables provide the framework for the organization
•The concepts table lists every concept that appeared in earlier versions of SNOMED CT, starting with version 3. •More than 366,000 concepts are organized into 18 hierarchies within the SNOMED CT system
•Each concept, or fully specified name as listed on the table, is given a concept identifier
Concepts are further identified by:
Concepts are further identified by various terms or phrases that define them. The combination of a concept and a term is a description. Descriptions are given a Description ID.
SNOMED CT Real-World Example
•TheraDoc is a medical informatics company that produces software used for clinical decision support
•One of its systems, Antibiotic Assistant, was designed to support the appropriate use of antibiotics (TheraDoc 2001)
•SNOMED CT was integrated into Antibiotic Assistant to allow the system to be integrated with other patient information systems in order to analyze possible drug interactions or adverse reactions to the medications
•TheraDoc's Antibiotic Assistant, powered by SNOMED CT, is designed is designed to work within the facility's existing information systems environment
•TheraDoc's powerful interface and inference engines can use existing data from ancillary and legacy systems to integrate patient-specific results reporting and monitoring with disease-specific point-of-care decision support
•Coupled with existing electronic medical records and order management systems, the Antibiotic Assistant can act as an integrated disease-specific ordering module to address and improve both processes and tasks
•Through sophisticated knowledge-based engines, the software considers all possible ways in which an infectious disease can be managed and eliminates those options that are contraindicated due to mitigating factors (for example, allergies, neutropenia) and patient attributes (for example, height, weight, age)
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
The 2004 text revision of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision, with updated clinical terms, but very few coding changes
Who developed the DSM? Why was it developed?
The American Psychiatric Association (APA) developed the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a tool for providing a set of codes that could be used to aid in the collection of clinical data using stand-alone personal computers.
History of DSM-IV: When was the first edition published, how many times has it been revised?
•The APA published the first edition of the DSM in 1952
•The APA's Committee on Nomenclature and Statistics developed DSM from ICD
•DSM-I contained a glossary of descriptions of mental disorders
•DSM has been revised three times since 1952 and is now published as the fourth revision, or DSM-IV-TR
•The updated text revision (TR) became effective in 2004 to maintain currency with updated clinical terms
•There were very few coding changes in the DSM-IV-TR version
What was done to facilitate ease of use of DSM-IV with ICD versions?
•To facilitate ease of use with ICD versions, the APA has worked closely with other organizations to make DSM-IV, ICD-9-CM, and ICD-10 fully compatible
All DSM-IV-TR codes are what? Why is this even more important?
•All DSM-IV-TR codes are ICD-9-CM codes
•This is even more important because the HIPAA law requires that valid ICD-9-CM codes be used for diagnostic purposes
According to the APA, the DSM-IV is what? What is it intended to be applicable to?
•According to the APA, "The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard classification of mental disorders used by mental health professionals in the United States
•It is intended to be applicable in a wide array of contexts and used by clinicians and researchers of many different orientations (e.g., biological, psychodynamic, cognitive, behavioral, interpersonal, family/systems)" (APA 2009).
What is the main purpose of DSM-IV-TR? How is it used? Why do clinicians use DSM?
•The main purpose of DSM-IV-TR is to provide a means to record data on patients treated for substance abuse and mental disorders
•DSM is used as a nomenclature that clinicians can reference to enhance their clinical practices and as a language for communicating diagnostic information. •Clinicians use DSM to assign a diagnosis
DSM contains a listing of the criteria for what? How are mental conditions evaluated?
•DSM contains a listing of the criteria for diagnosing each mental disorder and its key clinical manifestations. •Mental conditions are evaluated along five axes.
The five axes used in DSM-IV-TR are:
Axis I | Clinical Disorders | Other Conditions That May Be a Focus of Clinical Attention
Axis II | Personality Disorders | Mental Retardation
Axis III | General Medical Conditions
Axis IV | Psychosocial and Environmental Problems
Axis V | Global Assessment of Functioning
Use of these axes by clinicians helps to establish what? What will this lead to?
•A systematic evaluation of patient symptoms
•This will lead to the establishment of diagnoses for the patient
•The diagnoses then are given a code or codes that are the same as ICD-9-CM codes
The newest updated version of DSM, the DSM-V will be published?
•The newest updated version of DSM, DSM-V, is scheduled to be published in 2012.
Nursing Vocabularies
•The use of vocabularies is a relatively new concept in the field of nursing
•Many nursing vocabularies are currently used to classify nursing diagnoses, interventions, and outcomes
History of Nursing Vocabularies: Why were they developed?
•Nursing vocabularies were developed to aid in the collection of data about nursing care
•They serve as a way to document nursing care and to facilitate the capture of these data on computer systems •The American Nurses Association (ANA) has established a steering committee on databases to support clinical nursing practice
•The committee has recommended use of a unified nursing language system in the nursing profession
Purpose and use of nursing vocabularies:
•The ANA recognizes approximately 13 standardized terminologies
•These are developed by separate agencies for various purposes
•These terminologies are described in table 6.1. All the classifications approved by the ANA are included in the Unified Medical Language System (UMLS).
Table 6.1. Widely used nursing vocabularies and classifications
•Vocabulary or Classification System: North American Nursing Diagnosis Association (NANDA) Taxonomy II

•Usage:
This classification is used to classify nursing diagnoses in all nursing settings. The NANDA multiaxial taxonomy is designed to provide a standardized nursing terminology to define patient responses, document care for reimbursement, and to allow for inclusion of nursing terminology in building clinical EHRs (North American Nursing Diagnosis Association 2005).

•Web Site: http://nanda.org (Johns 264)
Table 6.1. Widely used nursing vocabularies and classifications
•Vocabulary or Classification System: Nursing Interventions Classifications (NIC)
•Usage: NIC is used to classify nursing interventions. Nursing interventions are any direct-care treatment that a nurse performs on behalf of the patient. These interventions are used to direct the care of patients
•Website: http://www.nursing.uiowa.edu/excellence/nursing_knowledge/clinical_effectiveness/nic.htm
Why are the nursing data sets and classification systems developed?
•The nursing data sets and classification systems are developed to capture documentation on nursing care •They are designed to capture nursing diagnoses, interventions, and outcomes for acute, surgery, home, and ambulatory care settings
According to the ANA, "A standardized vocabulary does what?
•According to the ANA, "A standardized vocabulary assists nurses to document care while providing a foundation for examining and evaluating the quality and effectiveness of that care
•An information infrastructure provides the foundation for benchmarking, measuring and comparing outcome data, and evaluating the quality and effectiveness of care" (ANA 2009)
The various ANA-recognized standardized terminologies have:
•The various ANA-recognized standardized terminologies have different structures
•Information on the specific structures can be found at the various Web sites listed in table 6.1
SNOMED CT:
e. To provide a controlled vocabulary for coding the contents of the patient record and for facilitating the development of computer-based patient records
Nursing vocabularies:
a. To document nursing care and to facilitate the capture of nursing information on computer systems
DSM-IV-TR
b. To provide a means to record information about patients treated for substance abuse and mental disorders
The Coding Process
The coding process varies from organization to organization, but some standards, elements, and steps are common to almost all organizations.
Standards of Ethical Coding
•In today's healthcare environment, coding plays an important role in the determination of reimbursement for healthcare facilities
•AHIMA developed its Standards of Ethical Coding, last updated in 2008
•The standards were developed by AHIMA's Coding Policy and Strategy Committee and approved by its Board of Directors
•The AHIMA standards are meant to serve as a guide for coding professionals (see figure 6.13)
AHIMA's Standards of Ethical Coding:
1. Coding professionals are expected to support the importance of accurate, complete, and consistent coding practices for the production of quality healthcare data.

2. Coding professionals in all healthcare settings should adhere to the ICD-9-CM (International Classification of Diseases, 9th revision, Clinical Modification) coding conventions, official coding guidelines approved by the Cooperating Parties,* the CPT (Current Procedural Terminology) rules established by the American Medical Association, and any other official coding rules and guidelines established for use with mandated standard code sets. Selection and sequencing of diagnoses and procedures must meet the definitions of required data sets for applicable healthcare settings.

3. Coding professionals should use their skills, their knowledge of currently mandated coding and classification systems, and official resources to select the appropriate diagnostic and procedural codes.

4. Coding professionals should only assign and report codes that are clearly and consistently supported by physician documentation in the health record.

5. Coding professionals should consult physicians for clarification and additional documentation prior to code assignment when there are conflicting or ambiguous data in the health record.

6. Coding professionals should not change codes or the narratives of codes on the billing abstract so that meanings are misrepresented. Diagnoses or procedures should not be inappropriately included or excluded because payment or insurance policy coverage requirements will be affected. When individual payer policies conflict with official coding rules and guidelines, these policies should be obtained in writing whenever possible. Reasonable efforts should be made to educate the payer on proper coding practices in order to influence a change in the payer's policy.

7. Coding professionals, as members of the healthcare team, should assist and educate physicians and other clinicians by advocating proper documentation practices, further specificity, and resequencing or inclusion of diagnoses or procedures when needed to more accurately reflect the acuity, severity, and the occurrence of events.

8. Coding professionals should participate in the development of institutional coding policies and should ensure that coding policies complement, not conflict with, official coding rules and guidelines.

9. Coding professionals should maintain and continually enhance their coding skills, as they have a professional responsibility to stay abreast of changes in codes, coding guidelines, and regulations.

10. Coding professionals should strive for optimal payment to which the facility is legally entitled, remembering that it is unethical and illegal to maximize payment by means that contradict regulatory guidelines
Elements of Coding Quality
•The coding function must be reviewed on an ongoing basis for consistency and accuracy
•Audits should occur to review the codes selected by coders and to serve as guides for further education for the coding professionals
•Review of records should be approached as a way to improve quality and not viewed as punitive in nature
Coding processes should be monitored for the following elements of quality:
Reliability: The degree to which the same results are achieved consistently (that is, when different individuals code the same health record, they assign the same codes)

Validity: The degree to which codes accurately reflect the patient's diagnoses and procedures

Completeness: The degree to which the codes capture all the diagnoses and procedures documented in the health record

Timeliness: The time frame in which the health records are coded
Coding Policies and Procedures: What do the policies ensure? Who institutes them?
•Every healthcare facility should establish coding policies and procedures that establish guidelines that coders should follow to ensure coding consistency
•Using the coding guidelines established by organizations such as the AHA, the AMA, AHIMA, and state health information management association policies can be developed for coding consistency
Which agency publishes the official guidelines for ICD-9-CM coding ? Who publishes information regarding CPT codes? What can both publications be used for?
•The AHA publishes the official guidelines for ICD-9-CM coding in a quarterly newsletter entitled Coding Clinic. •The AMA publishes information regarding CPT codes in a newsletter entitled CPT Assistant
•Both publications can be used as a basis for developing facility policies and procedures.
Steps in the Coding Process: what must be ensured for accurate coding? Who defines what a complete record is?
•For accurate coding, the coder must have a complete health record on the patient
•Each facility needs to define what constitutes a complete record
•The coder must review the contents of the record to determine the patient's condition and the treatment and care he or she received
Steps in the coding process: Inpatient record, what should it contain prior to being coded? What must the coder do with these documents?
•For an inpatient record, the health record should contain the following documents prior to being coded: a face sheet, operative and procedural reports, pathology reports, progress notes, and a discharge summary
•The coder needs to review these documents to verify diagnoses and procedures
Steps in the coding process: What happens after the record is reviewed by a coder? What do codes have to be sequenced according to?
•After the record is reviewed, the coder selects the diagnoses and procedures that need to be coded and assigns appropriate code numbers
•Codes then have to be sequenced according to Uniform Hospital Discharge Data Set (UHDDS) guidelines.
Steps in the coding process: What happens after the diagnoses and procedures are coded? How is this data used?
•After the diagnoses and procedures are coded, the codes are entered into the facility's database
•These data then become the foundation for statistical, reimbursement, and clinical information systems
Quality Assessment for the Coding Process: How do assessments occur? What does a monitoring/audit program outline?
•Assessment of the coding process should occur through regular monitoring of coding accuracy
•Monitoring is the ongoing internal review of coding practices conducted by an organization on a regular basis
•A monitoring/audit program plan should be a written plan that outlines the objectives and frequency of the audits, the record selection process, the qualifications of auditors, and corrective actions the organization will take as a result of the audit findings
Quality Assessment for the Coding Process: What initially should be performed? What should the audit entail?
•Initially, a baseline audit should be performed
•The audit should be a review of a large sample of the coding completed. It should include a sample of records coded by all coders for all types of services
•Moreover, the sample should be representative of all physicians and types of cases treated by the organization
•The baseline audit provides an overview of the organization's current coding practices
Quality Assessment for the Coding Process: When should follow-up audits be conducted? What do follow-up audits provide? How are audit results used?
•The organization should conduct follow-up audits according to the schedule established in the monitoring/audit plan
•Follow-up audits will provide ongoing monitoring of the coding process to ensure coding accuracy
•The results of the audits also can be used to outline areas in which coder education and training are needed.
Figure 6.14 is an example of a coding audit review sheet.
Chapter 7 also discusses management of documentation and coding quality and corporate coding compliance programs.
6.5 Instructions: Indicate whether the following statements are true or false (T or F)
1. __T__ Coding plays an important role in the determination of reimbursement of healthcare facilities.

2. _T___ The coding function must be reviewed on an ongoing basis for coding consistency and accuracy.

3. __F__ The AMA publishes the official guidelines for CPT coding in its newsletter, Coding Clinic.

4. __F__ Codes are sequenced in the patient's health record according to AHIMA's Standards of Ethical Coding.

5. __T__ A baseline audit should include a sample of records coded by all coders for all types of services
Coding Technology: How is tech changing aspects of the health information profession? Where has it made jobs more efficient, and what tool is used?
•Technology is changing many aspects of the health information profession
•One of the primary areas where it has assisted in making jobs more efficient is in the area of coding
•As early as the 1980s, information technology was applied to make the coding process more effective and efficient
•The type of tool used to aid in the coding process is commonly referred to as an encoder
•The development of other technologies, including natural language processing (NLP), will likely have an even greater impact on the coding process
Encoders: What are they, when were they developed and why were they initially developed?
•Encoders for ICD were developed in the early 1980s •Over the subsequent years, greater sophistication has been built into these technology solutions
•An encoder is computer software that helps the coding professional to assign codes
•Initially, encoders were developed for assisting coders in assigning ICD-9-CM codes. Today, however, encoders include assistance with other coding systems.
How does the information science and technology behind the encoding software vary from vendor to vendor?
•Some encoders are built using expert system techniques such as rule-based systems
•Other encoding software is more simplistic, merely automating a look-up function similar to the manual index in ICD or other coding classifications
Encoder interfaces, what are they and how do they vary? How do some encoders work?
•Encoders have many different types of interfaces, depending on the vendor
•An interface can be defined as the total component of screens, navigation, and input mechanisms used to help the end user operate the encoding software
•Some encoder systems have an interface that prompts the coder through a series of questions
•As the coder answers the questions, the encoder leads the coder to codes for diagnoses and procedures
Alternatively, what do other encoders allow? How do they work in more sophisticated software systems?
•Alternatively, other encoders allow coders to input classification codes directly into the system and then go through a series of edit checks to ensure that only allowable code numbers are entered
•In more sophisticated software systems, the encoder also prompts the coder to review the sequencing of the codes that have been selected in order to optimize reimbursement
Encoding software: what should good encoding software include? What is encoding software frequently linked to?
•Good encoding software should include edit checks to ensure data quality
•For example, an inappropriate combination of codes or inconsistent data should be flagged for the coder's attention
•Encoding software is frequently linked to other information systems applications
•This includes direct links to DRG grouper software and billing systems
The use of encoders in the HIM department: Where are they particularly predominant? What is today's movement toward? What does CAC stand for?
•The use of encoders has become a predominant tool in the HIM department, particularly in acute care facilities. •Today, however, there is even a greater movement toward more complete computerization of the coding function using a supporting technology called computer-assisted coding (CAC)
CAC: different types
•There are several different types of CAC including using software to aid the physician in selecting the correct code with processes such as drop down boxes or the use of touch screen terminals
What is NLP?
•One form of CAC is natural language processing, or NLP. •In an NLP or artificial intelligence software, digital text from online documents stored in the organization's information system is read directly by the software, which then suggests codes to match the documentation
•For example, the digital text in an online emergency department record would be interpreted automatically by the CAC system and, through the use of expert or artificial intelligence software, would automatically suggest appropriate code numbers
•The coding professional would then review the selections and verify codes before releasing the case into the billing system. See an example of this in figure 6.15
What is the goal of CAC?
The goal of CAC is to become the essential tool for hospital coding by meeting both current and future requirements.
While the motivations and goals for CAC are clear, what are significant challenges in the hospital setting? What are three important deliverables?
CAC developers must demonstrate the effectiveness of their solutions for hospital inpatient and outpatient services while working with HIM professionals to serve up three important deliverables (Morsch et al. 2008):

1. Incorporate CAC into an integrated workflow process that collects data from disparate source systems and gives the hospital coder a combined view of NLP text and scanned handwritten documents.

2. Efficiently allow the hospital coder to interact with the information to accurately complete the coding. This information is then flowed downstream into the encoding and abstracting process so that a final bill is efficiently produced.

3. Support the post-coding process with thorough attribution of all selected codes in each case, so that the HIM staff can comply with audit requirements using a pre-existing set of structured reports.
Medicare prospective payment system (PPS)
•In the early 1980s, the federal government implemented the Medicare prospective payment system (PPS) for inpatient reimbursement
•Each patient is assigned to a Medicare Severity refined diagnosis-related group (MS-DRG) that determines the facility reimbursement amount based on a relative weight (RW) (figure 6.16)
Figure 6.16. Example subclassification breakouts under MS-DRGs
Example 1 subgroup
MS-DRG 313 | Chest pain | RW0.5404
Example of 2 subgroups
MS-DRG 231 | Coronary with PTCA and MCC | RW7.6784
MS-DRG 232 | Coronary bypass with PTCA without MCC | RW 5.5589
How are patients categorized in the MS-DRG system?
•In the MS-DRG system, patients are categorized into MS-DRGs that represent cases that are medically similar with respect to diagnosis, treatment, severity of illness and length of stay
•ICD-9-CM diagnoses and procedure codes are used to determine placement into the MS-DRG payment categories
How Medicare is reimbursement similar to the MS-DRG system?
•Similar to the MS-DRG system, Medicare reimburses hospitals for outpatient services based on the outpatient prospective payment system (OPPS), which categorizes patients into groups
•These groups are known as ambulatory payment classifications (APCs) according to the types of services commonly provided in that setting
•Primarily, the CPT/HCPCS coding system is utilized to determine correct payment of services.
Medicare reimburses hosptials for outpatient services based on this:
Outpatient services based on the outpatient prospective payment system (OPPS), which categorizes patients into groups
Groups categorized by the outpatient prospective payment system (OPPS) are known as:
These groups are known as ambulatory payment classifications (APCs) according to the types of services commonly provided in that setting
In both the MS-DRG and APC groupings, coders enter the codes that have been selected into what computer program?
•In both the MS-DRG and APC groupings, coders enter the codes that have been selected into a computer program called a grouper
•The grouper then assigns the patient's case to the correct group based on the ICD-9-CM and/or CPT/HCPCS codes. See table 6.2 for an example of APC groupings.
Table 6.2 Example of APC groupings:
APC | Group Title | SI | Relative Weight | Payment Rate | National Unadjusted Copayment | Minimum Unadjusted Copayment

APC: 0001
Group title: Level I Photochemotherapy
SI: S
Relative Weight: 0.39998
Payment Rate: 23.79
Natnl Unadjusted Co-pay: 7.00
Min Unadjust Co-pay: 4.76
6.6 Instructions: Indicate whether the following statements are true or false (T or F).
1. __F__ An encoder is computer software that assists in determining coding accuracy and reliability.

2. __T__ An interface is the total component of screens, navigation, and input mechanisms used to operate encoding software.

3. __T__ Good encoding software should include edit checks.

4. __T__ The NLP encoding system uses expert or artificial intelligence software to automatically assign code numbers.

5. _T___ Diagnosis-related groups categorize patient cases that are medically similar with respect to diagnosis, treatment, and length of stay
Coding and Corporate Compliance: Fraud and compliance plans
•Each year, it is estimated that millions of dollars of the U.S. healthcare industry budget is misappropriated because of fraudulent practices by healthcare organizations and providers
•Through the Office of the Inspector General (OIG), the federal government establishes annual compliance plans for the healthcare industry
Compliance plan: Definition and goal
•A compliance plan can be defined as a plan to ensure that a facility is providing and billing for services according to the laws, regulations, and guidelines that govern it
•The goal of these plans is to help providers monitor their billing and coding practices to prevent fraud and abuse. (Compliance is also discussed in chapter 7.)
History of Corporate Compliance: What is the basis for prosecution of health care fraud and abuse? When was it signed into law and by whom? What was it's intent? Under this act, what did the government have to prove?
•The basis for prosecution of healthcare fraud and abuse is the Federal False Claims Act (FCA)
•This act was signed into law by Abraham Lincoln in 1863
•Its original intent was to encourage private citizens during the Civil War to report fraudulent actions taken against the Union Army
•Under this act, the government had to prove that an individual acted with specific intent to defraud the government
When was the Federal False Claims Act (FCA) amended, and what was it changed to include?
•In 1986, the FCA was amended to include provisions that eliminated the requirement that specific intent to defraud be proven
•The law now has become the basis for prosecuting healthcare providers who knowingly present a false claim for payment to the government
•Therefore, when a healthcare provider shows a pattern or practice of coding that results in overcharges to Medicare and Medicaid, that provider can be prosecuted.
Which law has become the basis for prosecuting healthcare providers who knowingly present a false claim for payment to the government?
Federal False Claims Act (FCA)
What do healthcare providers need to develop to avoid fraud?
•To avoid fraudulent behaviors, healthcare providers need to develop compliance plans that ensure the establishment of internal controls
•Since 1997, the OIG has released its compliance program guidelines for segments of the healthcare industry, including hospitals, home health agencies, clinical laboratories, third-party medical billing companies, DME suppliers, hospices, nursing homes, and physicians' practices.
Elements of Corporate Compliance: what should healthcare providers use to develop and implement their own compliance programs? What does this outline?
•Healthcare providers should use the compliance programs released by the OIG to develop and implement their own compliance programs
•The guidelines outline elements that represent a plan that healthcare providers can follow. The various compliance program guidelines can be found on the OIG Web site at http://hhs.gov/oig
Where were several basic elements required for corporate compliance programs outlined?
•Several basic elements required for corporate compliance programs were outlined in the OIG's "Compliance Program Guidance for Hospitals," published in the Federal Register on February 23, 1998
•A supplemental plan for hospitals was published in the Federal Register on January 31, 2005.
Corporate compliance programs for hospitals should include at least the following seven elements:
1. The development and distribution of written standards of conduct, as well as written policies and procedures that promote the hospital's commitment to compliance (for example, by including adherence to compliance as an element in evaluating managers and employees) and that address specific areas of potential fraud such as claims development and submission processes, code gaming, and financial relationships with physicians and other healthcare professionals

2. The designation of a chief compliance officer and other appropriate bodies (for example, a corporate compliance committee) charged with responsibility for operating and monitoring the compliance program and that report directly to the CEO and the governing body

3. The development and implementation of regular, effective education and training programs for all affected employees

4. The maintenance of a process, such as a hotline, to receive complaints and the adoption of procedures to protect the anonymity of complainants and to protect whistleblowers from retaliation

5. The development of a system to respond to allegations of improper/illegal activities and the enforcement of appropriate disciplinary action against employees who have violated internal compliance policies, applicable statutes, and regulations or federal healthcare program requirements

6. The use of audits and/or other evaluation techniques to monitor compliance and assist in the reduction of identified problem areas

7. The investigation and remediation of identified systemic problems and the development of policies that address the nonemployment or retention of sanctioned individuals
Each year, the OIG publishes a work plan that details what? What should facilities do with this document? Where can this plan for 2010 be found?
•Each year, the OIG publishes a work plan that details areas of compliance it will be investigating for that year
•Facilities should study this document carefully and plan their compliance and auditing projects to ensure that they are in compliance with identified target areas
•The OIG work check plan for 2010 can be found online at http://www.oig.hhs.gov/publications/docs/workplan/2009/WorkPlanFY2009.pdf
Policies and Procedures for Corporate Compliance: How should they be developed? Which organization outlines specific areas of concern that need to be addressed in facilities policies? Who plays an active role in the development of HIM dept and organization-wide policies?
•Policies and procedures for corporate compliance must be developed at the facility level and for the HIM department
•The OIG outlines specific areas of concern that need to be addressed in facilities' policies
•HIM professionals play an active role in the development of both HIM department and organization-wide policies
In October 1999, AHIMA published a practice brief titled:
•"Seven Steps to Corporate Compliance" (AHIMA Compliance Task Force 1999)
•Organizations should use the guidelines in this practice brief to develop specific HIM compliance plans
As recommended by AHIMA, HIM compliance policies and procedures should ensure that:
All rejected claims pertaining to diagnosis and procedure codes are reviewed

Proper and timely documentation of all physician and other professional services is obtained prior to billing

Compensation for coders and consultants does not provide any financial incentive to code claims improperly

A process is in place for pre- and postsubmission review

The proper selection and sequencing of diagnoses occurs

The correct application of official coding rules and guidelines occurs

A process exists for reporting potential and actual violations

A process is in place for identifying coding errors
6.7 Instructions: Indicate whether the following statements are true or false (T or F)
1. _T___ The federal Office of the Inspector General established compliance plans for the healthcare industry.

2. __F__ The basis for prosecuting healthcare fraud and abuse is the Federal False Compliance Act.

3. _T___ The OIG compliance programs offer guidelines that healthcare organizations can follow to establish their internal compliance programs.

4. __T__ A corporate compliance program should include the development and implementation of education and training programs for all affected employees.

5. _F___ HIM professionals are not involved in developing policies and procedures for corporate compliance.
As the number and sophistication of clinical vocabularies increase, there has been a significant movement toward what?
•Research in understanding the fundamental elements and structures in both vocabularies and classification systems
What is one of the most farsighted endeavors toward bringing together the various medical vocabularies?
•One of the most farsighted endeavors toward bringing together the various medical vocabularies is the Unified Medical Language System (UMLS) project being conducted by the National Library of Medicine (NLM).
National Library of Medicine UMLS Project:
•The NLM established a research project in 1986
•This long-range project is called the Unified Medical Language System (UMLS) project.
•The purpose of the UMLS is to aid in the development of systems that help healthcare professionals retrieve and integrate electronic biomedical information from a variety of sources.
UMLS uses three knowledge sources to make it easier for users to link separate information systems:
1. The metathesaurus provides a uniform collection of more than one hundred biomedical/health-related vocabularies, coding systems, and classifications and links the different names used in the various vocabularies and classifications, such as SNOMED CT, LOINC, and RXNorm to a common concept. The UMLS Metathesaurus contains the complete set of SNOMED CT.

2. The specialist lexicon contains syntactic information for many terms. (For example, it lists the parts of speech, various forms of a word, and spelling variations of the terms within UMLS.)

3. The semantic network provides a system for categorizing objects and identifying the relationships among various concepts.

The UMLS knowledge sources overcome retrieval problems that occur when different terminology and separate databases are used. They are currently being used in a variety of applications, including patient data creation, natural language processing, and information retrieval. The NLM maintains fact sheets describing the progress of this project on its Web site (http://www.nlm.nih.gov/pubs/factsheets/umls.html).

Development of the Nosologist Role

Nosology is the branch of medical science that deals with classification systems. A nosologist is a person who works with using and developing classification systems. The AHIMA Coding Futures Task Force envisions that the role of the coder will change dramatically over the next decade. At present, the coder's primary responsibility is the assignment of codes. In the future, the coder will become responsible for the development, maintenance, and management of classification systems and vocabularies.

In today's healthcare environment, HIM professionals, especially those with career paths in clinical coding, are enjoying a wealth of opportunity in the job market. There is a critical need for qualified coding professionals to classify, manage, and maintain clinical information for analysis and transactions. As a result of increased regulation in healthcare, heightened compliance risks, and progressively more complex reimbursement tied to code assignments, coding professionals have a greater array of choices within the profession than ever before.

Along with increased demand for coding professionals is a clear broadening of roles within the HIM profession. Today's work force demands knowledge and job skills that go beyond the basic conventions of standard diagnosis and procedure code assignment from health records. Clinical terminologies are expanding into a broader use of data sets beyond the traditional ICD-9-CM and HCPCS/CPT code sets to include SNOMED-CT, LOINC, specialized terminologies for pharmaceuticals and nursing care, and a host of others to serve an environment hungry for data that is easily digested by computer software and reliable, consistent, and accurate.

Many levels of HIM expertise are needed, and a variety of skills are important for career success. Most employers are seeking a minimum of a bachelor's degree in a healthcare discipline as well as "high-end" knowledge that facilitates integration of data management with a specific business case, software application, or clinical workflow support process. Current employment trends favor master's degree preparation in HIM, health informatics, computer information management, or related fields of study. A solid clinical knowledge base is required for many positions related to clinical terminology use involving clinical coding systems and data analysis.

To complete the picture, there are a number of healthcare professionals managing health information today. HIM roles involve physicians, nurses, technicians, and other allied health professionals in some job settings. Career pathways in HIM frequently merge with an educational foundation or experience in these disciplines. These pathways are helpful for illustrating how selected jobs evolve over time and how entry-level positions lay the foundation for new opportunities with greater responsibility, variety, and compensation potential (AHIMA Practice Council for Clinical Terminology and Classification 2007).
The UMLS knowledge sources overcome retrieval problems that occur when what is used? What does the NLM maintain?
•Different terminology and separate databases are used. •They are currently being used in a variety of applications, including patient data creation, natural language processing, and information retrieval
•The NLM maintains fact sheets describing the progress of this project on its Web site (http://www.nlm.nih.gov/pubs/factsheets/umls.html).
...
Development of the Nosologist Role

Nosology is the branch of medical science that deals with classification systems. A nosologist is a person who works with using and developing classification systems. The AHIMA Coding Futures Task Force envisions that the role of the coder will change dramatically over the next decade. At present, the coder's primary responsibility is the assignment of codes. In the future, the coder will become responsible for the development, maintenance, and management of classification systems and vocabularies.
...
In today's healthcare environment, HIM professionals, especially those with career paths in clinical coding, are enjoying a wealth of opportunity in the job market. There is a critical need for qualified coding professionals to classify, manage, and maintain clinical information for analysis and transactions. As a result of increased regulation in healthcare, heightened compliance risks, and progressively more complex reimbursement tied to code assignments, coding professionals have a greater array of choices within the profession than ever before.

Along with increased demand for coding professionals is a clear broadening of roles within the HIM profession. Today's work force demands knowledge and job skills that go beyond the basic conventions of standard diagnosis and procedure code assignment from health records. Clinical terminologies are expanding into a broader use of data sets beyond the traditional ICD-9-CM and HCPCS/CPT code sets to include SNOMED-CT, LOINC, specialized terminologies for pharmaceuticals and nursing care, and a host of others to serve an environment hungry for data that is easily digested by computer software and reliable, consistent, and accurate.

Many levels of HIM expertise are needed, and a variety of skills are important for career success. Most employers are seeking a minimum of a bachelor's degree in a healthcare discipline as well as "high-end" knowledge that facilitates integration of data management with a specific business case, software application, or clinical workflow support process. Current employment trends favor master's degree preparation in HIM, health informatics, computer information management, or related fields of study. A solid clinical knowledge base is required for many positions related to clinical terminology use involving clinical coding systems and data analysis.

To complete the picture, there are a number of healthcare professionals managing health information today. HIM roles involve physicians, nurses, technicians, and other allied health professionals in some job settings. Career pathways in HIM frequently merge with an educational foundation or experience in these disciplines. These pathways are helpful for illustrating how selected jobs evolve over time and how entry-level positions lay the foundation for new opportunities with greater responsibility, variety, and compensation potential (AHIMA Practice Council for Clinical Terminology and Classification 2007).
6.8 Instructions: Indicate whether the following statements are true or false (T or F):
1. _T___ The UMLS project was initiated to bring together the various medical vocabularies.

2. __F__ The metathesaurus, one of the UMLS knowledge sources, contains syntactic information for many terms.

3. __T__ The UMLS knowledge sources are currently being used in natural language processing.

4. _F___ A nosologist's primary responsibility is the assignment of diagnosis codes.

5. __T__ In the future, coders' roles will change
Real-World Case
The following real-world case was adapted from AHIMA Today 2009.

Can computer assisted coding (CAC) be helpful to outpatient coders? CAC is a supporting technology that has reached an exciting stage of development. It holds a great deal of promise for assisting in further automation of the coding process. Although the technology holds great promise, it also faces a huge challenge because of the complexity and variability of human speech. However, promising new CAC products are beginning to emerge in certain medical arenas, such as emergency medicine and radiology. Facilities that have begun to implement CAC report the following benefits (AHIMA Today 2009):

Reduced number of systems requiring review (previously the hybrid record required the review of components in the EHR/scanned documents/paper record)

Increased productivity and efficiency

Increased accuracy

Increase in productivity by 20 percent

Decrease in overtime by 85 percent

Decrease in external auditor recommendation changes by 50 percent

Decrease in external audit fees by 60 percent

Increase in Medicare Case Mix Index (CMI) by 0.08 or 4 percent with same patient population
In recent decades, coding, classification, and vocabulary systems have grown in importance.
This is clear in the critical role that coding now plays in the healthcare industry's reimbursement process and its use in research and quality assurance efforts.
Nomenclatures, classification systems,
Nomenclatures, classification systems, and clinical vocabularies were created to help organize healthcare data. In medicine, a nomenclature is a system that lists preferred medical terminology. A classification system groups together similar diseases and procedures and organizes related entities for easy retrieval.
The purpose and use of clinical classifications today are varied.
For example, physicians use classifications such as ICD to classify morbidity and mortality information for statistical purposes, to index hospital records by disease and operations, and to report diagnoses. In addition, clinical classifications are used in the reporting and compilation of healthcare data to assist in evaluating medical care planning for healthcare delivery systems, determining patterns of care among healthcare providers, analyzing payments of healthcare services, and conducting epidemiological and clinical research studies.
Although ICD-9-CM is perhaps the most prominent classification system in use today:
Although ICD-9-CM is perhaps the most prominent classification system in use today, health information technicians use many other systems in their daily practice, such as CPT, HCPCS, ICD-O-2, DSM, and nursing vocabularies. The continued development of these and other classification systems and vocabularies reflects the complexity of describing the medical care process.
Every healthcare organization must have policies and procedures in place that do what?
Every healthcare organization must have policies and procedures in place that set guidelines for managing the coding process and ensuring the consistency of the organization's coding output. Further, every organization should establish a monitoring/audit program to review and assess coding accuracy on a regular basis. Moreover, every organization should develop a corporate compliance plan that monitors its billing and coding activities to prevent fraudulent practices.
Finally, technological advances are having a tremendous impact on the coding process today and will likely have an even greater impact in the future.
Important projects such as the Unified Medical Language System project conducted by the National Library of Medicine, coupled with the growth and maturity of automated coding and natural language processing systems, will revolutionize the coding function.
Historical importance of clinical vocabularies: First universally accepted medical nomenclature in United States
Standard Nomenclature of Disease and Operations
Historical importance of clinical vocabularies:
ICD-9-CM is most recognized classification system
•World Health Organization
•Developed for morbidity and mortality data
Clinical Vocabularies
•Clinical users
•Administrative users
ºCurrent Procedural Terminologies
ºHealth Insurance Portability and Accountability and Act
data sets
•International Classification of Disease, 9th Revision,
Clinical Modification
•Healthcare Common Procedure Coding System
•Current Dental Terminology
•National Drug Codes
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)
•Classification system for reporting medical diagnoses and procedures
•ICD-9-CM is one of the most common classification systems in United States
•ICD-9 was published by World Health Organization
•ICD-9-CM was modification of ICD-9 for use in United States
ICD-9-CM
Maintained by Cooperating Parties
National Center for Health Statistics
American Hospital Association
American Health Information Management Association
Centers for Medicare and Medicaid Services
Cooperating Parties Responsibilities
To serve as clearinghouse to answer questions about ICD-9-CM
To develop educational materials and programs on ICD-9-CM
To work cooperatively in maintaining the integrity of ICD-9-CM
•To recommend revisions and modifications to current and future revisions of ICD
•AHA's Editorial Advisory Board for Coding Clinic supplements the work of the cooperating parities
•NCHS updates diagnoses
•CMS updates procedures
•AHIMA provides training and certification
•AHA maintains Central Office on ICD-9-CM and publishes Coding Clinic for ICD-9-CM
ICD-9-CM Coordination and Maintenance Committee
Cochaired by NCHS and CMS
Committee is made up of advisors and representatives of all Cooperative Parties
Purposes and Use of ICD-9-CM
Classifying morbidity and mortality information for statistical purposes
Indexing hospital records by disease and operation
Reporting diagnoses by physician
Storing and retrieving data
Reporting national morbidity and mortality data
Purposes and Use of ICD-9-CM
•Serving as the basis of diagnosis-related group (DRG) assignment for hospital reimbursement
•Reporting and compiling healthcare data to assist in the evaluation of medical care planning for healthcare delivery systems
•Determining patterns of care among healthcare providers
•Analyzing payments for health services
•Conducting epidemiological and clinical research
ICD-9-CM Overview of Structure
Three volumes
Volume I - tabular list
Numerical listing of diagnosis codes
Volume II - alphabetic index
Alphabetic index for all codes in diagnosis codes
Volume III - tabular list and alphabetic index
Tabular list and alphabetic index for all procedures
ICD-9-CM Volume I
Classification of diseases and injuries
17 chapters
Type of condition and anatomical system
Sections 3 digit code numbers
Categories represent closely related conditions or a single disease index
•Supplemental classifications
Supplementary Classification of Factors Influencing
Health Status and Contact with Health Services (V
codes)
Supplementary Classification of External Causes of
Injury and Poisoning (E codes)
V Codes
Classify occasions when circumstances other than disease or injury is reason for patient's visit
Specific reason such as organ donor
Specific treatment of disease of previously diagnosed condition such as follow-up after surgery
Circumstances influence health status but is not a current injury or illness such as personal history of smoking
•Alphanumeric codes
•Codes begin with the letter V
V15.04, Allergy to seafood
E Code
Classify environmental events, circumstances, and conditions as the cause of injury, poisoning, and other adverse effect
Alphanumeric code beginning with E
E925.0 Accident caused by an electric current in domestic wiring and appliances
Appendixes
Appendix A: Morphology of Neoplasms
Appendix B: Glossary of Mental Disorders (obsolete)
Appendix C: Classification of Drugs by American Hospital Formulary Service List Number
Appendix D: Classification of Industrial Accidents According to Agency (obsolete)
Appendix E: List of 3 digit categories (obsolete)
Volume 2 and Volume 3
Volume 2
Index to diseases and injuries
Main term appear alphabetically by type of disease, injury, or illness
Volume 3
Tabular and alphabetic lists of procedures
Organized by anatomical system except last chapter
International Classification of Diseases, 10th Revision, Clinical Modification
ICD-10 developed by WHO
Currently used by many countries
Used in United States for mortality data
ICD-10 needed to be revised to accommodate reimbursement systems in United States
ICD-10-CM and ICD-10-PCS to be implemented in United States October 1, 2013
ICD-10-CM
Contains only diagnosis codes
Changes include:
Includes combination codes for conditions and common symptoms or manifestation
Decrease cross references
Provide codes for laterality
Providing expanded codes to capture more details
Flexibility and expandability
Purpose and Use of ICD-10-CM
Planned replacement for ICD-9-CM volumes 1 and 2
Alphanumeric codes
International Classification of Diseases, 10th revision, Procedure Classification System
Purpose and use
To improve accuracy and efficiency of coding
To reduce training effort
To improve communication with physicians
Replacing ICD-9-CM procedure codes
Overview and Structure
No correlation to ICD-1-CM
Multi-axial 7 character alphanumeric code structure
Uses numbers 0-9 and letters A-H, J-N, and P-Z
7 Characters
1 = Section of ICD-10-PCS
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 (such as diagnostic vs. therapeutic)
Example Code: 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