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Intro to coding : Nomenclatures, terminologies, other classifications, and clinical vocabularies
Terms in this set (45)
a system of words used in a particular topic or subject. It is used in respect of giving names systematically following certain established rules.
the term "clinical"
pertains to the practice of medicine, relating to the patient.
CPT® / The Current Procedural Terminology (CPT)
fourth edition includes codes, the descriptions of the codes, and related guidelines. These codes are intended to report procedures and services performed by physicians and other healthcare providers. The codes in CPT are five digits long.
The AMA is the source for CPT, a medical nomenclature utilized to report services to payers.
who maintains the CPT
CPT Editorial Panel. . This group meets three times a year to discuss requests for new codes as well as difficulties encountered with procedures and services and their relation to CPT codes.
How often is the CPT updated?
yearly, new versions go into effect Jan 1st
Whats included in the CPT
Procedures included in the CPT are considered to be consistent with common medical practice and performed by many providers in multiple locations. These codes are referred to as Category I codes.
It is important to note that being included in the CPT book does not guarantee coverage by any payer.
The six main sections of CPT: CAT 1
Evaluation and Management
Pathology and Laboratory
CPT Cat II codes
codes include supplemental tracking codes used for performance measurement. These codes serve as monitoring tools, and do not replace CPT codes.
CPT CAT III codes
temporary codes for emerging technologies not yet part of the regular CPT. When these codes are provided, it is not appropriate to assign an unlisted code from the main part of CPT. As the Category III procedures become more standard, it is very common that they become part of Category I codes.
examples of Cat 2 codes
3017F: Colorectal cancer screening results documented and reviewed.
3077F: Most recent systolic blood pressure greater than or equal to 140 mm Hg.
3551F: Intermediate risk for thromboembolism.
HCPCS / The Healthcare Common Procedure Coding System
A 2 level coding system used for Medicare and other health insurance programs to ensure that these claims are processed in an orderly and consistent manner. The two principal subsystems level I and level II.
Level I of the HCPCS
comproised of CPT® (Current Procedural Terminology), a numeric coding system maintained by the American Medical Association (AMA). These healthcare professionals use the CPT to identify services and procedures for which they bill public or private health insurance programs.
does not include codes needed to separately report medical items or services that are regularly billed by suppliers other than physicians.
American Medical Association, in charge of the addition, deletion, or revision of CPT codes
Level II of the HCPCS
a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office.
established in the 80's, they are alpha numberic codes.
42 CFR Sec. 414.40 (a)
CMS establishes uniform national definitions of services, codes to represent services, and payment modifiers to the codes.
level III HCPCS codes
developed and used by Medicaid State agencies, Medicare contractors, and private insurers in their specific programs or local areas of jurisdiction. For purposes of Medicare, level III codes were also referred to as local codes.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) required CMS to adopt standards for coding systems that are used for reporting healthcare transactions. Published in the Federal Register on August 17, 2000 (65 FR 50312) were regulations to implement this part of the HIPAA legislation. These regulations provided for the elimination of level III local codes by October 2002,
who establishes Level II HCPCS codes?
CMS's Alpha-Numeric Editorial Panel.
Level II HCPCS codes
primarily represent items and supplies and non-physician services not covered by the AMA's CPT codes; Medicare, Medicaid, and private health insurers use HCPCS procedure and modifier codes for claims processing.
alphanumeric procedure and modifier codes comprise the A to V range. The updated codes are available at: www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html
Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®)
considered an input system. It uses the primary documentation of medical or clinical care. The system provides codes for all of the clinical information that happens during the patient care. is only used in an electronic health record (EHR) system.
the most comprehensive, multilingual clinical healthcare terminology in the world.
International Health Terminology Standards Development Organization (IHTSDO)
Owned, maintained, and distributes the SNOMED CT. A not-for-profit association which is owned and governed by its national members.
How does SNOMED CT assist in improving patient care?
Because of its involvement in contributing to the development of electronic health records (EHR) that record the patient's clinical information. By having the EHR available quickly and in multiple locations, meaning-based retrieval is possible. This allows effective access to the patient's health information in a meaningful manner, allowing decision support and consistent reporting and analysis.
How does SNOMED CT work?
contains concepts with unique meanings and formal logic based definitions and is organized into hierarchies.
SNOMED CT content is represented using three types of component:
SNOMED CT concepts
Every concept has a unique numeric concept identifier. Within each hierarchy, concepts are organized from the general to the more detailed.
SNOMED CT concept descriptions
All concepts have a single unambiguous Fully Specified Name, that contains the "semantic tag" in parenthesis and identifies the hierarchy to which the concept belongs.
The concept can also have several associated descriptions, each representing a synonym that describes the same clinical concept. Every description has a unique numeric description identifier.
SNOMED CT relationships
link concepts to other concepts whose meaning is related in some way. These relationships provide formal definitions and other properties of the concept.
How is SNOMED CT created?
currently released in January and July of each year and content evolves with each release. Four basic principles guide the development of clinical content and technical design including:
inclusive involvement of diverse clinical groups and medical informatics experts.
quality focused content development with adherence to strict editorial rules.
a quality improvement process that is open to public scrutiny and vendor input.
minimal barriers to adoption and use.
The types of changes made for each release include ?
new concepts, new descriptions, new relationships between concepts, and new reference sets, as well as updates and retirement of any of these components. Drivers of these changes include:
changes in understanding of health and disease processes
introduction of new drugs, investigations, therapies and procedures
new threats to health
proposals and requests for change submitted by users of SNOMED CT.
How Is SNOMED CT Used?
SNOMED CT is useful for clinical documentation, as it supports the representation of detailed clinical information, in a way that can be processed automatically. Realization of the capability of SNOMED CT to support clinical information and meaning based retrieval requires careful consideration of the actual setting, in terms of scope of use, record structure, data entry, data retrieval and communication.
Why SNOMED CT?
The use of an electronic health record (EHR) improves communication and increases the availability of relevant information.
SNOMED CT enabled clinical health records benefit individuals by:
Enabling relevant clinical information to be recorded using consistent, common representations during a consultation.
Enabling guideline and decision support systems to check the record and provide real-time advice, for example, through clinical alerts.
Supporting the sharing of appropriate information with others involved in delivering care to a patient through data capture that allows understanding and interpretation of the information in a common way by all providers.
Allowing accurate and comprehensive searches that identify patients who require follow-up or changes of treatment based on revised guidelines.
Removing language barriers (SNOMED CT enables multilingual use).
SNOMED CT enabled clinical health records benefit populations by:
Facilitating early identification of emerging health issues, monitoring of population health and responses to changing clinical practices.
Enabling accurate and targeted access to relevant information, reducing costly duplications and errors.
Enabling the delivery of relevant data to support clinical research and contribute evidence for future improvements in treatment.
Enhancing audits of care delivery with options for detailed analysis of clinical records to investigate outliers and exceptions.
SNOMED CT enabled health records inform evidence based healthcare decisions by:
Enabling links between clinical records and enhanced clinical guidelines and protocols.
Enhancing the quality of care experienced by individuals.
Reducing costs of inappropriate and duplicative testing and treatment, limiting the frequency and impact of adverse healthcare events.
Raising the cost-effectiveness and quality of care delivered to populations.
ICD-0-3 / The International Classification of Diseases for Oncology, 3rd Edition
maintained and copyrighted by the World Health Organization. The classification uses ICD-10 to classify tumors in a multi-axial style using:
primarily by cancer registries to code the topography (or site) and the morphology (or histology) of neoplasms.1
The axis for site
uses the ICD-10 classification, giving a much greater detail about the site for non-malignant tumors. The ICD-O also includes the sites for hematopoietic and reticuloendothelial tumors.
The morphology axis
includes a five-digit code. These codes range from M-8000/0 to M-9989/3. The first four digits indicate the specific histological term, such as carcinoma, adenocarcinoma, squamous cell carcinoma, etc. The digit that comes after the slash (/) provides the behavior of the neoplasm.
There is an additional separate one-digit code available to identify histologic grading or differentiation. The system contains a single combined alphabetical index that includes topography and morphology.
Uncertain whether benign or malignant
In situ neoplasms
Malignant neoplasms, primary site
Malignant neoplasms, secondary
Malignany, uncertain whether primary or metastatic site
DSM / Diagnostic and Statistical Manual of Mental Disorders
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.
who maintains the DSM?
maintained by the American Psychiatric Association and used for gathering and communicating statistics related to public health.
three major parts to the DSM
diagnostic criteria sets
diagnostic classification of the DSM
refers to the list of actual mental disorders. They are the official part of the DSM system. DSM refers to "making a DSM diagnosis." The selection is made by choosing the disorder in the classification that best replicates the signs and symptoms of the patient. Diagnostic labels associate with a diagnostic code. These codes are commonly used by organizations for data collection and billing. These diagnosis codes come from ICD-9-CM/ICD-10-CM.
Diagnostic criteria of the DSM
In order to qualify for a particular diagnosis, each disorder includes:
-what symptoms must be present (and for how long)
-symptoms, disorders, and conditions that must not be present
The purpose of the diagnostic criteria is as a set of guidelines.
the descriptive text of the DSM
According to the APA, the following headings are used to describe each disorder:
Subtypes and/or Specifiers
Associated Features and Disorders
Specific Culture, Age, and Gender Features
published in 1994, with version 5 published in 2013. In the interim, DSM-IV-TR was used to accommodate updates. The TR means Text Revision. To account for slight variations between DSM and ICD, a crosswalk is used between the two systems.
released May 19, 2013, and is currently used in the United States. DSM-5 manuals contain both ICD-9 and ICD-10 codes under their diagnoses but health professionals are currently only using the ICD-10 codes for records and reimbursement.
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