Chapter 5: Clinical Vocabulary and Classification Systems

Classification System
(1) A system for grouping similar diseases and procedures and organizing related information for easy retrieval.
(2) A system for assigning numeric or alphanumeric code numbers to represent specific diseases and/or procedures.
Clinical Vocabulary
A formally recognized list of preferred medical terms.
Computer-Assisted Coding (CAC)
Utilizes natural language processing (NLP) and algorithmic software to electronically analyze entire medical charts to pre-code with both CPT procedure and ICD-9 diagnostic nomenclatures.
Current Procedural Terminology (CPT)
A comprehensive, descriptive list of terms and numeric codes used for reporting diagnostic and therapeutic procedures and other medical services performed by physicians; published and updated annually by the American Medical Association.
Diagnostic And Statistical Manual of Mental Disorders, Fourth Revision, Text Revision (DSM-IV-TR)
The 2004 text revision of the Diagnostic and Statistical Manual of Mental Disorder, Fourth Revision, with updated clinical terms, but very few coding changes. It is a tool for providing a set of codes that could be used to aid in the colleciton of clinical data using stand-alone personal computers.
E codes (external cause of injury code)
A supplementary ICD-9-CM classification used to identify the external causes of injuries, poisonings, and adverse effects of pharmaceuticals. They are used in addition to codes from the main chapters of ICD-9-CM.
Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system.
Healthcare Common Procedure Coding System (HCPCS)
An alphanumeric classification system that identifies healthcare procedures, equipment, and supplies for claim submission purposes; the three levels are as follows: (1) Current Procedural Terminology codes, developed by the AMA; (2) Codes for equipment, supplies, and services not covered by Current Procedural Terminology codes as well as modifiers that can be used with all levels of codes, developed by CMS; (3) Local codes developed by regional Medicare Part B carriers and used to report physicians’ services and supplies to Medicare for reimbursement (eliminated December 31, 2003, to comply with HIPAA)
The total component of screens, navigation and input mechanisms used to help the end user operate the encoding software.
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. The total component of screens, navigation and input mechanisms used to help the end user operate the encoding software.
International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)
The planned replacement for ICD-9-CM, volumes 1 and 2, developed to contain more codes and allow greater specificity.
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, reducce training effort, and improve communication with physicians.
International Classification of Diseases for Oncology, Third Edition (ICD-O-3)
A system used for classifying incidences of malignant disease.
A term referring to the state of being diseased (including illness, injury, or deviation from normal health); the number of sick persons or cases of disease in relationship to a specific population.
(1) A term referring to the incidence of death in a specific population.
(2) The loss of subjects during the course of a clinical research study.
Natural Language Processing (NLP)
A field of computer science and linguistics concerned with the interactions between computers and human (natural) languages that converts information from computer databases into readable human language.
A recognized system of terms used in science or art that follows preestablished naming conventions.
Disease Nomenclature
A listing of the proper name for each disease entity with its specific code number.
The branch of medical science that deals with classification systems.
Nursing Vocabularies
A classification system used to capture documentation on nursing care.
Read Codes
The former name of the United Kingdom’s CTV-3; named for James Read, the physician who originally devised the system to organize computer-based patient data in his primary care practice.
Systemized Nomenclature of Medicine Clinical Terminology (SNOMED CT)
A concept-based terminology consisting of more than 110,000 concepts with linkages to more than 180,000 terms with unique-readable codes. It is a standardized vocabulary, sometimes referred to as a controlled reference terminology. It is a systematized, mulitaxial, and hierarchically organized nomenclature of medically useful terms, considered to be the most comprehensive, multilingual healthcare terminology in the world.
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. They are always alphanumeric.
World Health Organization (WHO)
The United States specialized agency for health, established on April 7, 1948, with the objective, as set out in its constitution, of the attainment by all peoples of the highest possible levels of health; responsible for the International Statistical Classification of Diseases and Related Health Problems (ICD-10).
Clinical Users
Providers who use clinical vocabularies and classifications to collect, process, and retrieve data for clinical purposes. They use the vocabularies to support activities such as clinical research, disease prevention, and patient care.
Administrative Users
Include healthcare facilities, professional organizations and government agencies. They use clinical vocabularies and classifications to support administrative, statistical, and reimbursement functions.
Current Dental Terminology, Code on Dental Procedures and Nomenclautres (CDT)
The system used for reporting dental services.
International Classification of Diseases (ICD)
A classification system for reporting medical diagnoses and procedures.
What are the responsibilities, of the four cooperating parties, that maintain ICD-9-CM?
~To serve as a clearinghouse to answer questions.
~To develop educational materials and programs.
~To work cooperatively in maintaining its integrity.
~To recommend revisions and modifications to current and future revisions.
What are the uses for ICD-9-CM?
~Classifying morbidity and mortality information for statistical purposes.
~Indexing hospital records by disease and operations
~Reporting diagnoses by physicians
~Storing and retrieving data
~Reporting national morbidity and mortality data
~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 systems.
~Determining patterns of care among healthcare providers.
~Analyzing payments for health services.
~Conducting epidemiological and clinical research
How many volumes is the ICD-9-CM published in?
What are the ICD-9-CM volumes known as?
~V1: Tabular List
~V2: Alphabetic Index
~V3: Tabular List and Alphabetic Index for Procedures
Which ICD-9-CM volume is not part of the international ICD-9 version?
Volume Three
What does ICD-9-CM volume 1 contain?
The numerical listing of codes that represent diseases and injuries.
What does ICD-9-CM volume 2 contain?
The alphabetic index for all the codes listed in volume one. Main terms appear alphabetically by type of disease, injury, or illness. Subterms are indented under the main term.
What are the subdivisions for Volume 1 of ICD-9-CM?
~Classification of Diseases and Injuries
~Supplementary Classifications
How many chapters, in Volume 1 of ICD-9-CM, does the classification of diseases and injuries contain and how are they organized?
Seventeen chapters, organized by type of condition and anatomical system. Each chapter is then divided even further into
~Sections (with a three-digit code)
~Categories (which represent a group of closely related conditions or a single disease.
~Subcategories (with a four-digit code)
~Sub-classification (with a five-digit code)(most specific)
What are the two supplementary classifications that are part of Volume 1 of the ICD-9-CM?
~The Supplementary Classification of Factors Influencing Health Status and Contact with Health Services. (V codes)
~The Supplementary Classification of External Causes of Injury and Poisoning. (E codes)
In Volume 3 of the ICD-9-CM, what does the Tabular List of Procedures contain?
Chapters organized according to anatomical system except the last chapter, Miscellaneous Diagnostic and Therapeutic Procedures. The chapters are then subdivided into two-, three-, and sometimes four-digit code numbers.
How can you tell a procedural code from a disease code?
The number of digits before the decimal. Procedural has two and Disease has three.
What enhancements does ICD-10-CM offer?
~Combination codes for conditions and common symptoms or manifestations.
~Decreasing cross-referencing by writing out the full code title for all codes.
~Providing codes for laterality such as codes fro left side, right side, and in some cases bilateral.
~Providing expanded codes to capture more detail in several sections such as injury, diabetes, postoperative complications and others.
What is the ICD-9-CM format?
XXX(category).XX(etiology, anatomic site, manifestation)
What is the ICD-10-CM format?
XXX(category).XXX(etiology, anatomic site, severity)X(extension)
What is the purpose of ICD-10-PCS?
~Improve accuracy and efficiency of coding
~Reduce training effort
~Improve communication with physicians
What is the structure of ICD-10-PCS?
It is a multiaxial seven-character alphanumeric code structure. It uses 10 digits (0-9) and 24 letters (A-H, J-N, P-Z). Because of this unique structure it is considered both complete and expandable.
What does ICD-10-PCS procedure code 1 stand for?
The section of the ICD-10-PCS system where the code resides.
What does ICD-10-PCS procedure code 2 stand for?
The body system.
What does ICD-10-PCS procedure code 3 stand for?
Root operation (such as excision, incision)
What does ICD-10-PCS procedure code 4 stand for?
Specific body part
What does ICD-10-PCS procedure code 5 stand for?
Approach used, such as intraluminal or open
What does ICD-10-PCS procedure code 6 stand for?
Device used to perform the procedure
What does ICD-10-PCS procedure code 7 stand for?
Qualifier to provide additional information about the procedure (for example diagnostic versus therapeutic).
What is the purpose of ICD-O-3?
To provide a detailed classification system for coding the histology (morphology [structure]), topography (site), and behavior of neoplasms (that is malignant, benign).
What is the structure of ICD-O-3?
A duel-axis classification. The codes are identical or compatible with other coding classifications and nomenclatures. They consist of the letter M followed by five digits.
What do the first four digits of the morphology code for ICD-O-3, stand for?
Identify the histological type of the neoplasm.
What does the fifth digit of the morphology code for ICD-O-3, stand for?
The behavior of the tumor.
What does the ICD-O-3 behavior code, /0, mean?
What does the ICD-O-3 behavior code, /1, mean?
Uncertain whether benign or malignant, borderline malignancy
What does the ICD-O-3 behavior code, /2, mean?
~Carcinoma in situ
What does the ICD-O-3 behavior code, /3, mean?
Malignant, primary site
What does the ICD-O-3 behavior code, /6, mean?
~Malignant, metastatic site
~Secondary site
What does the ICD-O-3 behavior code, /9, mean?
Malignant, uncertain whether primary or metastatic site
What are HCPCS level 1 codes?
The AMA’s CPT codes. The CPT codes primarily cover physicians’ services but are used for hospital outpatient coding as well.
What are HCPCS level 2 codes?
National codes, maintained by CMS. Used to code medical services, equipment, and supplies that are not included in CPT. They are alphanumeric and start with an alphabetic character from A to V. This is then followed by four numeric characters
What dot HCPCS level 2, temporary codes begin with?
G, K, OR Q
What are the eight sections of the CPT codebook?
~Evaluation and Management Services ~Anesthesia ~Surgery ~Radiology (including nuclear medicine and diagnostic ultrasound) ~Pathology and Laboratory ~Medicine ~Category II Codes ~Category III Codes
What are CPT Category II Codes, designed as?
Supplemental tracking codes that can be used for performance measurement. Although optional, they are used to provide greater specificity regarding a patient’s visit and treatment details.
Why were Category III Codes 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 book. These codes are not optional and should be used to report procedures performed.
What does the CPT Appendix A provide?
A complete list of modifiers and their descriptions. The modifiers are written as two-digit codes that follow the main CPT codes.
What does the CPT Appendix B provide?
A summary of the additions, deletions, and revisions that have been implemented for the current edition. This appendix can be used to update information and data that contain the codes.
What does the CPT Appendix C provide?
Clinical examples for codes found in the evaluation and management section (E/M) of the book. These examples can be used to assist a coder in reporting an E/M code.
What does the CPT Appendix D provide?
A listing of add-on codes. They must be preceded by a primary procedure code and would never be reported alone.
What does the CPT Appendix E provide?
A summary of codes that are exempt from modifier 51.
What does the CPT Appendix F provide?
A summary of codes that are exempt from modifier 63.
What does the CPT Appendix G provide?
Codes that include conscious/moderate sedation.
What does the CPT Appendix H provide?
An alphabetic index of performance measures by clinical condition or type but was removed from the book.
What does the CPT Appendix I provide?
Genetic testing code modifiers used for reporting with lab procedures related to genetic testing.
What does the CPT Appendix J provide?
A listing of sensory, motor, and mixed nerves that are useful for nerve conduction studies.
What does the CPT Appendix K provide?
Procedures included in the code book that are not yet approved by the FDA.
What does the CPT Appendix L provide?
A reference of the vascular families including which are considered first-, second-, and third-order vessels.
What does the CPT Appendix M provide?
A table of deleted codes and crosswalks to current codes.
What does the CPT Appendix N provide?
A listing of codes that have been resequenced.
What are the four main term entries in the index of the CPT codebook?
~Procedure of service ~Organ or other anatomic site ~Condition ~Synonym, eponym, or abbreviation.
Main terms, in the CPT codebook, are followed by subterms. What do the subterms do?
Modify the main terms and are indented under them.
What are the codes for the section Evaluation and Management?
What are the codes for the section Anesthesia?
What are the codes for the section Surgery?
What are the codes for the section Radiology?
What are the codes for the section Pathology and Laboratory?
What are the codes for the section Medicine?
What are the codes for the section Category II Codes?
What are the codes for the section Category III Codes?
What are the main content areas of SNOMED CT?
~Concept ~Descriptions ~Relationships ~History
What is the Concept portion of SNOMED CT?
A clinical idea to which a unique ConceptID has been assigned. Each concept is represented by a row in the concepts table.
What is the Description portion of SNOMED CT?
The human-readable phrases or names associated with the concepts portion. All of the concept descriptions are listed in the descriptions table.
What is the Relationship portion of SNOMED CT?
An association between two concepts. The nature of the association is indicated by a relationship type. Each one is represented by a row in the relationship table.
What is the History portion of SNOMED CT?
It includes some information about the history of changes to concepts and descriptions.
What are the five axes used in DSM-IV-TR?
Axis I: Clinical Disorder and 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
What is Axis I used for?
Diagnoses such as depression or schizophrenia
What is Axis II used for?
~Paranoia Disorders and like conditions
~Down’s Syndrome and like conditions
What is Axis III used for?
Symptoms or physical conditions such as brain disorders.
What is Axis IV used for?
Events such as death of a loved one that impact the patient’s condition.
What is Axis V used for?
Patient’s level of functioning including appropriate to date and time.
What is NANDA-I?
North American Nursing Diagnosis Association-International
Why was NANDA-I established?
To develop, refine and promote terminology that accurately reflects nurses’ clinical judgments.
What is the purpose of a nursing diagnosis?
It is used to determine the appropriate plan of care for the patient. It drives inventions and patient outcomes, enabling the nurse to develop the patient care plan. It also provides a standard nomenclature for use in the EHR, enabling clear communication among care team members and the collection of data for continuous improvement in patient care.
Why were nursing data sets and classifications developed?
To capture documentation on nursing diagnoses, interventions, and outcomes for acute, surgery, home, and ambulatory care settings.
What should coding processes be monitored for?
~Reliability ~Validity ~Completeness ~Timeliness
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.
The degree to which codes accurately reflect the patient’s diagnoses and procedures.
The degree to which the codes capture all the diagnoses and procedures documented in the health record.
The time frame in which the health records are coded.
What should a complete inpatient health record contain?
~Face sheet ~History ~Physical ~Consultations ~Operative and Procedural Reports (if applicable) ~Pathology Reports ~Progress Notes ~Discharge Summary
Inpatient codes must be sequenced according to what?
Uniform Hospital Discharge Data Set (USDDS) guidelines.
The ongoing internal review of coding practices conducted by an organization on a regular basis.
What should a monitoring/audit program 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.
What should a baseline audit include?
~A sample of records coded by all coders, for all types of services. ~It should be representative of all physicians and types of cases treated by the organization.
What is a rule-based or “logic based” encoder?
An encoder 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.
What is a knowledge based encoder?
An encoder that utilizes more of an electronic code book by automating a look-up function similar to the manual index in ICD or other coding classifications.
What is UMLS?
Unified Medical Language System
What is the purpose of UMLS?
To aid in the development of systems that help healthcare professionals retrieve and integrate electronic biomedical information form a variety of sources. Its knowledge sources overcome retrieval problems that occur when different terminology and separate databases are used.
What are the three knowledge sources used by UMLS?
~Metathesaurus ~Specialist Lexicon ~Semantic Network
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.
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.
Semantic Network
Provides a system for categorizing objects and identifying the relationships among various concepts.

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