1",'

Ghapter 6Glinical Vocabularies andGlassification SystemsKarcn Scott, MEd, RH,A, CCS-P, CPC

Loarning Objoctivog. To discuss the history of the developnent of clinical vocabularies

. To undersmnd the history, uses, :md structure of ICD-9-CM, ICD-10' ICD-O-3'HCPCS, CPT, SNoMED CT, DSMIV-TR, and nursing vocabularies

. To describe the coding process

. To identify the technology used in the coding process

. To undersland the history, elemenls, policies, and procedures fbr corpolaleconrpliance

. To discuss new dircctions in clinical vocabularies

K6y T€lms

Classilication system

ClinicAl vocabulary

Cwrcnt Prccedural Terminolog! (CPT)

Dio|nastic ancl Statistical Manual of Mental Disorders, Fourth Reision, TexlRevlsior (DSM-IV-TR)

E codes

Encoder

Healthcare Common Procedure Coding System (HCPCS)

Clairification of Diseases, Ninth Reriiion, Clinical Mod.ilication (ICD-9'CM)

Intentational Classification ol Diseases, Tenth Revision, Clinical Modiflcalion(rcD-10"cM)

:193

1,94 Chapter 6

tntenalional Cl.tsslication af Diseases, Tenth Re sion, Procedute Codin? Svstem(rcD-t0-PCS)

Intemational Clctssrrtcatian af Diseaset for Oncalogy, Third Edition (ICD-O-3)

Morbidily

Mortality

Natuml longDage processing (NLP)

Nomenclatute

Nosology

NuNing vocabula e$

Read Codes

Systemized Nomenclature of Medicine Clinical Teminology (SNOMED CT)

V codes

World Heahh Organization (WHO)

IntroductionOver the yea$, diseases and nedical-surgical procedures have come to be known by dif_flren! names. For example, Downs'syndrone is sometimes referred to 0s mongolism ortrisomy 21. Clearty, |he use of more than one term for the same disease makes it ditlcult tocolleciand retrieve infbrmation. In an efforl to organize and standardize medical language'the healthcarc industry has developed nomenclatures, classification systens' and clinicalvocabularies.

In medicjne, a nom€nclaturc is a recognized syslem that lists prefefied nedical te!'minology, Nomenclatures, or "naming" system, such as CPT, also are refened to as clirri'cal terminology. Classification systems group together similar diseases and proceduresThey also organize related entities for e4sy ret'iev^l The Intemational Classification ofDheasas, Nitrth Rcvisinn, Cl ical Moddicatio" (ICD-g-CM), is an example of a clas-sification system. Clinical vocabutaries have been developed to crcate a list of clinicalwords or phrases with tleir meanings.

These systems facilitate the organization, storage, and retrieval of healthoare diag-nostic and procedural data. Moreover, they aid in the development and imPlemeDtatio!of computerized patient record systems. This chapter discusses the various nomencia-tures, classilication systems, and clinical vocabularies used in the healthcare industrytoday.

Theory into Practice

Hiltcrest Health Care Clinic is a multispecialily group practice with clinics in five different locations. The office manager has determined that vaioDs editions ofcodebooks are

brladat

Crnk" \ocao- la es and Cldssi f i .a l ion 5y, le ls

being used throughout the practice to assign codes for reimbursement. She also noticedthat many of the providels do not use codebooks al all but, instead, assign codes ftoma list preparcd by their office staff. Such lists ollen conlain incorect codes, as do out-dated codebooks. The end result is incorrect code assignment, denied rcimbursement,aod erroneous database entries, Clearly, pollcies alld procedures are needed to contrclthe coding process.

195

History and Importance of Clinical Vocabularies

ln the tate 1800s, the Analomical Society developed one of the first medical nomencla-tures.In 1895, this internadonal organization publishedlhe Basle Namina Anatotllica Thi\work iDitiated the standardization of anntomical tems used in medicine

The fil.st medical nomenclaturc 1o be univelsally accepted in the United States wasdeveloped by the NewYorkAcademy ofMedicine ̂ndti edlhe Stan.lard NomencLature (t

Disease antl Operations. ID 1937, the American Medical Association (AMA) assumed thecopyright and editing responsibility for this work and expanded it to include a nomencla_lure lor procedures iN well as diseases. The expanded work was published in one volumetilled Standanl Nomenclatwe oI Disease and Standard Nomenclature of OPetations.

ICD-g-CM is the most recognized classification system used loday. It evolved lioma olassillcation developed by Dr Jacques Bertillon. His system was published in 1893^s the BeftiLlon Clctssification ef Causes oJ Death ln 1898, the Amedcan Public HealthAssocintioD recomnended thal registrars i,t the United Stales, Canada' and Mexico use thcBeltillon classifi catiorr.

This cl,rssification system was rcvised throughout lhe eariy 1900s In I948, the WorldHcalth Orgarization (WHO) published the sixth revision of the system The sixth revi-sion inclucled a classification fbr morbldlty and morfality data. Throughoul lhe 1900s,various healthcare AssociAtioDs and public health organizations representlng numetousoountries worked to create a standardized classification $ystem fol healthcare

ln 1975, lepresentatives 1tom numelous countries met in Geneva, SwitzerlAnd' todevelop the InterntLtional Cla\.\irtcaion aI Dis?drcr under the direction of WHO Today,the tCD cllssif'lcirdon syslen is used throughout lhc wodd.

Developnren! of these systems has helped to standardize terminology 1br lhc collec-lion, processing,0Dd ret eval ofmedical information. Additional systenrs of classificationand nomenclrtufes :ue discussed later in this chapler.

Clinical Vocabularies

Users of cl inical vocabularies con be divided inlo lwo main groups: cl inical and admin'istrative.

Cl.inicd users are providers who use clinical vocabularies to collecl, process, andretrieve datr! for cljDical purposes. They use the vocabularies to support activities such asclinical reseLlrch, disease prevention, And palienl carc. An example ofa clinicol user wouldbe a physician who uses ICD-g-CM codes to track a padent's diagnoslic history.

Administrati,e urer"s include healthcare facilities, professional organizations, andgovemmenl agencies. These gfoups use clinical vocabularies to support administrative,

TIIIi

196 Chaoter 6

statistical, and reimbursement funcdons. An example of this is when Clrftent ProceduralTeminologJ (CPT) codes are used to leport physician services to lhe Medicare paogramto determine reimbursement. The specific users of clinical vocabularies are discussed inthe sections that follow.

The Health Insurance Ponabilily and Accounlabilily Act (HIPAA) required the estab-lishment of electronic bansaclions and coding siandards. Ir 2000, the Departnent ofHealth and Human Services (HHS). il1 accordance with I{IPAA, established otficial medi-cal coding sct standards. To be in compli.rnce with the HIPAA law, all covered entities arercquired to use the lbllowing official nredical coding sets:

, lnlernalional CltLssilication of Diseases, Ninth Revi\ian, Clitrical lodiJj(tLtion(lCD-g CM), including tlre OIficiAl ICD-g-CM Guidelines for Coding andReportingr Volumes I and 2 are used for reporting all diseases, in,uries' impLrir'ments, other health problems And causes of such, an Volume 3 is used kr rePortpro,(dure' peuormed 'n ho.pital inprl ienti .

' Healthcare Cotnmo Ptucedurc Coding Slrl?rr, which iDcludes Cutre t Proce'dLr1ll Terminlogy (CPT): This systenr is used lbr reportirg physician aDd otherhealthcare seNices, ilrcluding all noninpttient Procedurcs.

, C n"nt Dental Temlinalog\, Cade an Detllal l>rocedutus dnd No Le (lofirusrCDTr. Thi> (ysLem i. used tor f(porlrnB JentJl serviee{.

, Ndtianal Drug Coder (NDC)| In $e origiral ruling tron Medicafe, the NDC wasdesign^led ns the ol'ficial data sel fol reporling drugs lsed by Pharlnacies. How-evef, this adoptbn was feperled in 2003. Cu ently, there is no olficial strndArdfbf ,eportiDg mediciltions on phrfmacy translctions.

lntornational Claesification of Diseases, Nlnth nevision,Clinioal ModlficationThe lntenntional ClarsiJication oJ Di.\eases (ICD) is a classilicatiol1 systetr lbr rePo ingmedical di:lgnoses and procedures.

HistoryICD-g-CM is one of the Inost common olassification systems used in the Unitcd Slutestoday, It is an adaptation of the /rrsrwtia al CLtssilication aJ Diseases, Ninth RcNision(ICD-g), published by WHO in CeDeva, Switzerland.

li the United States, ihe federAl govemment, thrcugh the National Center 1br HealthSratistics (NCHS), modified ICD-9 to create ICD-g-CM. ICD-g-CM was issued for usein the U.S. iD 1978. The intent of this moditicntion was to provide a classification systemtbr morbidily datr.

ICD-9-CM is maintaired by four organizations known as rhe Cooperating Parties:NCHS, thc American Hospiral Association (AHA), lhe Amedcan Heahh InlbfmationManagement Association (AHIMA), and the Centers tor Medicale and Medicaid SeNices(CMS). The Cooperaling Parties assume the tbllowing responsibilities:

. To seNe as a clearinghoDse to answer questions on ICD 9 CM

. To develop educational materials and programs on ICD-9-CM

_t

Cllnica Vocab!laries arid C assificatlon Sysiems

. To work cooperatively in maintaining the integdiy of ICD-g-CM

. To recornmend revisions and modifications to culrent and future revisioDs of ICD

The wofk of the Cooperating Pardes was supplemented by AHA s Editodal AdvisoryBaafi fot Coding Cliniq which was composed ollepresentatives of hospitals, heath datasystems, and the fedeml government (NCVHS 1991)

Pdmarjly, NCHS is responsible for updating the diagnosis classiflcation (Vollunes

I and 2), and CMS is responsible for updating the procedure classiflcation (Volume :,AHIMA works to help provide training and certification, and the AHA maintains the Cen-tral Office on ICD-9-CM and pubtishes CodinS Clinic for ICD'9'CM, which coDt^ins theOfiicial Coding Cuidelines and official Suidance on the usage ofICD-9-CM codes'

ln 1985, the ICD-g-CM Coordination and Maintenance committee was established'Cochaired by representatives of NCHS and CMS, the committee is made up of advisorsand representatites oiall the Cooperating Parties. lt meets twice a year lo provide a publiclbrum for discussing possible revisions and updltes to ICD-g'CM Discussions flt thesemeetings flre advisort'only. The direclor of N_CHS und the adrnlnistrator nf CMS deter'mine all final revisions.

Purpoao and lrsoAccording to the Cenfal Office o! ICD"9'CM, ICD-g-CM has the following usesi

. Classifying morbidity and morlality inlbrmation ior statistical purposes

. Indexing hospital records by disease and opemhons

. Reporting diagnoses by physicians

. Stoling and retrieving data

. Repofiing national morbidity and mofiality data

. Serving as the basis of diagnosis"rela@d group (DRG) assignmenl fbr hospiulrclnDursement

' Reporting trnd compiling healthcale data to assist in the evaluation of nredicalcarg plannlng for healthcare delivery systems

. Determining pattens of care among healthcare providers

. Anrrlyzing payments for health services

. Conducting epidemiological and clinical research

Ov6rvi6w of gtruduroICD-g-CM is published in three volumes. Volumc I is known as fie Tabular Lisl. lt con-tains the numerical listing of codes that rcpresent diseases and injuries. Volunlc 2 is theAlphabetic lndex. It colsisls of an alphabetic index for all the codes listed in volume IThe Tnbulrr List and Alphabetic lndex for Procedures are published as volume 3. Volume3 is not palt of the international version of ICD-g. Il is used only in the U.S. to reporlprocedures peformed on hospital inpatienis.

197

198

I!1l

Chapter 6

volume 7Volume I of ICD-g-CM is divided into three subdivisions: classification of diseases andinjuries, supplementary classifi cations, and appendixes.

The classification of diseases and injuries is divided into seventeen chaplers (Seefigure 6.1.) The chapters are organized by lype ol condition and anatomical systern Forexample, chapter 5, Mental Disorders, represents a chapter that Sroups diseases by typeof condition. Chapier 6, Diseases of the Nervous System alld Sense Organs, rcprcsents achapler that groups diseases by anatomical system.

The chrpters are fwther divided into sections. Sections are groups of three-digit codeoumbers, An example of a section in chapter 5 is the disease classification for organrcpsychotic conditions (290-294). (See figure 6.2.)

Sections are subdivided inlo categories. Categodes represent a Sroup of closelyrelated conditions or a single disease entity. Category 290, Senile and presenile organicpsychotic conditions, is an example of a categofy found in chapter 5.

CAtegories are further divided into subcategories. At this level, four-digit code num-bers are used. Figure 6.2 provides an example of a subcategory: code number 290 1, Pre-senile dementia.

The most specific codes in tbe ICD-g-CM syslem are found at the subclassific|tionlevel. Fiveiigit code numbers represent this level. In figure 6.2, code 290.10 represents acode at the subclassification level.

Two supplementafy classiilcfllions arc pan of volume l: the Suppiemenlaly Classi-fication of Factors Influencing Health Status and Contact with Health Services (V codes)

Flgure 6.1. Chapter titles in Lhe ICD"g.CM Classification of Diseases and.Iniuries

I lnftcln)us ond Parusiric Dhe[ses

2. Neoplnsns

3. Endocrire, Nuritional, and MerAbolic Diseases und llnmuniLy Di$orders

4. Diserses oi the Blood and Blood-Fonring Orga'rs

5. Men( l Disorden

6. Diselses ofdre Nervous Sysrem lnd Sense Organs

7. Dise!ses ofrhc Circulatory Systen

8. Dissases ofdre Respirarory System

9. Diserses olthe Digesrive Sysrem

i0. Diseases ofrhe Cenitoudnmy SysreD1l Complicrdons ofPregnancy, Cbildbirth, and rhe Puerpedum12. Diseases of the Skin and Subcutaneous Tissue

13. Diseascs oflhe Musculoskeletal System and Connecdve Tissue

14. CongenilalAnomlies

15. CertaiD Conditjoos Originating iD the Pernratal Period

16. Symproms, Signs, and Ill Defined Condidons

17. Injury and Poisonjng

T'C in cal Vocabu aries and C assification Svstems 199

Figure 0,2, Example ol an ICD-g-CM secdon

290 Senile and presenile o.godc pslchotic conditionsCode iirst the lssocialed neurological condtt,on

ORGANTC PSYCHOTTC CONDITIONS (290-294)

psychotic organic brain synd.ome

harysrchatic lr%ltunes oI ory\nic eiiola4t 1310.0 3lA 9)pslchases classifnble ta 295-298 and ||itha\l

i"vannent oJ aientation, Lohprehensioh, calcuLatiohleanhs capaciry, and iudEheht, but ossociated withphrsical direase, injurt, or co dil ion ollectins the brain

te.s., folLo|/ins childbirthI (295.4-298 6)

lE-t,d;1

deftehlia not clasifcd os senile, plesenile, ot arteriosct./otL.(291.14-294.t I)

psrchaset clastifnble to 295 -298 occu ine in the serLithirithout denentia ar deliiu,fl (295 A'298 8)

seniljt, with nentul chan|et of nonPsrchotic sererit'! (314 1)transjent aryahic pslchatic cohditiais (2% A-2939)

290.0 S€nil€ dcmontla, uncomplicaled

NOS

E;;if niLd nclnory liltrbancc!, nol afllaunting ta detne P'associatetl \|ith tetik bnin discase 1310.1)

de Ln iun o r co nJ ut i an ( 2 90. 3 )det$ ional I p a ruao id ] le a I we s ( 294. 20 )tl?p rc s s i I e leat u r. s (290. 2 1 )

290.1 Pres€niledementiaBrain syndrome with presenile brain dise0se

artcrbscbrotic denentio (29A.40 -290,43 )denentia a*ocioad ||ith other cerebrcl canditions

(294.10-294.t t)

290.10 Pr€s€niledern€ntiaruncompliclt€dPresenile denentirl

NOSslnpr rype

2t0,ll Pres€nil€ d€menti! with deliriumPfesenile dementia with acure confusionel state

290.12 P.es€nile d€m€ntia with delusionll IesluresPresenjle dementia, paranoid type

290.8 Prer€ntle den€nlia with depftssiv€ teatur€sPresenile dementi!, depresed type

,oo1

Chapter 6

and the Supplementary Classification of Extemal Causes of Injury and Poisoning (Ecooes),

V codes are usedto classify occasions when circumstances other than disease or injuryarc recorded as the reason for the patient's encounter wilh the healthcare providet Suchcircumstances genemlly occur in one of the followilg three ways:

. When a person who is not curently sick encounters a health service providerfor some specific reason, such as to aci as an organ or tissue doDol, to receiveprophylactic vaccination, or to discuss a problem that in itself is nol adisease or iDiury (for example, when a patient sees a physician for ameasles vaccination)

. When a pefson with a known disease or injury, \ryhether curent or resolvmg,encounters the healthcare system for a specific treatment of that disease orinjury (tbr exanple, when a patient seeks follow-lrp care for a pleviouslyapplied cast)

. When some circumstance or problem influences the person's health status but isnol in ilself a curent injury of illness (for example, when a patient has a personalhistory oi smoking)

V codes Are always alphanumeric codes. They ate easy rc identify beoause thcy beginwith tbe nlpha cbaracter y and ar€ followed by numerical digits. An example is V15 04'Allergy to seafbod,

E codes provide a means !o classily eDvironmental events, circumslances, 0nd oondi'tions as the cause oi injury, poisoning, and other adverse effect, These codes must be usedin addition to codes from the main chapters of ICD-g-CM. E codes plovide additionalirformation used by irsurance comprnies, sfllety programs, and public health agencies todetermine the causes of injuries, poisonings, or other advgrse siluations, Even lhough useof many E codes is optionol, many facilities use them as secondary codes !o identify thecause ofaccidenls aDd injuries. Some states have mandated reporting ofE codes in ceftaincircumslaDces, such as in reporting head uaund.

E codes begin with the alpha character i'and are fblbwed by numerical chaructefs.8925.0 represenls the code for an accident caused by an electric current in domeslic wu'irg and appliances.

The last subdivision of volune I consists of the appeDdixes. ICD-g-CM includes fiveappendlxesl

AppenJr{ A: M,'rphology of NeoplJ.r.

Appendix Bi Clossary of Mental Disordcrs

Appendix C: Classification of Drugs by American Hospital

FoImulary SeNice Lis! Number

Appendix D: Classitication ofIndustrial Accidenls Accordin8 to Agency

{opendix E: Lr.r of lhree-Digir Ca.eCor:es

clinical Vocabularies and Classiflcation Svsteras

Volune 2The Index to Diseases and Injuries is pdnted as volume 2 of ICD-g-CM Main termsappear alphabetically in the index by type of disease, injury, or illness Subtems areindented under the main term, For example, the main term Bradycardia and the subtermsfor bradycardia appear as shown in figure 6.3. '-1

Volune 3The thjrd volume ofICD-g-CM contains the tabular and alphabetic lists ofprocedures TheTabular List of Procedurcs contains chapters organized according to anatomical system,except for the lasl chapter, Miscellaneous Diagnostjc and Therapeutic Procedures Figure 6.4shows the procedure chapter titles. According to the HIPAA regulations, these codes are tobe used only for inpatient hospital billing.

ICD-9-CM procedure codes are organized according to lhese chapters, and then lhechapters are divided into two-, three-, and sometimes four-digit code numbers All pfoce-dure codes are written with two digirs to the left of the decimal point FiSure 6.5 pfovidesan example of a tabular listing from the beginning of chapter 2, Opemtions on lhe Endo-crine Systern (06-0?).

The Alphabelic Index !o Procedures is olganized in the same manner as the Alpha-betic Indeito Diseases. Figure 6.6 shows an example of the alphabetic organization ofprocedufes.

20I

Figure 6.3. Example of lndex entrics for main terms and subterms ln ICD'9'CM

B.Achyccphsly 756.0B.ochynorphlern md ectopla lentis 759.89tsradl€yt dls€ffc (epidemic vomitine) 078.82Brodyc8rdla 427.89

chro ic (s inus) .12?.81newbom 763.83nodal12?.89posloperative 997.1rcflox 337.0sinoatrial427.89

with paroxysmrl tachyanhythmia or tachycardia 427.81chro ic 42?.81

sinus 427.89with paroxysNd tachyanhythmi! or taclycardia 427.81

chrcnic 42? 8lpesisent 427.81

Lnhyclrdi^ syndrome 427.81!a9a1427.89

Bradyp!€r 786.09Brrilstbrd's disease 732.3

radiclhead 732.3larsal scaphoid ?32.5

202 Chapter 6

Figure 6.4. Chapter titlei in the ICD-g"CM tabular list of procedures

1. Operations on the Netrous System2. Operations on lhe Endocrine Syst€m3. Opelations on tbe Eye \a. ope.ar:on" on rhe Ed5. Operalions on the Nose, Mouth, and nurynx6. OpeElion, on Lhe Raphatoq S)srem?. Operations on the Cardiovascular System8. Operations on the Hemic and Lynphatic SysEm9. Operations on the Digestive Systen

10. Operations on $e Urinary Systenll. Op3 ations on the Msle Cenital Oryans12. Operalions on the Fcmale Genital Organs13. ObstelricAlProcedures14. Operqrions on the Musculoskeletal System15, Operations on tlle Int%umentary Syslem16. Miscellaneous Diagnoslc and Thempeutic PrccedurEs

Figure 6.5. Example from the ICD-9-CM tobular llsc of procedurcs

06 Operations on $yrold and parsthyrold elmdsIncludesr incidentalresection of hyoid bone

06.0 Incblon of lhyrold field

I Exctuder: I divkioh aJ isthnur (t8.91)

06,01 Asplratlon of thyrold flold' Pllcutancous of needle dlainage of thyroid fleld

aspiration biopsy al thrrcid (06.I I )drainase br irctsion (06.09)posta pe mtiv e as pi ntion of le Ld P6.U )

Reopening ofwound of thyrold fleldReopening ofwound ofthyroid field for:

control of (postoperativ€) hemonhas.

removal of h!m310maOther incillon of thyroid feld

D.ainago of hematoma \Drainage of thyroglossal rac! |Exploralionr I

neck ) by incisiorthyoid (field) |

Removal of foreign body IThyroidotomy NOS I

p o st op e rct iy e etp I o rut i o n ( 06. 02 )renavol oJ hendton'o by aspiration (06.01 )

J

cl nical Vocabularles and classification Svstems

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

Acromioplasty 81.83for recurent dislocation ofshoulder 81.82p x l i r l r c p L . e m e o r 8 . 8 liotrlreplacemert 81.80

Actinotherapy 99.82ActiYiti€s of daily livins (ADL)

rherapy 93.83training for the blind 93.78

wnh snouldering moxa 93.35fof anesthesia 99.91

advancenient of rcund lig0meni 69.22c rshing ofnasal reptum 21.88excision of palnar tlscia 82.35

Chock Yorr Undoratandlnll G,l

lxsrrrdtir,rr Use the following excerpt fiom theAlphabetic lndex 1o complete the questions below.

Bscillory-see corditionBaci l lur ie 791.9

asymptomaiic, in pregnancy of pu€rPerium 646,5luberculous (ree 41ff Tuberculosis) 0i6.9

Bacillus-rd? al.ro Inf€ction, bacillusaboltlls inibclion 023.1an!hracis inibction 022.9coli

irfection 041,4generalized 038.12intesLinal 008.00

pyemia 038.42septicemia 038.42

Flexn€r's 004.1ftrsiformis infeshlion l0lmallei infbction 024Shiga's 004.0suipestiter infection (ree dlro Intection, Salmonella) 003.9

Back-se? conditionBackach€ (postural) 724.5

psychogenic 307.89sacroiliac 724.6

L List the jlrst four main terNs ihat appear in the excerpt.

203

2. List lhe lirst lbur subterms lhat aDDear under Bacillus.

244 Chapier 6

3. Indicate whelher each ofthe followiDg codes represenis a disease (D) or a procedure (P)'

99.82098.0301.5113.4844.045.24

b . _

d . _

f . _

lnternational classification of Diseases' Tenth Revision'clinical Modification

Establisbed by WHO, the ICD systen was deslgned to be totally Ltvlsed at ten-y"Jr intet-

u"i"-f" ih" Inla-fssoi, wHO published the newest version of ICD; lnlernational Statisti'

i.i ciliitniii"i "f

oiseasei anti Related Heahh Problems' Tenth Rerision' knofln.as

icb- iij. itri. ,""i.ii" is currently in use by many countdes throughout the world and has

i""" ur"O ;" ttt" U.S. to capture moftaliti staditics since 1999 Howeyer' studies in lhe

U.S, Oetentnea that fCD-10 needed to be modified to capture data thal would suppo ouf

reimbu$ement system prior to implementatlon

Purpose and lJsoifrliin.riu"an*don of ICD-10 is known as the I ternatio'tdl classification of

iji"iiii.irii nri"ion, clinicol ModiJicatiot According to NcHS IcD-10-cMi'rhe

"1,r"".JiJ"".t"", for ICD-9-CM 'oiume' I and 2 Th;s rcvi" ion i \ considcreJ Lo be

i" """i"*iii""i"*,

Uoth ICD-9-CM md lcD-10, and was developed to corrtain a lireatmanv mofe codes and rl low grertcr speclr i , j lD lhrn exi jung ICD codc sel:

Ovofllew of Structuroe.t|lrougb ttte tradhlonal ICD sfiucture remains, ICD-10_CM is a comllete.Alphalrumerlo

"oainei"h",n". Tlt" former supplementcry cldssification information (V and E codes) w'ls

iniorp"oratcd rnto Lhe matn classification system with difterent letters prcceding lhe nunler_

icaiponio, ' ' of t t t . .oOes lCD-I0 conlJins new chrptet ' and se\erxl calegories.h'rve b-ccn

i.'iti.i""J ,"0 , '.* i.JlLrre. Lrdcled Io mJinrr.n con,irtencl with modern rDedi"ine Tl-e

aii"ase "to..:Iication

has been expanded to provlde greater specificrty al dre sixdr'digit

level And with a seventh-digil exlensionA dr01t of ICD-1o-CNiis available from the NCHS Web site at cdc'gov/nchs/about/

otheract/icdg/icd locm.htm. A draft of otficirl gu'delnes for ICD-10-CM has btcr) devcl-

oped and c:rn be downloaded from cdc gov/nc h5/drtJ-/icd9/drali-i l0guidel n pdl-

t \rmtlc" oi ICD- l0-CM codes irclude Ihe lbl lowing:

. Maligntnt Neoplasm

C34.I MaliSnant neoplasol of upper lobe, bronchus oL lung

C34.10 Malignant neoplasm of upper lobe, bronchus or lung, unspecified side

C34.11 Matignant neoplasm of upper lobe' right bronchus or lul1g

C34.12 Maiignan! neoplasm of upper 1obe, left bronchus or lung

. Dinbetes

E10.2 Type I diabeles mellilus with renal complications

1.c inical Vocabularies and Classlfcation Sysiems

E10.21 .Iype I diabetes mellitus with diabetic nephropathy'Iype I diabetes meliitus with intercapillary Slomerulosclerosis

Type 1 diabetes with intracapillary giomerulonephitis

810.22'lype I diabetes mellitus with Ebstein's disease

E10.29 Type 1 diabetes mellitus with other diabetic renal complication

lnternational Classification of Diseases' 10th Revision'Proceduro Codlng system

ICD-10-CM does not include a procedure volume. Thus, when the U.S. began pllnning,toclinically modify WHO'S ICD-10, it was dctelmined ftat creating a separate volume rorprocedu;es would be insuftlcient. As a rcsult, CMS contracted with 3M Health InformationSystcms to develop a sepamte prccedurc code syslem that would serve as a replacemenlfor ICD-9-CM, Volume 3. Thiicoding system is known as the /ttem.rtional Classifrca'tion oJ Diseases, Ihth Retision, Procedure Clnssification System, or ICD-1o-PCS'

Purpoao and Us6Acc;rding to CMs, the agency fesponsible for upddting the procedufe section of ICD-g-CM, the design of ICD-1o-PCS included the following goalsi

. To imprcve acouracy and el'ficiency of coding

. To reduce training effort

. T' Inpfove comnlunicrt ion with phiscirns

Ov€rvlow of StructuroICD-Io-PCS has no co elation !o the ICD-lo'CM struclure, It consists of a nlultiaxialseven-character alphanumeric code structurc. The ten digits 0 through 9 and the 2't leltersA-H, J-N, and P-Z are chamoters used in ICD-I0-PCS Although this systemhas the capa-bility and flexibility to replace all existing pfocedulal coding syslems, it is cuntntly beingrecommenderl to replace 6nly ICD-9-CMprocedure codes (NcvHS 1991) Because of ilsunique structure, IiD-I0-PCS is considered to be both complete and expandablc.

Because many different and confusing names of procedures are in use in tbe nedicalfield, each root procedure has been defined in ICD-10-PCS. This helps to clarily terms thatcunently have overlapping neaning, such as excision, resection, oL removal

Procedures are divided inio sixteen sections rela@d to general type of procedure(medical and surgical, imaging, and so on). All procedure codes have seven characlersThe firsl chalacter ofthe prccedure code always specifies the section where the prccedureis indexed, 'the second through seventh characters have a standard meaning within gach

section. In nedical and surgical procedures, the seve! characters are defined as lbllowsl

I = section of the ICD-I0-PCS system where the code resides

2 = The body system

3 = Root operation (such as excision, incision)

4 = Specific body pafi

245

t2AA Chapter 6

5 = Approach used, such as illtraluminal or open

6 = Device used to perfom the procedurc

7 = Qualifier to provide additional information about the procedure (fbr e^irmplc,diagnostic versus therapeutic)

An example of an ICD-I0-PCS code is 095HBYZ, Dilation Euslachian Tube, Rightwith Device NEC, Transorifice Intraluminal.

0 Surgicai Secdono Bolly s) stcm-Edr rore. \ inu5

5 Procedure is a dilation

H Eustachian tube, dght

B Transorificeintraluminalapproach

Y Device NEC

Z No qualifier

The draft ICD-I0-PCS code system rnd training manual are available onliDe fiomcms.hhs.gov/paymentsystems/icd9/icd I 0.asp?

lmpl€montation of lCD.lO in the U.S.At the time of this wriling, the National Conmittee on Vital and Health Statistics(NCVHS) had recommended tbat borh ICD"lo-CM and ICD-I0-PCS be adopted as thenational standards under the HIPAA electronic kansactions and coding standards rule torcplace the current uses of ICD-g-CM. The next step is for lhe govemment to publish anotice of proposed rulemdking tn the FederuL R?girlci! Aller the required time frame forcomments has passed, a final rule will be published wih an effective date, The new codingsystem(s) would be implemented as the standard in 0 designated time frame (typically twoyea$) from then to ailow fbr tmining and the upgrading ofcoding systems.

Coders should begin to familiarize themselves wilh the new systems. The Jaunlal ofAmerican Health hlformation Manaeement Associdtlo, aDd other publications are begin-ning to publish preparation articles that will enabie coders to stay cunent and be preparedfbr the changes as lhey take effect. Extensive training sessions and coding )raterials arebeing developed to assist coders and facilities with this transition.

Intelnational Classificatlon of Diseases for Oncologly, third EditionThe third edition of the Intemqtional Classifrcation of Diseases for Oncolog!, ThirdEdition (ICD-O-3) ;s a system used for classil]ing incidences of malignant disease. Hos-pitals use ICD-O-3 for several pulposes, for example, to develop cancer regisFies. Cancerregistries lis! all the cases of cancer diagnosed and treated in the facility.

lllstory of ICD.GSWHO published the first edition of the /rr?mdrional Classilication oJ Diseases Iar OncoL-og) (ICD-O) in 1976. It was developed joinrly by rhe Unired Srares Cancer Insriture andWHO's InterDational Agency for Research on Cancer

_l

rClinlcal vocabularies and Classiflcation Systems

In 1968, the American Cancer Socieiy published Manual ofTunor Nomenclature 4t1dCoding (MOTNAC), Also in 1968, wHo asked the Iniernational Agency for Research-onCancei to develop a chapter on neoplasms for the ninth rcvision of IcD WHO decided topublish a supplemental neoplasm classification based on MOTNAC for ICD-9''

ICD-O-3 was published for use in coding caqcers diagnosed in the United StaIes atterl anuaD l . 2001 .

Purpose and U3gOriginally, ICD-O was developed to aid in the collection of information in the field of

onc-ology. lOncology is the study of neoplasms Inew tissuel' ot tumors.)-Its pu'pose is toproviaJa aetaited Jlassification system fbr coding the hisiology (moryhology^[structure]),iopography (site), and behavior of neoplasms The cunent version of ICD-O provides adetailed ciassification used by pathology departments, cancer registries, and heallhcareprcviders who trcat cancer patients.

Overview of structuroA duafaxis classification is used in ICD"O-3 to code the toPogfiphy and mophology oflhe neoplasm. These codes are identical or compatible with other coding classificationsand nomenclatur'es. For exampie, the topograpliy codes used in ICD-10 ior malignantneoplasms are the same codes used in ICD-O_3

The nrorphoiogy codes identily the type of tulnor found and its behavior' The mor-phology codi nurn-birs coDsist of lhe letler M followed by fiv€ diSits The first tbur digitsidentiiy the histological type of the neoplasm. The fifih digit identifies the behavior ol thetumor, The tbllowing morphology codes fbr some leukemias provide 0n examplei

LeukemiAsM9891/3 Acule monocytic leukelnia

M9895/3 Acute myeloid leukemia tuith multilineage dysplasia

M9896/3 Acute myeloid leukemia, AMLI

M9897/3 Acute myeloid leukemia, MLL

The fifth-digit (behavior) codes lhat appear after the slash arc used to iDdicate thelol lowirgl

/0 Benign/1 Uncertain whether benign or maliglant, borde ine malignancy

/2 Carcinoma in situIntraepithelialNoninflltratingNon-invasive

/3 Malignan!, primary site

/6 Malignant, metastatic siteSecondary site

/9 Malignant, uncerlain whether pdmary or metastailc slte

247

2Aa Chapter 6

Check Youl UndeBtanding 6.2

/rr/racti.,,rr List the lype ofbehavior for the tumors rcpresented bv the lbllowing codes

l

2.

l

M8140/0

M8490/6M833r/3

M8120/2

Healthcare Common Plocedule Coding Systom

HCPCS was originally called the HCFA Common Procedure Coding System. Thc nameof the system w;s changed in 2001, when the Health Care Financing Administmtion (theagency that administered the Medicarc and Medicaid programs) changed its name to theC;nters for Medicare and Medicaid Services (CMS) HCPCS is [sed to repo physicians'services to Mcdicare lbr reimbursement,

History of HcPCsHCPCS (Dronounced "Hick Picks") is ii ooliection ol codes aDd descriplofs used 10 rcPre-sent healthcxre prooedurcs, supplies, prcducts, and services When thc Medicarc programwas firsl implelnented in the early 1980s, the Health Care FinancjDg Administration(HCFA) fouDd it necessary to expand the HCPCS system because nol all supplies, proce-dures, rnd services could be coded using the CPI system An example of this shortcomirgis durable medical equipment (DME). CPT does not contain codes lor DME. Thclefore,HCFA developed aD additional level of codes lo report suppljes and services that alc notio CPT (for exAmple, DME).

Polposo and UaoIn 1983, Medicare introduced HCPCS to promole uniforn reporting lnd st.ttistic0l dat'lcollection ol medical procedurcs, supplies, products, and services Most stll|e Medicaidprograms also use portions of the HCPCS coding system. Physicians and plovidefs useHCPCS codes to report the services and procedures they deliver.

Ovorui6w of StructureHCPCS js divided into two code levels of groupsr I and IL

Level I codes are theAMA s CPT codes. These five-digi! codes and two-digit Drodifiefs arecopyrighted by the AMA. CPT codes pdmarily cover physicians' services but ale used forhospital outpatient coding as well. CPT codes are upda@d annually, effective JaDudry l.

Level II codes, also called NatioDal Codes, are mainlained by CMS. With lhe exccption oflempomry codes, level Il codes are updated inDually on January L Temporary codcs bcgrnwith the ietters O ,<, or 0, Temporary codes are updated tbroughout the year. Level II alsocontains modifiers in the folm of letters and alphanumeric charactels.

Level II codes were developed to code medical servicas, equipment, and supplies tbatare not included in CPL Today, when people refer to HCPCS codes, they are ofien refer-ring to Level II codes; Level I codes are most often refered to merely as CPT. TechDicall,.

li

Cllnica Vocabularies and Classification Systems

HCPCS includes both Level I (CPI) and Level II codes. The codes are alphanumeric andstafi with an alphabetic chaiacter faom A to V The alphabetic character is followed by fournumeric chaEcters. The alphabetic cha&cter idertifies the code section and type of serviceor supply coded. At times, Level II codes we.e designed to reflect code assignment basedon Medicare payment regulations. Figure 6.7 showslhe different code choices for patientsundergoing r colonoscopy based on their medic"l necessiq.

Figure 6.8 provides a list of the major sections in Level II.Level II also contains modifie$ that can be used with all levels of HCPCS codes.

including CPT codes. The modifiers penit greater repo.ting specificity in reference to themain code. Sample level II modifiers appear in fl1gure 6.9.

209

Figure 6.7. CPT ICPCS code choices for colonoscopy

Exanplel

R€ason for ColonoEcopy Appropriate code

Problem, such as bleedins or polyps CPTcodes 45378-45392

C olorecl,il c ancef scree nin g, patientdoes not nreet Medicarc definitionofh jgh r isk G0l2 l

colorectal cuncer screening,palienl meets deinirion ofhigh risk G0105

Fleure 6.8, HCPCS Level II section titles

A0000-A0999A4000-A4899A9000-A9999B4000-B9999D0000-D999980100-E99r9c0000-G9999J0000-J899919000-J9999K0000-K9999L5000-L9999M0000-M0009P2000-P2999

Q0000-Q9999R0000-R5999s0009-s9999v0000-Y2999v5000 v5299

nunsport Services Including Arnbul0nccMcdical and Surgical SuppliesAdministrative, Miscelldreous, and llvestigalionAlEnrerol and Par€nreflrl Therapy

Du.oble MedioAl EquipnenLProceduresProfessional Services (Temporary)

Drugs Olher Thm ChemotlempyClemotherapy Drugs

Domestio Radiology ServicesTe'nlorary Nationd Codes

21"4 Chapter 6

Figure 6,9. Sample HCPCS Level II modifiers

-AA Aneslhesia services performed pe$onlll) by anesthesiologist-El Upper lefl eyelid

L2 L ' ie , e l e)e l .J-E3 Upper right eyelid-E4 Lower right eyelid-NU New equipment-QC Sjr-ele channel monitodng

Current Procedulal lerminology' Velsion 4

As mentioned earlier, the CPT system is copyrighted and maiDtained by the AMA. Therchave been seve.al nitjor updates to the system since the original edition was published in1966. Code updates are published annurlly md take effect every January I.

Hbtory of CPl.4CPT is a conprehensive descriptive ljsting of lerms and codes lbr repoldng di gnosticand therapeulic procedures and medical services. Currently, it is updaled annually by theAMA s cPT Editorial Panel. This paiel is composed of physicians and other healthcareprolessionrls who revise, modify, and update the publicalion.

The Editorial Panel gels advlce on revisions fiom the cPf Advisory Conmittee Thiscommiltee is nominated by the AMA House of Delegates and is composed of representa-tives ftom lnore than ninety Dredioal specialties aDd healtbcare provlders As defined bythe AMA, the commitlee has three objectivesl

. To serve as a rcsource to the Editorial Panel by giving advice on plocedurc cod-ing And nomenclaturc as relevant to the member's specialty

. To provide documentation to staff and the Editorial Panel regarding the nedicalappfopriateness of various medical and surgical procadures

. To suggest revisions to CPT

Pulposo and Us€The puryose of CPT is 10 provide a syslem for standard terninology and coding !o reportmedical procedures and services. CPT is one ofthe most wideiy used systems lbr rcportingmedical services to health insurance caffiers. In addition. it is used for other adninistrativepurposes, such as developilg guideliDes fbr medical care revigw Organizations that collectdata for medical education and research purposes also use CPT.

Today. CMS requires that CPT codes be used to report medical services provided topalierts in specific settings. Starting in 1983, HCFA (now called the CMS) rcquired thatCPI be used to repo services prcvided to Medicare Part B bencficiaries. In October 1986,HCFA required state Medicaid agencies to use CPT as paft of the Medicaid ManageneDtInformatioD System. As pat of the Omnibus Budget Reconciliation Act, HCFA requiredin July 1987 that CPT be used for reporting outpatien! hospital surgical procedures andambulatory surgery center prccedures. The most recent mandate for CPI use occurredwith the final rule of the Health Insurance Poflability and Accountabiiity Act (HIPAA).HIPAA m^ndates that CPT be used as the requircd code sei for pbysicians'services andother medicai services such as physical thenpy and ost laboratory prccedures.

C n, a l \ocaou,d. |es and Cld, ) 'ca ' io_ 5r"Len s

Overuiew of StructureThe CPT codebook consists of an inlroduction, eight sections containing the codes,appendixes, and an index. Five digil codes arc used, most are numeric, although specificseitions include an alpha character. The eight sections inclLrde: evaluation and manage-ment services, anesthisia, surgery, radiology (including nuclear medicine and diagnosticultrasound), pathology and laboratory, medicine, Category ll and Category III codes'

The inhoaluction contains a list of lhe codebook section numbers and their sequences andinslructions for use. Info.mation that appears in the irtroduction applies to all sections olthe codebook. A coder who is unfamiliar with CPT codirg should read Ihe intoduction'

Symbols and punctuation marks are used to assist coders in conect usage of CPTcorles. The symbols used in the CPT codebook are explained in the intoduclion and ar€tbund aI lhe

_bottom of each page ol the coding scction of the book For exanrple, r bullet

l isleo lo lhc left of a coJe signif ie. lhrl lhe code I ' i neu fol lhrl )ear-s updateLl buok

SectlonsThe sections are as lbllowsi

Evahation and Management 99210-99499Anesthesia 00100-{1999Surgery 10040-69990Radiology 70010-79999PalhologyandLaboiatory 80049-89399Medicine 90281-99199Category II Codes 0500F-401lFCategory III Codes 0003T-00887

Eacll of these sections begins wilh guidelines containing specific inslructions anddeftnitions !ha! are unique to the section. Coders must understand the information in theguidelines in order to code coffectly fiom each section,

categary 1l and lll CodesAccording to CPt Category II codes were desigDed as "supplemental tracking codes thalcan be uscd for performance measurenenl." Although these codes axe oPtional. they can beused to provide greater speciflcity regarding a patienCs visit and treatment details.

Category III codes were added lo the CPT book 10 allow for temporary codingassignmeDt for new technology and services that do not meet the igorous requlrementsnecessary to be added to the main section of the CPT book. The codes are nol optionaland should be used lo repof procedures perfbrmed. Codes in the Category III section areevaluated and added every six months. As Category I codes (codes ranging fiom 00100 to99499) are crealed to describe new procedurcs. the coresponding temporary calegory IIIJode' $ i- be deleled lron r\r CPT .). lem.

Appendixcs follow the tast section of codes. The appendixes provide informalion lo helplhe coder in the coding process. Appendi{ A provides a complete list of modifiers and theirdescriptions. Modifien are written as two-digit codes that follow the main CPT codes

271

-.-4-__

2X2 Chapter 6

For erample, the two-digit modifier for prolonged evaluation and management seflicesis -21.

Appendix B is a summary of the additions, deletions, and revisions that have beenimpiemented for the cunenr CPI edition. This appendix can be used to update informationand data that contain CPT codes.

Appendix C provides clinical examples for codes found in the evaluation and manage-ment section (E/M) of the book. These examples can be used as a tool to assist the coderin rcportitg an E/M code.

Appendix D is a listing of CPT add-on codes. These codes must be preceded by aprimary ptocedure code and would never be reported alone

Appenclix E is a surnmary of CPI codes that are exempt frcm modifler 51, and appen-dix F is a summary of CPI codes lhat are exempt from modifier 63

Appendix G contains codes that include conscious sedationAppendix H is an alphabetic index of pedormance measures by clinical condition or

type. This appendix was developed to provide turther description ofthe codes found in theCategory II section of CPT.

Appendix I contains genetic tesiing code modifiers used for rePoning with lab proce-dures related to genetic testing.

The index of the CPT codebook lists main terms alphabetically. Main |erm entries are oflour typesl

. Procedure or service

. Organ or olher analomic site

. Corrdition

. Synonym, eponym, or abbreviatioD

Main tefms are followed by subterms. The subterms modit'y the main terms and a(eindented under them. Coders begin their search for the coffect CPI code by checking lhealphabetic index in the above order uotil finding a iikely code to descibe the procedureperfolmed. The coder should then verify the code(s) selected in the main section of thecodebook to be certain the code best describes the procedure(s) performed. Figure 6.10shows a po ion of the CPf index,

[isrre 6.10. Portion ofthe CPT index

FaceCT Scon

Masnetic Resonance Imasins (Mltl)

Frc€ Lift

5e, Hemitirciat Microsomia

70486-7048817000-17004,70540-705432 1 0 1 5

15824-15828

t'7280-t7286

Clinlcal Vocabularies and classiflcation Svstems

Check Your ljndorstandi[tl 6.3

lnsrl ctjrtrr Lis! the section offte CPT codebook in which each of lhe fbllowing codes is located.

1 .

2.

l .

4.

5 .

6.'t.

993r I

90807

33,170

01200

87551

71295

0071T

Systematized Nomonclature of MediclneThe Systematized Nomenclature of Medicine Clinical Tbrminology (SNOMED CT) isa controlLed reference temlinology. The Americln College of Pathologisls (ACP) detinesSNOMED CT as a systematized, muitiaxial, and hierarchically oryanized nomenclatureof medically useful telms.

HiatoryACP published rhe first edition of SNOMED in 197?. SNOMED is based on the System-atized Nonenclature ofPathology (SNOP), which was published by ACP in 1965 lo organizeinlbrmadon trom surgical pathology reports. Because SNOP was widely used And acceptcdin the medical comn1unily, it was expanded as a nomenclatufe for other specialties

Numefous versions of SNOMED have been published since 1977. The ourrenl ver-sion includes more than 150,000 lerms lhat are used in countries throughout lhe worldSNOMED CT is the most comprehensive controlled vocabuiary developed to date

The lpdated version of SNOMED is SNOMED CT (clinical terms) is a "ooNpre-hensive nultilingual clinical teroinology tool providing the informatioD framework forcljDical decision making for electronic rnedicnl lecord" (Brouch 2003) This ve$ion Isan adapt.ltion of earlier versions of SNOMED and also contains the United Kingdom'sNational Health Service's Clinical Terms (previously known as Read Codes), Read Codesusers are beirrg nigrated over 10 SNOMED CT.

ln 2003, the DepartmeDt of Health and Human Services "purchased a license forSNOMED CT, allowing all federal and pdvate developers of [Electronic Henlth Recol.d]EHR sysiems to freely incorporate rhe vocabulary sys@m" (Giannangelo and Berkowitz2005). Mapping between ICD"9-CM and SNOMED codes is being compleled by theNalional Library ofMedicine (NLM) to help vendors crcsswalk between ICD-9-CM codesrequired for reimbursement and SNOMED CT's larger number of diagnostic lerms,

Purpose and lJs6In the field ofmedicine, two physicians may Llse lwo different terms for the same medicalcondition. This makes it dillicult to gather and retrieve information. Standadized vocabu-lary is needed to facilitate the indexing, storage, and retrieval of patient information in anEHR. SNOMED CT creates a stardardized vocabulary.'Ihe Computer-based PatieDt Record Instjlute (CPRI) has studied the ability of ctu'rent nomenclatures to capturc information for EHRS. The institute has determined that

214 Chapter 6

SNOMED CT is the most comprehensive controlled vocabulary for coding the contents of

the health record anal facilitaling the development of computerized rccords

Ovgtviow of StructuteUsing SNOMED as a foundation, SNOMED CT presents data in a completeiy^machine-read;ble format. Accoraling to SNOMED Intematioial, the core conleot data of SNOMEDCT includes the following tables:

. CoDcepts

. Descriptions

. Relationships

. History

SNOMED CT has been mapped to ICD-9_CM {ts well as other commonly used vocab-ularies such as ICD-O3, ICD"10, and LOINC.

The corc lables provide the frameltork ior the organization. The concepls tablclists everyconcept thal appeared in earlier versions of SNOMED CT, stdting with versioD 3 Morc thaD366,000 concipts are organized into 18 hierarchies wilhin the SNoMED CT system Eachconcept, or fuliy specified name as listed on the tflble, is given a concept identifier

Concepts are iurrher identified by various tenns oi phrases that dellne them The combi-nation of;concept and a term is a dlscriPtion Desoiptions are given a Description ID'

Real-Wo d ExampleTheraDoo is r rnedical informuti,rs conlpany that produces software used fbf clinicul dec isionsuppor!. One of its systems, Antibiotic Assis!&Dt, was designed to support tbe apploprlateus; of aDtibiolics. SNOMED CT was iffegrated into Antibiotic Assistant to allow re systemto be integraled wilh other putient intbrmation syslens in order |o analyze Possible druginteractionls or'adverse reaclions to xhe medications, Accolding to SNOMED Internrlional,ThemDoc's Antibiolic Assistant, powered b) SNOMED CT. convcrts the ra\r d'Ll'r ink)usable iribnnalion, dram tically rcducing the time ircnr rccognition of c potenllnl Problelr10 intefvention. Instead of having to t ck down information form rarious soullcs . , thephysician rcceives comprehensive infbmation in real ljme as pafl of his daily routrDe, nnd lsrubie to decjclc on an imrnediale course of aclion" (SNOMED Intemational 2005).

Diagnostic and Statistical Manual of Mental Disoldels'Foulth Edition, Toxt Rovi$ionThe Americrn Psychiatric Association (APA) developed the Diagnostic Lnd StatisticalManual of Mental Diso,drrs (DSM) as a tool for providing a set of codes that could beused to aid in the collection of clinical data usiDg stand-alone personal compuleN

Hi3tory of DSM.IVThe APA published the first edilion of rhc DSM iD 1952. The APAS Conrmittee onNomenclature and Statistics developed DSM from ICD. DSM-I contained a glossafy ofdescriptions ofoenlal disorders. DSM has been revised three times since 1952 and is nowpublished as the fourth revision, or DSM-IV.TR. The updated text revisior (TR) becameeffective in 2004 to maintain currency with updated clinical terms. There werc very fcwcodrng chanBes in the DSM-IVTR \ersion.

To facilitarc easd of use with ICD versions, the APA has worked closely with other orga-nizations to make DMS-IV ICD-g-CM, and ICD-10 fully compatible. AIl DSM-IV-TR codes

C Inrcdl \ocaourdr ,es and Ciass ica l io S\ :Lens

are ICD-g-CM codes. This is even morc important because the HIPAA law requires that validICD-g-CM codes be used for diagnostic pulposes. According to the APA' '"fhe DSM-IV isa diagnostic manual that employs Ihe ICD-g-CM codes to assist the clinician medical recordkeeping. Because the DSM-IV-TR is a diagnostic manual, thele are a number of sublypes andspecifiers that arc not codable to the ICD-g-CM" (2005).

Purpose and UseThe ,nain purpose ofDSM-Iv-TR is to provide a means Io rccord data on patienls tfeltedfbl substance abuse and mental disorders. DSM is used as a nomenclatul€ that clinicianscan reference to enhance tbeif clinical practices and as a language for communicatingdiagnostic information. Clinicians use DSM to assign a diagnosis

DSM contains a listing of the criteria tbr diagnosing each mental disorder and its keyclinical mrnifestations. Mental conditions are evaluated along five axes

Ovorvi€w of SttucturoThe five axes used in DSM-IV-TR are:

Axis I Clinical Disorde$Other Conditions Thal May Be a Focus of Clinical Attention

Axis II Personalily DisordersMentai Retardation

Axis lII General Medical CoDditions

Axis IV Psychosocial and Envitonmental Problems

Axrj V Glubil Assessmenl of Funclioning

Use ol' these axes by clinicians helps to establish a systematic evaluationsymptoms. This will lead to the est4blishment of diagnoses for the patient Thethen lre given a code or codes that ar€ the same as ICD-g_CM codes.

Read Codeg

215

of patieDtoraSnoses

The Read codes were developed in the Unrted Kingdom during the 1980s, They weredesigned lor u'e in computer-brsed tbrmab

Hlatory of Read CodosDr James Read was a geaeral medical practitioner in Loughborough, England ln 1982, hedeveloped a set of alphanumeric codes for use on his office computel. The codes allowedhim to record the most commoD diseases and conditions for whicb he saw patients. From1982 to 1987, the Read Codes were expanded and produced a coding system for therccording of many areas ofclinical care.

h 1987, the British Medical Association and the Royal College of General Practitio-neN established a v/ork pdty to lnvestigate classification systems that couid be used ingeneul medical practices. A year later, this group concluded that the Read Codes shouldbecome the standard code set fbr recording medical data in general practice Therciorc, theRoyal College of General Practitioners adopted the Read Codes as the standard-

The United Kingdom's National Health Service (NHS) also began to use Read Codesin o$er parts of re NHS. In 1990, the U.K. Department of Health purchased the ReadCodes. They became Crown Copyright, and the name changed to the NHS Codes

276 chaoter 6

After the NHS secured the copyrighl to the Read Codes' they formed the NHS Cenlre

for Coding and Classilication (CaC). The CCC is now responsible for developing a'd

maintaining the Read Codes.

Purpoge and lj3eThe purpose of the Read Codes was to provide ; aet of codes that could be used to aidin the collection of clinical data using stind-alone personal computers The Read codesrranslatc cl inrJal drtd rnlo a f i le slruclure thal i ' easi l i u)ed wilh compulers

The codes also translate other information thxt has an impact on patlent crre lnTor-mation on patient occupations, thempeutic regimes, adminlstJative dala. and equipment

intbrmation are some ofthe other types ofinformation thrt the Read Codes lrcnslrte Thus,

the Read Codes can be used in all a.spects of healtbcare Io translate many types ot clinicaland nonolinical iniormition.

Ovgrviow of StructuroThe Read Codes are organized into chaptels. Some of the main chapters in venion 3 include:

OccuprtionsHistory and ObservationsDisordersInvesti€ialionsOperalions and ProceduresRegimes and TherapiesPrevendonCauses of Injury and PoisoningTumor Morphology

These chaplers are further divided into hielalchies of five byrcs repfesented by.alpha-numeric choraiters. The numeric characterc used are 0 through 9' and ihe alphabelicalcharaote$ used arc from A lhrough Z Theoreticatly, the design of the hierarchy oi codesallows for'916.132.832 codes in version 3.

Nursing VocabulariesThe use of vocabulades is a relatively new concept in the lield of nursing Many nursingvocabularies are cudendy used to classify nursing diagnoses, inlerventions, and outcomes.

Hl3tory of Nuralng VocabularlosNursing vocabularies were developed 10 aid in the collection of dall aboDt nu^ing care.They serve ns a way to document nursing care and to facilitate tbe caPture of these dataon computer systems. The American Nurses Association (ANA) has established a steeringcommittee on dalabases to suppod clinical nursiDg praclice. The commitlge has recom-mended use of a unil'red nursing language systen in the nursing profession.

Pulpose and U3eThe ANA recognizes approximately thirteen standardized terminologies. These alt devel-oped by separate agencies for various purposes. These terminologies are descfibed jn

table 6.1. All the classifications approved by the ANA are included in the Unified MedicalLanguage System (UMLS).

I

C in cal Vocabuiaries and Classifcaiion Systems 217

Table 6.1. Widely used nursing yocabularies and classifications

(NANDA)

This cl a$i fication is used to clasif} nuNing dhgnoses in all nusing setlings. The NANDAnultiaxial uxonohy isd€sisned to provide a sundlrdized llNing rcrninology to deiinepatient responses, docunent cde for Einbursenenr, aod to allow for inclusiotr ofnu$nEterdinology in building clinical EHRS. (No h Anencdn NuNing Diaenosis A$eirtion 20051.

(NIc) +

NIC is used to cla$iiy nusing interv€nrions. Numins inlervenrions.re any dircct-carctreatnent thd a Duse r.rfom6 on behalfol rhe patient. These inlervendons are lsed r. direcl

(NOC)

NOC is used ro closity nuruing outcomcs Nuaing outcodes sre theend result ol.are Thetcan meuslre quoliry ofcdre, cost efticienot, und progr€ss of realoeDt.

(HHCC)

HHCCcontlitrs two nxeaehE! vocrbularies used forcli$ifying and doounenringafrbulsrory {nd home herlth c!rt. The HHCCofNu^ing Dirgnoses Md ihe HHCC ofNuNing ldtervenrions rrc used

(NMMDS)

NMMDS copxtrrs Drrsitrg d.k lbr rhcconlpaLnoi ofpatiert oulconBs,

Tl s l$rfor.o1., u.co ro.lo*irj frr,n! Jrrlio*s, Inedenhon... lnJ orkJ r.e .

SNOMED CT SNOMED ir { rdccn( termroloA} lorhcxkhcMe, SNOMEDol!

(PNDS)

'fhh drt3 set is u st0ldaidizcd nuruidg vocdbuloy for use whcn p0tienrs undergosurgery llallows for rhcc{pt0re of dun lron p&ddmlsioncrre lnrilpdienr dilchogd,

(ccc)The CCC is uscd toch$ify DursirC diagDoss rnd ourcomes, lnd inreryentions.

This Ermirology h now retired9905l813.Pdl

0cNP)

ICNP provide$ dalo ro innuence deoision-nlking, €duclrion, lnd heahh policy,

Alrehative Lir*\ABC codes represenr inre8$rive lEatdcorc pioducrs and services(cooplenentary and alterlorile medicine),

& cods {LoINC)

LOINC isused to pool rcsults-such !s blood bemoglobin, serunpor.$iuq orvinl sisnsfor clinical cae, outcohes managenen| andEs.arh.

2r8 Chapier 6

The nursing data sets and classification systems are developed to captufe docum€nta-

tion on nursintcarc. They arc desiSled to capture nu$ing diagnoses, interventions, and

outcomes for acute, surgery, horne, and ambulatory care settlngsAccording to theANA,'A standifdized vocabulary assists nurses to documen! care wlnle

providing a f;ndatio for examining and evalultinS the quality ind etfectrveness ofthetcare'An rnfomaLon inf id\ruclJle pro\:dei lhe .oundll ion for benchmdrkinB meirsunng:rnd com-paring outcome data, irnd evaluadng the quality and effbctiveness of care" (ANA 2002)

Ovgrview of SttucturoThe various ANA-recogn izecl standartlized teflrinologies have dillerent shuctures' Inlbmaionon the specilic slrucu;s can be found at the various Web sites listed in table 6 l (p 217)

Chock Youi Und6r3tandinSl 6.4

/rrtru.rlrrrj Match the iollowing classification systems with theif iunctions

1. - SNOMED CT

2. - Nursing vocabularies

3. _ DSM-IV-TR

a. To document nuL$jng care and to frcilitate dre caplure olnursing inlbrna on on conrpulel

b. io provicle a rneans to recod information about patients !rcated fof subslance abuse andmental disordeis

c. Io ar. l i r the col lc,uon ofci inr.r l uuk J, i i rg n,nd_alone pcr ionl l JumPUter ' jd. To provide a systen lbr coding the clinical servrces provrded by physrcrans And olher clinicd

prcfessionalse. io provide a conuolled vocubuldry lbr coding lhe conEnts of the Patienl record and {br

facilitrting lhe developm€n! of compuxer-based Datient recorcls

The Coding ProcessThe coding process varies fiom oryanization to organization, but some stlndalds, ele_menls, :rnd steps ale common to almost all olganizations,

Standards of Ethical CodlngIn today's heaithcafe environmeDt, coding plays an important role in the determination ofrcimbursenent for healthcare facilities. AHIMA developed its Standards of Ethical Cod"ing, last updated in December 1999. The standards wele developed by AHIMA'S CodiflgPolicy and Slralegy Committee and approved by its Board ofDireclors, The AHIMA stan-dards are Deant to serve as a guide for coding protessionals. (see figure 6.1I )

El€ments of Coding QualityThe coding function must be reviewed on an ongoing basis for consistency and accuracyAudits should occur to review lhe codes selected by coders. Coding processes should bemonitorcd tbr the fbllowing elements of quality:

. ReliabiliD: The deg\ee to which the same rcsults are achieved consistently (lhal is,when different individuals code the sanle health record, they assign the same codes)

rC inical Vocabu aries and c assificatlon Systems

. Validitt: The degree to which codes accumtely reflect the patienfs diagnoses andprocedures

Completeness: The degree to which the codes capture all the diagnoses and pro-cedures documented in the health record -7'1,r, / in.r\. The (ime lf-me ln $hrch rhe neahh records are codeJ

219

f igure 6. l l . AHIUA \ Slandard. of Elhical Coding

L Coding prolessionah de expected to suppon Lhe imponance of accurate, complete, and consistentcodinS practices for the production ofquality healthcare dara.

Codirrg profe$ionals in all healthcare sertings should adhere to the ICD'9-CM (lnLernationalcla$ificaLion ofDiseases,9th revision, CLinical Moditication) codjng conventions, oaiciai codingguidelines approved by the Cooperating Panies,{ tle CPT (Cunent Procedural Termirology) rulesestnblished by rhe Amcrican Medical Asociation, and any other oticial codinS rules and guidelinescstablished ibr usc wirh nandated standard code sets. Selecrion und sequencing ofdiagnoses rndproccdures nrusl meet the definitions oirequired dara sets tbr applicuble heafthcare settings.

Coditrg protlssionals should use rhei skilh, thei! howledse ofcufontly nunddted coding andolassiilcrtion systens, and oficialresources ro select the apprspriate diagnostic lnd procedurdlcodes.

Codiig prctbssionals should only assign and repon codes that:rre clearly and conlhtenilysuppor'tcd by physician documenLaLion in the healLh record

C{)ding prolcssionals should consult physicians for clilification and additionld docunrcntrrion pdorro colle rssigomcnt whcn theE aro conflicting or anrbiguous dota in the heullh record.

Coding professionals should nor change codes or rhe nnF0rives ofcodes on the billing bs(Lrctsothot nrcnDings urc misepresented. Diugnoses or procedures should not be i appropdatcly includcdorexcludcd because payment or nrsur0nce policy covemge requirements will be aff€ctcd. Whcnindividuul paycL policies conflict with olloial codins rules und suidelines, tlese policics should beobrained iD writing *henever possible. Reuson0ble efforts should be made ro educate tu pnycr onproPercoding practices in order to rniluence I chonge in the payeis policy.

Coding professiotrols, 0s memb€n ofthe heahhcare teau, should asshr ond educarc pbysiciaDs lndother cliniciln$ by advomting prop€r docunenlation puctices, funher specificity. md reseqLrencingor jnclusion oidilgnoses orprocedules when needed to more accurately rcflefl the acuity, severity,lnd rhe occunence ofevenrs.

Codjng pfofessionuls should pfflicipale jn the development oi jnstitutionul coding policies and slrculdensure tlrat codnrg policjes complenent, not conllict with, olicial coding rulcs lDd BuidcliDcsCodnrS professnnrah should mrintain and conrirually enhlnce rhei! coding skilh, as rhey hale Iprotcsional responsjbility lo sray abrelst otcharges ii codes, coding guidelines, and regulurions.

Coding profession0k should srive fo. oprirral piyment to vhich lhe iacilily is lcgllly enrirled,t€nembeling thar ir is unerhical and illegal ro maximize payrneni by rnems rh0t conrrudicl

2.

3.

5

7

9.

rTlr. Cooper!rlng Pdtics irc tu AmericRn llerhli lnfbrmaior N4aiagemedrA$ociariod,Adrericar HospimlAsrociaion,c.nte8 ror MelicaE and Medicaid Services. lnd Nu.ionll Cenrer lor He.lth Stltistics.

coptright o1990 by ir.Americii HerlLh Inlornarion Maugemcnr Associarioi. All righ6 Eserled.

220 Chapter 6

CodinEl Policies and Procedures

Every healthcare tacility should establish coding policies and procedures that establishguid;lines that coders should follow to ensure coding consistency UsinS lhe codingguidelines established by organizations such as the AHA, the AMA, AHIMA, and stateirealth iDfonnation management association policies can be developed 1br coding con_

The AHA publishes the official guidelines ior ICD-9-CM coding in a qua eriy news-letter entitled Collng Cltnic. The AMA publishes information regarding CPT cocles ir- -newsletter entitled CPfArrirtdrl. Both publications can be used as a basis for developingfacility poiicies and procedures.

Steps in the CodinEi Proqess

For accutate coding lo occur, the coder must have a complete heahh recold on thc Patient.Each facility needs to detine what constjtutes a complete record The coder must l€vrcwlhe contents of the reoord to determine lhe patient's condition and the treatment and carehe or she received.

For an inpatient record, the heallh record should contain the ibllowing doclrlnenlsprior l(J being codedr a lace shecl, operative and pfocedural rcports, pathology rcpofts,ancl a dischirrge summary. The coder necds to Ieliew lhese documents !o veify LliLlgnoscsand proceLlufes.

After tbc record is reviewed. the coder selccls the diagnoses and ploceclurcs tllirt ncedto be coclcd aDd irssigns apptopriate code numbe$ Code$ then have to be scquencedaccording (o Unifbrm Hospital Discharge Dala Set (UHDDS) guidelines.

Aliel the cliagnoses and prccedures are coded, the oodcs are enlered irto lbe lacility'sdatabNe. These da|a then become lhe fbundation fbr stalisticAl, reimbursemcnl. and clini-cal jnfbrnr tion systems.

Quality Assessmont for the Coding Proc€3s

Assessmen! of the coding plocess should occur through rcgular monitoring oI codirgaccuracy. Monitoring is the ongoing internal review of coding practices conducted by anorganizati on a regular basis. A monitoring/audil program P1afl should be a wlittcn planthat outlines the objectives and iiequency of the audits, fie record selection process, thequalifications of auditors, and cor.eclive actions the organization will |ake as a fesult of|l1e audit findings.

Initially, a baseiiDe audit should be perfoDned. The audit should be a review ol a largesample ol lhe coding completed. It should include a sample ofrecords coded by all codersfof all types of services. Moreover, the sampie should be representative of al1 physiciansand lypes of cases treated by the organization. The baseline audit provides 4n overview otthe organizadon's cuffent coding praclices.

The organization should conduct follow-up audits accordiDg to the schedule estab'lished in the monitoring/audit plan. Follow-up audits will provide ongoing monitoring ofthe coding process to ensure coding accuracy. The resuhs ofthe audits llso can be used tooutline areas in which coder education and training are needed. Figure 6.12 is an exampleoI a codins audit review sheet.

rClinica Vocabularies and Classification Systems 221

Figure 6.12. Example of a coding audit rcyiew sheet

Coding Aodit R€Yiew Sheet

Co

Date of ReviewMedical Record #Djscharge Date

Initlal Codes Assigned ReYiewer's RecommeDdrtions

Principal DiagnosisA. Choscn and coded correctly _B. Chosen cor.ecdy, coded inconecrlyC. Choscn inconectly, coded conecdyD. Choser and coded inconectly

Sccondffy DiognososA. Choscn and coded conrctlyB, Chosen corrccdy, coded inconecrly_. _. . - . - . . . . , - - - . ,_ . .J . -_- ' rcorcc yD. Chosin and coded inconectly

Principal PmcedureA, Cholen and codcd conectlyB. Ch$en conectln ood€d incon€ctly.C. Choscn inconec y. coded comcrlyD. Chosen and coded inconecrly

Secon&ry ProceduresA. Ch$en and coded conecrlyB, ChGen concctly, coded incorcctlyC, Chosen incon€ctly, coded 0orectlyD. Chosen and codcd inconectly

DRGA. Chosen and coded cor€cttyB. Chosen corcclly, coded inconecilyC. Chosen inconecily, coded corectlyD, Chosen ard coded incorcclly

Noter A rcviev sheer can aho b€ constructed to monitor CPT codilg infomarioi instedd of DRc asiglnenr!.Coprrighr @ 2000 by tie Anerican Hcatth Infomalion Mlnagenent Associalion. Alt .ighB Esned,

222 Chapter 6

chock Yout Und€rstandlng 6.5

lnrtrrcrio,rsj In{licate whether the following stalemenls are true or false (T or F)

1. - Coding plays an inponant rcle in the determinadon ofreimbursement ofhealthcare facilities

2. - The coding function must be reviewed on an'ongoing basis for coding consistency andaccuracy.

3. - The AMA publishes the oflicial guidelines for CPT coding in its newsle$et ' Codtll g C Lini

4. - Codes are sequenced in the palient's h€alih record according to AHIMA s Standards ofEthical Coding.

5. - A baseline audit should include a sampte of rccords coded by all coders for all tvpes of

Coding TechnoloElyTechnology is changing many aspects ofthe health information profession One ot.the prl-

mary are;i where iihai assi;ted ln making jobs more efficient is in the area of coding As

earli as the 1980s, information technology \ryas applied xo make the coding process more

effe;dve and efficient. The type of tool used to aid in the coding process is commoDlyrefeffed to as an encoder. The developmeDt of otber technologies, including natural lan'guagc processing (NLP), will likely have an even greater impact on the coding process

EncodersEncoders fbr ICD wele developed in fie early l98us Over the subsequcnl years gleirter

sophistication has been built into these technology solutions An encoder ls comPutersoitwarc tbat helps the codin€ professional lo xssign codes lnitially, encoders wer'e devel-oped for assisting coders in assigning ICD_g_CM codes Today, however, encoders includeassislance with other coding systens.

The inlbrmatio[ science and technology belind thg encoding sotlware vilrics fromvendor to vendor. Some encoders are built using experl systenr techniclues such as rule-based systems. Olher encoding sollwarc is nore simplislic, mereLy automating a look-upfunctiorl sinilar to the manual index in ICD or olher coding classifications

Encodeff have many different types of iDterfaces, depeDding on |he vendor' An inter-face can be defuecl as the total componett of screens, navigation, and inpul mecbanismsused to help the end user operute fie encoding software, Some encoder systems have aDintedace that prompts the coder lhrough a series of questions As the codel arswers thequestions, lhe encoder leads the coder 1o codes lbr diagnoses aDd procedures.

Altemalvely, odrer encoders allow coders to input classification codes directly into lbe sys-tem and then go thLrough a series of edit checks to ensure lhat only allowable code numbers areentered, In more sophisticated sottwarc sysrcms, the encoder also prompts the coder to reviewlhe sequencing of the codes lhat have been selected in oder to oplimize rcimbuNement

Good encoding software should include edit checks to ensure data quality For exarn-ple, an inappropriate combination of codes or inconsistent data should be flagged for ihecoder's attendon. Encoding software is frequently liDked to other infomation systemsapplications. This inctudes direct links to DRG grouper soflware and billing systems

The use ofencoders has become a predominant tool in the HIM department, pafiicularlyin acute care facilities. Today, however, there is even a greater movement lowald more com_plete computerization of the coding function using a supporting technology called naturai

T,Ij

C,in;.4 \ocabu ar ie: a^o C as5 'ca- io 5!s 'en )

laneuase processing, or NLP In an NLP sy'tem digllal tcxl Irom onllne document' stoled

:" ii. 3"i""*i""tl iJ",-u,'on .y.r"t is-read drre-cLl) b) lhe 'oflwffe "nd lhen ruromali-

.^r j" a" i .a. r" i .^r tot . , Lt t . a.gi i " t t "* ' in rn onl ine energency depanmenL record $ould

oa i 'n," io"," .r ur 'ot" l .al ly b) i re NLP is lem and lhrorgh lhe use ol€rped or r f l i l l (11l

intel l r r ;nce sol twxre, would aulomrlr ' ly ' r rg8e\ l pprupriale code numbers.

1[ i , ryp. ot 5] ' lem $; l l dr l rnJl i . ' " l ] chrnge lne role ol lhe coder l fom bern! r , l ronr-

tin. int".pii,., nni t.unslator ol textual rlita tt, 6eing rn editor, valid tor : ,*9i!:]-"i-.:""oirionln"l'tt, Innd" outot,ralically and electronicrLly

-NLP Computer Assisred codrng ICAC)

is iriuse predominantly in the outpalient selting. where repetiti\e rilsks !irn.De eJsrly iluto-

mated to iree up lhe coder to fbcus on mote compler chffl review rnd,codlng assrglllllent

(See figure o.l -i.) Thc trerld towrrd this type of inform^tion system use ls €xpecteo lo grow

eccoii ine ro .he IHIMa e-HtM Work Cioup orr Computer-Assi ' ted Cudtng:

As tbe-lrarsition lo EHRS and the udoprion ol ICD_10_CM and ICD_IO_PCS occur n rhe US Lht

detailed ard logjcd struclure oftbes€ svslcns will in'reasc the use of CAC toois across nranv djl

le t (nr dorr . - rn ' ln -dJ i r on. cs CAc rccnrru '8r be 'ome' ncreJ ' in8 l ) ' "Pni ' r rcr teo 'herc r ' l l b !

lc . . Jrmrr .J l . c .drng p,nre*onr l i Lo i ( r lo r r rndi r 'unr l c 'n i ' r l ' " ' l nB r - 'ks ( A( ' " wrc

" ' " . . . , . t - ' , r , - r - ' ' , L . : . t D r o l i s i o n - r ' r I e r $ o r l l l { b ) 1 l l o s ' n s r h e r n r ' r c " ' e ' v ' n l ( J r r ' '

o ' ' , r " 'o t .u . t , ' " . t t ' " , .u , , i iocrrg l rorc- i " r . . ' r ' tmo( Je\cL4sl ' l l ' 'nd. ' n p ' ] t " " : ' - "1:

. l r r r rxr r r ' r . rL \crurrnr o l o . ' r i Con ' - rer_- ' r ' red 'u I rg r " br ' lJ rng lc 'hnol iv *nJ\e umc ' r '

comc. rnd it heralds A ncs era for coding proiessionrls (2004 48G)'

223

trieurc 6.13. Scre€n shot of cornpuler"assisted coding program

224 Chapter 6

Other Technical ToolsIn the early 1980s, the federal govemmenl implemenled the Medicare prospectlve paymen!system (PPS) for inpatienl rciDbumement. Each patient is assigned to a diagnosis relatedgroup (DRG) that determines the facilily reimbursgmenl amounl. (See table 6.2 )

ln the DRG system, palients are categorized into DRGS that represent cases that iLfemed_ically similar wilh respect to diagnosis, treatnent, and lenglh of stay. ICD 9-CM diagnosesand procedufe codes arc used to determine placement into tbe DRG payment cateSories.

Similar to the DRG system, Medicare reimburses hospitals for outpatient seryicesbased on the Outpatienl Prospective Paynent System (OPPS), which categorizes patientsinto groups. These groups are known as Ambulatory Payment Classifications (APCS)accofding to the types of services commonly provided in that setting. Primarily, the CPT/HCfCS cndi| lg sl slem I\ ul i l . , /ed lo dctennine Lorrcct 13) Inent of sefvi!es

tn both the DRG and APC groupin8s, codeN enter the codes that have been selecledinlo a computer program called a grouper. The grcuper then assigns the palient's case tothe conec! group based on the ICD-g-CM aDd/or CFIHCPCS codes (See tablc 6 3 lorirn example ofAPC groupings.)

l . _2 _

check Your lJndorctandin8l 0,8

lrrrnrdiorsr Indicrtc whether the tbllowing siatenrcnts are !rue or {alse (T or F)

An encoder is conlputef soliware thal assirjts in determining coding acclrncy md reliability

An inleriace is lhe tohl cofiponenl ol screens, navig.rtion. And input mechrrrisnrs uscd10 operate encoding softwafe.

Good encoding sot'tware should inchrde edil checks.

The NLF encoding syst6m uses expert or rutilicial iDtelliSence soiiware to aut()Inrrtically.Nsign code numbers.

5. - DiAgnosis-related groups crtcgodze palienl c$es lhrt e medically simil0, wilhfespecl to diagnosjs, tre ment, And lengtb of stay.

Goding and Corporate ComplianceEach year-, it is estimated that millions of dollars of the U.S. healthcare industry budgel ismisappropdated because of liaudulent practices by healthcarc organizations tnd provid-ers. Through the Office of the Inspector Genelal (OIG), the federal government eslablisbesanDual conpliance plans for lhe heahhcare industry. A compliance plan can be dcflned asa plan to ensure that a facility is providing and billing lbr services according ro the laws,regulations, and guidelines that govetn it. The goal oi these plans is !o help providersmonitor lheir biliing and coding praotices to prevert fraud and abuse.

History of Corporate Compliance

The basis lbr proseculion of healthcare liaud and abuse is the Fedefal False Clcxrs Acl(FCA). This act wds signed inlo law by Abraham Lincoln in 1863. Its original inrcnt wasto encouragc private citizens during the Civil War to report fraudulent actions laken againstIhe Union Arny. Under this act, the govemment had to prove that an irdividual acted witi'rsDecific intent 1o defraud the sovernment,

Clrnical Vocabularies and C ass fcation Systerns 225

Trble 6.2. Example of DRC groupings

FY 2006

DRG I DRG

Ff 2006

DRC MDC TIPE DRG ri0eGeonoiric A.ithm€ticne'n LOS mean LOS

0 l SURG CRANIC1TOMY ACE >I?wcc

3 4341 1.6 t0. t

2 01 SURC CRAN]OTOMY AGE>I?wo cc

r .958' 3.5

O I SURC CRANIOIOMY AGE O-I? t .9860 t2 ,7 t 2 . 1

0r suRc NO LONGER VALID 0.0000 0.0 0.0

5 0 l SURC NOLONCERVALID 0,0000 0 0 0.0

0 l SURO CARPALTUNNELRELEASE

0,78?8 2,2 3.0

01 SURC PERIPH & CRANIALNERVE & OTHBR NERVsYsr PRoc w cc

2.6914 6.7 t .1

0 l SURC PERIPH & CRANIALNERVE & oTHER NERVsYsr PRoc wo cc

r.5635 2 0 3 0

MED SPINAL DISORDERS &INJURIES

t.4045

t 0 0t MED NERVOUS SYSTEMNEOPLASMS W CC

12222 6.2

t l 0 l MED NERVOUS SYSTEMNEOPLASMS WO CC

0.8736 2.9 3,8

l 2 0 l MED DEGENERAT1VENERVOUS SYSTEMDISORDERS

0.89911 5.5

l3 0 l MED MUITIPLE SCLEROSIS &CBREBELLAR ATAXIA

0,857s 5.0

MED INTRACRAN]ALHEMORRHAGE ORCEREBRAL INFARCTION

1.2;156 5,8

15 0 t MED NONSPECIFIC CVA& PRECEREBRALoccLUsIoN woINFARCT

0 942\ 3.1

0 l MED NONSPECIFICCEREBROVASCULARDISORDERS W CC

l . l 35 l 5 0

226 Chapter 6

Thble 6.3. Example ofAPC groupings

APC Gmup Title stR€lativeW€ight Rate

NationelUnadju5ted Unadjust€d

0001 Level I Pholochemotherapy S 0.3998 23.19 7.00 4.',16

0002Levcl l Fine Needle Bjopsy/

T 0.9157 55.68 I L t 4

0003 Bone Marow Biopsy/Aspiration T 2.6156 t59.23 3 i .85

0004Levcl I Needle Biopsy/Aspiratjon Eicept Bone Manow T t.7'77 | r05.76 22.36 2 t . 1 5

0005Levcl ll Needle Biopsy/Aspiration Ei(cept Bone Manow

'l t .5834 213.25 7 1 . 5 9 12.65

0006 Level I Incision &Dlainagc T t . 5 1 0 0 89.86 2t.76 l7 .91

0007 Level II Incision & Draimge T l |.611,1 694.59 138.92

0008 Lcvol III lncjsion and Druina8e T t6.2953 969.15 193.95

In 1986, the FCA was amended to include provisions thal eliminated the requirenentthat specit'ic inteDtto defiaud be proven. The law now has become the basis for proseculinghealthcare prcviders who knowingly prcsent a lalse claim for payment to the governmenlTherefbrc, when a healthca(e provider shows a pattern or pmctice ofcoding that results iDovercharges to Medicare and Medicaid, that provider can be prosecuted

To avoid frauduleni behaviors, heafthcare providers need to develop compliance pl0nstha! ensure tbe eslablishment of internal contlols Since 1997, the OIC has rcleased itscompliance progmm guidelines for segments of the heAlthcare industry, includjng llospitals, home health agencies, clinical labora{ories, third-party medical billing companies'and DME suppliers, hospices, nursing homes, and physicians'practices.

Elements of Corporate Compliance

Heaithcare providers should use lhe compliance programs released by the OIG to developand implement their own compliance prcgrams. The guidelines outline elements thatrcpresent a plan that healthcare provjders can follow. The various compliance progranguidelines can be found on the OIG Web site at hhs.gov/oig.

Several basic elements required fof corporate compliance progranN were outlined inthe OIG's "Compliance Program Guidance fbr Hospitals," published in lhe b'edetul Regis-tzr. on February 23, 1999. A supplemental plan for hospitals was published in the FelerdlRegirte,'on January 31,2005. Corporate compliance programs for hospitals should includeat least the following seven elemelts:

1. The development and distribution of written standards of conduct, as wcll aswritten policies and procedures that promote the hospital's commitment to com-

C in cal vocabu aries and C assificatlon svstems

pliance (for example, by including adherence lo compliance as an elemenl rn .evaluating managirs and employees)and that address specific aress ofpolentialfraud \uch "s claim) development dnd \ubmission processes cooe gamxlg ano

financial relationships with physicians and other healthcare professionals

2. The designation of a chief compliance offrcer and oiher appropriate bodies (for

exa[rpleia corporate complianae commitlee) charged with responsibility for ,operaiing and monitoringibe compliance program and that report directly to the

CEO and the govening bodY

3. The development and implementation of fegular' effective educalion and tlarn-

ing programs for all affected employees

4. The maintenance of a process, such as A hotline, to receive complaints and the

adoption ofprocedures to protect the anonymily of complainants and to protecl

whistlebloweN from retaliation

5. The development of a system to rcspond to allegations of 'Inproper/illc8'Ll rctiv_

i l ie' rnd uie enforcemenl ofipproPrirte Ji.cipl in-ry c.hon ag_rnsl enrplolee"who have violated intelnal compliance policies, applicable statules' and regula-trL'n\ or fedetf l l heJlthcare progrom requircmenl)

6. The use of audits and/or olher evaluation lechniclues to monilor compliance and

assis! in the reductjon of identified problem arens

7. The invesligatjon and renlediation of identifled systemic problems.And tlledevelopment of policies that address the nonemployment or relenllon ol sanc-tioned individuals

Each year, lhe OIG publishes a wolk plzin thal details oreas of compliturce it will bc

investigatiDg for rhat ye;r Facililies should \tudy thrs documenl carelully irnd plirn therr

compli-ance-aDd auditing projects to ensure drxt the) are in colnpliance widr.jdcntr ed

!"reit arell'. The olC w6ri phn rbr 2005 can be lbund online xl oi8 hhs gov/publirirlion(/do;s/wof kpl:,n/2005/2005%)0u orko,.20Plrn pdf

Policies and Procedures fol Corpolate Gompliance

Policies and plocechiLes for corporate compliance must be developed at the fAcility levcland for rhe LilM clepartment. The OIC ouilines speciic areas ot' concem that need to beaddfessed in facilides'policies. 4lM professionals play an aclive role ill the devebpnentof both HIM department and organizatioD-wide policies

h October i999, AHIMA published a practice brief titled "Seven Sleps to CorpofaleComplidnce." OrganizatioDs should use the gurdelines rn thrs Pmcrlce brief to developspecitic HIM cornpliaDce plaos. As recomnended by AHIMA, HIM complrrnce policiesand Drocedures shoDld ensure lhal:

. All rejected claims pertai ng to diagnosis aod procedure codes are revrewcd'

. Proper and limely documentation of all physician aDd other professional se icc'is obrained prior ro billing.

. Compensation for coders and consultants does not provide any financidl iicentiveto code claims improperly.

227

J

224 Chapter 6

'rLI

. A process is in place for pre- and postsubmission leview

. The proper selection and sequencing of diagnoses occuLs.

. The corect application of ofticial coding rules and guidelines occurs

. A process exists for reporting potential and actual violations.

. A process is in place for identifying coding errors.

Chock Your Understanding 6.7

lr$tr&dtdrr lldicate wheiher the following statemenls are true or false (T or F).

i .

2.

3 .

5 .

- The federal Office of the lnspectof Geuer.tl established conpliance plans tor theheahhcare industr/.

-- Tlre basis for prosecuting healthc.ue iraud and abus€ is the Federal False Conpliance Ac!

-- The OIG compliancc prognms ofier guidelires that healthcare oryarizations crnlbllow to estabtish lheir inrernal compliance progranN.

- A corporate complianoe progrnm should include the devclopnrent and inplenlenurlionoI cducntio and traiDirg programs for I alibcted employees.

- HIM pfolessionals are not involvcd in developing policies rnd procedurcs fot!oryoratc compliance.

New Directions in Clinical Vocabularies

As lhe nulrber and sophist icl i t ion of cl inicAl vocabuL|| ies jncrease, therc hAs bcen a sig-nilicant novement toward research in undefstlurdins the fundanental elenrents AnLl suu!-tures rn oorh vocabularie( ond cla5s,f icarion s) <remsl One of the mo"t farsightecl cndeL\ orctoward brirgiDg togedrel the varidls nredical vocabularjcs is lhe Unified Medical LungurgeSystem (UMLs) project being conducted by the NatioDal Library of Medicine (NLM).

National Libhry of Medicine UMLS Proiect

Thc NLM established a research project iD 1986. This long-mDge projccl is called thc U -i led Med..Jl L.nguJge Sy.tcr ' UMI S) projecl.

The puryose ofthe UMLS is to aid in lhe development ofsystems that help healthc|rJcprofessionals retdeve and integrate electronic biomedical information from a variety ofsources. UMLS uses three knowledge sources to make it easier for users to link sep ntelnlormauon systenN:

. The metathesdurus provides a uniform coilection of mote than one hundredbiomedical,&ealth-related vocabulades, coding systens, and classifications andlinks the different names used in the various vocabulades and classifications-such as SNOMED CT, LOINC, and RXNofm Io a common concept.

. The specialist lexicon contains synttctic information for many terms. (For exam-ple, it lists the parls of speech, various fonns of a word, and spelling variations o1'the rerms witbin UMLS.)

Ctni . " \ ,oLao-1" 'es and Classi f i " r .on Srsr 'n"

. The sefiantic neflrorl provides a system for categorizing objects and idelrtifyingthe rel4tionships among vadous concepts

The UMLS knowledge sources ovelcome retrielal problems ftal occur wlcn difl-erentterminology and sepamt; databases are used They are currently being rlsed in lr variety

of applic;;ns, including patien! data creation, natural language proc€ssing, and informa_

don';etrieval. The NLM -nraintains

fact sheets <.lescribing lhe progrcss of this projecl on irs

Web site.

D€velopm€nt of the Nosologist Role

Nosology is the branch ofmedical science lhil deals with classification systens A nosolo-gist is ;;erson who works with using and deleloplng elsssiitcation systerns The AHIMAboding Futures Task Force envisions thal the role of the coder will change drrrnaticallyover tf,e next decade. At present, the codefs primary rcsponsibility is the assigDmenl of

codes. In the future, the c;der will become a nosologist rcsponsible fo! the developnent,maintenance, and management of classification systems :rnd voclbulrlies A peek intothis tuture role was prov;ded in the following scenario as 3n outgrowth ot the work of the

Coding Futures Tlrsk Force (Johns 2000):

lr's 20 L0 nnd d brave new world lbr codersJanc Smith. RHIT. CCS, is a health intbmation technician and clirhal coder lho Ls row

eNployed in the cunic nosology, or classificolion, deParLment ofCommunity Heajtlr systcnr JMe

recognized some time ago thar coding would beconre more and flofe lutomated in the lutuLc ond

th0r;hc could set 0 bertt job ii she had I deeper undeNilndins and broflder knowledge oi lcxical

rechnologics dd medical vocabuluties Sh€ continued her oducatior and lended an eDvirblo and

chal lc lL oe po.r r ron. Nor : l le wotk. srLh col leJguE rho h-ve b lckgrounl l rL hcJrh. in tor . ' l i ian

rndluBcnrcnt. m<dical rno nur.rnE inlormaoc5 Jl ni.xl jcjen-e' conrpurer sc'ence _nJ (rxlrrr'(\

Jane's nosology group works on vadous projecrs associlted vith mersi g riDd nrAPping ovcthP'ping cLinicalvocibulolies to suppo developmenL ofthc computer_blsed paticnt record, autonureil

decision suppon, and outco es Anrlysis With nole dran 25 diflerent nredical vocrbuldries ir usc 'n

the systen, overlapping teans uc u rcmendous ptoblem-resuldng in dlPlication lnd difficuky itr

trenshtion and r€trievalofdaia for patient cafe, rcsearch, rnd decision supPortThc nosology group\ cunlnt Prcjecl involvcs comparinlg th€ output of two systcms thrl use

difelcnL upproaches in merging anr.l mrpping clnlicul loclbularies. The grcup wanis to cvnl alchow vell these two sysEms can initillly map lelms iiom lwo selected vocabul:rries-LolNc mdSNOMEDCT.Jsne's team wan$to dete ninc which ol the i*o svstens does a beller job i'l mcrgingthe two cunical vocabularies Jare, whosejob title is now clinicalnosologist' developed thc iniliil.esearch plln for the compaLhon. In prep0ration ior the analysis, she reviewed system oPiioDs 4rrdsclected lh€ bert possjble syslehs lbr the tesr.

Wheo the teln hss linished its testing, il will be abte to recommend whether thc healrh svstenshould purcbase eilher oflhe two systems and ircor?oraLe it into the enlerprise'widc clinical con!puting system. The result, idellly, willbe mor€ rcliatrle, consistent, and accuraledala lbr autonoteddecision suppon systens and clinicd informarion systems.

Like Jane'sjob, the h€ulh infornation industry is very ditrerent than whar it was l0 ve^rs rgoFaltrnoling technoiogy has fed developmen! of a conplex web olplayers, tiom invesroa to he.lthcare teans and fo ardrhinking organjzllions who have anticipaled technological bre.kd orghsand accordingly reengjneered to capiralize oD fiem.

A convergence oflechnology breakthroughs has rnade code asignments tbr Patienr clire, billing,lDd resedcb purposes essentially aulomotic. codjng specisiists are still important. but tarhe. thanassign codes, they now analyze coded data for quality confol lnd rends md mairtanr datamapPingsfron locabularies to clasification svslens.

229

234 Chaptef 6

Check Your Undorsianding 6,8

1nrr,'lldirrrr Indicate whether the following statements are true or false (T or F).l. - The UMLS project was initi ed ro bring rogerher the various medical vocdbutaries.2. - The rcrarhe\ruru\. une or rhe U\4LS fnowtedge \ourre\. conHrn\ \)nrdcr. !

inibrmation for many |erms.

3. - The UMLS knowledge sources rre cufient]y bejng used in naturat languagcprocessinS.

4. _ A nosologist's primary .csponsibjiity is rhc assignnent ofdiagnosis codes.5. __ In the future, coders will become nosotogists.

Real-World Case

Can natural Ianguage proccssing be helpful to outpatient coden ? NLp is a supporting tech-nology that has rcached an exciting strge ofdevclopmenl. It holds a great deal ofpromisefor assisting in lurther nutomation of thc coding process. Atthough ihe technology holdsg.eat pronrise. il also faces huge challenge becausc of tbe complexiiy and vnrirbility ofhuman speech. However, promising new NLP producLs 0re beginning l(J emerge in ceriainmedical arcnas, such as energency nedicinc. To valid^te fie claims that an NLp sysremcan improve codilrg accul.Acy, 3M Health Iifoulation Systems designed and performeda study of ICD-g-CM and CPT to detefmine how 0 NLp technology system marched upwith real'world codeN.

To determiDe whethef al) NLP tutotnated systeln was as accurate at assigDing ICD andCPT codes to emergercy loom records as experienced oodefs, the researo-hers-cvaluateci328 emefgercy loom charts using both the NLp system and the experienced coders. Thcstudy results indicaEd that in the spccjnlized ren8 of emergeDcy medicine, the NLp sys_tem coolpared favor bly to uclual coders in assigDing ICD and CpT codes. (This case wasadapted from Warner 120001.) Since that time, olher studies have shown that rools utiliziDgNLP hnre hecorrre increosrngl) nlole etlccl i !c

Summaty

ln fecenl decad€s, coding, classification, rnd vocAbulary systems have grown in impor_tance. This is clear iD the critical role thal coding now plats in the healihcar.e industry'sreimbursement process and its usc in lesea(h and qualiw jssurance efforts.

Nomenclatures, classitication systelns, dnd clLnjc:rl vocrbul.rries were crearcd to helporganize healthcare data. In medicine, ft nomenclature is a system dat lisls preferred necli_cal.termrnology._A classification system groups together similar diseases and proceduresand oiganizes related entitjes for easv rctrieval.

The purpose and use of ctiDjcal ;lassificarions roday are va ed. For examDle. DhvsFcrin" u:.e clussif icul ion. such l. ICD lo chs\ify Inorb.drry aDd mon"l ir; infornri ibn-forstatistical p-urpo-\es, lo index bospital recofils by disease and operations, and to rcpodiagnoses. In addition, clinical classiflcations are used in the reporiing and compilaiionof healthcarc data to assist in evaluating rnedical care planning tbr h-ealthcare delivery

clinica vocabularles and Classification Svstems

systems, determining pattems of care among healthcare providers, xnalyzlng pa) ments of

hedllhcate .en icei. !nd conducllng epidelniolot cal and cl inical relerrch \tudrc'

Although ICD-g-CM is perhaps the most prominent classification system 1n use to^day,

health info;adon technicians use many otbei slstems in their daily praclice such as CPT'

HCPCS, ICD-O-2, DSM, and nursing vocabularies The continued development ot these

and other classification systems and vocabularies rcflects the complexity ofdescribing the

medical care process,Every healthcife organizatjon must have pollcies and procedures in plsce that set

guidelines fbr managing the coding prccess rnd ensurjng the conslstency oT the organl-

;ation's coding output. Fu ber, every organizalion should estabiish a monitoring/audltprogram to review and assess coding accur3cy on a regular basis Moreover' evely orga-nization should develop a corporate complisnce plan thct monltors lts Dllllng ano coolng

acti!ities to preveill fraudule[t practices.Finally. iechnological aalvances are having a lremendous impirct on the coding process

today ̂ nd will likely have an even greater irnprct in the future lmPortant prcJecls such

as the Unitied Medical Language System project conducted by rhe Nationcl Librirr) of

Medicine, coupled with the growth and matulily of automated codlng dnd natural linguageprocessing systems, will revolutionize the coding fiinction

Fqf€ronceaAHIMA e-HIM Work Croup on ConpuleFA$isted CodinS. 2004 (November Deccmbet Dcl!ing inlo

coirpureFassisred codinS. "/, nnaL of AnEi&4 Heatth ltfotuutiatt MMaSencht Astaciari'tr 75(10)r48A-481t'

ANA Comnirtee ibL Nut$ing Pnclice lnlban!tion Iniianrucrure 2005. Frequently Asked QuestirlslStand0rdized T€rnrinologies. AvAihble online tionr dlthedc net/CNPil/HomeStuli/FAQ Itm

Anrericnn Psychiutric A$ociarion 2005 Ftequenlly Asked Qucsriotrs about DSM Avrilable onli|t iiorn

www.psych.ors/reseurch/doddsm/dsm-inqviaq8 I30l clm

Biouch, K.2003 (July-Ausus0. AHIMA prolect ofii-rs insishls into SNOMED,ICD'g-CM ln!ruirrg proccss'

Jauflt'tl al Anericak Health kfonnaliu Mana|eftN Alsocitltit,1'7 4l'7)ts2-55

Ccnters fbr'Mcdicore und Medicaid Setvicc! 2003 (Miv). tllPAA lnlbrftrlion Series: 4 OveNiew 01'

Elecrolic Tmnslrdions and code SeN, L BaliiDore, MDTCMS.

codcRyi€. 2005. Nnnriol Langudge Processing NLP) conputeFAssisEd Codiug solulion Avriluhle orline

Ciannanrelo, K., nd L. Berkowilz. 2005 (April). SNOMED CT helps drive EHR success lt)untut il

Aneticoa H a1lth In Jarntuliar Muhdeenan Atfl cnttiah 76(4)166-6'7

Johns, M.2000. A crystalballfor codi\E. Jaunll olAtherican Heu|h |ttb uti.n l\lahasenteDt Aso.iahan7l(8) :26-33

NllionnlC.!n riee orVirlllDd Hcllth Sludsrics. l99l (.lune) NCvH'l /99r' DHHS Publicilion No (PHS)

9l-1205 Hy.1Is!ille, MD:HHS. Available online irom cdc.go!/nchvdala/ncvhVnchvs90 pdl

SNONIED l ernntionll, nil SNOMED Clinicll Teds (SNOMED CT) in ftelaDo. s Artibiotic AsittunlUr.le ie! Adnnnble Clitli.ul Decdi.r, Srrrorl Avoltable online lroDr wvwsnomed org

Warnef H R., Jr. 2000. Can natuii lrLnguaee proce$ing ajd otrrpltieDt codea?./orlral aJAntetiran nedhht{a hation MaMg4ne Asro.iattotr 7I(8):78 8L