HHS 503 Ch.5 PDF

Health Information Management Technology: An Applied Approach, Sixth Edition Chapter 5: Clinical Terminologies, Classifications, and Code Systems ahima.org ahima.org © 2020 AHIMA Definitions Vocabulary/terminology: A set of terms specific to a domain Nomenclature: A system of names that follows pree...

Health Information Management Technology: An Applied Approach, Sixth Edition Chapter 5: Clinical Terminologies, Classifications, and Code Systems ahima.org ahima.org © 2020 AHIMA Definitions Vocabulary/terminology: A set of terms specific to a domain Nomenclature: A system of names that follows preestablished conventions Classification: A mono-hierarchical method of organizing related terms together ahima.org © 2020 AHIMA Definitions Code: An identifier Code set: An accumulation of numeric or alphanumeric codes Code system: An accumulation of terms and codes for exchanging or storing information ahima.org © 2020 AHIMA Definitions Clinical Terminology: A set of standardized terms and codes used in the healthcare industry to encode clinical data ahima.org © 2020 AHIMA History and Importance Name and arrange medical content Historically to identify causes of death Expanded to uses for patient care, measuring patient outcomes, research and claim submission for reimbursement ahima.org © 2020 AHIMA Expanded Uses and Data Capture Claims data Surface clinical content EHR data Detailed clinical content ahima.org © 2020 AHIMA Data Capture Details are key to use: granular Clinical terminologies Code systems Combination of data is sufficient: aggregate Classifications Code systems ahima.org © 2020 AHIMA Primary and Secondary Data Use Primary use: granular Example—clinical decision support Secondary use: aggregate Example—billing and payment ahima.org © 2020 AHIMA Clinical Terminologies, Classifications, and Code Systems Selection of a standard for reporting Primarily regulation driven Content standards for representing electronic health information Interoperability building block ahima.org © 2020 AHIMA Clinical Terminologies Form the basis for coded data Provide the data structure Semantic interoperability Health information exchange ahima.org © 2020 AHIMA Clinical Terminologies Reference terminologies Provide common semantics Supports meaning-based retrieval Example SNOMED CT ahima.org © 2020 AHIMA SNOMED CT Clinical terminology used for documentation and reporting No book of codes and no assignment by a coding professional Implemented in software applications Granular level of clinical data capture ahima.org © 2020 AHIMA SNOMED CT (continued) Purpose is to standardize clinical phrases Used for sharing of clinical information Standard for certified EHR systems Structure Concepts Descriptions Relationships ahima.org © 2020 AHIMA SNOMED CT (continued) SNOMED CT identifier Unique integer Includes Item identifier Partition identifier Check-digit Namespace identifier when component originates in an extension Nonsemantic ahima.org © 2020 AHIMA SNOMED CT (continued) Concepts Concept definition Sufficiently defined Partially defined (primitive) ahima.org © 2020 AHIMA SNOMED CT (continued) Descriptions Types Fully specified name Synonym Preferred term ahima.org © 2020 AHIMA SNOMED CT (continued) Relationships Connection between a source and destination concept Form the polyhierarchical structure of SNOMED CT Is a relationship type ahima.org © 2020 AHIMA Current Procedural Terminology (CPT) Nomenclature used for reporting procedures Print, e-book, and in software applications Assignment by a professional coder Standard for certified EHR systems ahima.org © 2020 AHIMA CPT (continued) Provides uniform language for services and procedures Reports services and procedures on healthcare claims Excludes inpatient claims Structure Codes, descriptions and guidelines Category I, Category II, and Category III Modifiers ahima.org © 2020 AHIMA Nursing Terminologies Terminology used to report nursing care Multiple terminologies available Content, structure, and purpose varies Examples Nursing Interventions Classification (NIC) Interventions Nursing Outcomes Classification (NOC) Outcomes ahima.org © 2020 AHIMA Classifications Key to secondary data use Aggregate clinical data Healthcare statistics Determine payment Monitor public health Improve financial performance ahima.org © 2020 AHIMA International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Developed and maintained by National Center for Health Statistics ICD-10 Coordination and Maintenance (C & M) Committee Updated in October and when necessary, April Print, online, and in software applications ahima.org © 2020 AHIMA ICD-10-CM Assignment by a professional coder Used to report diagnoses on healthcare claims Structure 3–7 characters ahima.org © 2020 AHIMA ICD-10 Procedure Coding System (ICD-10PCS) Created by 3M Health Information Systems Maintained by Centers for Medicare and Medicaid Services Reports procedures for inpatient claims Updated in October and when necessary, April Print, online, and in software applications Assignment by a professional coder ahima.org © 2020 AHIMA ICD-10-PCS 7-character code Sections Medical and surgical procedures Medical and surgical-related procedures Ancillary procedures Tables, index, and definitions ahima.org © 2020 AHIMA ICD-11 Foundation component Linearization ICD-11-MMS Collaborative and open development and maintenance process Development version continuously updated Annual official release ahima.org © 2020 AHIMA ICD-11 Reflects scientific and medical advances Can be integrated with electronic health applications Easy to implement Accessible and easy to use Improved links to terminologies and derived and related classifications ahima.org © 2020 AHIMA ICD-11 New content Chinese medicine disorders and patterns Supplementary section for functioning assessment New chapters Sleep-wake disorders Conditions related to sexual health Extension codes ahima.org © 2020 AHIMA ICD-11 Foundation component URI Multiple parents Stem codes and extension codes Code combinations Conventions Alphabetic index ahima.org © 2020 AHIMA International Classification of Functioning, Disability and Health (ICF) Used to measure health and disability Print and online Assignment by a health professional ahima.org © 2020 AHIMA ICF Components Body functions Activities and participation Environmental factors Body structures ahima.org © 2020 AHIMA International Classification of Diseases for Oncology, Third Edition (ICD-O-3) Derived classification Used by tumor or cancer registries Reports topography and morphology of neoplasm Print and online ahima.org © 2020 AHIMA ICD-O-3 Used to report cancers to state and national registries Dual classification Greater detail of the histology than ICD-10 ahima.org © 2020 AHIMA Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Classification for mental disorder Print, online, and in software applications Determination of a mental disorder by a clinician ICD-10-CM codes incorporated into DSM-5 Used for Clinical assessments Developing treatment plans Communicating between healthcare providers ahima.org © 2020 AHIMA Code System An accumulation of terms and codes for exchanging or storing information Broad term Characteristics of a terminology or a classification Primary or secondary data use ahima.org © 2020 AHIMA Logical Observation Identifiers, Names, and Codes (LOINC) System for identifying health measurements observations, and documents No book of codes or no assignment by a coding professional Implemented in software applications ahima.org © 2020 AHIMA LOINC Standardizes names and codes for the identification of laboratory and clinical variables Fully specified name made up of five or six parts Facilitates sharing of data Standard for certified EHR systems ahima.org © 2020 AHIMA Healthcare Common Procedure Coding System (HCPCS) Level II Two code systems Level I: CPT Level II: professional services, procedures, products, and supplies Level II published by CMS Updated quarterly Print, online, and in software applications Standard for certified EHR systems ahima.org © 2020 AHIMA HCPCS Level II Assignment by a professional coder Used for reimbursement of ambulatory care Modifiers ahima.org © 2020 AHIMA RxNorm Standardized nomenclature for clinical drugs No book of codes or no assignment by a coding professional Implemented in software applications Interim updates: weekly and full update monthly Standard for certified EHR systems ahima.org © 2020 AHIMA RxNorm Used to communicate drug related information Standard for certified EHR systems Concept unique identifier Semantic clinical drug term type Ingredient Strength Dose form ahima.org © 2020 AHIMA Health Data and Information Sets Data set: list of recommended data elements with uniform definitions Data collected used for National and state statistics Clinical decision support Clinical quality measures ahima.org © 2020 AHIMA Outcomes and Assessment Information Set (OASIS) Collected on Medicare beneficiaries receiving skilled services from a Medicare-certified home health agency RN and therapists collect the data Home health agency process and improvement outcome measures based on OASIS data ahima.org © 2020 AHIMA Healthcare Effectiveness Data and Information Set (HEDIS) Sponsored by NCQA Designed to collect administrative, claims, and health record review data Form the basis for performance improvement Use by healthcare purchasers and consumers to compare performance ahima.org © 2020 AHIMA Uniform Hospital Discharge Data Set (UHDDS) Data collected by acute care, short-term stay hospitals Core data elements incorporated into IPPS Example: principal diagnosis ahima.org © 2020 AHIMA Common Clinical Data Set Established by the ONC Originated from federal reporting requirements tied to certification criteria Some but not all have a standard attached Example: SNOMED CT attached to the data element smoking status ahima.org © 2020 AHIMA Database of Clinical Terminologies, Classifications, and Code Systems Unified Medical Language System (UMLS) Centralized location of health and biomedical terminologies and standards UMLS Knowledge Resources Metathesaurus Semantic Network SPECIALIST Lexicon and Lexical Tools ahima.org © 2020 AHIMA Metathesaurus Contains codes and terms from over 200 terminology, classification, and code systems Examples: SNOMED CT, ICD-10-CM, and LOINC ahima.org © 2020 AHIMA