Chapter 5 Flashcards
What does ICD–9–CM stand for?
International classification of diseases, ninth revision, clinical modification
Nomenclature
System that lists preferred medical terminology,
- a.k.a. naming system and clinical terminology
- example CPT
Why are these classification systems developed?
Development of these systems has helped to standardize terminology for collection, processing, and retrieval of medical terminology
Who developed the first medical nomenclature and what was it called?
New York Academy of Medicine
-“standard nomenclature of disease and operations”
Who are the users of clinical vocabulary and classification?
1) Clinical users: ex- physician uses ICD-9-CM codes to track a patient’s diagnostic history
2) Administrative users: ex- CPT codes are used to report physician services to Medicare program for reimbursement
What are the medical coding sets established by HHS in accordance with HIPPA?
1) ICD-9-CM
2) HCPCS-health care financing administration procedure coding system( includes CPT-current procedural terminology)
3) CDT-current dental terminology
4) NDC-national drug codes
Who published ICD-9-CM and where?
Published by WHO in Geneva Switzerland
ICD-9-CM is maintained by what organizations a.k.a. cooperating parties?
1) National Center for Health Statistics NCHS
2) American Hospital Association AHA
3) American Health Information Management Association AHIMA
4) Centers for Medicare and Medicaid Services CMS
What are the responsibilities of the cooperating parties?
1) answer questions on ICD-9-CM
2) develop programs on ICD-9- CM
3) maintain the integrity of ICD-9-CM
4) recommend modifications to current and future versions of ICD
What is the duty of each cooperating body in ICD-9-CM?
1) NCHS: responsible for updating the diagnosis classification
2) CMS: responsible for updating the procedure classification
3) AHIMA: provides training and certification
4) AHA: maintains the central office on ICD-9-CM and publishes the coding clinic for ICD-9-CM (coding guidelines and usage)
What are some of the uses of ICD-9-CM?
-classifying morbidity and mortality info for statistical purposes
-starring and retrieving data
-reporting diagnosis by physician
-determining patterns of care
-conducting clinical research
-analyzing payments
-reporting healthcare data for evaluation
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What is the structure of ICD-9-CM?
It is divided into three volumes:
1) volume one- tabular list:
2) volume two- alphabetical index
3) volume three- tabular list and alphabetical index (only in US, not international version)
Explain volume one of ICD-9-CM?
It is divided into three subdivision:
1) classification of diseases and injuries:
(17 chpts -> sections (3 digit codes) -> categories -> subcategories (4 digit codes)
2) supplementary classifications:
-V codes:
when circumstances other, than disease or injury, are the reason for patient encounter with the healthcare provider
-E codes:
classify conditions as the cause of injury and other effects
3) appendixes:
Appendix A, B, C, D, E
Describe the difference in coding of V and E codes?
alphanumeric codes
V codes: begin with the V letter then numbers: V15.04
E codes: begin with the E letter then numbers: E925.0
Explain volume two of ICD-9-CM?
The main terms are alphabetically in the index by the type of disease, injury, or illness; with sub terms indented under the main term
What are some of the new enhancements of ICD-10-CM?
- combination codes (a single code may be used to for two diagnosis)
- provides expanded codes for more detail
- decreased cross-referencing (by writing out the full title for all codes)
- provides laterally codes (for left and right side)
Describe the difference of the specificity of codes in ICD-9-CM and ICD-10-CM?
ICD-9: most specific five digit code numbers
ICD-10: six digit code level with seven digit extension
Why was ICD-10-PCS established?
ICD-10-CM does not include a procedure volume; therefore CMS developed a separate procedure code system to replace ICD-9-CM Volume 3
What does ICD-10-PCS stand for?
International Classification of Diseases, 10th Revision, Procedure Coding System
What was the purpose for updating the procedure section of ICD-9-CM or (what are the goals of ICD-10-PCS)
1) improve accuracy of coding
2) reduce training effort
3) improve communication with physicians
Describe the structure of ICD-10-PCS?
- Divided into 16 sections according to general type of procedure
- Then each procedure has seven characters
What are the seven characters in ICD-10-PCS?
1- section where the code is 2- body system 3- room operation 4- specific body part 5- approach used 6- device used for procedure 7- any additional information about the procedure
What are some of the transition issues from ICD-9 to ICD-10?
- understanding the general structure of the system
- impact to workflow
- conduct an inventory
- software changes
What is ICF?
International Classification of Functioning, Disability, and Health
Broad components:
1) body functions and structures
2) activities and participation
3) additional info on environmental factors
Explain ICD-O-3?
International Classification of Diseases for Oncology, 3rd Edition
Purpose:
A system for classifying malignant diseases (cancer)
Structure:
A dual axis classification to code the:
1) topography: uses same code as ICD-10
2) morphology: identifies the type of tumor and it’s behavior ex- M9891/3
- the letter M
- four digits identify the histology type
- last digit identifies the behavior of tumor
3) alphabetical index
Why is HCPCS?
Healthcare Common Procedure Coding System.
used to report physicians’ services to Medicare for reimbursement
Why did HCPCS change it’s name?
It was called the HCFA Common Procedure Coding System.
Why? Health Care Financing Administration changed its name to Centers for Medicare and Medicaid Services
Explain the 2 code levels for HCPCS?
Level I: AMA’s CPT codes.
Level II: aka National Codes are maintained by CMS.
What is CPT?
A listing of terms and codes for reporting diagnostic and therapeutic and medical services
Who is the CPT advisory committee and what are their objectives?
They advise the Editorial pPanel who revise, modify and update the CPT.
objectives:
1) to serve as a resource to the editorial panel by giving advice
2) to provide documentation
3) to suggest revisions
What are the eight sections of the CPT code book?
- evaluation and management services
- anesthesia
- surgery
- radiology
- pathology and lab
- medicine
- category II codes
- catagory III codes
What is the structure of the CPT book?
Introduction, eight sections, appendixes, and index
What is the purposes of category II and III codes?
Category II: supplement tracking codes for performance measurement (optional)
Category III: to allow temporary record coding for new technology (that do not meet requirements to be added to main section of CPT book)
(not optional)
What is the relationship between category I and III codes?
As category I codes are created, the temporary category three codes are deleted
Category III codes are added every six months.
If category III codes have not been utilized within five years, they will be removed
The appendixes provide information to help the colder in coding. Describe each appendix.
Appendix A: a list of modifiers (two digit code that follow the main CPT code)
Appendix B: a summary of additions and revisions
Appendix C: clinical examples for codes
Appendix D: list of CPT add on codes (must be preceded by primary code)
Appendix E: summary of CPT codes except from modifier 51
Appendix F: summary of CPT codes except from modifier 63
Appendix G: codes for conscious sedation
Appendix H: index of performance measures by clinical condition
Appendix I: genetic testing code modifiers
Appendix J: list of sensory, motor, & mixed nerves
Appendix K: CPT codes not approved by FDA
Appendix L: reference of vascular families
Appendix M: deleted CPT codes and crosswalk to current codes
Appendix N: resequenced codes
What are the main term entries of the index for the CPT book?
1) procedure or service
2) organ
3) condition
4) synonym or abbreviation
What is SNOMED CT?
Systematized Nomenclature of Medicine Clinical Terminology
It is a systemized nomenclature of medically useful turns (standardized vocabulary)
Created by the American College of Pathologist ACP
What is the purpose for SNOMED CT?
Because two physicians may use to terms for the same medical condition
What are the main areas of SNOMED CT?
- concept
- descriptions
- relationship: between two concepts
- history: changes to concept
8 fields, 2 classification field( disease/diagnosis D and P procedures), one modifier and linkage term field(G)
What is DSM-IV-TR?
Diagnostic and Statistical Manual of Mental Disorders, fourth edition, Text Revision
published by American Psychiatric Association
Develop because ICD was not detailed for clinical and research use in mental disorders
What is the structure of DSM-IV-TR and purpose?
Axis I: clinical disorders Axis II: personality disorder Axis III: general medical conditions Axis IV: psychosocial and environmental problems Axis V: global assessment of functioning
Purpose of these axes is to establish an evaluation of patient symptoms for diagnosis
Why should coding processes be monitored?
1) reliability: different people code the same codes
2) validity: code reflects patient’s diagnosis and procedure
3) completeness: codes capture all diagnoses and procedures documented
4) timeliness:
What are the steps in the coding process?
1) the coder must have a complete health record on the patient
2) coder reviews documents to verify diagnosis and procedure
3) coder selects what diagnosis and procedure needs to be coded, and assigns appropriate codes according to you UHDDS guideline
4) then codes are entered into facility’s database
Define encoder.
The type of tool used to aid in the coding process
Define interface.
The total component of screens navigations and mechanisms used to help the end-user operate the encoding software
What is CAC?
Computer – assisted coding
a technology for complete computerization of coding
What is a NLP?
Natural language processing.
A form of CAC
What is the UMLS project
Unified Medical Language System
Established by National Library of Medicine NLM
What are UMLS’s knowledge resources?
1) metathesaurus: uniform collection of healthcare related vocabularies, coding, etc
2) specialist lexicon: syntactic information
3) semantic network: characterizes and identifies relationships between concepts
What is nosology?
It is a branch of medical science that deals with classification systems
