Overview of Coding

Question 1

mplemented in 2001 to classify a tumor according to primary site (topography) and morphology (histology, behavior, and aggression of tumor).

Answer 1

International Classification of Diseases for Oncology, Third Edition (ICD-O-3)

Question 2

classify a tumor in the following way:

Primary site (four-character topography code)
Morphology (six-character code)

Four-digit histology (cell type) code
One-digit behavior code (such as malignant, benign, and so on)
One-digit aggression code (differentiation or grade)

Answer 2

ICD-O-3 codes

Question 3

indicate the type of cell that has become neoplastic and its biologic activity; in other words, the kind of tumor that developed and how it behaves.

Answer 3

ICD-O morphology codes

Question 4

M as the first character of each morphology code
4-digit cell type (histology) (e.g., 8010)
1-digit behavior (e.g., /o)
1-digit grade, differentiation, or phenotype (e.g., /x1)

Answer 4

three parts to a complete morphology code:

Question 5

classifies health and health-related domains that describe body functions and structures, activities, and participation; complements ICD-10, looking beyond mortality and disease

Answer 5

International Classification of Functioning, Disability and Health (ICF)

Question 6

electronic database and universal standard used to identify medical laboratory observations and for the purpose of clinical care and management.

Answer 6

Logical Observation Identifiers Names and Codes (LOINC)

Question 7

contains prescription drugs and a few selected over-the-counter (OTC) products, which pharmacies use to report transactions and some health care professionals use for reporting on claims.

Answer 7

National Drug Codes (NDC)

Question 8

provides normalized names for clinical drugs and links its names to many of the drug vocabularies commonly used in pharmacy management and drug interaction software, including those of First Databank, Micromedex, MediSpan, Gold Standard Drug Database, and Multum; by providing links among these vocabularies, RxNorm can mediate messages among systems that do not use the same software and vocabulary.

Answer 8

RxNorm

Question 9

set of files and software that allows many health and biomedical vocabularies and standards to enable interoperability among computer systems; used to enhance or develop applications, including electronic health records, classification tools, dictionaries and language translators; used to link health information, medical terms, drug names, and billing codes across different computer systems.

Answer 9

Unified Medical Language System (UMLS)

Question 10

standard claim submitted by health care institutions to payers for inpatient and outpatient services.

Answer 10

UB-04 (or CMS-1450)

Question 11

standard claim submitted by physicians’ offices to third-party payers.

Answer 11

CMS-1500