Coding Intro

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NOMENCLATURE

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system that lists preferred medical terminology.

(clinical terminology)

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CLASSIFICATION SYSTEM

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group together similar diseases and procedures

ie- icd 9-cm

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One of first nomencalcures developed when?

by whom?

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Late 1800s by

Anatomical Society

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First nomenclature accepted in US,
developed by NY Academy of Medicine

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Standard Nomenclature of Disease and Operation

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Most recognized nomenclature used today:

1948, 6th edition:

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ICD - 9 - CM

includued morbidity & mortality data

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Users of clinical vocabularies

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clinical-use clinical vocabularies to
collect, process, retrieve data for clinical purposes.

* support activities like clinical research, disease prevention, patient care.

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Users of clinical vocabularies

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administrative (h/c facilities, professional org, govt agencies

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ICD-9

published by?
mOdified to what, when? by whom?

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WORLD HEALTH ORGANIZATION

ICD 9-CM
in 1978
by Ntl Ctr for Hlth Stats (NCHS)

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Tow fed agencies mainaining ICD-CM (clinical modifications)

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NCHS - updates diagnosis

CMS- undpates procedure

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morbidity

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rate of incidence of disease

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mortality

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no. of deaths in a given pd.

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DRG

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diagnostic related group

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ICD -9 - CM purposes

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-classification of morbidity & mortality info for statistical purposes

- indexing hospital records by disease & operations

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ICD - 9 -CM purposes:

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- classification of morb/mort info for stat purposes
- indexing of hospital records by disease & operations
- reporting of diagnosis by physicians
- storage & retrieval of data
- repoting ntl. morbidity/mortality rates
- serves as basis for DRG assignment for hosp. reimbursement

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ICD - 9 -CM
Purposes in US

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-reporting/compiling of h/c data to
assist in eval. of med. care planning for h/c delivery system
- determination of patterns of care among h/c providers
- analysis of pymt for hlth srvcs
- conducting epidemiological &
clinical research

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epidemology

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study of causes, distribution, and control of diseases in pop.

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ICD - 9 - CM (CM added in 1978)

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Vol 1 - tabular list
Vol 2 - alphabetic indexes

* of diseases

Vol. 3 - Tabular & alphabetic index for procedures
* only used for hospitals

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ICD - 9 - CM
structure of diagnostic codes

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- 3 characters
- 3 characters, decimal, then 1 or 2
digits

ie- 486 = pnemonia
507.0 = aspiration
518.81 = respiratory failure

* the more characters, the greater specificity

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ICD -9-CM
Structure of procedural coodes

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-3 to 4 digits

-2 digits, decimal pt, then 1 or 2 digits after decimal

ie- 34.1
45.15

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ICD - 0 - 3

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Intl Classification of Disease for
Oncology

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ICD - 0 - 3
what? where used? when published?developed by who?

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- system used to classify incidences of malignant disease
- used in hospital cancer registry programs
- published in 1976
- developed by US Cancer Institue & WHO Intrntl Agency for Research on Cancer.

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ICD - O - 3
Purpose

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-collection of info in field of oncology
- detailed classification system for coding histology (study of microscopic tissue) ; morphology
(tissue structure) & topography (site) & behavior of
neoplasm (abnormal new growth of tissue - tumor)

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Example of ICD - O - 3

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M8500/3

* M= morphology (type of tissue)
#s = code
/3 = behavior

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ICD - O - 3

*other requirements

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- code one way in ICD - 9, differently in IDC - O

- easy to code but must do other things also
TNM staging (tumors, nodes, mestastis)
- collaborative staging

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ICD- O-3
structure of site codes

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- alphanumeric
- start w a C, 2 digits, decimal pt, then 1 digit

ie- C66.9

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ICD- O-3
structure of morphology codes

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- alphanumeric, starts w/ M, then
4 digits
ie - M8000

behavior is after morphology
*slash (/), then behavior

ie- M8000/3

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ICD -O-03

behavior key

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0= benign
1= uncertain behavior
2= CA in situ*
3= malignant primary site
6= malignant metastic site
9= malignant, uncertain whether primary or secondary

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Health Care Procedure Coding System

HCPCS

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-originally called HCFA (H/C Financing Admin) Coommon Procedure Coding System
- name changed in 2001 when
HCFA changed name to CMS

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HCPCS

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- collection of codes & descriptors
used to represent h/c procedures, supplies, products and servcs.
*promotes uniform coding

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HCPCS
Purposes

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-promotes uniform reporting & statistical data collection of medical procedures, supplies, products & srvcs
- report srvcs and procedures delivered by docs and other qualified h/c pros

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HCPCS
Structure

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3 levels

Level 1- CPT Codes
Level 2- Ntl Codes (HCPCS)
Level 3- Local or regional codes

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HCPCS
Level 1 Codes

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- CPT codes
(Current Procedural Terminolgy)

* 5 digits
*no decimal pts
*maintained by AMA

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HCPCS
Level 2 Codes

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Ntl Codes (HCPCS)

* 5 character alphanumeric codes
* maintained by CMS
*durable supplies

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HCPCS
Level 3 Codes

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local or regional codes
*maintained by pt B - Medicare Carriers
* very limited

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CPT
Common Procedural Terminolgy
mainained by?
updated when?

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-maintained by AMA
-updated yearly

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CPT
(Current Procedual Terminology)

Purpose

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-provide system for standard terminology/coding to report medical procedures & stvcs
-most widely used system for reporting medical srvs to h/i carriers
- used administratively to develop guidelines for medical care review & claims processing
-collect data for med educ & research

*everyone uses except inpatient hospital srvcs

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Structure of CPT Code book

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6 sections:

- E & M
- Anesthesia
- Surgery
- Radiology
- Pathology & Lab
- Medicine

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SNOWMED

(Systmetized Nomenclature of Human & Vet Medicine)

defined? by whom?

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-Systemized, multiaxial, hierarchially organized nomenclature of medically useful terms
-Amer College of Pathologists

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DMS
(Diagnostic & Statistical Manual for Mental Disorders

where used?

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-used in psychiatric facilities
- American Pyschiatric Assoc

* DMS 4 - 3rd revision

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Elements of coding quality

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-coding must be reviewed on ongoing basis for consistency & accuracy
- should be monitored for the following elements of quality

*reliability - same results achieved consistently
*validity - degree that codes accurately reflect pt dx & procedures
*completeness- degree which codes capture all dx & proced documented in the record
*timeliness- time frame which h/r coded
**15, 30, 45 days (revenue cycle)