Unit 5Unit 5Ch 6: Nomenclatures and Ch 6: Nomenclatures and

Classification SystemsClassification SystemsTuesday, April 5Tuesday, April 5thth at 8PM EST at 8PM EST

HS 410 - 01HS 410 - 01Adrienne Palmer, BSPH, MHA, FACHEAdrienne Palmer, BSPH, MHA, FACHE

Medical communicationsMedical communications

Medical languageMedical language– Greek and Latin derivationsGreek and Latin derivations– EponymsEponyms– Modern wordsModern words– Overtime changes occurOvertime changes occur

LanguagesLanguagesEssential for accurate and consistent Essential for accurate and consistent indicationsindications

VocabularyVocabulary– Clinical vocabularyClinical vocabulary– Nomenclature or terminologyNomenclature or terminology

Clinical terminologyClinical terminology

Importance of standardization:Importance of standardization:– It is difficult to communicate electronically if It is difficult to communicate electronically if

variances in meaning exist.variances in meaning exist.

SNDOSNDO

Standard classified nomenclature of Standard classified nomenclature of disease (SNDO)disease (SNDO)– Published by the American Medical Published by the American Medical

Association in 1933Association in 1933– Classifies diagnostic terminology in Classifies diagnostic terminology in

order of localization (site) and etiology order of localization (site) and etiology (Cause)(Cause)

– Use through 1961, then deemed to Use through 1961, then deemed to simplisticsimplistic

SNOPSNOP

Systematized nomenclature Systematized nomenclature pathology (SNOP)pathology (SNOP)– Published by the American College of Published by the American College of

pathologistspathologists– classifies pathological specimensclassifies pathological specimens– Use since 1965, but its use gradually Use since 1965, but its use gradually

diminished as it did not cross fields of diminished as it did not cross fields of specializationspecialization

SNOMEDSNOMED

Systematized nomenclature of Systematized nomenclature of medicine (SNONET)medicine (SNONET)– Published at American College of Published at American College of

pathologists in 1977pathologists in 1977– Expansion of SNOPExpansion of SNOP– Crosses fields of specializationCrosses fields of specialization– Classifieds in multiple waysClassifieds in multiple ways– Can be used with computersCan be used with computers

CPTCPT

Current procedural terminology (CPT)Current procedural terminology (CPT)– Published by the American Medical Published by the American Medical

AssociationAssociation– Conference of listing a medical terms Conference of listing a medical terms

and codes used to designate diagnostic and codes used to designate diagnostic and therapeutic proceduresand therapeutic procedures

– Can be used with computersCan be used with computers

Electronic communicationElectronic communication

Unified medical language systemUnified medical language system– MEDLINEMEDLINE– MEDLARSMEDLARS– MeSHMeSH

UMLS purpose: UMLS purpose: – Helps computers understand medical Helps computers understand medical

meaning; therefore providers can meaning; therefore providers can retrieve biomedical information from retrieve biomedical information from various sources, including EMRsvarious sources, including EMRs

Knowledge sourcesKnowledge sourcesUMLS Metathesauras – uniform, integrated UMLS Metathesauras – uniform, integrated distribution formatdistribution formatSPECIALIST lexicon – syntactic information SPECIALIST lexicon – syntactic information for many terms, component words, and for many terms, component words, and English words not in metathesaurusEnglish words not in metathesaurusUMLS semantic network – information UMLS semantic network – information about types or categories of meta-about types or categories of meta-thesaurus concepts and relationshipsthesaurus concepts and relationshipsUpdated regularlyUpdated regularlyAvailable to the public at no costAvailable to the public at no cost

Classification systemsClassification systems

TaxonomiesTaxonomies

CodingCoding

ICD ( international classification of ICD ( international classification of diseases)diseases)– ICD-9-CMICD-9-CM– ICD-10ICD-10

Updating the ICDUpdating the ICD

NCHS ( national Center for health NCHS ( national Center for health statistics)statistics)

CMS ( centers for Medicare and CMS ( centers for Medicare and Medicaid services)Medicaid services)

American Hospital AssociationAmerican Hospital Association

American health information American health information management Associationmanagement Association

Coders Coders

Apply classification systems to dataApply classification systems to data

Must possess extensive knowledge of Must possess extensive knowledge of the number of related areasthe number of related areas– Biomedical sciencesBiomedical sciences– Information technologyInformation technology– Healthcare data content, structure, and Healthcare data content, structure, and

systemssystems– Reimbursement methodologiesReimbursement methodologies

ICD-9-CMICD-9-CMVolume 1 – tabular numerical listing Volume 1 – tabular numerical listing of diagnosis codesof diagnosis codesVolume 2 – alphabetic listing of Volume 2 – alphabetic listing of diagnosesdiagnosesVolume 3 – both tabular and Volume 3 – both tabular and alphabetic listings of procedures that alphabetic listings of procedures that are primarily used in a hospital are primarily used in a hospital settingsettingE-codes and V-codesE-codes and V-codes

CPTCPTWhen a practitioner does when When a practitioner does when providing a performing medical providing a performing medical servicesservices– Evaluation and managementEvaluation and management– Anesthesia and surgewillryAnesthesia and surgewillry– Pathology, laboratory, and radiologyPathology, laboratory, and radiology– MedicineMedicine

Can be complex and requires coder Can be complex and requires coder skillsskills

DRGsDRGs

Diagnosis – related group (DRG)Diagnosis – related group (DRG)

In 1982, U.S. Congress passed TEFRAIn 1982, U.S. Congress passed TEFRA

In 1983, CMS introduce the PPS for In 1983, CMS introduce the PPS for inpatient hospital servicesinpatient hospital services

Medicare adopted the DRG model Medicare adopted the DRG model developed by Yale University to developed by Yale University to make PPS workmake PPS work

Role of DRGsRole of DRGs1. Evaluate quality of care: Classify hospital stays 1. Evaluate quality of care: Classify hospital stays in terms of what was wrong with the patient in terms of what was wrong with the patient (major diagnosis) and what was done for the (major diagnosis) and what was done for the patient (resources used)patient (resources used) MDC– Major Diagnostic categoryMDC– Major Diagnostic category– 25 MDCs cover over 500 diagnoses25 MDCs cover over 500 diagnoses

2. Calculate reimbursement: Reimbursement on 2. Calculate reimbursement: Reimbursement on these DRGs is on a flat rate basisthese DRGs is on a flat rate basis– Adjustments on an annual basisAdjustments on an annual basis– Adjustments for cost outliers, patient transfers, capital Adjustments for cost outliers, patient transfers, capital

costs, and medical educationcosts, and medical education

3. Evaluate utilization of services3. Evaluate utilization of services

DRGsDRGs

Statistically consistent – patients Statistically consistent – patients grouped in a particular DRG consume grouped in a particular DRG consume similar amounts of resources as similar amounts of resources as measured by length of stay and costmeasured by length of stay and cost

Medically meaningful – patients Medically meaningful – patients grouped in a particular DRG possess grouped in a particular DRG possess similar clinical conditions or similar clinical conditions or treatmenttreatment

DRGsDRGs

Medicare PPS has been expandedMedicare PPS has been expanded– SNF PPSSNF PPS– OPPSOPPS– APCAPC– HH PPSHH PPS– HHRGHHRG– IRF PPSIRF PPS– CMGCMG

HIM transformationHIM transformationPPS and DRG have major impactPPS and DRG have major impact– Becomes more complex, ties coded diagnosis and Becomes more complex, ties coded diagnosis and

procedure to amount reimbursed and impacted focus on procedure to amount reimbursed and impacted focus on ethics and compliance.ethics and compliance.

NosologistsNosologistsEncodersEncodersGroupersGroupersOptimizing programsOptimizing programsNatural language processing encoding systemsNatural language processing encoding systemsEthics and up-codingEthics and up-codingCoding compliance program to prevent Coding compliance program to prevent healthcare fraud and abuse healthcare fraud and abuse

Other classification systemsOther classification systems

SNOMEDSNOMED

CPTCPT

HCPCSHCPCS– RBRVS (resource-based relative value RBRVS (resource-based relative value

scale)scale)

DSM-IVDSM-IV

Other classification systemsOther classification systemsClassification systems for mental Classification systems for mental retardation or developmentally disabledretardation or developmentally disabledNursingNursingOncologyOncologyInjury, disabilities, and handicapsInjury, disabilities, and handicapsDentalDentalPrescription drugsPrescription drugsAlternative billing codes (ABC)Alternative billing codes (ABC)Others address multiple specialtiesOthers address multiple specialties

Emerging issuesEmerging issuesCase mix – type and volume of patients a Case mix – type and volume of patients a healthcare organization treats.healthcare organization treats.

Case mix management and analysisCase mix management and analysis

Automation and impact on coders – Automation and impact on coders – potential for off-site coding and reduced potential for off-site coding and reduced costs; more of a oversight and quality costs; more of a oversight and quality assurance role for codersassurance role for coders

Clinical data representationClinical data representation

Data mappingData mapping

Questions?Questions?