1",'

Ghapter 6 Glinical Vocabulariesand

GlassificationSystems
Karcn Scott, MEd, RH,A, CCS-P,CPC LoarningObjoctivog
. . . . . . of To discuss historyof thedevelopnent clinicalvocabularies the of :md the uses, structure ICD-9-CM,ICD-10'ICD-O-3' To undersmnd history, vocabularies HCPCS, CPT,SNoMED CT,DSMIV-TR, andnursing To describe codingprocess the usedin thecodingprocess To identifythe technology fbr policies, procedures corpolale and elemenls, To undersland history, the conrpliance in To discuss newdircctions clinicalvocabularies

K6y Tlms Classilication system ClinicAlvocabulary (CPT) Cwrcnt Prccedural Terminolog! FourthReision, Texl Dio|nasticanclStatistical Manualof MentalDisorders, Revlsior(DSM-IV-TR) E codes Encoder (HCPCS) Healthcare Common Procedure CodingSystem Clairification of Diseases, Ninth Reriiion, Clinical Mod.ilication(ICD-9'CM) ClinicalModiflcalion Intentational Tenth Revision, Classification Diseases, ol

(rcD-10"cM)

:193

1,94

Chapter6

Codin?Svstem Re Tenth sion,Procedute af tntenalionalCl.tsslication Diseases,

(rcD-t0-PCS)
Morbidily Mortality

rl
a d a t

ThirdEdition(ICD-O-3) af ClctssrrtcatianDiseaset Oncalogy, Intemational for

(NLP) processing NatumllongDage Nomenclatute Nosology NuNingvocabulae$ Read Codes ClinicalTeminology(SNOMEDCT) Nomenclature Medicine of Systemized V codes (WHO) WorldHeahhOrganization

Introduction
procedures cometo be knownby dif_ have and Overtheyea$, diseases nedical-surgical or to referred 0s mongolism is Downs'syndrone sometimes flren! names. example, For makes ditlcult to it disease 21. |he trisomy Clearty, useof morethanonetermfor thesame language' medical and In retrieve infbrmation. anefforlto organize standardize colleciand systens'andclinical classification nomenclatures, industry developed has thehealthcarc vocabularies. nedicalte!' that listsprefefied is syslem In medicjne, nomnclaturc a recognized a to suchasCPT,alsoarerefened asclirri' Nomenclatures, "naming"system, minology, or and grouptogether similardiseases procedures systems cal terminology. Classification They also organizerelatedentitiesfor e4syret'iev^l The Intemational Classification of of is Dheasas, Nitrth Rcvisinn, ical Moddicatio" (ICD-g-CM), an example a clasCl a to havebeendeveloped crcate list of clinical sification system. vocabutaries Clinical wordsor phrases with tleir meanings. diagfacilitatethe organization, storage, retrievalof healthoare and Thesesystems procedural in the development imPlemeDtatio! and nosticand data.Moreover, theyaid patientrecordsystems. the of computerized This chapter discusses variousnomenciaindustry in the healthcare tures,classilication used systems, clinical vocabularies and today.

Theory into Practice

grouppractice with clinicsin five differ HealthCareClinic is a multispecialily Hiltcrest are ofcodebooks The that ent locations. officemanager determined vaioDseditions has

n C r n k " \ o c a o - l a e s a n d C l d s s i f i . a l i o5 y , l e l s

195

She for to codes reimbursement. alsonoticed the beingusedthroughout practice assign codes ftom assign al providelsdo not usecodebooks all but, instead, that manyof the as lists ollen conlainincorect codes, do outa list preparcd their office staff.Such by deniedrcimbursement, The datedcodebooks. end resultis incorrectcodeassignment, to procedures needed contrcl are Clearly,pollciesalld database entries, aod erroneous the codingprocess.

History and Importance of Clinical Vocabularies

nomencladeveloped of the first medical one Society ln the tate 1800s, Analomical the Thi\ Anatotllica publishedlhe Basle Namina organization tures.In1895, internadonal this in tems used medicine of work iDitiated standardization anntomical the was in accepted the UnitedStates 1o The fil.stmedicalnomenclaturc be univelsally (t NomencLature by ofMedicine^ndti edlheStan.lard developed theNewYorkAcademy (AMA) assumed the Medical Association the antl ID Disease Operations. 1937, American a it for and copyright editingresponsibility thiswork andexpanded to include nomencla_ in work waspublished onevolume The lurelor procedures well asdiseases. expanded iN of tilled StandanlNomenclatweoI Diseaseand StandardNomenclature OPetations. liom usedloday.It evolved system classification ICD-g-CMis the mostrecognized in Bertillon.His systemwaspublished 1893 developed Dr Jacques by a olassillcation PublicHealth oJ Clctssification Causes Death ln 1898,theAmedcan ^s theBeftiLlon ef and Canada' Mexicousethc UnitedStales, i,t AssocintioD recomnended registrars the thal Beltillonclassifi catiorr. throughout eariy1900sIn I948,theWorld lhe system rcvised was This cl,rssification of the Hcalth Orgarization (WHO) published sixthrevision the systemThe sixth revilhe fbr sion inclucled classification morbldlty andmorfality data.Throughoul 1900s, a numetous representlng and varioushealthcare AssociAtioDs public healthorganizations fol classification $ystem healthcare worked create standardized to a oountries to SwitzerlAnd' met in Geneva, countries ln 1975,lepresentatives numelous 1tom of the Cla\.\irtcaion Dis?drcrunderthe direction WHO Today, aI develop InterntLtional lhc the tCD cllssif'lcirdon syslenis usedthroughout wodd. 1br terminology lhc collecDevelopnren! these of systems helped standardize has to systenrs classification of Additional lion,processing,0Dd evalofmedicalinformation. ret andnomenclrtufes discussed in thischapler. :ue later

Clinical Vocabularies
clinical admin' and Users clinical of vocabularies bedivided con inlo lwo maingroups: istrative. and to Cl.inicd usersare providers who use clinical vocabularies collecl,process, activities suchas purposes. to retrieve datr! cljDical for Theyusethe vocabularies support ofa prevention, palienlcarc. example clinicoluserwould An clinicalreseLlrch, disease And diagnoslic history. to be a physician who uses ICD-g-CMcodes tracka padent's and organizations, Administrati,eurer"s healthcare facilities,professional include administrative, govemmenl gfoupsuseclinical vocabularies support to agencies. These

T
196
Chaoter6

of An and funcdons. example this is whenClrftentProcedural statistical, reimbursement paogram to services lhe Medicare are TeminologJ(CPT) codes usedto leportphysician are in users clinicalvocabularies discussed of reimbursement. specific The to determine the sections follow. that the Act TheHealthInsurance PonabililyandAccounlabilily (HIPAA)required estabIr and lishmentof electronic bansaclions codingsiandards. 2000,the Departnentof (HHS).il1accordance I{IPAA,established otficialmediwith HealthandHumanServices entities are with codingsctstandards. bein compli.rnce theHIPAAlaw,all covered To cal codingsets: to usethe lbllowingofficialnredical rcquired , Ninth Revi\ian, Clitrical lodiJj(tLtion of lnlernalional CltLssilicationDiseases, for (lCD-g CM), including OIficiAlICD-g-CMGuidelines Codingand tlre impLrir' in,uries' all I for Reportingr Volumes and2 areused reporting diseases, 3 an problems causes such, Volume is usedkr rePort And of ments, otherhealth pro,(dure' peuormed ho.pital 'n inprlienti. Cutre t Proce' Healthcare CodingSlrl?rr, whichiDcludes Cotnmo Ptucedurc (CPT):This systenr used reportirgphysician other aDd lbr is dLr1ll Terminlogy ilrcluding noninpttient all healthcare seNices, Procedurcs. dnd C n"nt DentalTemlinalog\, Cadean Detllall>rocedutus No Le(lofirus rCDTr. JentJl serviee{. i. tor Thi>(ysLem used f(porlrnB the Ndtianal Drug Coder(NDC)| In $e origiral rulingtron Medicafe, NDC was Howby Pharlnacies. drugslsed ns design^led theol'ficialdatasel fol reporling is no olficialstrndArd in evef,thisadoptbnwasfeperled 2003.Cu ently,there translctions. fbf ,eportiDg mediciltions phrfmacy on

I I
I
i

'

, ,

lntornational Claesificationof Diseases,Nlnth nevision, Clinioal Modlfication

(ICD) is a classilicatiol1 systetrlbr rePo ing ThelntenntionalClarsiJication Di.\eases oJ medical di:lgnoses procedures. and History ICD-g-CMis one of the Inostcommon olassification systems usedin the UnitcdSlutes today,It is an adaptation the /rrsrwtia al CLtssilication Diseases, Ninth RcNision of aJ (ICD-g),published WHO in CeDeva, by Switzerland. li the UnitedStates, federAl govemment, ihe Center Health 1br thrcughthe National (NCHS),modifiedICD-9 to create Sratistics ICD-g-CM.ICD-g-CMwas issued use for in the U.S.iD 1978. Theintentof thismoditicntion to provide classification a system was tbr morbidilydatr. ICD-9-CM is maintaired four organizations by known as rhe Cooperating Parties: NCHS, thc AmericanHospiralAssociation (AHA), lhe AmedcanHeahh Inlbfmation (AHIMA), andtheCenters Medicale Medicaid Management Association SeNices tor and (CMS).The Cooperaling Parties assume tbllowingresponsibilities: the . . To seNeas a clearinghoDseanswer questions ICD 9 CM to on To develop educational materials programs ICD-9-CM and on

_t

Cllnica Vocab!lariesarid C assificatlonSysiems

197

. .

the in To work cooperatively maintaining integdiyof ICD-g-CM of to and revisions modifications culrentandfuturerevisioDs ICD To recornmend

Advisory by Pardes supplemented AHA s Editodal was The wofk of the Cooperating data heath of ollepresentatives hospitals, Baafi fot CodingCliniq whichwascomposed (NCVHS1991) and systems, thefedemlgovernment (Vollunes classiflcation the for Pdmarjly,NCHS is responsible updating diagnosis (Volume :, classiflcation the for I and 2), and CMS is responsible updating procedure theCenand training certification, theAHA maintains and AHIMA worksto helpprovide the Clinicfor ICD'9'CM, whichcoDt^ins CodinS tral Officeon ICD-9-CMandpubtishes ofICD-9-CM codes' on and OfiicialCodingCuidelines officialSuidance theusage wasestablished' committee and ln 1985,the ICD-g-CMCoordination Maintenance is by representativesNCHS andCMS, the committee madeup of advisors of Cochaired a twicea yearlo provide public lt Parties. meets oiall andrepresentatites theCooperating flt possible and revisions updltesto ICD-g'CM Discussions these lbrum for discussing nf und The direclorof N_CHS the adrnlnistrator CMS deter' flre meetings advisort'only. mineall final revisions. and lrso Purpoao According theCenfal Officeo! ICD"9'CM,ICD-g-CMhasthefollowingusesi to . . . . . . ' . . . purposes ior Classifying morbidityandmorlalityinlbrmation statistical and records disease opemhons by Indexing hospital Reporting diagnoses physicians by data Stolingandretrieving andmofialitydata Repofiing national morbidity fbr group Serving thebasisof diagnosis"rela@d (DRG)assignmenl hospiul as rclnDursement of in healthcale to assist theevaluation nredical data Reporting compiling trnd cargplannlng healthcare for delivery systems providers pattensof careamong healthcare Determining payments healthservices Anrrlyzing for Conducting epidemiological clinicalresearch and

Ov6rvi6wof gtruduro Lisl. lt conICD-g-CMis published threevolumes. in VolumcI is knownas fie Tabular Volunlc2 is the diseases injuries. and tainsthe numerical listingof codes that rcpresent listedin volumeI lndex.It colsislsof an alphabetic indexfor all the codes Alphabetic 3. as are TheTnbulrrList andAlphabetic lndexfor Procedures published volume Volume 3 is not palt of the international version ICD-g. Il is usedonly in the U.S. to reporl of peformedon hospital procedures inpatienis.

I
198
Chapter6

! 1
l

volume 7 and of classification diseases VolumeI of ICD-g-CMis dividedinto threesubdivisions: cations, appendixes. and injuries, supplementary classifi chaplers(See The classification diseases injuriesis dividedinto seventeen and of systernFor and by figure6.1.)The chapters organized lype ol condition anatomical are by diseases type a that Sroups example, chapter MentalDisorders, 5, represents chapter rcprcsents a Organs, System Sense alld of condition. Chapier Diseases the Nervous 6, of system. chapler groups that diseases anatomical by code are of Sections groups three-digit The chrpters fwther dividedinto sections. are for classification organrc An in 5 oumbers, example a section chapter is the disease of (290-294). (See psychotic conditions figure6.2.) a represent Sroupof closely inlo categories. Categodes Sections subdivided are organic 290,Senileandpresenile related entity.Category conditions a singledisease or 5. psychotic foundin chapter conditions, an example a categofy is of At CAtegories furtherdividedinto subcategories. this level,four-digitcodenumare 290 1, Precode of bersareused. Figure6.2 provides example a subcategory: number an senile dementia. are codesin tbe ICD-g-CMsyslem foundat the subclassific|tion The mostspecific represents a level.Fiveiigit codenumbers represent level.In figure6.2,code290.10 this codeat thesubclassification level. ClassiTwo supplementafy classiilcfllions pan of volumel: the Suppiemenlaly arc (V with HealthServices codes) ficationof Factors Influencing HealthStatus Contact and

and.Iniuries Flgure 6.1. Chapter titles in LheICD"g.CM Classificationof Diseases I lnftcln)us Parusiric ond Dhe[ses 2. Neoplnsns 3. Endocrire, Nuritional,andMerAbolic Diseases llnmuniLy und Di$orders 4. Diserses theBloodandBlood-Fonring oi Orga'rs 5. Men( l Disorden 6. Diselses ofdre Nervous Sysrem Sense lnd Organs 7. Dise!ses ofrhc Circulatory Systen 8. Dissases ofdre Respirarory System 9. Diserses olthe Digesrive Sysrem i0. 1l Diseases ofrhe Cenitoudnmy SysreD Complicrdons ofPregnancy, Cbildbirth, rhePuerpedum and

12. Diseases theSkinandSubcutaneous of Tissue 13. Diseascs oflhe Musculoskeletal System Connecdve and Tissue 14. CongenilalAnomlies 15. CertaiD Conditjoos Originating thePernratal iD Period 16. Symproms, Signs, Ill Defined and Condidons 17. InjuryandPoisonjng

T'
Svstems ariesandC assification C in calVocabu 199 Figure0,2, Exampleol an ICD-g-CMsecdon
ORGANTC PSYCHOTTC CONDITIONS (290-294) psychotic organic brainsynd.ome

lE-t,d;1

harysrchatic lr%ltunesoI ory\nic eiiola4t1310.03lA 9) pslchases classifnble ta 295-298 and ||itha\l calcuLatioh i"vannent oJaientation, Lohprehensioh, with leanhs capaciry,andiudEheht, but ossociated phrsical direase,injurt, or co dil ion ollectins the brain te.s.,folLo|/ins childbirthI (295.4-298 6)

290

o.godc pslchoticconditions Senile and presenile condtt,on neurological Codeiirst thelssocialed

deftehlia not clasifcd os senile,plesenile,ot arteriosct./otL.

(291.14-294.t I) psrchaset clastifnbleto 295-298occu ine in theserLith ar irithoutdenentia deliiu,fl (295A'298 8) (3141) sererit'! seniljt,withnentul chan|etof nonPsrchotic (2% A-2939) pslchatic cohditiais transjent aryahic uncomplicaled 290.0 Snildcmontla, NOS

E;;if

ta niLdnclnoryliltrbancc!, nol afllaunting detne P' \|ith associatetl tetik bnin discase 1310.1) ut deLniun or conJ i an (290.3) 20 id det$ionalI p aruao ] le aIwes (294. ) tl?prcssi I eleat ur. s (290.21)

290.1 Presniledementia braindise0se Brainsyndrome presenile with -290,43 (29A.40 artcrbscbrotic denentio ) canditions denentia a*ocioad ||ith othercerebrcl (294.10-294.t t) 290.10 Prsniledernntiaruncomplicltd Presenile denentirl NOS slnpr rype 2t0,ll Presnil dmenti!with delirium state Pfesenile dementia acure with confusionel 290.12 P.esnile dmntia with delusionllIeslures paranoid type Presenjle dementia, 290.8 Prerntle dennlia with depftssiv teaturs depresed type Presenile dementi!,

,oo

Chapter 6 (E of of and the Supplementary Classification ExtemalCauses Injury and Poisoning cooes), or other occasions whencircumstances thandisease injury V codes usedtoclassify are providet Such wilh the healthcare for encounter as arc recorded the reason the patient's genemlly occurin oneof thefollowilg threeways: circumstances . provider a who is not curently sick encounters healthservice Whena person doDol, receive to or reason, suchasto aci as an organ tissue for somespecific prophylactic vaccination, to discuss problemthat in itself is nol a or a for whena patientseesa physician a disease iDiury (for example, or measles vaccination) curent or resolvmg, or Whena pefson with a knowndisease injury,\ryhether or of treatment that disease system a specific for encounters healthcare the pleviously follow-lrpcarefor a injury (tbr exanple,whena patientseeks applied cast) but healthstatus is the or influences person's Whensomecircumstance problem (for example, has whena patient a personal nol in ilself a curent injury of illness historyoi smoking)

thcy Theyateeasyrc identifybeoause begin Are alphanumeric codes. V codes always y andarfollowedby numerical is digits.An example V15 04' with tbe nlphacbaracter Allergyto seafbod, 0nd provide means classily events, circumslances, oondi' !o eDvironmental E codes a codes mustbeused effect, These and tionsasthecause injury,poisoning, otheradverse oi in additionto codesfrom the main chapters ICD-g-CM.E codesplovideadditional of to irformationused irsurance sflletyprograms, publichealthagencies and by comprnies, Evenlhough use poisonings, otheradvgrse siluations, determine causes injuries, the of or codes identifythe !o of manyE codes optionol, is manyfacilitiesusethemas secondary in reporting ofE codes ceftain cause ofaccidenls injuries. aDd have mandated Some states circumslaDces, as in reporting such headuaund. chaructefs. E codes beginwith the alphacharacter i'and are fblbwed by numerical current domeslic in wu' 8925.0represenls codefor an accident the caused an electric by irg andappliances. five Thelastsubdivision volune I consists the appeDdixes. of of ICD-g-CMincludes appendlxesl AppenJr{ M,'rphology NeoplJ.r. A: of Appendix Clossary MentalDisordcrs Bi of Appendix Classification Drugsby American C: of Hospital FoImulary SeNiceLis! Number Appendix Classitication D: ofIndustrial Accidenls Accordin8 Agency to {opendix Lr.r oflhree-Digir E: Ca.eCor:es

Svsteras and clinical Vocabularies Classiflcation

20I

2 Volune The Index to Diseases Injuriesis pdntedas volume2 of ICD-g-CM Main terms and injury, or illness Subtemsare alphabetically the index by type of disease, in appear the under mainterm,For example, maintermBradycardiaandthesubterms the indented as in for bradycardia appear shown figure6.3. '-1 3 Volune The lists and the ofICD-g-CMcontains tabular alphabetic ofprocedures Thethjrdvolume system, to according anatomical organized contains chapters Tabular List of Procedurcs Figure6.4 Procedures and Diagnostjc Therapeutic Miscellaneous exceptfor thelaslchapter, codes to are these procedure to theHIPAAregulations, titles.According shows the chapter hospital billing. beusedonly for inpatient and chapters, thenlhe to according lhese codes organized are ICD-9-CMprocedure All four-digitcodenumbers pfoceare into two-,three-, sometimes and chapters divided point FiSure pfovides 6.5 are durecodes writtenwith two digirsto theleft of thedecimal on 2, of listingfrom thebeginning chapter Opemtions lhe Endoan example a tabular of (06-0?). crineSystern as in is Index!o Procedures olganized the samemanner theAlphaTheAlphabelic of organization of an Figure6.6 shows example the alphabetic beticIndeito Diseases. procedufes. ln and entrics mainterms subterms ICD'9'CM for Figure 6.3. Example lndex of
B.Achyccphsly 756.0 B.ochynorphlern md ectopla lentis759.89 tsradlyt dlsffc (epidemic vomitine) 078.82 Brodyc8rdla 427.89 c h r oi c ( s i n u s ) . 1 2 ? . 8 1 newbom 763.83 nodal12?.89 posloperative 997.1 rcflox337.0 sinoatrial427.89 427.81 with paroxysmrl tachyanhythmia tachycardia or chro ic 42?.81 sinus 427.89 427.81 with paroxysNd tachyanhythmi! taclycardia or chrcnic42?8l pesisent427.81 Lnhyclrdi^syndrome 427.81 !a9a1427.89 Bradyp!r 786.09 Brrilstbrd's disease 732.3 radiclhead 732.3 larsal scaphoid ?32.5

202

6 Chapter

Figure6.4. Chaptertitlei in the ICD-g"CMtabular list of procedures

1. 2. 3. a. 5. 6. ?. 8. 9. 10. ll. 12. 13. 14. 15, 16. Operations the Netrous System on Operations lhe EndocrineSystm on Opelationson tbe Eye \ ope.ar:on" rheEd on Operalionson the Nose,Mouth, and nurynx Raphatoq S)srem OpeElion,on Lhe Operations the Cardiovascular on System on Operations the Hemic andLynphatic SysEm on Systen Operations theDigestive Operations $e UrinarySysten on Op3ations theMsle Cenital on Oryans Operalions theFcmale on Genital Organs ObstelricAlProcedures Operqrions theMusculoskeletal on System Operations tlleInt%umentary on Syslem Miscellaneous DiagnoslcandThempeutic PrccedurEs

Figure 6.5. Examplefrom the ICD-9-CM tobular llscof procedurcs 06 Operations $yrold andparsthyrold on elmds Includesr incidentalresection bone of hyoid 06.0 Incblon lhyroldfield of (t8.91) aJ I Exctuder: divkioh isthnur I ' 06,01 Asplratlon thyrold of flold Pllcutancousneedle of dlainage thyroid of fleld aspiration biopsy thrrcid(06.II ) al drainase irctsion(06.09) br posta mtive as ntion ofle LdP6.U ) pe pi
Reopening ofwound of thyrold fleld Reopening ofwoundofthyroidfield for: controlof (postoperativ) hemonhas.

removalof h!m310ma Other incillon of thyroid feld D.ainagoof hematoma Drainageof thyroglossalrac! Exploralionr neck thyoid (field) Removalof foreign body ThyroidotomyNOS

\ | I ) by incisior | I I p ostoperctiye etpIoruti on (06.02) renavol oJhendton'o by aspiration (06.01 )

Svstems and cl nicalVocabularles classification

203

Figure 6.6. Example of alphabetic entries in the ICD-g-CM index to procedures Acromioplasty 81.83 ofshoulder 81.82 for recurentdislocation p x l i r l r c p L . e m e o8 l 8. r 81.80 iotrlreplacemert Actinotherapy 99.82 ActiYitis daily livins (ADL) of 93.83 rherapy for training theblind93.78 wnh snouldering moxa93.35 fof anesthesia 99.91 of 69.22 advancenientrcundlig0meni 21.88 c rshing ofnasalreptum excision palnar tlscia 82.35 of

Chock Yorr Undoratandlnll G,l below. the lndex1ocomplete questions fiom theAlphabetic excerpt lxsrrrdtir,rr Usethefollowing Bscillory-see cordition 791.9 Bacillurie 646,5 asymptomaiic, pregnancy purPerium in of (ree 0i6.9 luberculous 41ff Tuberculosis) Infction, bacillus Bacillus-rd? al.ro aboltlls inibclion023.1 inibction an!hracis 022.9 coli irfection041,4 generalized 038.12 intesLinal 008.00 pyemia 038.42 septicemia 038.42 Flexnr's 004.1 ftrsiformis infeshlionl0l malleiinfbction 024 Shiga's 004.0 (reedlro Intection, suipestiter infection Salmonella) 003.9 Back-se? condition (postural) Backach 724.5 psychogenic 307.89 sacroiliac 724.6 L List the jlrst four main terNs ihat appearin the excerpt. 2. List lhe lirst lbur subterms aDDear under Bacillus. lhat

244

6 Chapier (P)' (D) a represenisdisease or a procedure codes whelher eachofthe followiDg Indicate
b._ d._ f._

3.

99.82 098.0 301.51 13.4 844.0 45.24

lnternational classification of Diseases'TenthRevision' clinical Modification

at ten-y"Jrintetto by Establisbed WHO, theICD systenwasdeslgned be totallyLtvlsed Statisti' of version ICD; lnlernational newest the u"i"-f" ih" Inla-fssoi, wHO published knofln.as TenthRerision' HeahhProblems' oiseaseianti Related i.i ciliitniii"i the "f throughout worldandhas in icb- iij. itri. ,""i.ii" is currently useby manycountdes in studies lhe since1999 Howeyer' moftaliti staditics i""" ur"O;" ttt" U.S. to capture datathalwouldsuppo ouf to capture to that U.S,Oetentnea fCD-10needed bemodified prior to implementatlon system reimbu$ement Purposeand lJso ifrliin.riu"an*don

Lo i\ for ICD-9-CM'oiume' I and2 Th;srcvi"ion considcreJ a corrtain lireat to "1,r"".JiJ"".t"", UothICD-9-CMmd lcD-10, andwasdeveloped i" """i"*iii""i"*, andrllow grertcr ICD codcsel: lhrn speclri,jlD exijung mofecodes manv

iji"iiii.irii

to AccordingNcHSIcD-10-cMi'rhe ModiJicatiot nri"ion, clinicol be

of ICD-10 is known as theI ternatio'tdlclassificationof

Ovofllew of Structuro is ICD-10_CM a comllete.Alphalrumerlo remains, ICD sfiucture ttte e.t|lrougb tradhlonal (V w'ls information andE codes) cldssification Tlt" formersupplementcry prcceding nunler_ lhe letters "oainei"h",n". Lhe with difterent system rnto matnclassification iniorp"oratcd b-ccn calegories.h'rve new lCD-I0conlJins chrptet'andse\erxl of icaiponio,'' ttt..oOes Tl-e rDedi"ine with modern Io ,"0 ,'.* i.JlLrre.Lrdcled mJinrr.ncon,irtencl i.'iti.i""J al specificrty dre sixdr'digit provldegreater to hasbeenexpanded aii"ase "to..:Iication exlension levelAndwith a seventh-digil from the NCHSWeb siteat cdc'gov/nchs/about/ A dr01t ICD-1o-CNiisavailable of for A locm.htm. draftof otficirl gu'delnes ICD-10-CMhasbtcr)devclotheract/icdg/icd n l0guidel pdl gov/nc h5/drtJ-/icd9/drali-i from cdc opedandc:rnbedownloaded Ihelbllowing: irclude t\rmtlc" oi ICD-l0-CMcodes . MaligntntNeoplasm oL lobe,bronchus lung of neoplasol upper C34.I MaliSnant side or of neoplasm upperlobe,bronchus lung,unspecified C34.10 Malignant or of neoplasm upperlobe'rightbronchus lul1g C34.11 Matignant or 1obe, bronchus lung left of neoplasm upper C34.12 Maiignan! . Dinbetes melliluswith renalcomplications E10.2 Type I diabeles

1.
Sysiems and c inical Vocabularies Classlfcation .Iype I diabetes nephropathy mellitus with diabetic E10.21 'Iype I diabetes with intercapillary meliitus Slomerulosclerosis giomerulonephitis with intracapillary Type 1 diabetes disease with Ebstein's mellitus 810.22'lypeI diabetes renalcomplication mellitus with otherdiabetic E10.29 Type1 diabetes
245

lnternational Classification of Diseases'10th Revision' ProceduroCodlngsystem

pllnning,to volume. Thus,whentheU.S.began a does include procedure not ICD-10-CM volumeror a separate ftat clinicallymodifyWHO'SICD-10,it wasdctelmined creating Information Health with CMScontracted 3M As procedu;es wouldbeinsuftlcient. a rcsult, as that wouldserve a replacemenl prccedurc codesyslem a to Systcms develop sepamte is 3. for ICD-9-CM,Volume Thiicoding system knownas the/ttem.rtional Classifrca' or System, ICD-1o-PCS' Clnssification Procedure Ihth Retision, tion oJDiseases, Purpoaoand Us6 of section ICD-gthe for fesponsible upddting procedufe Acc;rdingto CMs, the agency included followinggoalsi the of CM, thedesign ICD-1o-PCS . . . of and To imprcveacouracy el'ficiency coding effort To reduce training with T' Inpfove comnlunicrtion phiscirns

Ovrvlowof Structuro of It ICD-Io-PCShasno co elation!o the ICD-lo'CM struclure, consists a nlultiaxial 9 The tendigits0 through andthe2't lelters code alphanumeric structurc. seven-character the this used A-H, J-N, andP-Z arechamoters in ICD-I0-PCSAlthough systemhas capait pfocedulal codingsyslems, is cuntntly being all bility andflexibilityto replace existing (NcvHS 1991)Because ils of codes to 6nly ICD-9-CMprocedure recommenderlreplace and to be bothcomplete expandablc. unique structure, IiD-I0-PCS is considered are names procedures in usein tbenedical of and Because manydifferent confusing that to This procedure been in ICD-10-PCS. helps clarily terms root has defined field,each oL resection, removal suchasexcision, neaning, cunentlyhaveoverlapping rela@d generaltype of procedure to Procedures dividedinio sixteensections are characlers haveseven (medical codes imaging, and so on).All procedure and surgical, the where prccedure prccedure specifies section the codealways Thefirsl chalacter ofthe 'the second within gach meaning havea standard seventh characters is indexed, through as are procedures, seve!characters defined lbllowsl the In section. nedicalandsurgical wherethecoderesides I = sectionof theICD-I0-PCSsystem 2 = Thebodysystem (suchasexcision, incision) 3 = Rootoperation bodypafi 4 = Specific

2AA

Chapter 6 used, suchasilltraluminal open or 5 = Approach usedto perfom theprocedurc 6 = Device (fbr to information abouttheprocedure e^irmplc, 7 = Qualifier provideadditional diagnostic versus therapeutic) Tube,Right of An example an ICD-I0-PCScodeis 095HBYZ,DilationEuslachian NEC,Transorifice with Device Intraluminal. 0 o 5 Surgicai Secdon Bollys) stcm-Edr rore.\inu5 Procedure a dilation is

H Eustachian tube,dght B Transorificeintraluminalapproach Y Device NEC Z No qualifier The draft ICD-I0-PCScodesystem onliDefiom rnd trainingmanualare available cms.hhs.gov/paymentsystems/icd9/icd I 0.asp?

lmplmontationof lCD.lO in the U.S.

At the time of this wriling, the NationalConmittee on Vital and Health Statistics (NCVHS)hadrecommended borhICD"lo-CM andICD-I0-PCSbe adopted the as tbat national standards underthe HIPAA electronic rule kansactions codingstandards to and rcplace current the usesof ICD-g-CM.The nextstepis for lhe govemment publisha to noticeof proposed rulemdking theFederuL tn R?girlci! Aller therequired time framefor comments passed, final rulewill be published aneffective has a wih date, Thenewcoding system(s) wouldbeimplemented thestandard 0 designated frame(typically as in time two yea$)from thento ailowfbr tminingandtheupgrading ofcodingsystems. Coders shouldbeginto familiarize themselves thenew systems. Jaunlalof wilh The American Healthhlformation Manaeement Associdtlo, otherpublications beginaDd are ningto publish preparation articles will enabie that coders staycunentandbe prepared to fbr the changes lhey takeeffect.Extensive as trainingsessions coding)raterials and are beingdeveloped assist to coders facilities and with thistransition.

Intelnational Classificatlonof Diseasesfor Oncologly, third Edition

The third edition of the Intemqtional Classifrcationof Diseases for Oncolog!, Third Edition (ICD-O-3);s a system usedfor classil]ingincidences malignant of disease. HospitalsuseICD-O-3for several pulposes, example, develop for to cancer regisFies. Cancer registries all the cases cancer lis! of diagnosed treated thefacility. and in lllstory of ICD.GS WHO published first editionof the/rr?mdrional the Classilication Diseases OncoLoJ Iar joinrly by rheUniredSrares og) (ICD-O)in 1976. wasdeveloped It Cancer Insriture and WHO'sInterDational Agencyfor Research Cancer on

r
Systems and vocabularies Classiflcation Clinlcal 4t1d published ManualofTunor Nomenclature Cancer Socieiy In 1968, American the for Research-on Agency the (MOTNAC), wHo asked Iniernational Also in 1968, Coding to of for on to a Cancei develop chapter neoplasms theninthrcvision IcD WHO decided on based MOTNACfor ICD-9' neoplasm classification publish supplemental a ' atter in diagnosed theUnitedStaIes caqcers for ICD-O-3waspublished usein coding l a n u a D. 2 0 0 1 . l Purposeand U3g in of to ICD-O was developed aid in the collection information the field of Originally, pu'pose to is ot tumors.)-Its is onc-ology. Inewtissuel' lOncology thestudyof neoplasms (moryhology^[structure]), system codingthehisiology fbr proviaJaaetaited Jlassification a of (site),and behavior neoplasms cunentversion ICD-O provides The of iopography and registries, heallhcare cancer departments, usedby pathology detailed ciassification patients. prcviders who trcatcancer Overviewof structuro and is A duafaxisclassification usedin ICD"O-3to codethe toPogfiphy mophologyof with othercodingclassifications or are identical compatible Thesecodes lhe neoplasm. codesusedin ICD-10 ior malignant the For and nomenclatur'es. exampie, topograpliy in thesame codes used ICD-O_3 neoplasms are The moridentilythe typeof tulnorfoundand its behavior' The nrorphoiogy codes phology codi nurn-birs coDsist lhe letlerM followedby fiv diSits Thefirst tbur digits of ol the The type identiiythehistological of theneoplasm. fifih digit identifies behavior the provide0nexamplei fbr codes someleukemias The tbllowingmorphology tumor, LeukemiAs leukelnia M9891/3 Aculemonocytic dysplasia tuithmultilineage M9895/3 Acutemyeloidleukemia AMLI M9896/3 Acutemyeloidleukemia, MLL M9897/3 Acutemyeloidleukemia, the afterthe slasharc usedto iDdicate codeslhat appear The fifth-digit (behavior) lollowirgl /0 Benign whether benign maliglant,borde ine malignancy or /1 Uncertain /2 Carcinoma situ in Intraepithelial Noninflltrating Non-invasive primarysite /3 Malignan!, metastatic site /6 Malignant, Secondary site slte pdmaryor metastailc whether /9 Malignant, uncerlain
247

_l

2Aa

Chapter6

6.2 CheckYoul UndeBtanding codes bv rcpresentedthelbllowing for List /rr/racti.,,rr thelypeofbehavior thetumors M8140/0 l M8490/6 2. M833r/3 l M8120/2

HealthcareCommonPlocedule CodingSystom
Thc CodingSystem. name Procedure HCPCSwasoriginallycalledthe HCFA Common (the Administmtion HealthCareFinancing in w;s changed 2001,whenthe of the system its programs) changed nameto the andMedicaid the that agency administered Medicarc (CMS) HCPCS [sedto repo physicians' is Services and C;ntersfor Medicare Medicaid to lbr services Mcdicare reimbursement, History of HcPCs used rcPre10 (Dronounced aDd "Hick Picks")is ii ooliection codes descriplofs ol HCPCS program thc Medicarc prcducts, services When prooedurcs, and supplies, senthealthcxre Administration FinancjDg the was firsl implelnented the early 1980s, Health Care in procenol system because all supplies, (HCFA)fouDd necessary expand HCPCS the it to of thisshortcomirg An couldbecoded usingtheCPI system example dures, services rnd lor (DME). CPT doesnot contain codes DME. Thclefore, is durable medical equipment that andservices alc not levelof codes reportsuppljes lo aD HCFAdeveloped additional DME). io CPT (for exAmple, Polposoand Uao dat'l lnd st.ttistic0l uniforn reporting introduced HCPCSto promole In 1983,Medicare products, servicesMost stll|eMedicaid and ol supplies, collection medicalprocedurcs, and Physicians plovidefsuse programs alsouseportions the HCPCScodingsystem. of procedures deliver. they HCPCS codes reporttheservices to and Ovorui6w Structure of js HCPCS divided into two codelevels groupsr andIL of I are are These five-digi! codes two-digitDrodifiefs and LevelI codes theAMA s CPTcodes. pdmarilycover physicians' but for copyrighted theAMA. CPTcodes by services ale used effective JaDudry l. hospital outpatient codingaswell. CPTcodes upda@d are annually, of by LevelII codes, calledNatioDal also Codes, mainlained CMS.With lheexccption are codcs bcgrn codes, levelIl codes updated on January Temporary L lempomry are inDually LevelII also tbroughout year. the with theietters ,<,or 0, Temporary codes updated are O in thefolm of letters alphanumeric charactels. contains modifiers and tbat equipment, supplies and LevelII codes weredeveloped codemedical to servicas, people theyareofienreferin when referto HCPCS codes, arenot included CPL Today, TechDicall,. LevelI codes mostoftenreferedto merelyasCPT. ring to LevelII codes; are

l i

and Systems Cllnica Vocabularies Classification includes are and HCPCS both LevelI (CPI) andLevelII codes. codes alphanumeric The stafi with an alphabeticchaiacterfaomA to V The alphabetic character followed by four is numericchaEcters. The alphabetic cha&cteridertifies the codesectionandtype of service based or supply coded. times,LevelII codes At we.edesigned reflectcodeassignment to payment choices patients for on Medicare regulations. Figure6.7showslhe different code undergoing r colonoscopy based theirmedic"l necessiq. on Figure6.8 provides list of themajorsections LevelII. a in Level II alsocontains modifie$ that can be usedwith all levelsof HCPCScodes. penit greater in to including CPTcodes. modifiers The repo.ting specificity reference the maincode.Sample levelII modifiers appear fl1gure in 6.9.

209

Figure 6.7. CPT ICPCS code choicesfor colonoscopy Exanplel Rason ColonoEcopy for Problem, suchasbleedins polyps or Colorecl,il cancefscree g, patient nin does nreet not Medicarc definition o f h j g hr i s k colorectal cuncer screening, palienlmeets deinirionofhigh risk Appropriatecode CPTcodes 45378-45392

G0l2l G0105

Fleure 6.8, HCPCS Level section II titles

A0000-A0999 nunsportServices Including Arnbul0ncc A4000-A4899 McdicalandSurgical Supplies A9000-A9999 Administrative, Miscelldreous, llvestigalionAl and B4000-B9999 Enrerol Parnreflrl and Therapy D0000-D9999 80100-E99r9 Du.oble MedioAl EquipnenL c0000-G9999 ProceduresProfessional (Temporary) Services J0000-J8999 Drugs Olher Thm Chemotlempy 19000-J9999 Clemotherapy Drugs K0000-K9999 L5000-L9999 M0000-M0009 P2000-P2999 Q0000-Q9999 R0000-R5999 Domestio Radiology Services s0009-s9999 Te'nlorary Nationd Codes v0000-Y2999 v5000v5299

21"4

Chapter 6

Figure 6,9. Sample HCPCS Level II modifiers -AA -El L2 -E3 -E4 -NU -QC pe$onlll) by anesthesiologist performed Aneslhesia services Upperlefl eyelid L' ie, el e)el.J Upper righteyelid Lowerrighteyelid Newequipment Sjr-ele channel monitodng

Current Procedulal lerminology' Velsion 4

by is and the As mentioned earlier, CPT system copyrighted maiDtained theAMA. Therc in sincetheoriginaleditionwaspublished nitjor updates the system to havebeenseve.al I. annurllymd takeeffecteveryJanuary 1966. Codeupdates published are Hbtory of CPl.4 descriptive ljstingof lermsand codeslbr repoldngdi gnostic CPT is a conprehensive by annually the it procedures medical services. Currently, is updaled and andtherapeulic and of This paiel is composed physicians otherhealthcare AMA s cPT EditorialPanel. the prolessionrls revise, who modify,andupdate publicalion. gelsadvlce revisions fiom thecPf AdvisoryConmitteeThis TheEditorial Panel on of and of commiltee nominated theAMA House Delegates is composed representais by provldersAs defined by specialties healtbcare aDd tivesftom lnorethanninetyDredioal theAMA, thecommitlee threeobjectivesl has . . . codon by To serve a rcsource theEditorial as to Panel givingadvice plocedurc specialty ing Andnomenclaturc relevant themember's as to regarding nedical the Panel To provide documentation staffandtheEditorial to procadures medical surgical and appfopriatenessvarious of To suggest revisions CPT to

Pulposoand Us for terninologyandcoding!o report The puryose CPTis 10provide syslem standard of a procedures services. is oneofthe mostwideiyused systems rcporting lbr and CPT medical for medical services health to insurance caffiers. addition. is used otheradninistrative In it purposes, asdevelopilg guideliDes medical such that fbr carerevigwOrganizations collect purposes useCPT. datafor medical education research and also provided services to Today. CMS requires CPT codes usedto reportmedical that be paliertsin specific (nowcalledthe CMS) rcquired that settings. Starting 1983, in HCFA 1986, to prcvided Medicare B bencficiaries. October Part In CPI beused repo services to ManageneDt HCFArequired Medicaid aspaft of theMedicaid state agencies useCPT to Act, InformatioD System. pat of the Omnibus As Budget Reconciliation HCFA required procedures and in July 1987that CPT be usedfor reporting outpatien! hospital surgical for ambulatory surgery centerprccedures. most recent The mandate CPI use occurred Act with the final rule of the HealthInsurance PoflabilityandAccountabiiity (HIPAA). for pbysicians'services and HIPAA m^ndates CPT be usedas the requircd that codesei prccedures. physical othermedicai services suchas thenpy and ostlaboratory

s C n , a l \ o c a o u , d . | ea n d C l d , )

' c a ' i o _ 5 r " L e ns

271

Overuiewof Structure the containing codes, eight sections of consists an inlroduction, The CPT codebook specific although mostarenumeric, arc appendixes, an index.Five digil codes used, and manageand evaluation inclLrde: The seitionsincludean alphacharacter. eightsections and medicine diagnostic (including nuclear radiology surgery, mentservices, anesthisia, III ll Category andCategory codes' pathology laboratory, medicine, and ultrasound), and and numbers theirsequences section contains list of lhe codebook a The inhoaluction ol to all sections applies in that inslructions use.Info.mation appears theirtroduction for Iheintoduction' read with CPTcodirgshould A thecodebook. coderwho is unfamiliar of in coders conectusage CPT marksare usedto assist Symbols and punctuation in are usedin the CPT codebook explained theintoduclion andar corles. The symbols _bottom r of pageol thecodingscction thebook For exanrple, bullet of each tbundaI lhe buok updateLl I'i lhrl lo lisleo lhc leftof a coJesignifie. lhecode neu fol lhrl )ear-s Sectlons The sections aslbllowsi are Evahation Management 99210-99499 and 00100-{1999 Anesthesia 10040-69990 Surgery 70010-79999 Radiology PalhologyandLaboiatory 80049-89399 90281-99199 Medicine 0500F-401lF II Category Codes 0003T-00887 Category Codes III and specificinslructions containing beginswilh guidelines Eacll of thesesections in the mustunderstand information the Coders deftnitions areunique the section. !ha! to guidelines orderto codecoffectlyfiom eachsection, in categary andlll Codes 1l thal tracking codes as to II weredesigDed "supplemental According CPt Category codes theycanbe codes oPtional. axe Although these measurenenl." canbeuscdfor performance details. greater a visit used provide to speciflcity regarding patienCs andtreatment coding Category codeswere addedlo the CPT book 10 allow for temporary III requlrements assignmeDt new technology services do not meetthe igorous for and that are of necessary be added the main section the CPT book.The codes nol optional to to Category section III are perfbrmed. in Codes the andshould used repof procedures be lo (codes fiom 00100to ranging I evaluated added and everysix months. Category codes As III calegory temporary the 99499) crealed describe procedurcs. coresponding are to new Jode'$ i- bedeleled lron r\r CPT.).lem. lo provide informalion help The Appendixcs follow the tastsection codes. appendixes of and list A a in Appendi{ provides complete of modifiers their lhecoder thecodingprocess. that follow the main CPT codes Modifien are writtenas two-digitcodes descriptions.

-.-4-__

2X2

6 Chapter seflices and evaluation management the For erample, two-digitmodifierfor prolonged is -21. that havebeen and deletions, revisions of AppendixB is a summary the additions, information to can CPI edition. Thisappendix beused update for impiemented thecunenr CPT codes. anddatathatcontain and foundin theevaluation managefor C clinicalexamples codes Appendix provides the (E/M) of thebook.These can examples be usedas a tool to assist coder mentsection in rcportitganE/M code. by mustbe preceded a Thesecodes codes. AppendixD is a listingof CPT add-on alone primaryptocedure wouldnever reported be codeand frcm modifler51,andappenthat E of Appenclix is a surnmary CPI codes areexempt exempt from modifier63 lhat are dix F is a summary CPI codes of sedation that conscious Appendix contains G codes include or by pedormance measures clinicalcondition indexof Appendix is an alphabetic H foundin the ofthe codes provide description to turther type. This appendix developed was Category section CPT. II of with lab procefor genetic used rePoning tesiing codemodifiers Appendix contains I dures related genetic to testing. are Main |ermentries of lists The indexof the CPT codebook maintermsalphabetically. lour typesl . . . . or Procedure service Organ olheranalomic or site Corrdition Synonym, eponym, abbreviatioD or

modit'ythemain termsanda(e The Main tefmsarefollowedby subterms. subterms lhe for thecoffectCPI codeby checking indented underthem.Coders begintheirsearch a iikely codeto descibethe procedure alphabetic indexin the above orderuotil finding in of perfolmed. selected the main section the The codershouldthenverify the code(s) performed. Figure6.10 codebook be certainthe codebestdescribes procedure(s) to the shows po ion of theCPf index, a
[isrre 6.10. Portionofthe CPT index
Face CT Scon Masnetic Resonance Imasins(Mltl) Frc Lift 5e, Hemitirciat Microsomia

70486-70488 17000-17004, t'7280-t7286 70540-70543 21015 15824-15828

Svstems and Clinlcal Vocabularies classiflcation

CheckYourljndorstandi[tl 6.3
lnsrl ctjrtrr Lis! the sectionoffte CPT codebookin which eachof lhe fbllowing codesis located.

1. 2. l. 4. 5. 6. 't.

993r I 90807 33,170 01200 87551 71295 0071T

SystematizedNomonclatureof Mediclne
(SNOMEDCT) is TheSystematized Nomenclature MedicineClinical Tbrminology of (ACP)detines of The a controlLed reference temlinology. Americln College Pathologisls nomenclature oryanized muitiaxial, andhierarchically SNOMEDCT as a systematized, usefultelms. of medically Hiatory on SNOMEDis based the SystemACP published first editionof SNOMEDin 197?. rhe lo (SNOP), published ACPin 1965 organize by whichwas atized Nonenclature ofPathology used acceptcd And pathology reports. Because SNOPwaswidely inlbrmadon trom surgical for as in themedical comn1unily,wasexpanded a nomenclatufe otherspecialties it The ourrenlversince1977. Numefous versions SNOMEDhavebeenpublished of lhe throughout world more than 150,000 lermslhat are usedin countries sion includes developed date to vocabuiary controlled SNOMEDCT is the mostcomprehensive The lpdatedversionof SNOMEDis SNOMEDCT (clinicalterms)is a "ooNpreframework for hensive nultilingual clinicalteroinologytool providingthe informatioD (Brouch2003) This ve$ion Is rnedicnl lecord" cljDicaldecision makingfor electronic the an adapt.ltion earlierversions SNOMEDand alsocontains UnitedKingdom's of of Read Codes (previously asReadCodes), known National HealthService's ClinicalTerms users beirrg are nigratedover10SNOMEDCT. "purchased licensefor a ln 2003,the DepartmeDt Healthand HumanServices of pdvatedevelopers [Electronic HenlthRecol.d] of SNOMEDCT, allowingall federal and (Giannangelo Berkowitz and EHR sysiems freelyincorporate vocabulary rhe sys@m" to beingcompleled the by 2005).Mappingbetween ICD"9-CM and SNOMEDcodesis ICD-9-CMcodes Nalional LibraryofMedicine(NLM) to helpvendors crcsswalk between required reimbursement SNOMEDCT's largernumber diagnostic for of lerms, and Purposeand lJs6 medical In thefield ofmedicine, physicians Llse different lwo termsfor thesame two may vocabuinformation. Standadized condition. This makes dillicult to gather retrieve it and in of information an lary is needed facilitate indexing, to storage, retrieval patient and the EHR. SNOMEDCT creates stardardized a vocabulary. 'Ihe the Computer-based PatieDt Record Instjlute(CPRI)has studied ability of ctu' has determined that The institute rent nomenclatures capturc to information EHRS. for

214

Chapter 6 of for vocabulary codingthecontents controlled SNOMEDCT is themostcomprehensive rccords of computerized the record facilitaling development anal thehealth Ovgtviowof Structute data SNOMEDCT presents in a completeiy^machineUsingSNOMEDas a foundation, dataof SNOMED the to format. Accoraling SNOMEDIntematioial, coreconleot read;ble the CT includes followingtables: . . . . CoDcepts Descriptions Relationships History

used vocab{ts mapped ICD-9_CM well asothercommonly to SNOMEDCT hasbeen asICD-O3,ICD"10,andLOINC. ularies such every tablclists The ior provide frameltork theorganization. concepls the Thecorclables 3 CT, versions SNOMED stdtingwith versioD MorcthaD of appeared earlier in concept thal wilhin theSNoMED CT systemEach into concipts organized 18hierarchies are 366,000 identifier is name listedon thetflble, givena concept as or concept, fuliy specified them Thecombithat oi tenns phrases dellne iurrher identified various by Concepts are ID' are Desoiptions givena Description anda termis a dlscriPtion nationof;concept d Real-Wo Example dec used software fbf clinicul ision conlpany produces that informuti,rs TheraDoo r rnedical is tbe to support apploprlate was AntibioticAssis!&Dt, designed Oneof its systems, suppor!. to Assistant allow resystem into us; of aDtibiolics. SNOMEDCT wasiffegrated Antibiotic drug in order|o analyze syslens intbrmation wilh otherputient Possible to be integraled to Accolding SNOMEDInternrlional, reaclions xhemedications, to interactionls or'adverse the powered SNOMEDCT. convcrts ra\r d'Ll'rink) b) ThemDoc's AntibiolicAssistant, of ircnrrccognition c potenllnl the usable iribnnalion, dram ticallyrcducing time Problelr form rarioussoullcs. , the Instead havingto t ck downinformation of 10intefvention. nnd physician infbmationin realljmeaspaflof hisdailyroutrDe, ls rcceives comprehensive (SNOMED 2005). Intemational course aclion" of rubie decjclc an imrnediale to on

Diagnosticand Statistical Manual of Mental Disoldels' Foulth Edition, Toxt Rovi$ion

(APA) developed Diagnostic Lnd Statistical the Association The AmericrnPsychiatric thatcouldbe a Manual of MentalDiso,drrs (DSM) as a tool for providing setof codes personal compuleN stand-alone of used aid in thecollection clinicaldatausiDg to Hi3toryof DSM.IV on The APA published first edilion of rhc DSM iD 1952.The APAS Conrmittee the a of and DSM from ICD. DSM-I contained glossafy Nomenclature Statistics developed and timessince1952 is now revised three descriptions ofoenlal disorders. DSM hasbeen text published thefourthrevision, DSM-IV.TR.The updated revisior(TR) became as or Therewercvery fcw clinicalterms. effective 2004to maintain in currency with updated codrng chanBes theDSM-IVTR\ersion. in of the To facilitarceasd usewith ICD versions, APA hasworkedcloselywith otherorgacodes AIl to DMS-IV ICD-g-CM, ICD-10fully compatible. DSM-IV-TR and nizations make

i an C I n r c d\lo c a o u r d r , e s d C i a s s c a l i o S \ : L e n s

215

that the This is evenmorcimportantbecause HIPAA law requires valid areICD-g-CM codes. '"fhe DSM-IV is pulposes. Accordingto the APA' for diagnostic ICD-g-CM codesbe used the to a diagnostic manualthat employsIhe ICD-g-CM codes assist clinicianmedicalrecord and of thelearea number sublypes manual, is Because DSM-IV-TR a diagnostic the keeping. (2005). to that specifiers arcnot codable the ICD-g-CM" Purposeand Use tfelted Io a ofDSM-Iv-TR is to provide means rccorddataon patienls The ,nainpurpose that DSM is usedas a nomenclatul clinicians disorders. abuse mental and fbl substance for and tbeif clinicalpractices as a language communicating can reference enhance to a useDSM to assign diagnosis information. Clinicians diagnostic and disorder its key each tbr a DSM contains listingof the criteria diagnosing mental alongfive axes evaluated are Mentalconditions clinicalmrnifestations. Ovorviwof Sttucturo used DSM-IV-TRare: in Thefive axes Axis I Axis II Axis lII Axis IV Axrj V ClinicalDisorde$ of Thal May Be a Focus ClinicalAttention OtherConditions Disorders Personalily MentaiRetardation MedicalCoDditions General Problems and Psychosocial Envitonmental of GlubilAssessmenlFunclioning

of evaluation patieDt a helpsto establish systematic Useol' these axesby clinicians for of This symptoms. will leadto theest4blishment diagnoses thepatientTheoraSnoses codes. as that thenlre givena codeor codes arthesame ICD-g_CM

Read Codeg They were The Readcodes weredeveloped the UnrtedKingdomduringthe 1980s, in tbrmab designed u'e in computer-brsed lor Hlatoryof ReadCodos Englandln 1982, he practitioner Loughborough, Read medical in Dr James wasa geaeral The allowed codes useon his officecomputel. codes for developed setof alphanumeric a From for him to record mostcommoD the diseases conditions whicbhe sawpatients. and a and 1982to 1987,the ReadCodeswere expanded produced codingsystemfor the rccording manyareas of ofclinical care. Practitioof 1987, BritishMedical Association theRoyalCollege General and h the that pdty to lnvestigate systems couidbe usedin classification neN established v/ork a should geneulmedical practices. yearlater,this groupconcluded theReadCodes that A practiceTherciorc, the medical data general in become standard the code fbr recording set theReadCodes the standardas RoyalCollege General Practitioners adopted of (NHS)alsobegan useRead to Codes HealthService TheUnitedKingdom's National the Healthpurchased Read of in o$er partsof re NHS. In 1990,the U.K. Department to and Codes. Theybecame CrownCopyright, the namechanged theNHS Codes

276

chaoter 6 the After the NHS secured copyrighl to the ReadCodes'they formedthe NHS Cenlre a'd for (CaC). The CCC is now responsible developing Codingand Classilication for maintaining ReadCodes. the Purpogeand lj3e that couldbe usedto aid wasto provide; aetof codes The purpose the ReadCodes of The Readcodes personal computers of in the collection clinicaldatausingstind-alone wilhcompulers thal drtd rranslatc clinrJal rnloa fileslruclure i' easiliu)ed thxt hasan impacton patlentcrre lnTorotherinformation alsotranslate The codes dala. adminlstJative and equipment regimes, thempeutic mationon patientoccupations, Codes lrcnslrteThus, thrt ofinformation theRead ofthe othertypes are intbrmation some ot manytypes clinical Io of in can theReadCodes be used all a.spects healtbcare translate iniormition. andnonolinical Ovgrviowof Structuro in Someof themainchapters venion 3 include: into are TheReadCodes organized chaptels. Occuprtions HistoryandObservations Disorders Investiialions and Operalions Procedures Regimes Therapies and Prevendon Causes Injury andPoisoning of TumorMorphology by.alphaof into hielalchies five byrcsrepfesented These chaplers furtherdivided are usedare 0 through9' and ihe alphabelical The numericcharacterc numericchoraiters. oi of the Z charaote$ usedarcfrom A lhrough Theoreticatly, design the hierarchy codes 3. codes version in allows for'916.132.832

NursingVocabularies
in is newconcept the lield of nursingMany nursing The useof vocabulades a relatively and inlerventions, outcomes. nursing diagnoses, vocabularies cudendy are used classify to Hl3toryof NuralngVocabularlos of nu^ing care. weredeveloped aid in thecollection dall aboDt 10 Nursing vocabularies data tbe of They serve a way to document ns nursing careandto facilitate caPture these (ANA) hasestablishedsteering a systems. American The Nurses Association on computer has praclice. The commitlge recomcommittee dalabases suppodclinicalnursiDg on to profession. mended of a unil'red use nursing language systenin thenursing Pulposeand U3e These develalt terminologies. approximately standardized TheANA recognizes thirteen jn are descfibed agencies variouspurposes. Theseterminologies opedby separate for included theUnifiedMedical in by table6.1.All theclassifications approved theANA are (UMLS). System Language

I
and C in cal Vocabuiaries ClassifcaiionSystems

217

yocabularies classifications Table 6.1. Widely used nursing and

(NANDA)

The Thiscla$i fication used clasif} nuNingdhgnoses all nusingsetlings. NANDA is to in to nultiaxialuxonohy isdsisned provide sundlrdized to a llNing rcrninology deiine patient ofnu$nE responses, docunent cde for Einbursenenr, to allowfor inclusiotr aod (No h AnencdnNuNingDiaenosis A$eirtion 20051. terdinology building in clinicalEHRS.

NIC is used cla$iiy nusing intervnrions. to Numinsinlervenrions.re dircct-carc any treatnent a Duser.rfom6 on behalfolrhepatient. thd These inlervendons lsed r. direcl are

(NIc)+
NOC is used closity nuruing Nuaingoutcodes theendresult sre ol.are Thet ro outcomcs quoliry canmeuslre ofcdre,costefticienot, progrss realoeDt. und of (NOC) HHCCcontlitrs nxeaehE! vocrbularies forcli$ifying anddoounenring two used afrbulsrory home Md {nd herlthc!rt. TheHHCCofNu^ing Dirgnoses ihe HHCCof NuNingldtervenrions used rrc NMMDS copxtrrs Drrsitrg d.k lbr rhcconlpaLnoi ofpatiert oulconBs,

(HHCC)

(NMMDS)
Tl s l$rfor.o1., SNOMEDCT lnJ u.co ro.lo*irj frr,n! Jrrlio*s, Inedenhon... orkJ r.e . SNOMEDol!

SNOMEDir { rdccn( termroloA}lorhcxkhcMe, 'fhh drt3 vocdbuloy usewhcnp0tienrs undergosurgery setis u st0ldaidizcd nuruidg for ll allowsfor rhcc{pt0re dun lron p&ddmlsioncrre of lnrilpdienr dilchogd, TheCCCis uscdtoch$ify DursirC diagDoss ourcomes, inreryentions. rnd lnd

(PNDS)

(ccc)
This Ermirologyh nowretired 9905l813.Pdl ICNPprovide$ ro innuence dalo policy, deoision-nlking, duclrion, heahh lnd

0cNP)
Alrehative Lir*\ABC codes pioducrs services represenr inre8$rive lEatdcorc and (cooplenentary alterlorilemedicine), and LOINC isusedto poolrcsults-such bloodbemoglobin, !s serunpor.$iuq orvinl sisns for clinical cae, outcohes managenen| andEs.arh.

& cods {LoINC)

2r8

Chapier6

documntato are systems developed captufe datasetsandclassification Thenursing and interventions, nu$ing diagnoses, to tion on nursintcarc.They arc desiSled capture care and surgery, horne, ambulatory settlngs for acute, outcomes care to nurses documen! wlnle assists vocabulary to According theANA,'A standifdized ofthetcare' ind the and providing f;ndatio for examining evalultinS quality etfectrveness a commeirsunng:rnd lhe for pro\:dei .oundllion benchmdrkinB infid\ruclJle AnrnfomaLon of and the paring outcome data, evaluadng quality effbctivenesscare"(ANA 2002) irnd Ovgrviewof Sttucturo Inlbmaion have dillerentshuctures' teflrinologies ANA-recogn standartlized izecl Thevarious table l (p 217) 6 listed in Websites slrucu;s canbefoundat thevarious on thespecilic
6.4 Chock Youi Und6r3tandinSl with systems theif iunctions /rrtru.rlrrrj Matchthe iollowingclassification 1. 2. SNOMED CT Nursing vocabularies

DSM-IV-TR 3. _ olnursinginlbrna on on conrpulel care nuL$jng andto frcilitatedrecaplure a. To document abuse and patients fof !rcated subslance about to a b. io provicle rneans recod information mental disordeis pcrionllJumPUter'j ofciinr.rluuk J,iirgn,nd_alone c. Io ar.lir thecollc,uon And provrded physrcrans olherclinicd by servrces a d. To provide systenlbr codingtheclinical prcfessionals record and{br of lhe vocubuldry coding conEnts thePatienl lbr a e. io provide conuolled recorcls Datient of facilitrtinglhe developmn! compuxer-based

The Coding Process

ele_ but to variesfiom oryanization organization, somestlndalds, The codingprocess all :rnd ale to menls, steps common almost olganizations,

Standardsof Ethical Codlng

of role heaithcafe environmeDt, codingplaysanimportant in the determination In today's of its facilities. AHIMA developed Standards EthicalCod" rcimbursenent healthcare for by 1999. wele developed AHIMA'SCodiflg ing, lastupdated December in The standards The and by PolicyandSlralegy Committee approved its BoardofDireclors, AHIMA stan(see as dards Deantto serve a guidefor codingprotessionals. figure6.1I ) are

Elmentsof CodingQuality
and mustbe reviewed an ongoing on basisfor consistency accuracy The codingfunction shouldbe Codingprocesses selected coders. by Auditsshouldoccurto reviewlhe codes tbr the fbllowingelements quality: of monitorcd . (lhal is, consistently rcsultsareachieved ReliabiliD: The deg\ee which thesame to codes) the whendifferentindividualscodethe sanlehealthrecord,they assign same

r
Systems Cinical Vocabu andc assificatlon aries . Validitt:The degree whichcodes to accumtely reflectthepatienfsdiagnoses and procedures and Completeness: degree whichthe codes The to capture thediagnoses proall cedures documented thehealthrecordin 7'1,r, /in.r\. The(imelf-me ln $hrchrheneahh records codeJ are
figure 6.ll.
L

219

AHIUA \ Slandard. Elhical of Coding

prolessionah expected suppon imponance accurate, Coding de of complete, consistent and to Lhe practices theproduction codinS for ofqualityhealthcare dara. cla$ificaLion conventions, oaiciaicoding ofDiseases,9th revision, CLinical Moditication) codjng guidelines Termirology) rules approved theCooperating by Panies,{ CPT(Cunent tle Procedural estnblished rheAmcrican rulesandguidelines by Medical Asociation,andanyotheroticial codinS cstablished uscwirh nandated ofdiagnoses rnd ibr standard codesets. Selecrion sequencing und proccdures meetthe definitions settings. nrusl oirequired dara sets applicuble tbr heafthcare

profe$ionals all healthcare 2. Codirrg in sertings should adhere theICD'9-CM(lnLernational to

protlssionals coding and 3. Coditrg should rhei skilh,thei!howledseofcufontly nunddted use olassiilcrtion lnd systens, oficialresources select apprspriate and ro the diagnostic procedurdlcodes. Codiig prctbssionals should only assign reponcodes that:rre clearly conlhtenily and and suppor'tcd physician by documenLaLion healLh record in the 5 pdor prolcssionals physicians clilificationandadditionld C{)ding should consult for docunrcntrrion ro collerssigomcnt record. whcntheEaroconflicting anrbiguous in theheullh or dota professionals Coding should change nor codes rhennF0rives ofcodeson thebilling bs(Lrctso or thotnrcnDings misepresented. urc Diugnoses procedures should bei appropdatcly not includcd or payment nrsur0nce policycovemge orexcludcd because or requirements beaffctcd. will Whcn paycL policies individuul conflictwith olloial codinsrulesundsuidelines, tlesepolicics should be possible. obrained writing*henever iD efforts be ro tu Reuson0ble should made educate pnycron proPercoding practices orderto rniluence chonge thepayeis policy. in in I pbysiciaDs 7 Codingprofessiotrols,membnofthe heahhcare 0s teau,should asshr educarc ond lnd othercliniciln$by advomting propr puctices, docunenlation funherspecificity. reseqLrencing md or jnclusion oidilgnosesorprocedules whenneeded moreaccurately to rcflefl theacuity, severity, lnd rheoccunence ofevenrs. jn pfofessionuls Codjng should pfflicipale thedevelopment jnstitutionul policies slrculd oi coding and ensure codnrg tlrat policjes complenent, conllictwith,olicial coding not rulcslDd BuidcliDcs professnnrah 9. CodnrS should mrintainandconrirually enhlnce rhei!coding skilh, asrheyhaleI protcsional responsjbility srayabrelst guidelines, regulurions. lo otcharges codes, ii coding and Codingprofession0k should srive fo. oprirralpiymentto vhich lhe iacilily is lcgllly enrirled, tnembeling ir is unerhical illegal maximize thar payrneni rnemsrh0tconrrudicl and ro by

rTlr. Cooper!rlng Pdticsirc tu AmericRn llerhli lnfbrmaiorN4aiagemedrA$ociariod,Adrericar HospimlAsrociaion, c.nte8 ror MelicaE andMedicaid Services. Nu.ionllCenrer He.lthStltistics. lnd lor coptrighto1990 by ir.Americii HerlLh Inlornarion Maugemcnr Associarioi. righ6 Eserled. All

220

Chapter6

Policies and Procedures CodinEl

that codingpoliciesand procedures establish Everyhealthcare tacility shouldestablish UsinSlhe coding consistency coding guid;linesthat codersshouldfollow to ensure such guidelines by established organizations as theAHA, theAMA, AHIMA, andstate 1br policiescan be developed codingcon_ association management irealthiDfonnation ior the TheAHA publishes officialguidelines ICD-9-CMcodingin a qua eriy newsirCPT cocles regarding information Cltnic.The AMA publishes letterentitled Collng for as can Both publications be used a basis developing entitled CPfArrirtdrl. newsletter and facilitypoiicies procedures.

Proqess Steps in the CodinEi

recoldon thc Patient. heahh a codinglo occur, codermusthave complete the Foraccutate recordThe codermustlvrcw a to Eachfacility needs detinewhatconstjtutes complete and and condition the treatment care lhe to of lhe contents the reoord determine patient's heor shereceived. record,the heallhrecordshouldcontainthe ibllowing doclrlnenls For an inpatient pathology rcpofts, rcports, and prior l(Jbeingcodedra lace shecl,operative pfocedural !o documents veify LliLlgnoscs to summary. codernecds Ieliew lhese The ancl dischirrge a andproceLlufes. tllirt and the the After tbcrecord reviewed. coderselccls diagnoses ploceclurcs nced is codenumbe$ Code$thenhaveto be scquenced apptopriate aDdirssigns to be coclcd (o guidelines. Discharge Set(UHDDS) Dala Hospital according Unifbrm irto oodcs enlered lbe lacility's are the and are Aliel thecliagnoses prccedures coded, and reimbursemcnl. clinifbr lhe These da|athenbecome fbundation stalisticAl, databNe. jnfbrnr tion systems. cal

Quality Assessmontfor the CodingProc3s

Assessmen! the codingplocessshouldoccurthroughrcgularmonitoringoI codirg of conducted an by reviewof codingpractices is internal accuracy. Monitoring the ongoing program be should a wlittcnplan organizati on a regular basis. monitoring/audil A P1afl process, the fie the and of thatoutlines objectives iiequency the audits, recordselection will qualifications auditors, cor.eclive actions organization |akeas a fesultof the of and |l1e auditfindings. The be Initially,a baseiiDe auditshould perfoDned. auditshould a reviewol a large be coded all coders by a ofrecords sample lhecodingcompleted. should ol It include sample of services. Moreover, sampie should representative al1physicians be fof all typesof the ot auditprovides overview 4n andlypesof cases treated theorganization. baseline by The praclices. cuffentcoding theorganizadon's estab' to The organization shouldconduct follow-upauditsaccordiDg the schedule of monitoring plan.Follow-up will provideongoing lishedin the monitoring/audit audits to llso canbeused The ofthe audits thecodingprocess ensure to codingaccuracy. resuhs Figure6.12is anexample in are outlineareas whichcodereducation training needed. and oI a codinsauditreviewsheet.

r
Initlal CodesAssigned

Clinica Vocabularies Classification and Systems

221

Figure6.12. Exampleof a codingaudit rcyiewsheet

Coding Aodit RYiewSheet Co Dateof Review Medical Record # DjschargeDate ReYiewer'sRecommeDdrtions

Principal Diagnosis A. Choscnand codedcorrectly B. Chosen cor.ecdy, coded inconecrly C. Choscn inconectly, coded conecdy D. Choser coded and inconectly Sccondffy Diognosos A. Choscn coded and conrctly B, Chosen corrccdy, coded inconecrly _ . _ . . - . - . . . . , - - - . , _ . . J . - _ - ' r c o r cy c D. Chosinandcoded inconectly Principal Pmcedure A, Cholenandcodcd conectly B. Ch$en conectlnoodd inconctly. C. Choscn inconec y. coded comcrly D. Chosenand codedinconecrly Secon&ry Procedures A. Ch$en andcoded conecrly B, ChGen concctly, codedincorcctly C, Choseninconctly, coded0orectly D. Chosenand codcdinconectly DRG A. Chosen coded and corctty B. Chosencorcclly, codedinconecily C. Choseninconecily, codedcorectly D, Chosen coded ard incorcclly

Noter rcvievsheer ahobconstructed monitor A can to CPTcodilg infomarioi instedd DRc asiglnenr!. of Coprrighr 2000 tie Anerican @ by Hcatth InfomalionMlnagenent Associalion. .ighBEsned, Alt

222

6 Chapter

chock Yout Undrstandlng 6.5 are lnrtrrcrio,rsj In{licatewhetherthe following stalemenls true or false (T or F) facilities ofhealthcare ofreimbursement Codingplaysaninponant rcle in thedeterminadon 1. consistency and basis coding for on functionmustbe reviewed an'ongoing 2. The coding accuracy. g ' for the TheAMA publishes oflicial guidelines CPTcodingin its newsle$etCodtll C Lini 3. 4. 5. of to halih recordaccording AHIMA s Standards in Codes sequenced thepalient's are EthicalCoding. for by coded all coders all tvpesof of includea sampte rccords A baseline auditshould

Coding TechnoloEly
prlprofession Oneot.the information ofthe health is manyaspects Technology changing of jobs moreefficient in the area codingAs is ln maryare;i whereiihai assi;ted making more xo \ryas technology applied makethecodingprocess information asthe 1980s, earli is The type of tool usedto aid in the codingprocess commoDly effe;dveand efficient. natural lan' including of The to asan encoder. developmeDt otbertechnologies, refeffed impacton thecodingprocess (NLP),will likely haveanevengreater guagcprocessing

Encoders
years gleirter in fbr Encoders ICD wele developed fie early l98us Overthe subsequcnl ls solutionsAn encoder comPuter has sophistication beenbuilt into thesetechnology wer'e develxssign codeslnitially,encoders lo soitwarc helpsthecodinprofessional tbat include encoders however, codesToday, in ICD_g_CM coders assigning opedfor assisting with assislance othercodingsystens. sotlwarevilricsfrom belind thg encoding and The inlbrmatio[ science technology such techniclues as ruleusingexperlsystenr are Someencoders built vendorto vendor. a mereLy automating look-up is nore simplislic, sollwarc systems. Olherencoding based in ICD or olhercodingclassifications index functiorl sinilar to themanual An on depeDding |hevendor' intertypesof iDterfaces, Encodeff havemanydifferent and navigation, inpul mecbanisms asthe totalcomponett screens, of facecanbe defuecl haveaD systems software, Someencoder fie usedto helpthe enduseroperute encoding the As of that prompts coderlhrougha series questions the codelarswers the intedace aDd questions, encoder lbr lhe leads coder1ocodes diagnoses procedures. the codes directlyinto lbesysto Altemalvely,odrerencoders allowcoders inputclassification are codenumbers to lhat a of tem andthengo thLroughseries edit checks ensure only allowable the the also sottwarcsysrcms, encoder prompts coderto review entered, moresophisticated In in lhe sequencing the codes havebeenselected oder to oplimizercimbuNement of lhat to dataquality For exarninclude edit checks ensure Goodencoding software should for be data ple, an inappropriate or combination codes inconsistent should flagged ihe of liDkedto otherinfomation systems Encodingsoftware frequently is coder'sattendon. and soflware billing systems This directlinks to DRG grouper applications. inctudes pafiicularly tool a Theuseofencoders become predominant in theHIM department, has lowaldmorecom_ a movement there even greater is in acute carefacilities. Today, however, plete computerization the coding function using a supportingtechnologycalled naturai of

T,
I

j
arie:a^oC as5'ca-io 5!s'en) \ocabu C,in;.4 document'stoled or laneuaseprocessing, NLP In an NLP sy'tem digllal tcxl Irom onllne b) drre-cLl) lhe 'oflwffe "nd lhen ruromaliiJ",-u,'on .y.r"t is-read :" ii. 3"i""*i""tl $ould record depanmenL t"*' in rn onlineenergency .^rj" a"i.a. r"i.^rtot., Ltt.a.gii"t or rflill(11l oa i'n,"io",".rur'ot"l.ally b) ire NLP islem and lhrorghlhe useolrped codenumbers. 'rrg8e\l pprupriale wouldaulomrlr' ly soltwxre, intellrr;nce r,lronr1[i, ryp. ot 5]'lem $;ll drlrnJli.'"l] chrngelne roleol lhe coderlfom bern! 223

validtor rn rlita ol -NLP tin. int".pii,.,nni t.unslator textual tt,6eing editor, : ,*9i!:]-"i-.:"" ICAC) codrng Assisred Computer and Innd" oirionln"l'tt, outot,ralically electronicrLly

ilutoeJsrly !irn.De rilsks where repetiti\e selting. in is iriusepredominantly theoutpalient assrglllllent chffl reviewrnd,codlng to to mated iree up lhe coder fbcuson motecompler lo use system lsxpecteo grow towrrdthistypeof inform^tion (See figureo.l -i.)Thc trerld Cudtng: orr eccoiiinero .heIHIMa e-HtMWorkCioup Computer-Assi'ted
occurn rhe US Lht and ol andthe udoprion ICD_10_CM ICD_IO_PCS lo As tbe-lrarsition EHRS djl nranv the oftbessvslcnswill in'reasc useof CAC tooisacross ard detailed logjcd struclure h r " n c r e J ' i n 8 l' ) P n i ' r r c r t e'o e r c ' l l b ! 8 l e t ( n rd o r r . - r nl'n - d J i ro n .c sC A c r c c n r r'u r b e ' o m e ' ( A( '" wrc l l c . . J r m r r . Jl . c . d r n gp , n r e * o n r l iL oi ( r l o r r r n d i r ' u n rc ' n i ' r l ' " ' l n B r - ' k s {b)1llos'nsrhernr'rc"'e'v'nl(Jrr'' Ier$orlll "'"...,.t-',r,-r-'',L.:.tDrolision-r'r n p']t"":' -"1: o'', r"'ot .u.t,'".tt'",.u,,iiocrrglrorc-i"r..'r'tmo( Je\cL4sl'll' 'nd.' *nJ\e umc'r' l c ' h n o li v 'u r . l r r r r x r r r ' r . r L\ c r u r r no l o . ' r i C o n ' - r e r _ - ' r ' r e d I r gr " b r ' l J r n g (2004 48G)' proiessionrls A comc.rnd it heralds ncs erafor coding

coding shot trieurc 6.13. Scren of cornpuler"assisted program

224

Chapter 6

Other TechnicalTools
paymen! prospectlve the govemmenl implemenled Medicare the In theearly1980s, federal related to is (PPS) inpatienl Each rciDbumement. patient assigned a diagnosis system for (Seetable6.2) amounl. group(DRG)thatdetermines facililyreimbursgmenl the cases that palients categorized DRGS represent thatiLfemed_ into are ln theDRGsystem, ICD 9-CM diagnoses and treatnent, lenglhof stay. wilh respect diagnosis, to icallysimilar cateSories. placement tbe DRG payment into codesarc usedto determine andprocedufe for seryices hospitals outpatient reimburses DRG system, Medicare Similar to the patients (OPPS), whichcategorizes Prospective PaynentSystem on based the Outpatienl (APCS) Classifications Payment groups. groupsare known as Ambulatory These into the provided thatsetting. Primarily, CPT/ in commonly to accofding thetypesof services of Lorrcct Inent sefvi!es lo HCfCScndi|lg slemI\ ulil.,/ed dctennine sl 13) thathavebeenselecled groupin8s, codeNenterthe codes tn boththe DRG andAPC caseto the program thenassigns palient's a grouper. grcuper The inlo a computer called groupbased the ICD-g-CMaDd/or CFIHCPCS codes (Seetablc6 3 lor the conec! on ofAPC groupings.) irnexample check YourlJndorctandin8l 0,8 (T are Indicrtc whether tbllowing the siatenrcnts !rueor {alse or F) lrrrnrdiorsr
l. _ 2_ md acclrncy reliability in coding An encoder conlputef soliware assirjts determining thal is uscd navig.rtion. inputmechrrrisnrs And ol An inleriace lhe tohl cofiponenl screens, is 10operate encoding softwafe. edil Goodencoding sot'tware should inchrde checks. to soiiware aut()Inrrtically iDtelliSence TheNLF encoding syst6m expert rutilicial uses or .Nsign codenumbers. palienl simil0,wilh groups c$es lhrt e medically DiAgnosis-related crtcgodze fespecl diagnosjs, ment,Andlengtbof stay. to tre

5.

Godingand Corporate Compliance

it industry budgel is Eachyear-, is estimated millionsof dollarsof the U.S.healthcare that practices healthcarc tnd misappropdated because liaudulent of by organizations provid(OIG),thefederal government ers.Through Officeof theInspector the eslablisbes Genelal plans lheheahhcare plan as anDual conpliance for A industry. compliance canbe dcflned ro a planto ensure a facilityis providing billing lbr services that according the laws, and regulations, guidelines and that govetnit. The goal oi theseplansis !o help providers monitorlheir biliing andcodingpraotices prevertfraudandabuse. to History of Corporate Compliance The basislbr proseculion healthcare of is FalseClcxrs Acl liaud and abuse the Fedefal (FCA).This actwdssigned inlo law by Abraham Lincolnin 1863. originalinrcntwas Its private to encouragc actions laken against citizens duringtheCivil Warto report fraudulent IheUnionArny. Underthisact,thegovemment to provethatanirdividualacted witi'r had sDecific intent1odefraud sovernment, the

and Vocabularies C assfcationSysterns Clrnical

225

of Trble 6.2. Example DRCgroupings

Ff 2006 FY 2006 Geonoiric ne'n LOS A.ithmtic meanLOS

DRG I

DRG

DRC

MDC 0l

TIPE

DRGri0e 3 4341

ACE SURG CRANIC1TOMY >I?

1.6 3.5 t2,7 0.0 00

2,2

t0. t

wcc

01
OI

SURC

AGE>I? CRAN]OTOMY

wo cc

r.958'
t.9860

AGE S U R C CRANIOIOMY O-I?

t2.1 0.0

0r
5 0l 0l 01

suRc

VALID NO LONGER

0.0000 0,0000 0,78?8 2.6914

SURC NOLONCERVALID
SURO

0.0
3.0 t.1

CARPALTUNNEL RELEASE

& SURC PERIPH CRANIAL NERV NERVE OTHBR &

6.7

w sYsrPRoc cc

0l

SURC

& PERIPH CRANIAL & NERVE oTHERNERV

r.5635

20

30

wo sYsrPRoc cc
MED t0 tl l2

& DISORDERS SPINAL INJURIES NERVOUS SYSTEM W NEOPLASMS CC SYSTEM NERVOUS WO NEOPLASMS CC DEGENERAT1VE NERVOUS SYSTEM DISORDERS & MUITIPLESCLEROSIS ATAXIA CBREBELLAR INTRACRAN]AL OR HEMORRHAGE INFARCTION CEREBRAL CVA NONSPECIFIC & PRECEREBRAL

t.4045 12222 0.8736 0.89911 2.9 6.2 3,8 5.5

0t
0l 0l

MED MED MED

l3

0l

MED MED

0,857s 1.2;156

5.0
5,8

15

0t

MED

0 942\

3.1

wo occLUsIoN
INFARCT

0l

MED

NONSPECIFIC CEREBROVASCULAR W DISORDERSCC

l.l35l

50

226

Chapter6

Thble6.3. ExampleofAPC groupings

Nationel Unadju5ted Rate

APC

Gmup Title

st
S

Rlative Wight

Unadjustd
4.',16 ILt4 3i . 8 5

0001 LevelI Pholochemotherapy

Bjopsy/ Levcll FineNeedle

0.3998
0.9157

23.19
55.68

7.00

0002

0003 BoneMarow Biopsy/Aspiration T

LevclI Needle Biopsy/ EiceptBoneManow 0004 Aspiratjon Levclll Needle Biopsy/ Ei(cept BoneManow 0005 Aspiration &Dlainagc 0006 LevelI Incision & 0007 LevelII Incision Draimge and 0008 LcvolIII lncjsion Druina8e

2.6156 | t.7'77 t.5834 t.5100

l |.611,1

t59.23

T
'l

r05.76
213.25 89.86
694.59 969.15

22.36 71.59 2t.76

2t . 1 5 12.65
l7.91 138.92

T T T

t6.2953

193.95

the provisions eliminated requirenent thal to the In 1986, FCA wasamended include for the The inteDtto defiaud proven. lawnowhasbecome basis proseculing be thatspecit'ic to prcsent lalseclaimfor payment thegovernmenl prcviders a who knowingly healthcare iD ofcodingthatresults provider a or shows pattern pmctice whena healthca(e Therefbrc, can that and overcharges Medicare Medicaid, provider be prosecuted to pl0ns compliance providers need develop to heafthcare To avoidfrauduleni behaviors, its of tha! ensure eslablishment internalcontlols Since1997,the OIC hasrcleased tbe includjngllospi industry, progmm guidelines segments the heAlthcare of for compliance medicalbilling companies' third-party clinical labora{ories, tals,homehealthagencies, and hospices, nursing homes, physicians'practices. andDME suppliers, Elements of Corporate Compliance programs providers released the OIG to develop by should lhe compliance use Heaithcare that their own compliance prcgrams. The guidelines outlineelements and implement progran a provjders follow.The variouscompliance rcpresent plan that healthcare can guidelines be foundon theOIG Websiteat hhs.gov/oig. can progranN wereoutlinedin basicelements required corporate compliance Several fof published lhe b'edetul RegisProgram in theOIG's"Compliance Guidance Hospitals," fbr 23, in A plan was tzr.on February 1999. supplemental for hospitals published theFelerdl January 31,2005. programs hospitals should include Regirte,'on compliance for Corporate at leastthefollowingseven elemelts: 1. Thedevelopment distribution writtenstandards conduct, wcll as of as and of writtenpolicies procedures promote hospital's to commitment comand that the

svstems aries C Cincalvocabu and assificatlon rn as lo adherence compliance anelemenl . (for example, including by pliance ofpolential aress specific that and managirs employees)and address evaluating cooe processes gamxlgano dnd development \ubmission \uch claim) fraud "s professionals and with financial relationships physicians otherhealthcare (for bodies and offrcer oiherappropriate of 2. Thedesignation a chiefcompliance for with responsibility , charged commitlee) complianae exa[rpleiacorporate program thatreportdirectlyto the and compliance and operaiing monitoringibe CEOandthe goveningbodY and educalion tlarneffective of and 3. Thedevelopment implementation fegular' affected employees for ing programs all and complaints the to suchasA hotline, receive of 4. The maintenance a process, and of complainants to protecl the to ofprocedures protect anonymily adoption from retaliation whistlebloweN rctiv_ of to to of 5. The development a system rcspond allegations 'Inproper/illc8'Ll enrplolee" ag_rnsl c.hon Ji.ciplin-ry ofipproPrirte ilie' rnd uieenforcemenl and statules' regulapolicies, applicable intelnalcompliance who haveviolated progrom requircmenl) heJlthcare trL'n\ fedetfll or and to lechniclues monilorcompliance olherevaluation 6. Theuseof auditsand/or problem arens of assis! the reductjon identified in tlle problems.And systemic of and 7. The invesligatjon renlediation identifled ol or the thataddress nonemployment relenllon sancof policies development tionedindividuals it of oreas compliturce will bc a Eachyear,lhe OIG publishes wolk plzinthal details carelullyirndplirntherr ye;r Facililies should\tudy thrsdocumenl for investigatiDg rhat widr.jdcntred drxt the) are in colnpliance to auditingprojects ensure compli-ance-aDd !"reit arell'.TheolC w6ri phn rbr 2005canbelbundonlinexl oi8 hhsgov/publirirlion(/ pdf orko,.20Plrn kpl:,n/2005/2005%)0u do;s/wof Policies and Procedures fol Corpolate Gompliance at mustbe developed the fAcilitylevcl compliance for and plocechiLes corporate Policies that needto be ot'concem speciic areas The andfor rhe LilM clepartment. OIC ouilines play an acliverole ill the devebpnent in addfessed facilides'policies. 4lM professionals policies and of bothHIM department organizatioD-wide to Sleps Corpofale brief titled"Seven a i999, AHIMA published practice h October briefto develop gurdelines thrsPmcrlce rn use OrganizatioDs should the Complidnce." policies by plaos. recomnended AHIMA, HIM complrrnce As HIM cornpliaDce specitic ensure lhal: andDrocedures shoDld . All rejected are codes revrewcd' aod claimspertai ng to diagnosis procedure se . Proper limely documentation all physician otherprofessional icc' aDd of and prior ro billing. is obrained iicentive . Compensation coders consultants not provide financidl any does and for to codeclaimsimproperly.

227

'r
224
Chapter6

. . . . .

A process in placefor pre-andpostsubmission is leview occuLs. The proper selection sequencing diagnoses and of occurs Thecorect application ofticialcodingrulesandguidelines of potential actual violations. A process exists reporting for and A process in place identifying is codingerrors. for

L I

6.7 ChockYourUnderstanding (T wheiher following the statemenls trueor false or F). are lr$tr&dtdrr lldicate
i.

planstor the established conpliance Thefederal Officeof the lnspectof Geuer.tl heahhcare industr/. False Conpliance Ac! Tlrebasis prosecuting iraud is for healthc.ue andabus theFederal crn prognmsofierguidelires healthcare oryarizations TheOIG compliancc that progranN. lbllow to estabtish lheir inrernal compliance progrnm and A corporate complianoe include devclopnrent inplenlenurlion the should for I alibcted employees. oI cducntio andtraiDirgprograms policies procedurcs rnd fot HIM pfolessionals not involvcd developing are in !oryoratc compliance.

2. -3 . --

5. -

New Directions in Clinical Vocabularies

jncrease, hAs therc bcen siga As lhenulrber sophisticlitionclinicAl and vocabuL||ies of elenrents suu!AnLl nilicantnovement toward research undefstlurdins fundanental in the vocabularie( cla5s,ficarion cndeL\ orc tures oorh rn One ond s)<remsl of themo"tfarsightecl toward Lungurge brirgiDg togedrel varidlsnredical the vocabularjcslheUnifiedMedical is (UMLs) project (NLM). System beingconducted the NatioDal Libraryof Medicine by National Libhry of Medicine UMLS Proiect ThcNLM establishedresearch project 1986. projcclis called U a iD Thislong-mDge thc iledMed..JlL.nguJge Sy.tcr ' UMI S) projecl. Thepuryose ofthe UMLS is to aidin lhe development ofsystems helphealthc|rJc that professionals retdeve and integrate electronic information from a varietyof biomedical sources. UMLS usesthreeknowledge sources makeit easier users link sep nte to for to lnlormauon systenN: . The metathesdurus provides uniformcoilection motethanonehundred a of biomedical,&ealth-related vocabulades, codingsystens, classifications and and linksthedifferent names usedin thevarious vocabulades classificationsand suchasSNOMEDCT,LOINC, andRXNofmIo a common concept. Thespecialist (Forexamlexicon contains synttcticinformation manyterms. for ple,it liststheparlsof speech, various fonnsof a word,andspelling variations o1' thererms witbin UMLS.)

i s C t n i . " \ , o L a o - 1 " ' ea n d C l a s s i f " r . o n S r s r ' n "

229

and objects idelrtifying for a neflrorl provides system categorizing Thesefiantic vadous concepts among therel4tionships

ftal retrielalproblems occurwlcn difl-erent ovelcome sources TheUMLS knowledge beingrlsedin lr variety currently are and terminology sepamt;databases used They are procssing, informa_ and language natural patien! data of applic;;ns, including -nraintains creation, of lhe progrcss thisprojeclon irs <.lescribing factsheets The don';etrieval. NLM Website.

Dvelopmntof the NosologistRole

systensA nosolowith classification lhil ofmedicalscience deals is Nosology thebranch The systerns AHIMA elsssiitcation gistis ;;erson who workswith usinganddeleloplng drrrnatically the role of the coderwill change thal TaskForceenvisions bodingFutures of is primaryrcsponsibility the assigDmenl the At overtf,e nextdecade. present, codefs fo! rcsponsible thedevelopnent, nosologist a In codes. the future,the c;der will become :rnd systems voclbulrlies A peekinto of and maintenance, management classification ot as3n outgrowth thework of the in thistuturerole wasprov;ded thefollowingscenario 2000): Force(Johns Tlrsk CodingFutures
newworldlbr coders lr's 20L0nndd brave and JancSmith.RHIT. CCS, is a healthintbmationtechnician clirhal coderlho Lsrow systcnrJMe Heajtlr ofCommunity deParLment or in eNployed thecunic nosology, classificolion, ond in moreandflofe lutomated the lutuLc codingwouldbeconre sometime ago thar recognized oi knowledge lcxical and undeNilndins broflder th0r;hc couldset 0 bertt job ii shehadI deeper and an and lended eDvirblo her Sh rechnologics medicalvocabuluties continued oducatior dd l rh c p o . r r r o n .o r : l l ew o t k .s r L h o l l e J g u E o h - v eb l c k g r o u n lrl Lh c J r h . i n t o ri.i'a n N challclL e o _nJ (rxlrrr'(\ sc'ence Jl inlormaoc5 ni.xl jcjen-e' conrpurer m<dical nur.rnE rno rndluBcnrcnt. ovcthP' nrAPping vith projecrs associlted mersi g riDd groupworkson vadous nosology Jane's paticnt record, autonureil ofthc computer_blsed to pingcLinicalvocibulolies suppo developmenL ir vocrbuldries usc'n nredical suppon, outco esAnrlysisWithnole dran25 diflerent and decision lnd in ptoblem-resuldng dlPlication difficukyitr u rcmendous teansuc thesysten,overlapping supPort rnd for cafe,rcsearch, decision and trenshtion rtrievalofdaia patient thrl use th comparinlg outputof two systcms group\ cunlnt Prcjeclinvolvcs Thc nosology The grcupwanisto cvnl alc anr.l mrppingclnliculloclbularies. in difelcnLupproaches merging vocabul:rries-LolNcmd how vell these two sysEms initillly maplelms iiom lwo selected can job a does beller i'l mcrging team SNOMEDCT.Jsne's wan$todete nincwhichol thei*o svstens thc developed iniliil the two cunicalvocabularies Jare,whosejobtitle is now clinicalnosologist' oPiioDs 4rrd system she plln In ior .esearch for the compaLhon. prep0ration theanalysis, reviewed lbr sclected bertpossjble lh syslehs thetesr. svsten whether healrh thc Wheothe teln hsslinished testing, will be abteto recommend its il clinicalcon! purcbase it should eilheroflhe two systems ircor?oraLe into theenlerprise'widc and lbr and putingsystem. result, consistent, accuraledala autonoted The idellly, willbe morrcliatrle, systems. decision suppon systens clinicd informarion and thanwharit was l0 ve^rsrgo is Like Jane'sjob, hulh infornationindustry veryditrerent the to tiom invesroa he.lth of Faltrnoling technoiogy feddevelopmen! a conplexwebolplayers, has technological bre.kd orghs who haveanticipaled careteansand fo ardrhinkingorganjzllions oD andaccordingly reengjneeredcapiralize fiem. to clire, billing, tbr codeasignments Patienr has A convergence oflechnology breakthroughs rnade but are codjng specisiists still important. tarhe.than lDd resedcbpurposes essentially aulomotic. datamapPings data quality for confol lnd rendsmd mairtanr assign codes, nowanalyze they coded svslens. fron locabularies clasification to

234

Chaptef6

Check Your Undorsianding 6,8 1nrr,'lldirrrr Indicatewhetherthe following statements true or false (T or F). are l. 2. 3. 4. _ The UMLS project wasiniti ed ro bringrogerher various the medical vocdbutaries. Thercrarhe\ruru\. or rheU\4LSfnowtedge une \ourre\. conHrn\ \)nrdcr.! inibrmation many|erms. for The UMLS knowledge sources cufient]y rre bejngused naturat in languagc processinS. A nosologist's primary.csponsibjiity rhcassignnent is ofdiagnosis codes. In the future, coders will become nosotogists.

5. __

Real-World Case
Cannatural Ianguage proccssing helpfulto outpatient be coden NLp is a supporting ? technologythathasrcached exciting an strgeofdevclopmenl. holdsa greatdealofpromise It for assisting lurthernutomation thc codingprocess. in of Atthough technology ihe holds g.eatpronrise. alsofaces hugechallenge il becausc tbecomplexiiy vnrirbilityof of and human speech. However, promising newNLP producLs beginning emerge ceriain 0re l(J in medical arcnas, suchas energency nedicinc.To valid^te claimsthat an NLp sysrem fie can improvecodilrgaccul.Acy, HealthIifoulation Systems 3M designed performed and a studyof ICD-g-CMandCPT to detefmine how 0 NLp technology system marched up with real'world codeN. To determiDe whethef NLP tutotnated al) systeln asaccurate assigDing and was at ICD CPT codes emergercy to loom records experienced as oodefs, researo-hers-cvaluateci the 328 emefgercy loom charts usingboththe NLp system theexperienced and coders. Thc studyresults indicaEdthatin thespccjnlizedren8of emergeDcy medicine, NLp sys_ the temcoolpared favor bly to uclual coders assigDing andCpT codes. in ICD (Thiscase was adapted fromWarner Since thattime,olherstudies have 120001.) shown rools that utiliziDg NLP hnrehecorrre increosrngl) etlccli!c nlole

Summaty
ln fecenldecads, coding,classification, vocAbulary rnd systems havegrownin impor_ tance. This is cleariD the criticalrole thal codingnow plats in the healihcar.e industry's reimbursement process its uscin lesea(h andqualiwjssurance and efforts. Nomenclatures, classitication systelns, clLnjc:rl dnd vocrbul.rries werecrearcd help to organize healthcare In medicine, nomenclaturea system lislspreferred data. ft is dat necli_ cal.termrnology._A classification system groups together similardiseases procedures and andoiganizes related entitjes easv for rctrieval. Thepurpose useof ctiDjcal and ;lassificarions rodayare va ed. For examDle. DhvsF crin" u:.e clussificulion. l. ICD lo chs\ify Inorb.drry mon"lir; infornriibn-for such aDd statistical p-urpo-\es, indexbospitalrecofilsby disease operations, to rcpo lo and and diagnoses. addition, In clinicalclassiflcations usedin the reporiingandcompilaiion are of healthcarc datato assist evaluating in rnedical careplanning h-ealthcare tbr delivery

Svstems and vocabularles Classification clinica pa) of providers, xnalyzlng ments healthcare pattems careamong of determining systems, \tudrc' relerrch .en cal epidelniolot andclinical hedllhcate icei.!nd conducllng 1n system useto^day, classification the Although ICD-g-CMis perhaps mostprominent in use technicians manyotbeislstems theirdailypraclicesuchasCPT' info;adon health ot development these The vocabularies continued ICD-O-2,DSM, andnursing HCPCS, the ofdescribing the rcflects complexity andvocabularies systems andotherclassification careprocess, medical in must havepollciesand procedures plscethat set Every healthcifeorganizatjon oT the ensurjng conslstency the organlrnd guidelines managing codingprccess fbr the a shouldestabiish monitoring/audlt ;ation's codingoutput.Fu ber, everyorganizalion evelyorgabasis Moreover' on codingaccur3cy a regular program reviewandassess to lts planthct monltors Dllllnganocoolng complisnce shoulddevelop corporate a nization fraudule[tpractices. acti!itiesto preveill on impirct thecodingprocess a are aalvances having lremendous Finally.iechnological prcJecls such irnprctin the future lmPortant today^nd will likely havean evengreater Librirr) of by projectconducted rhe Nationcl System as the UnitiedMedicalLanguage linguage dnd codlng natural coupled with thegrowthandmatulilyof automated Medicine, the processing systems, revolutionize codingfiinction will
Deccmbet Dcl!ing inlo 2004(November CodinS. AHIMA e-HIMWorkCroupon ConpuleFA$isted 75(10)r48A-481t' Astaciari'tr Heatth ltfotuutiattMMaSencht codinS. nnaLof AnEi&4 coirpureFassisred "/, AskedQuestirlsl ANA ComnirteeibLNut$ingPnclice lnlban!tion Iniianrucrure2005.Frequently Itm net/CNPil/HomeStuli/FAQ tionrdlthedc AvAihble online Trnrinologies. Stand0rdized onli|t iiorn about DSM Avrilable Asked A$ociarion2005 Ftequenlly Psychiutric Qucsriotrs Anrericnn clm I30l www.psych.ors/reseurch/doddsm/dsm-inqviaq8 ln!ruirrgproccss' into ofii-rs insishls SNOMED,ICD'g-CM AHIMA prolect Biouch, K.2003(July-Ausus0. 4l'7)ts2-55 Alsocitltit,1'7 Healthkfonnaliu Mana|eftN Jauflt'tlal Anericak 01' 4 Setvicc! 2003(Miv). tllPAA lnlbrftrlion Series: OveNiew Ccnters fbr'Mcdicore Medicaid und MDTCMS. and Elecrolic Tmnslrdions code SeN,L BaliiDore, orline solulionAvriluhle Codiug Processing codcRyi. 2005. Nnnriol Langudge NLP) conputeFAssisEd lt)untutil driveEHRsuccess 2005(April).SNOMEDCT helps Ciannanrelo, nd L. Berkowilz. K., 76(4)166-6'7 AneticoaHa1lthInJarntuliarMuhdeenanAtfl cnttiah Aso.iahan Heu|h |ttb uti.n l\lahasenteDt M.2000.A crystalballforcodi\E. Jaunll olAtherican Johns, 7l(8):26-33 l99l (.lune) NCvH'l /99r' DHHSPublicilionNo (PHS) NllionnlC.!n rieeorVirlllDd Hcllth Sludsrics. pdl irom cdc.go!/nchvdala/ncvhVnchvs90 MD:HHS. Available online 9l-1205 Hy.1Is!ille, CT) in ftelaDo. s ArtibioticAsittunl l nil SNONIED ernntionll, SNOMEDClinicll Teds (SNOMED org onlinelroDrwvwsnomed ie! Adnnnble Clitli.ul Decdi.r,Srrrorl Avoltable Ur.le nedhh proce$ing otrrpltieDt codea?./orlralaJAntetiran ajd WarnefH R.,Jr.2000. Cannatuii lrLnguaee 7I(8):78 8L t{a hation MaMg4ne Asro.iattotr

Fqfroncea