HTH 1304, Health Information Technology and Systems 1

Course Learning Outcomes for Unit III Upon completion of this unit, students should be able to:

4. Differentiate various health information standards in terms of their ability to support the requirements of a health care enterprise. 4.1 Explain specific health care coding sets used in the nomenclature and classification of medical

diagnoses. 4.2 Outline government regulations regarding health care coding sets.

5. Identify health information technologies necessary for effective data storage and use in health care

organizations. 5.1 Describe the interoperability required in the transmission of diagnostic information.

Course/Unit Learning Outcomes

Learning Activity

4.1 Unit Lesson Chapter 5 Unit III PowerPoint Presentation

4.2 Unit Lesson Chapter 5 Unit III PowerPoint Presentation

5.1 Unit Lesson Chapter 5 Unit III PowerPoint Presentation

Required Unit Resources Chapter 5: Coded Data

Unit Lesson Medical coding is an essential piece of the patient discharge process as it completes one stage of the health care delivery process and gets the ball rolling into the next stage. Coding is defined as the assignment of character values that are grouped in certain ways to identify specific diagnoses and procedures (Davis & LaCour, 2017). While the primary use for medical coding is medical billing, including payment and reimbursement, this coding data can also be used for a multitude of other reasons. Coded information can be used to determine trends in diagnoses that, in turn, help with forecasting and planning. Having this type of information at their disposal, health professionals can strategically prepare to fight off an epidemic or even prevent one from occurring. Not only can medical coding data be used for research, but it can also be used in other nonclinical ways such as measuring outcomes for audit or assessment purposes, reporting required information to accrediting bodies, and/or determining productivity baselines. The American Health Information Management Association (AHIMA) has been a pioneer, not only in the HIM arena but also in medical coding practices. Evidence of this initiative comes in the form of the Standards of Ethical Coding published by the organization in an effort to guide professional coders in the right direction when it comes to correct coding. The Health Insurance Portability and Accountability Act (HIPAA) is also a governing body when it comes to code sets. HIPAA’s Standards for Code Sets puts forth guidelines as to how clinical coded data is transmitted from one entity to another entity. Code set transmissions must be secure, and information must only be assessed by those who will be using the data for meaningful purposes. HIPAA

UNIT III STUDY GUIDE

Classification and Code Sets

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has implemented these regulations to further advance the coding field as well as to ensure that patient’s information is safeguarded and protected as it flows from one institution to the next. Code sets come in two types: nomenclature and classification. Nomenclature medical coding is basically a system of naming health care activities or procedures in order to stay consistent in electronic communication (Davis & LaCour, 2017). Examples of nomenclature code sets would be the Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT). In each of these coding sets, the selected code is related to a specific definition, and no other code will be related to that definition. We will go over a few examples later to show how the coding is unrelated to other codes in that coding set. Classification medical coding would be the opposite of nomenclature as the coding is interrelated and may build on other codes. The task of classification coding is to categorize codes, hence creating a relationship between them. Unlike nomenclature coding, classification code sets have related subcategories and sub-terms which create a sequence that helps coders code more specifically. The International Classification of Diseases (ICD) may be one of the more important coding classification systems that we use in the United States. This classification system can be used to diagnose diseases as well as document and report procedures performed by health care providers. The International Classification of Diseases, Tenth Revision—Clinical Modification (ICD- 10CM) and the International Classification of Diseases, Tenth Revision, Procedural Coding System (ICD- 10PCS) are the two systems used to perform these tasks (Davis & LaCour, 2017). Nomenclature and classification systems have greatly improved the ability of stakeholders to communicate more effectively with each other. This “language” allows for professionals in the health care field to create even more specific code sets regarding certain areas of medicine. An example of that would be the International Classification of Diseases for Oncology (ICD-O) which particularly deals with neoplasms. Hundreds of these coding systems have been developed throughout the world, and the attribute of uniformity is the catalyst. The Healthcare Common Procedure Coding System (HCPCS) is a vital nomenclature coding system used by health care providers and doctors. The task of HCPCS is to code for services, products, and equipment provided by health care institutions to patients for billing and reimbursement purposes. HCPCS is used in outpatient settings such as emergency rooms, rehabilitation clinics, and outpatient surgery centers. This coding system is split into two levels with Level I being the fourth revision of the Current Procedural Terminology (CPT-4). CPT-4, or Level I, uses codes to identify common medical services such as radiology imaging or basic laboratory tests ordered by a physician. CPT-4 coding would also include services or procedures rendered on doctor’s office visits or for any drugs that may be administered. While Level I codes consist of five numerical characters, Level II codes are alphanumeric, consisting of a mix of numbers and letters. Level II, or simply HCPCS codes, are used to report products, supplies, and services not included in CPT (Davis & LaCour, 2017). For example, ambulance transportation for a patient would be an example of coding that does not use CPT-4 but rather would be coded using Level II. The Centers for Medicare and Medicaid Services jointly maintains the HCPCS coding system with the goal of creating a uniform and standardized code set that will ensure interoperability to all who use the system. HCPCS/CPT-4 is updated regularly, usually on a quarterly basis, and communicated through means such as the Federal Register (Centers for Medicare & Medicaid Services, n.d.). The International Classification of Diseases, Tenth Revision—Clinical Modification (ICD-10-CM) is used worldwide, and it is tasked with reporting medical diagnoses and documenting reasons behind patient medical encounters (Davis & LaCour, 2017). ICD-10-CM consists of a three-seven-character system that is alphanumeric, which is helpful if the system needs to be expanded or coding needs to be added. ICD-10-CM is a classification code set, so there are many categories and sub-terms that help physicians and coders be as specific as they can be while diagnosing illnesses and diseases. For example, the ICD-10-CM code for a glaucoma diagnosis is H40. A sub-term that can be used to create a more specified code would be H40.1211 which is the code for a mild stage of low-tension glaucoma in a patient’s right eye. The latter code is much more detailed, which creates better statistical data as well clearer billing and reimbursement.

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The International Classification of Diseases, Tenth Revision, Procedural Coding System (ICD-10-PCS) is used in inpatient settings to code medical procedures (Davis & LaCour, 2017). ICD-10-PCS is a seven- character coding system using both letters and numbers to classify items. There are 17 sections of ICD-10- PCS, each one a procedural category. For example, the radiology section deals with imaging such as X-rays, while the obstetrics and laboratory sections deal with all things pregnancy-related and test-related, respectively. The Systemized Nomenclature of Medicine—Clinical Terms (SNOMED-CT) is a European nomenclature coding system with the goal of assisting in the exchange of electronic health record (EHR) information (Davis & LaCour, 2017). This system contains millions of medical terms which include procedures and diagnostic information that can be directly translated to other coding systems such as ICD-10 or HCPCS. The chart below outlining the diagnostic coding and treatment and/or procedural coding for kidney stones shows how useful SNOMED-CT can be in linking medical terminology:

CODE SET CODE MEANING/DEFINITION

SNOMED-CT 95570007 Kidney Stone (Disorder)

6722002 Nephrolithotomy for removal of calculus (procedure)

ICD-10-CM N20 Calculus of kidney

ICD-10-PCS 0TC1 Extirpation / Kidney, Left

HCPCS S0400 Global fee for extracorporeal shock wave lithotripsy treatment of kidney stone(s)

CPT-4 50060 Nephrolithotomy; removal of calculus

As you can see, the SNOMED-CT coding for kidney stones can be directly related to the ICD-10 and HCPCS coding systems. We can link the ICD-10-CM coding for the calculus of a kidney, which is N20, directly to the SNOMED-CT code for the general medical term for kidney stones, 95570007. Even further, the CPT-4 procedural code for the removal of a kidney stone is 50060, which can be directly linked to the SNOMED-CT code for nephrolithotomy which is 6722002. Think about how helpful this could be for two entities that need to effectively communicate this type of information but have to overcome a language barrier to do so. SNOMEDCT would be critical in this situation as it can make the connection between the two. Two of the more specialized code sets in the health care industry are the National Drug Codes (NDCs) and Current Dental Terminology (CDT) (Davis & LaCour, 2017). NDCs are used to identify drugs used for human consumption in the United States. These codes are updated bimonthly, and they aid in the tracking, distribution, and dispensing of pharmaceutical drugs. These codes are helpful if there is ever a recall on a specific drug. With thousands of drugs in circulation, both generic and non-generic, this is a very important code set for safety in the medication industry. Code on Dental Procedures and Nomenclature or Current Dental Terminology (CDT) defines terms for dental procedures and treatments. The American Dental Association manages these codes, and they are updated biannually.

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The common thread in each of these code sets is the focus of improving and advancing communication within the health care field. Each of the code sets discussed above, whether a nomenclature system or a classification system, were developed for uniformity and increased interoperability across systems. Interoperability is defined as the ability for multiple systems to transmit electronic health information to each other without the user being involved in the translation (Office of the National Coordinator for Health Information Technology, n.d.). Information is automatically converted so that it can be used in the recipient system, increasing efficiency and saving time and effort on the part of the user. There have been many initiatives led by the Office of the National Coordinator for Health Information Technology (ONC) that have improved health information, specifically the adoption of EHRs and the ability for more users to access them. As of today, those efforts have led to roughly 41% of hospitals having access to clinical information from outside entities, but there is still room for improvement (Office of the National Coordinator for Health Information Technology, n.d.). To help continue the development and advancement of interoperability between health data systems, the ONC introduced an interoperability roadmap. This roadmap contains administrative and technical milestones with the goal of strategically planning the future of interoperability with the cooperation of all stakeholders involved. Coded information provides a tremendous benefit to the health information field. We can exchange information faster and more efficiently than ever before, and health care providers now have more access to patient information. As technology continues to increase so will the ability to transmit, manage, and utilize health data, not only for the betterment of the patient but also for the betterment of society as a whole.

References Centers for Medicare & Medicaid Services. (n.d.). HCPCS – General information.

https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html Davis, N., & LaCour, M. (2017). Foundations of health information management (4th ed.). Elsevier. Office of the National Coordinator for Health Information Technology. (n.d.). Connecting health and care for

the nation: A shared nationwide interoperability roadmap. HealthIT. https://www.healthit.gov/sites/default/files/hie-interoperability/nationwide-interoperability-roadmap- final-version-1.0.pdf

Suggested Unit Resources In order to access the following resources, click the links below. The National Correct Coding Initiative (NCCI) was developed by the Centers for Medicaid and Medicare Services with the task of improving and maintaining accurate coding policies. The NCCI is updated annually. The overall purpose of NCCI is to prevent improper coding that will affect payment and reimbursement. Centers for Medicare & Medicaid Services. (2018). National correct coding initiative edits.

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html The Office of the National Coordinator for Health Information Technology (ONC) created an interoperability roadmap that outlines the coordination needed between stakeholders in the exchange of health information. The Office of the National Coordinator for Health Information Technology. (n.d.). Connecting health and care

for the nation: A shared nationwide interoperability roadmap. HealthIT. https://www.healthit.gov/sites/default/files/hie-interoperability/nationwide-interoperability-roadmap- final-version-1.0.pdf

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Learning Activities (Nongraded) Nongraded Learning Activities are provided to aid students in their course of study. You do not have to submit them. If you have questions, contact your instructor for further guidance and information.

• Chapter 5: Competency Milestone and Critical Thinking Questions, pp. 182–183, 185

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