Nicohwilliam – Graduate Assistants

Assignment: Answer Real world cases 5.1 and 5.2 questions; at least one page for each real world case; cite textbook. Please see chapter readings from textbook below

Real-World Case 5.1
The 2015 Edition EHR technology certification criteria state the following:
Smoking status: Enable a user to electronically record, change, and access the smoking status of a patient in accordance with the standard specified.
⦁ 45 CFR 170.315(a)(11). Coded to one of the following SNOMED CT codes:
⦁ Current everyday smoker. 449868002
⦁ Current some day smoker. 428041000124106
⦁ Former smoker. 8517006
⦁ Never smoker. 266919005
⦁ Smoker, current status unknown. 77176002
⦁ Unknown if ever smoked. 266927001
⦁ Heavy tobacco smoker. 428071000124103
⦁ Light tobacco smoker. 428061000124105

Objective: Record smoking status for patients 13 years or older.
Measure: More than 85 percent of all unique patients 13 years old or older seen by the eligible professional or admitted to the eligible hospital’s or critical care hospital’s inpatient or emergency department during the EHR reporting period have smoking status records as structured data.
A quick reference for meeting the smoking status promoting interoperability requirement is ­included in the American Academy of Family Physicians (AAFP) Tobacco and Nicotine Cessation Toolkit. The AAFP supports the incorporation of tobacco cessation into EHR templates (AAFP 2015). The quick reference provides guidance on what should be included in a tobacco cessation EHR template.

Real World Case 5.1

1. Why would SNOMED CT be used to record the smoking status of a patient on an EHR template?
2. Why was ICD-10-CM not chosen as the system to capture smoking status?
3. Review the SNOMED CT codes. Which ones have a namespace identifier and an extension? What part of the identifier is the namespace and what part is the extension?

Real-World Case 5.2
Opioid use is a major concern for healthcare professionals and organizations worldwide. Even governmental agencies are becoming involved. For example, the National Institutes of Health launched the Helping to End Addiction Long-term as a way to speed scientific solutions to curtail the national opioid public health crisis. The accurate identification of opioid use disorder is important to the success of the research that will take place. DSM-5, ICD-10-CM, SNOMED CT, and in the future ICD-11-MMS are all possible ways to identify cases for research.

Real World Case 5.2

1.            Why would DSM-5, ICD-10-CM, SNOMED CT, and ICD-11-MMS be used to record opioid use disorder?

2.             If you were helping with a research study on opioid use disorder and asked to identify what should be included from SNOMED CT, ICD-10-CM, and ICD-11-MMS for opioid use disorder, what would your report say?

Websites may be used to look up opioid use disorder:


3.             Considering the same research study, what would you point out as changes in the classification for opioid use disorder between ICD-10-CM and ICD-11-MMS?

Health Information Management Technology,
An Applied Approach
Nanette Sayles, Leslie Gordon

Copyright ©2020 by the American Health Information Management Association. All rights reserved.
Except as permitted under the Copyright Act of 1976, no part of this publication may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any means, electronic, photocopying,
recording, or otherwise, without the prior written permission of AHIMA, 233 North Michigan Avenue,
21st Floor, Chicago, Illinois 60601-5809 (

ISBN: 978-1-58426-720-1
AHIMA Product No.: AB103118

Clinical Terminologies, Classifications, and Code Systems
Health information management (HIM) professionals play a crucial role in capturing and organizing clinical data. With the adoption of electronic health records (EHRs), organizing clinical data may involve several labels. For example, the Office of the National Coordinator for Health Information Technology (ONC) uses vocabulary (a list of collection of clinical words or phrases with their meanings), terminology, or code set to describe standards to support interoperability (ONC 2018a). Vocabulary is a list or collection of clinical words or phrases with their meanings. Standards organizations may also use the label nomenclature (a recognized system of terms that follows pre-established naming conventions), classification (a clinical vocabulary, terminology, or nomenclature that lists words or phrases with their meanings), or code system (an accumulation of terms and codes for exchanging or storing information). See table 5.1 for general definitions of each label. Nomenclature is a recognized system of terms that follows pre-established naming conventions. Classification is a clinical vocabulary, terminology, or nomenclature that lists words or phrases with their meanings and facilitates mapping standardized terms to broader classifications or administrative, regulatory, oversight, and fiscal requirements. A code is an identifier of data. A code set is any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic or procedure codes, and includes the descriptors of the codes. A code system is the accumulation of terms and codes for the exchange or storing of information.
This chapter discusses clinical terminologies, classifications, and code systems used in the healthcare industry to encode clinical data in a standardized manner. Clinical terminologies are sets of standardized terms and their synonyms that record patient findings, circumstances, events, and interventions with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement. They contain terms and codes just as a code system does. As this chapter will explain, certain clinical terminologies are more appropriate for the collection of clinical data at a granular level (data consisting of small components or details at the lowest level) such as SNOMED CT. Others are best utilized for the ­aggregation of clinical data for secondary data purposes; for example, ICD-10-CM.
In addition, terminologies, classifications, and code systems are a key type of data managed by the data governance function. Understanding their purpose and use is necessary to succeed in managing the usability of the data employed by the healthcare organization.

History and Importance of Clinical Terminologies, Classifications, and Code Systems
Clinical terminologies, classifications, and code systems exist to name and arrange medical content so it can be used for patient care, measuring patient outcomes, research, and administrative activities such as reimbursement. What started as a way to identify causes of death for statistical purposes, expanded to reporting diagnoses and procedures on claims for reimbursement. Today, the electronic health record (EHR) can capture the detail of ­diagnostic studies, history and physical examinations, visit notes, ancillary department information, nursing notes, vital signs, outcome measures, and any other clinically relevant observations about the patient. Figure 5.1 illustrates a comparison of claims data and EHR data and the vast difference in clinical content.

Figure 5.1 What lies beneath?

Source: Shulman and Stepro 2015. Used with permission.

Investigating the reasons for collecting data illustrates the importance of clinical terminologies, classifications, and code systems. If data granularity, or detail, is the goal, then clinical terminologies are the best option. On the other hand, if the objective is aggregate data, then classifications are the better choice. Aggregate data is data extracted from individual health records and may be combined to form deidentified information about groups of patients that can be compared and analyzed. With regards to code systems, some are for the collection of clinical data at a granular level while others are for aggregation. Table 5.2 lists examples of data uses and their data requirements. As the table shows, granular data is needed when the details are key to use whereas aggregate data suits when the combination of data provides information about related entities that is sufficient.

Additionally, primary and secondary data uses are relevant to understanding clinical terminologies, classifications, and code systems. A terminology that allows for the collection of clinical data at a granular level is needed for primary data use such as for clinical decision support. One that aggregates the data will work for secondary data use. An example of secondary data use is the identification of diagnoses and procedures for the purpose of billing and payment. For more information on primary and secondary data, see chapter 7, ­Secondary Data Sources.
The determination of which clinical terminologies, classifications, and code systems are used as the standard is primarily driven by regulation. Standards are critical for creating an interoperable health information technology (IT) environment (ONC n.d.). An interoperable health IT environment is one in which seamless health information exchange is possible across different EHR systems and the information is understood and shared with those in need of it at the time it is needed. Clinical ­terminologies, classifications, and code system standards are one of the ONC’s interoperability building blocks. They support system interoperability by providing the mutual understanding of the meaning of data exchanged between information systems.
Congress creates legislation authorizing the establishment of standards through regulatory agencies. For example, the Electronic Health Record Standards and Certification Criteria Rule defines the standards that must be used for EHR technology to be certified by the authorized Certification Bodies. Included in this rule are the content standards for representing electronic health information such as SNOMED CT for problems and RxNorm for clinical drugs, which will be discussed later in this chapter.

Clinical Terminologies
A clinical terminology is a set of standardized terms and codes for the healthcare industry for use in encoding clinical data. Examples of clinical terminologies include SNOMED CT, Current Procedural Terminology, and various nursing terminologies. Clinical terminologies form the basis of coded data and provide the data structure required for semantic interoperability and health information exchange. Semantic interoperability is the mutual understanding of the meaning of data exchanged between information systems. Health information exchange is when health information is electronically traded between providers and others with the same level of interoperability. Clinical terminologies may also be reference terminologies. A reference terminology in the health information technology (HIT) domain is “a terminology designed to provide common semantics for diverse implementations” (CIMI 2013).

SNOMED Clinical Terms
SNOMED Clinical Terms, or SNOMED CT, is the most comprehensive, multilingual clinical healthcare terminology in the world (SNOMED International 2017a). There is no book of SNOMED CT codes and no coding professional assigns a SNOMED CT identifier. The terminology instead is implemented in software applications where healthcare providers record clinical information using identifiers that refer to concepts that are formally defined as part of the terminology during the process of care (SNOMED International 2017b). It allows for the collection of clinical data at a granular level. For example, at the point of care a physician using an EHR uses a drop-down list to view the clinical terms relevant to their practice and the patient’s problem. While not seen by the physician, the clinical terms have SNOMED CT identifiers attached to them. By selecting the clinical term, the identifier is captured and thereby provides the primary source of information about the patient.

SNOMED CT Purpose and Use
SNOMED CT’s overall purpose is to standardize clinical phrases, making it easier to produce ­accurate electronic health information. Doing so enables automatic interpretation and sharing of clinical information. Semantic interoperability is also possible. (Semantic interoperability is discussed in more detail in chapter 11, Health Information Systems.)
With the consistent, reliable, and comprehensive capture of clinical phrases with SNOMED CT, its uses and benefits are many.
With the SNOMED CT encoded data sent securely during the transfer of care to other providers or to patients, the barriers to the electronic exchange are reduced resulting in improved quality of the information. SNOMED CT coded data combined with other encoded data, such as medication and lab results, have a number of uses including clinical decision support, clinical quality measures, and registries (Helwig 2013). For more information on registries, see chapter 7, Secondary Data Sources. Quality measures are discussed in chapter 18, Performance Improvement.
SNOMED CT is also one of several standards chosen for the entry of structured data in certified EHR systems (ONC 2015). This includes patient problems, encounter diagnosis, procedures, family health history, and smoking status. The National Library of Medicine (NLM) produces the Clinical Observations Recording and Encoding (CORE) problem list subset of SNOMED CT. This subset includes SNOMED CT concepts commonly used for encoding clinical information at a summary level, such as the problem list.

SNOMED CT Content and Structure
SNOMED CT is made up of three main components—concepts, descriptions, and relationships. Each component is assigned a unique, numeric, and machine-readable SNOMED CT identifier (SCTID). The SCTID identifier is a unique integer that includes an item identifier, a partition identifier, and a check-digit. It may also include a namespace identifier when the component originates in an extension. SNOMED International issues a namespace identifier to an organization with the responsibility of creating, distributing, and maintaining a SNOMED CT extension. An extension occurs when the SNOMED CT International release does not contain content needed at the national, local, or organizational level.
The SCTID is nonsemantic; therefore, no meaning is inferable from the numerical value of the identifier or from the sequence of digits. Figure 5.2 provides an example of the SCTID for the concept nosocomial pneumonia found in the international edition and Figure 5.3 shows the SCTID for disorder of right lower extremity found in the US national extension. The partition identifier of 00 and 10 indicates the nature of the component identified is a concept.

Figure 5.2 SCTID for the concept nosocomial pneumonia SNOMED CT International Edition 20180731 release

Source: © AHIMA.

Figure 5.3 SCTID for the concept disorder of right lower extremity US national extension 20180901 ­release

Source: © AHIMA.

Concepts are a unique unit of knowledge or thought created by a unique combination of characteristics. SNOMED CT defines a concept as “a clinical idea to which a unique concept identifier has been assigned” (SNOMED International 2018). Examples of clinical concepts are diagnoses (for example, coronary arteriosclerosis) and procedures (for example, coronary artery bypass grafting). A concept has only a single meaning even though more than one term may be associated with a concept. The SNOMED CT concept definition is a set of one or more axioms, or true statements, that serve as a starting point for further reasoning and arguments (SNOMED International 2017a). The axioms may either partially or sufficiently specify the SNOMED CT concept’s meaning. When the defining characteristics are enough to define the concept in the context of its hierarchy, it is sufficiently defined. In the case of a concept that does not have the required characteristics to distinguish it from similar concepts, it is partially defined; that is, it is a primitive concept. The concept nosocomial pneumonia is sufficiently defined by the following characteristics:
⦁ Nosocomial pneumonia is a healthcare-associated infectious disease
⦁ Nosocomial pneumonia is an infective pneumonia
⦁ Nosocomial pneumonia has the following ­attributes:
∘ Pathological process: infectious process
∘ Associated morphology: inflammation and consolidation
∘ Finding site: lung structure

An example of a primitive concept is unsolved lobar pneumonia. Its characteristics are:
⦁ Unsolved lobar pneumonia is a lobar pneumonia
⦁ Unsolved lobar pneumonia is an unsolved pneumonia
⦁ Unsolved lobar pneumonia has the following attributes:
∘ Associated morphology: inflammation and consolidation

∘ Finding site: structure of lobe of lung

Descriptions are human-readable representations of concepts. A SNOMED CT concept may have multiple descriptions. Each is designated a description type: a fully specified name or a synonym. In SNOMED CT the fully specified name (FSN) is the unique text assigned to a concept that completely describes it, and the synonym is an alternative way to describe the meaning of the concept in a specific language or dialect. More than one synonym may exist. One of the synonyms is noted as the preferred term and is the description or name assigned to a concept that is used most commonly in a clinical record or in literature for a specific language or dialect. In the example of transient cerebral ischemia, the fully specified name is transient ischemic attack (disorder). The term enclosed in parentheses at the end is called the semantic tag. It allows differentiation among concept domains such as ulcer (disorder) from ulcer (morphologic abnormality). Examples of synonyms for transient ischemic attack (disorder) are transient cerebral ischemia, temporary cerebral vascular dysfunction, and transient ischemic attack. In the case of transient ischemic attack (disorder) the preferred term is transient cerebral ischemia for the English language, US dialect.

Relationships are a type of connection between two concepts; for example, a source concept and a destination concept. These relationships between SNOMED CT concepts define them. Structured according to logic-based representation of meanings, they form the poly-hierarchical structure of SNOMED CT. At the top of the ­hierarchy is the root concept. ­Descended from the root concept are specific domain hierarchies. For example, coronary arteriosclerosis belongs to the clinical finding domain hierarchy while coronary artery bypass grafting belongs to the procedure domain hierarchy. Figure 5.4 shows how the concept arthritis of the knee belongs only to the clinical finding ­domain hierarchy.

Figure 5.4 SNOMED CT design

Source: SNOMED International 2017b. Used with permission.

Values of a range of relevant attributes make up the defining characteristics of a concept (SNOMED International 2018). Defining characteristics include the “is a” relationship and defining attribute relationships. The “is a” relationship type indicates the source concept is a subtype of the destination concept. For example, figure 5.4 shows the “is a” relationship type ­indicating arthritis of knee is a subtype of ­arthropathy of knee joint. The defining attribute relationship is not found in all domain hierarchies. For example, the defining attribute relationships for rheumatoid arthritis of hand joint, associated morphology and finding site, are used to associate the source concept rheumatoid arthritis of hand joint to the target concepts of inflammation (associated morphology) and hand joint structure (finding site).

Current Procedural Terminology
The American Medical Association (AMA) owns the copyrights to Current Procedural Terminology (CPT). According to the AMA, “CPT is the most widely accepted nomenclature for the reporting of physician procedures and services under government and private health insurance programs” (AMA 2018). The CPT Editorial Panel in consultation with medical specialty societies represented by the CPT Advisory Committee is responsible for maintaining the terminology.
CPT identifies the services rendered rather than the diagnosis on the claim. The International Classification of Diseases (ICD), which identifies the diagnosis, is discussed later in this chapter. CPT and ICD form units of information about a patient visit in that the diagnosis represented by ICD supports the medical necessity of the service represented by CPT.
CPT is published annually as a print and e-book. It is also available in software applications such as physician practice management systems. Assignment of the CPT code is most often the responsibility of a professional coder based on the healthcare provider’s documentation of the medical services or procedures provided.

CPT Purpose and Use
The purpose of CPT is to provide a uniform language that allows for accurate descriptions of medical, surgical, and diagnostic services. It is designed to communicate consistent information about medical services and procedures among physicians, clinical staff, patients, accreditation ­organizations, and payers for administrative, ­financial, and analytical purposes.
Despite being copyrighted by the AMA, the Health Insurance Portability and Accountability Act (HIPAA) mandates the use of the CPT in healthcare data electronic transactions. HIPAA named CPT (including codes and modifiers) as the procedure code set for all but hospital inpatient procedures. CPT codes are the five-character identifiers that represent the service or procedure the individual receives from a healthcare provider. Two-character modifiers indicate the service or procedure performed has been altered by some circumstance but not changed in its definition. Thus, physicians and hospitals must use CPT to report medical and procedure services performed by physicians and other healthcare professionals to public as well as private insurers.

CPT Content and Structure
CPT includes codes, descriptions, and guidelines and covers the breadth of health services physicians provide. Descriptions for evaluation and management services such as a new patient office visit, anesthetic services, surgical procedures, ­radiology services, pathology and laboratory tests, and medical care are all found in CPT. The Centers for Medicare and Medicaid Services (CMS) categorizes CPT as Level I of the Health Care Common Procedure Coding System (HCPCS) discussed ­later in this chapter.
CPT is divided into categories: Category I, Category II, and Category III. Category I is the major terminology. It contains a description along with a five-digit code for each service or procedure. Two-digit modifiers are available to qualify the service or procedure. For example, the modifier 50 is used to indicate a bilateral procedure. Criteria for inclusion in Category I include the US Food and Drug Administration has approved the service or procedure, many providers in different locations ­perform it, and it is clinically effective.
Category I CPT includes the following six main sections:
1. Evaluation and Management (E/M)
2. Anesthesia
3. Surgery
4. Radiology
5. Pathology and Laboratory
6. Medicine

The following are examples of Category I CPT services along with their identifiers:
33511 Coronary artery bypass, vein only: 2 coronary arteries
71046 Radiologic examination, chest; 2 views
82951 Glucose; tolerance test (GTT), 3 specimens (includes glucose)
90839 Psychotherapy for crisis; first 60 minutes

Category II CPT is used for performance measurement. This category was created to support data collection about the quality of care rendered by coding certain services and test results that ­support nationally established performance measures and have an ­evidence base as contributing to quality patient care. They represent clinical findings or services where there is strong evidence of contribution to health outcomes and high-quality care. The Level II codes are alphanumeric, consisting of four numbers followed by the letter F. The following is an example of a Category II CPT service along with its identifier:
1065F Ischemic stroke symptom onset of less than 3 hours prior to arrival
Category III CPT is for emerging technologies, services, and procedures. They are considered temporary and they may or may not eventually be moved to Category I. Category III codes are alphanumeric, consisting of four numbers followed by the letter T. The following is an example of a Category III CPT procedure along with its identifier:
0345T Transcatheter mitral valve repair percutaneous approach via the coronary sinus
CPT also includes an introduction, an index, and appendices. Within the introduction are section numbers and their sequences and instructions for use of CPT. The index is used to locate a code or code range and is organized by main and modifying terms. Appendices provide information to supplement the main portion of CPT. For example, Appendix A, Modifiers, describes all the modifiers available for use with a CPT code.

Nursing Terminologies
Just as the field of nursing covers a wide range of services, so do the terminologies available to identify those services. The choice of terminology ­depends on the nursing care documented. In addition, some are location specific. For example, the Nursing Outcomes Classification (NOC) may be used to represent the outcomes of nursing interventions in all settings and the Omaha System is used in the home health setting.

Nursing Terminologies Purpose and Use
Nursing terms provide an effective basis for use in contemporary data systems (Warren 2015, 218). The American Nursing Association (ANA) has specific criteria nursing terminologies must meet to be approved. This includes support of all or part of the nursing process such as assessment and ­diagnosis. Several organizations, including universities and associations, are responsible for nursing terminology development and maintenance.

The purpose of nursing terminologies is to represent clinical information generated and used by nursing staff (Warren 2015, 207). Nursing terminologies are designed to communicate consistent information about nursing services for a variety of reasons including directing patient care, measuring progress of treatment, as well as for administrative functions, education, and analytical purposes.
Although there is no mandate to use nursing terminologies, the ANA’s board of directors published a position statement regarding the inclusion of recognized terminologies within EHRs as well as other HIT applications. The ANA indicated support for the following recommendations:
⦁ Plan implementation of terminologies
⦁ Obtain consensus on which terminology to use
⦁ Make education and guidance available to assist with choosing the terminology
⦁ Use SNOMED CT and LOINC for problems and care plans when exchanging data among settings
⦁ An exchange between providers using the same terminology requires no conversion to SNOMED CT or LOINC
⦁ A clinical data repository involving multiple terminologies draws from national recognized terminologies of ICD-10, CPT, RxNorm, SNOMED CT, and LOINC (ANA 2018)

Nursing Terminologies Content and Structure
Each nursing terminology covers content specific to its use. Table 5.3 lists the content coverage of some of the ANA-recognized nursing terminologies.
Table 5.3 Content coverage of ANA-recognized nursing terminologies
ANA-recognized nursing ­terminology
Content coverage

NANDA International
Thirteen domains:
1. Health promotion
2. Nutrition
3. Elimination/exchange
4. Activity/rest
5. Perception/cognition
6. Self-perception
7. Role relationship
8. Sexuality
9. Coping/stress tolerance
10. Life principles
11. Safety/protection
12. Comfort
13. Growth/development

Nursing Interventions Classification (NIC)
Seven domains:
1. Physiological: Basic
2. Physiological: Complex
3. Behavioral
4. Safety
5. Family
6. Health system
7. Community

Nursing Outcomes Classification (NOC)
Seven domains:
1. Functional health
2. Physiologic health
3. Psychosocial health
4. Health knowledge and behavior
5. Perceived health
6. Family health
7. Community health

Clinical Care Classification (CCC)
Two taxonomies:
1. CCC of nursing diagnoses and outcomes
2. CCC of nursing interventions and actions

Omaha System
Three components:
1. Assessment
2. Intervention
3. Outcomes

International Classification for Nursing Practice (ICNP)
Multiaxial representation with seven axes:
1. Focus
2. Judgment
3. Means
4. Action
5. Time
6. Location
7. Client
Source: Matney 2019, TK.

The structure also varies among terminologies. For example, each nursing intervention in the Nursing Interventions Classification (NIC) includes a label name, definition, unique number (code), set of activities to carry out the intervention, and background readings, whereas each nursing outcome in the Nursing Outcomes Classification (NOC) includes a definition, list of indicators for evaluating patient status in relation to ­outcome, a target outcome rating, a place to identify the source of the data, a scale to measure patient status, and a short list of references used in developing the outcome (Matney 2019, TK).

Classifications are key to secondary data use because they aggregate clinical data for healthcare statistics, design payment systems, and determine the correct payment for healthcare services. They also provide data that are used in monitoring public health risks. Information can be obtained from data encoded with a classification to improve clinical, financial, and administrative performance. Some of these classification systems are discussed in the following sections.

International Classification of Diseases, Tenth Revision, Clinical Modification
The National Center for Health Statistics (NCHS) is the governmental body responsible for the maintenance of ICD-10-CM. It originates from the World Health Organization’s International Statistical Classification of Diseases and Related Health ­Problems, Tenth Revision (ICD-10). However, ICD-10-CM greatly expands the classification, resulting in greater specificity and clinical detail.
ICD-10-CM identifies the diagnosis established by the provider. An example is the ICD-10-CM code and the CPT code result (diagnosis of patient and procedure performed) in a package of information about a patient visit performed in the physician’s office. This bundle is an example of aggregate data that can be used for many purposes.

ICD-10-CM can be updated twice a year, in ­October and April, by NCHS. The October update always occurs; the April update occurs when it is necessary for improving the timelessness of data collection. Twice a year the ICD-10 Coordination and Maintenance (C&M) Committee holds public meetings to review proposals for ICD-10-CM revisions. Representatives from NCHS are members of this committee and, based on their advice, the director of NCHS makes the final decisions on ICD-10-CM revisions.
Assignment of the ICD-10-CM code is most often the responsibility of a professional coder based on the healthcare provider’s documentation of the patient’s diagnosis.

ICD-10-CM Purpose and Use
The purpose of ICD-10-CM is to provide a classification of diseases for morbidity. Morbidity is the state of being diseased including illness, injury, or deviation from normal health. It is intended to classify diagnoses established by physicians at the conclusion of a patient encounter.
ICD-10-CM has many uses. All of those identified previously for classifications apply to ICD-10-CM. One use is mandated by HIPAA, which specifies the use of national standards for electronic healthcare transactions. ICD-10-CM (including the official ICD-10-CM guidelines for coding and ­reporting) is named as the standard for diseases, injuries, impairments, other health-related problems, their manifestations, and causes of injury, disease, impairment, or other health-related problems. Thus, healthcare providers must report diagnoses to public as well as private insurers using ICD-10-CM.

ICD-10-CM Content and Structure
ICD-10-CM contains three to seven-character codes and descriptions for patient conditions. This includes symptoms, syndromes, diseases, and other reasons for patients requiring healthcare services. Instructions, referred to as conventions, are also a part of the classification. These are general rules to apply when using ICD-10-CM.
ICD-10-CM is divided into 21 chapters. Many are based on a body system; others are for certain types of conditions such as pregnancy. Within each chapter are blocks of conditions related in some manner, such as a single disease entity, categories, subcategories and, when appropriate, subclassifications. Figure 5.5 displays the blocks for Chapter 4, Endocrine, Nutritional, and Metabolic Diseases, category E11, subcategory E11.2, and subclassification E11.21.

Figure 5.5 Chapter 4, Endocrine, Nutritional, and Metabolic Diseases blocks, category, subcategory, and subclassification

Source: NCHS 2018.

Another component of ICD-10-CM is the alphabetic index. There are two major sections to the alphabetic index—the Index to Diseases and Injuries and the Index to External Causes. Two tables—one for neoplasm and the other for drugs and chemicals—are also included in the index. All content in the index is organized by main and modifying terms. Main terms represent the condition of the patient and modifying terms further explain the condition. For example, failure is the main term and congestive heart the modifying terms for the diagnosis of congestive heart failure.

ICD-10-Procedure Coding System
The Centers for Medicare and Medicaid Services (CMS) is the federal agency responsible for the ICD-10-Procedure Coding System (ICD-10-PCS). It was developed through a contract with 3M Health Information Systems and is being maintained by CMS.
Like CPT ICD-10-PCS identifies the procedure performed by the provider. However, ICD-10-PCS was created as the companion to ICD-10-CM and not as a replacement for CPT. A diagnosis coded in ICD-10-CM code combined with a procedure coded in ICD-10-PCS would be used by a hospital to explain the reason for a patient being admitted and discharged for care and the inpatient procedures performed during the stay. The aggregated data are used to determine hospital payment ­under the inpatient prospective payment system discussed in chapter 15, Revenue Management and Reimbursement.
Updates are possible for ICD-10-PCS twice a year on April 1 and October 1. The April update is available to address new technologies whereas the October 1st update happens yearly. CMS representatives on the ICD-10 Coordination and Maintenance (C&M) Committee provide advice to the administrator of CMS who makes the final decisions on ICD-10-PCS revisions. CMS makes data files for software vendors and publishers to produce online and print ICD-10-PCS products available on their website.
Upon discharge of the patient from the hospital, a professional coder assigns the ICD-10-PCS code based on the physician documentation.

ICD-10-PCS Purpose and Use
The purpose of ICD-10-PCS is to provide a system for classifying procedures performed on hospital inpatients. It provides a unique code for all substantially different procedures, both currently known and those that may be identified at some future date in time.
Uses for ICD-10-PCS include those identified for classifications in general. Just as HIPAA mandates ICD-10-CM, there is also a requirement for ICD-10-PCS. ICD-10-PCS (including the official ICD-10-PCS guidelines for coding and reporting) is the standard for preventive, diagnostic, therapeutic, or other management procedures or other actions taken for diseases, injuries, and impairments on hospital inpatients reported by hospitals. Hospitals are required to use ICD-10-PCS to report procedures to public as well as private insurers.

ICD-10-PCS Content and Structure
ICD-10-PCS contains seven-character codes and descriptions for procedures. Most of ICD-10-PCS describes medical and surgical procedures. The other sections are divided into the following groups:
Medical and surgical-related sections
⦁ Obstetrics
⦁ Placement
⦁ Administration
⦁ Measurement and monitoring
⦁ Extracorporeal or systemic assistance and performance
⦁ Extracorporeal or systemic therapies
⦁ Osteopathic
⦁ Other procedures
⦁ Chiropractic
Ancillary sections
⦁ Imaging
⦁ Nuclear medicine
⦁ Radiation therapy
⦁ Physical rehabilitation and diagnostic audiology
⦁ Mental health
⦁ Substance abuse treatment
⦁ New technology

ICD-10-PCS is made up of a number of parts including tables, an index, and definitions. The tables are arranged in alphanumeric order and are formatted as a grid that lays out the valid combinations of character values for a procedure code. There are two parts to the table. The upper portion lists the first three characters and their definition, and the lower portion contains columns for the remaining four characters. Each column lists the possible options for completing the seven-character code.

Figure 5.6 Example of an ICD-10-PCS table

Source: CMS 2018.

ICD-10-PCS has an alphabetic index organized by two types of main terms. One type is based on common procedure names such as cholecystectomy and the other type on the value of the third character of the seven-character ICD-10-PCS code. The meaning of the third character varies depending on the section. For example, the third character value for the medical and surgical procedure section is root operation or the objective of the procedure. Resection, as shown in table 5.4, is one of the root operations and is listed as a main term in the index.

Another part of ICD-10-PCS is the definitions. Arranged in section order, definitions are tied to the values of characters 3 through 7 of the seven-­character code. Explanations and examples may also be included with the definitions to aid in understanding how the character value is to be applied. To illustrate, the definitions and any associated explanation and examples for the third through fifth characters are shown for T, 0, and 0 in table 5.4.

International Classification of Diseases 11th Revision
The foundation component of the International Classification of Diseases 11th Revision (ICD-11) is a network of knowledge placed into a database. It is from the foundation component that a linearization and country-specific modifications are built. A linearization is a subset of the foundation component; once created the subset becomes the Tabular list. The Tabular list is built for a use case, such as reporting mortality and morbidity or primary care. The entities selected from the foundation become categories that are jointly exhaustive and mutually exclusive of each other. Each category has a single parent and residual categories (other and unspecified) are generated. For example, the International Classification of Diseases 11th Revision for Mortality and Morbidity Statistics (ICD-11-MMS) is a linearization of the ICD-11 foundation component. ICD-11-MMS will replace the World Health Organization (WHO)’s ICD-10. NCHS has not yet decided if a US specific linearization will be created as a possible replacement for ICD-10-CM.
The establishment of a collaborative open development and maintenance process results in the ICD development version being continuously updated. However, WHO plans to produce an annual official release for international mortality and morbidity use. The first version of ICD-11-MMS was made available on June 18, 2018, and is meant to be used in preparation for implementation. The WHO member states agreed to adopt the eleventh revision of ICD-11 at their world assembly in May of 2019 with reporting using ICD-11 to come into effect on January 1, 2022 (WHO 2019).
The advancements in the information technology field and WHO’s intent with ICD-11 to make better use of the digital world may mean the process for ICD-11 code assignment evolves as well. Technology advancements occurring in areas such as artificial intelligence (AI), specifically natural language processing and machine learning, may result in the initial assignment of the ICD-11 code “automatically” based on the healthcare provider’s documentation of the patient’s condition by the time ICD-11 is implemented. An OptumIQ survey of healthcare senior executives on AI concluded three-quarters of healthcare facilities are actively implementing or have plans to execute an AI strategy (Optum 2018).

ICD-11 Foundation Component and ICD-11-MMS Purpose and Use
WHO embarked on the revision of ICD-11 in 2000 with the goal to produce a classification that reflects scientific and medical advances, can be integrated with electronic health applications and information systems, and makes it significantly easier for healthcare organizations to implement. Accessibility and ease of use were important considerations as was instituting a collaborative open development and maintenance process. In addition, WHO wanted to improve links to terminologies such as SNOMED CT and derived and related classifications such as the International Classification of Functioning, Disability, and Health and International Classification of Diseases for Oncology, both of which are discussed the following section.
While ICD’s primary purpose is to classify diseases and injuries, the ICD-11 foundation component’s entities also include external causes, signs, symptoms, abnormal findings, complaints, and social factors found in a wide range of health ­records. ICD use includes mortality, morbidity, ­epidemiology, case mix, quality and safety, and primary care (WHO 2018a).

ICD-11 Foundation Component and ICD-11-MMS Content and Structure
ICD-11-MMS has 26 chapters, one supplemental section, and an extension code chapter. Many of the 26 chapters are the same as in ICD-10. However, new content expands the classification into areas not covered in the past. For the first time WHO includes ancient Chinese Medicine disorders and patterns, which allows for the recording of epidemiological data about these conditions. The supplementary section for functioning assessment is available as well. There are also new chapters for sleep-wake disorders, conditions related to sexual health, and extension codes.
The ICD-11 foundation component includes a uniform resource identifier (URI). This identifier is a unique character string for each entity. For example, the foundation URI for combined diastolic and systolic hypertension is The foundation component allows for an entity to be classified in more than one place, that is an entity may have more than one parent. In the case of influenza, certain infectious or parasitic diseases, lung infections, and infections due to influenza virus are its parents.
ICD-11-MMS contains stem codes and extension codes. A stem code is a standalone code and can be a single entity or a combination of clinical detail (WHO 2018b). An extension code starts with a X, adds detail to the stem code, and must be used with it. Combinations of stem codes or a stem code and extension code(s) result in a string of codes. WHO requires a forward slash (/) or an ampersand (&) and a syntax showing what codes belong together. Code CA40.0Y&XN9YS is the string for Pneumonia due to Legionella pneumophila where the stem code CA40.0Y identifies pneumonia due to other specified bacteria and the extension code XN9YS identifies Legionella pneumophila. The ampersand (&) combines the two. Code BD54/5A11 is an example of two stem codes. This string is for diabetic foot ulcer (BD54) where the cause of the foot ulcer is type 2 diabetes (5A11). A forward slash (/) separates two stem codes.
A code has a minimum of four characters. The first character, either a number or letter, signifies the chapter number. To not confuse an ICD-11-MMS code with one in ICD-10, the second character is a letter. The third character is a number to prohibit the spelling of “undesirable words.” For any character where a letter is an option, the letters “O” and “I” are not allowed to avoid confusion with the numbers “0” and “1.” Some examples of ICD-11-MMS codes and descriptions are MC18 Ocular pain, BA40.0 Unstable angina, and NC72.20 Fracture of neck of femur, subcapital.
Conventions are also a part of ICD-11-MMS. These include instructions such as code also or use additional code. The ICD-11-MMS Reference Guide contains information on the conventions and instructions on how to apply them. Another component of ICD-11-MMS is the alphabetic index, a list of clinical terms (including synonyms or phrases) used to locate the codes or code combinations for conditions.

International Classification of Functioning, Disability, and Health
International Classification of Functioning, Disability, and Health (ICF) is one of the three reference classifications approved by the WHO Family of International Classification (WHO-FIC) Network. A WHO reference classification is a product of international agreements, is broadly accepted for international reporting on health, and may be used as a model for the development or revision of other classifications (Madden et al. 2012). According to WHO, “ICF is the WHO framework for measuring health and disability at both individual and population levels” (WHO 2018c).
ICD is also a WHO-FIC Network reference classification. ICD classifies heath conditions, whereas ICF classifies states of functioning, disability, and health. For example, a patient with a spinal cord injury with moderate impairment with control of voluntary movement would be represented with an ICD code for condition of the patient, spinal cord injury, and an ICF code for the level of functioning, moderate impairment with control of voluntary movement. ICF provides a standard language, terms, and concepts and an organized data structure for health and disability information (WHO 2013).

WHO updates ICF once a year in October. While the application of the ICF concepts and framework in clinical practice is the responsibility of health professionals such as physical therapists, the individual or the individual’s advocate is an integral part of the assessment.

ICF Purpose and Use
WHO specifies four primary ICF purposes:
1. To provide a scientific basis for understanding and studying health and health-related states, outcomes, and determinants
2. To establish a common language for describing health and health-related states to improve communication between different users, such as healthcare workers, researchers, policy makers and the public, including people with disabilities
3. To permit comparison of data across countries, healthcare disciplines, services, and time
4. To provide a systematic coding scheme for health information systems (WHO 2018d)

ICF has a variety of uses including clinical practice, for population-based census or survey data, in educational systems, policy making, and advocacy. Although considered during clinical data content standards discussions, the US has no ­federal mandate that requires ICF be used.

ICF Content and Structure
ICF is both a model and a classification. The ICF model is a nonlinear, systemic, biopsychosocial model consisting of multiple components including Health Condition, Body Functions and Structures, Activities and Participation, Contextual ­Factors (that is, Environmental and Personal Factors), and Umbrella Terms. Functioning is the umbrella term for Body Functions, Body Structures, Activities and Participation. It denotes the positive or neutral aspects of the interaction between the health condition and contextual factors; for example, completing the daily routine. Disability is the umbrella term for impairments, activity limitations, and participation restrictions. It denotes the negative aspects of the interaction between an individual and that individual’s contextual factors. An example is a person with a panic disorder has anxiety, which limits their ability to go out alone, leading to no social relationships.
As a classification, ICF includes four code components—Body Structures, Body Functions, Activities and Participation, and Environmental Factors. The ICF model component health condition is described by ICD-10.

The first level of classification is the chapter and branches are the tiered levels of the classification (Porter 2019, 305). An example of this structure is shown as follows.

⦁ Body Structures (code component)
∘ 7 Chapter 7 Structures related to movement (chapter = first-level classification)

∘ 730 Structure of the upper extremity (first branch = second-level classification)

∘ 7301 Structure of forearm (second branch = third-level classification)

∘ 73010 Bones of forearm (third branch = fourth level of classification) (WHO 2017)

International Classification of Diseases for Oncology, Third Edition
International Classification of Diseases for Oncology, Third Edition (ICD-O-3) is a derived classification of the WHO Family of International Classifications and is based on ICD. A derived classification is one based on a reference classification such as ICD or ICF by adopting the reference classification structure and categories and providing additional detail or through rearrangement or aggregation of items from one or more reference classifications.
Tumor or cancer registries regard ICD-O-3 as their system for classifying the topography and morphology of neoplasms. Topography refers to the anatomical site of a neoplasm’s origin and morphology refers to the structure and form. Specifically, morphology pertains to cell type or histology and the neoplasm’s biological activity or behavior. The common source for the clinical content to be classified with ICD-O-3 is the pathology report.
ICD-O-3 was published in 2000 with corrections added in 2001 and 2003. WHO produced an additional update—ICD-O-3.1—in 2011. Both ICD-O-3 and ICD-O-3.1 are searchable online through WHO’s International Agency for Research on Cancer web page.

ICD-O-3 Purpose and Use
The purpose of ICD-O-3 is to classify diseases for oncology, a branch of medicine that focuses on tumors. Data collected via ICD-O-3 is reported to state, ­national, and North American cancer registries.

The ICD-O-3 data have uses including the ­following:
⦁ Planning and evaluating the patient’s case management
⦁ Administrative information for facility planners, cancer committees, and practitioners
⦁ Developing and evaluating cancer control programs
⦁ Cancer research (NCI n.d.)

ICD-O-3 Content and Structure
ICD-O-3 is a dual classification. It contains a set of codes for topography and morphology of tumors. The site of origin of the neoplasm is captured by the topography code. This code is the same four-character category as in the malignant neoplasm section of the second chapter of ICD-10. The exceptions are those categories that relate to secondary neoplasms and to specified morphological types of tumors. In addition, ICD-O-3 includes a topography for specific types of tumors such as ­reticuloendothelial tumors.

With very few histological types available in ICD-10, ICD-O-3 provides greater detail of the histological classification. The morphology code describes the characteristics of the tumor itself, including cell type and biologic activity. For example, code M8170/3 is a hepatocellular carcinoma where the first four digits indicate the histological term (hepatocellular), and the fifth digit after the slash is the behavior code (malignant). A separate single digit indicates the histological grading or differentiation. Figure 5.7 shows the structure of a complete ICD-O-3 code.

Figure 5.7 Example of the structure of a complete ICD-O-3 code

Source: ©AHIMA

There are five main sections of ICD-O-3 are the following:
1. Instructions for Use
2. Topography-Numerical List
3. Morphology-Numerical List
4. Alphabetic Index
5. Differences in Morphology Codes between the second and third editions.

The Alphabetic Index is used for searching for a noun or adjective to locate the code for topography identified with a leading C and morphology identified with a leading M.

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
The American Psychiatric Association (APA) developed the Diagnostic and Statistical Manual of Mental Disorders (DSM). As the standard medical classification for mental disorders, the fifth edition provides a reliable source of clinical criteria for mental health and medical professionals when establishing a diagnosis. For example, contained within DSM-5 are diagnostic criteria for depressive, anxiety, feeding and eating, and personality disorders.
A clinician with the appropriate clinical training and experience uses DSM-5 to identify mental disorders. ICD-10-CM codes are incorporated into the classification.
APA updates the ICD-10-CM codes for DSM-5 diagnoses yearly and issues other revisions as needed to address advances in the science of mental disorders. Changes are posted when approved on the APA website. Accessible via a link, the documents list updates to reflect changes or corrections, and other information relevant to mental health. The clinician is responsible for diagnosing the mental disorder using DSM-5, while most ­often a professional coder is responsible for ­assigning the ICD-10-CM code based on the documentation of the patient’s diagnosis.

DSM-5 Purpose and Use
DSM-5 fills the need for “a clear and concise ­description of each mental disorder” (APA 2013, 5). It standardizes the clinician’s diagnostic process for patients with mental disorders.
By including the ICD-10-CM codes, the clinician can document mental health disorders for administrative requirements such as requesting payment for psychiatric services or to report public health statistics.
DSM-5 may be used to conduct clinical assessments and to develop a comprehensive treatment plan. It is also used as a standard language for communicating between healthcare providers about mental disorders for a variety of purposes such as research. Although DSM-5 has forensic use, the APA warns there are risks and limitations to using it in this setting, as a clinical diagnosis of a DSM-5 mental disorder does not necessarily meet legal criteria for the presence of a mental disorder. It also does not determine a status such as competency or criminal responsibility.

DSM-5 Content and Structure
DSM-5 contains three sections, an Appendix, and an Index. The first section, DSM-5 Basics, provides an introduction along with instructions on how to use the manual. The APA’s statement regarding forensic use is also a part of this section. Section II, Diagnostic Criteria and Codes, contains the diagnostic criteria, descriptive text, and ICD-10-CM codes.
Section III, Emerging Measures and Models, provides supplemental content that is not required for clinical use but could be helpful to the clinician. Included in this section are proposed mental disorders, which require further research.

Code Systems
Code system is a very broad term. Given its definition at the beginning of this chapter, some of the terminologies and classifications previously covered could also be called code systems. Thus, a code system may have characteristics of a terminology or a classification. Depending on the system, it may be used at the point of care or for secondary data use. Common healthcare code ­systems are addressed in the following sections.

Logical Observation Identifiers, Names, and Codes
LOINC is “a is a common language (set of identifiers, names, and codes) for identifying health measurements, observations, and documents” (Regenstrief Institute n.d.). An observation is a measurement, test, or simple assertion and observation identifiers are the universal identifiers (names and codes) for the observation. An observation may be a test ordered or reported, a survey question, or a clinical document. LOINC provides names and codes for identifying laboratory and clinical variables. For example, the LOINC code 24356-8 and its long text name, Urinalysis complete panel—Urine, describes what was observed. Regenstrief Institute is the organization responsible for the development and maintenance of LOINC. The LOINC Committee, a group of experts organized by the Regenstrief Institute to study available standards, determined no code system available was granular enough for observation identifiers. Thus, LOINC was created to fill this gap.
Regenstrief Institute updates LOINC twice a year in June and December. No book of LOINC codes is produced. Regenstrief Institute releases a number of file formats on its website for downloading. Regenstrief Institute also provides several tools for the industry. For example, it offers a web-based LOINC search application used to explore LOINC and a more extensive resource, Regenstrief LOINC Mapping Assistant (RELMA). The purpose of RELMA is to assist in the mapping of local terms to the universal LOINC codes.

LOINC Purpose and Use
The purpose of LOINC is to standardize names and codes for the identification of laboratory and clinical variables. Settings where LOINC is used include clinical institutions to health systems, information technology vendors, research projects, government agencies, and international e-Health projects (McDonald et al. 2018). Professional societies and insurance companies also use LOINC.
LOINC facilitates the exchange of data between diverse electronic systems including the clinical laboratory information management and the EHR. This clinical data can then be used for clinical care and research. Another use is in outcomes management where the clinical data are examined to study the outcome and improve care.
LOINC is also one of several standards chosen for the entry of structured data in certified EHR systems (ONC 2015). This includes using LOINC in a number of situations such as reporting clinical lab test results and vital signs per the Common Clinical Data Set discussed later in this chapter. Other requirements include exchanging patient summaries at transitions of care, using and exchanging social, psychological, and behavioral data, and reporting results to cancer registries and public health agencies for electronic quality measure reporting, patient assessment instruments required in post-acute care settings (Vreeman 2019). Having a structured format for laboratory test information in certified EHRs enables the exchange of data for use in clinical care and research.

LOINC Content and Structure
There are two major groups of LOINC content—laboratory and clinical. The laboratory piece includes just as the name suggests: laboratory tests such as chemistry, urinalysis, serology, and toxicology. For the clinical piece LOINC, the scope is broad. Names and codes are available for observations like vital signs, obstetric ultrasound, radiology studies, respiratory therapy, nursing, clinical documents, and patient assessment instruments to name a few.

The fully specified name of an observation is consists of the following five or six main parts:
1. Component analyte
2. Kind of property
3. Time aspect
4. System
5. Scale
6. Method (only used when different methodologies significantly change the interpretation of the results) (McDonald et al. 2018)

For example, a 12-hour creatinine clearance test breaks down into the following parts:
⦁ Component/analyte: creatinine renal clearance
⦁ Kind of property: Volume rate (VRat)
⦁ Time: 12 hours
⦁ System: Urine and serum/plasma
⦁ Scale: Quantitative
This test can be described formally with the ­following syntax:
Creatinine renal clearance:VRat:12H:Ur+Ser/Plas:Qn
In LOINC, each lab test is assigned a unique permanent code. The code identifies the test results in electronic reports in clinical laboratory information management and EHR systems, thereby facilitating data exchange for use in clinical care, quality measurement, and research. The code for a 12-hour creatinine clearance test is 2163-4.

Healthcare Common Procedure Coding System Level II
HCPCS consists of two code systems: Level I and Level II. Level I includes CPT, discussed previously. HCPCS Level II standardizes the reporting of professional services, procedures, products, and supplies. CMS publishes and maintains HCPCS Level II. One section within HCPCS Level II, the Dental Codes, or D codes, are a separate category and are published by the American Dental Association, not CMS.
CMS requires physicians to use HCPCS Level II to report services provided to Medicare and Medicaid patients. Hospitals must report ambulatory surgery services, radiology, and other diagnostic services using HCPCS Level II.
CMS updates HCPCS Level II quarterly on January 1, April 1, July 1, and October 1. A professional coder assigns the HCPCS Level II code based on the physician documentation.

HCPCS Purpose and Use
The primary purpose of HCPCS Level II is to meet the operational needs of Medicare and Medicaid reimbursement programs. Thus, as expected, HCPCS Level II is required for reimbursement of ambulatory services provided in healthcare settings. This includes physician and hospital outpatient reimbursement. Other uses of the code system include benchmarking, trending, planning, and measurement of quality of care.

HIPAA mandates HCPCS Level II as the standardized coding system for describing and identifying healthcare equipment and supplies in healthcare transactions that are not identified by the HCPCS Level I, CPT codes. Thus, healthcare providers must report these services to public as well as private insurers, using HCPCS Level II.

HCPCS Content and Structure
Level II of HCPCS contains products, supplies, and services. Included in HCPCS Level II are ambulance services, drugs, and durable medical equipment, prosthetics, orthotics, and supplies. Modifiers are used with HCPCS Level II codes to explain various circumstances of procedures and services. Modifiers are also used to enhance a code narrative to describe the circumstances of each procedure or service and how it applies to an individual patient. In some situations, insurers instruct providers and suppliers to add a modifier to provide additional information regarding the service or item identified by the HCPCS Level II code.

HCPCS Level II is divided into the following chapters:
⦁ A Codes: Transportation Services including Ambulance, Medical and Surgical Supplies, Radiopharmaceuticals, and Miscellaneous
⦁ B Codes: External and Parental Therapy
⦁ C Codes: Outpatient Prospective Payment System (Temporary)
⦁ D Codes: Dental Procedures
⦁ E Codes: Durable Medical Equipment
⦁ G Codes: Procedures/Professional Services (Temporary)
⦁ H Codes: Alcohol and Drug Abuse Treatment Services
⦁ J Codes: Drugs Administered Other than by Oral Method
⦁ K Codes: (Temporary Codes)
⦁ L Codes: Orthotic and Prosthetic Procedures and Devices
⦁ M Codes: Medical Services
⦁ P Codes: Pathology and Laboratory Services
⦁ Q Codes: (Temporary)
⦁ R Codes: Diagnostic Radiology Services
⦁ S Codes: Temporary National Codes (Non-Medicare)
⦁ T Codes: Temporary National Codes
⦁ V Codes: Vision and Hearing Services
The index for Level II codes lists terms alphabetically. Drugs are not included in the index but are found in their own table.

RxNorm is both a standardized nomenclature for clinical drugs and a semantic interoperability tool. The NLM, an institute of the National ­Institutes of Medicine, is responsible for the maintenance of RxNorm. The nomenclature is recognized as a standard for exchanging clinical drug information.
RxNorm normalizes names and unique identifiers for clinical drugs and links its names to the varying names of drugs present in many different vocabularies within the Unified Medical Language System (UMLS) Metathesaurus (NLM 2018a). A normalized name in RxNorm is the ingredient, strength, and dose form for a drug.
RxNorm is updated weekly and there is a monthly full release update. The package includes the standardized nomenclature for clinical drugs and a tool for supporting semantic interoperation between drug terminologies and pharmacy knowledge base systems (Meredith 2019, 237-238). NLM also provides several tools for the industry including a web-based RxNorm browser application called RxNav.

RxNorm Purpose and Use
RxNorm’s purpose is to allow computer systems to efficiently and unambiguously communicate drug-related information between hospitals, pharmacies, and other organizations (NLM 2018b). Its objective is to normalize names of generic and branded drugs and attach a unique identifier to that name.
Common RxNorm uses include the following:
⦁ Support interoperability during e-prescribing and formulary management
⦁ Communication between hospital, pharmacy, and other organizations’ computer systems, for order entry and analytics and for managing a medication list
⦁ Development of an allergy value set to support effective and interoperable health information exchange (Meredith 2019, 237-238)
RxNorm has been named as the standard for a number of governmental programs. This includes medications for the entry of structured data in certified EHR systems under the Meaningful Use (now called the promoting interoperability program) (ONC 2015). RxNorm is also the standard for medication and medication allergy reporting per the Common Clinical Data Set discussed later in this chapter. The Merit-Based Incentive Payment System e-prescribing measure lists RxNorm as the standard for medications.

RxNorm Content and Structure
The drug name and all of its synonyms represent a single concept, which is assigned an RxNorm concept unique identifier (RXCUI). Figure 5.8 shows the RxNorm graph for an amoxicillin 400 mg chewable tablet. This display shows a text string search using the classic view. At the top after the description is the RxCUI, 308188. On the left is the ingredient (amoxicillin), ingredient plus strength (amoxicillin 400 mg), and ingredient plus strength plus dose form (amoxicillin 400 mg chewable tablet). The combination of ingredient plus strength plus dose form is known as a semantic clinical drug term type. At the bottom are windows displaying the clinical dose form group (bottom left) and dose form group (bottom middle).

Figure 5.8 RxNorm graph for amoxicillin 400 mg chewable tablet

Source: NLM 2019. Created from publicly available data from the U.S. National Library of Medicine (NLM), National Institutes of Health, Department of Health and Human Services.

Clinical Terminologies, Classifications, and Code Systems Found in Health Data and Information Sets
There are many reasons for forming a data set, a list of recommended data elements with uniform definitions. One reason might be to collect statistical data for reporting to national and state ­registries (discussed in more detail in chapter 7, Secondary Data Sources). Other purposes of data and information sets are to gather data for clinical decision support and for computation and reporting of clinical quality measures (discussed in more detail in chapter 18, Performance Improvement). Many of the data elements contained in a data and information set are now captured electronically when data documentation is done at the time of care.
Data and information sets may come from federal data reporting requirements, such as Meaningful Use (now called the promoting interoperability program), and others from public initiatives related to standardized performance measures. (Meaningful use is discussed in chapter 16, Fraud and Abuse Compliance.) Data sets may be formed for such activities as research, clinical trials, quality and safety improvement, reimbursement, ­accreditation, and exchanging clinical information (Giannangelo 2007). Some of these data sets are listed as follows.

Outcomes and Assessment Information Set
The Outcomes and Assessment Information Set (OASIS) is a standardized data set designed to provide the necessary data items to measure outcomes and patient risk factors of Medicare beneficiaries who are receiving skilled services from a Medicare-certified home health agency. According to CMS, “OASIS data items address sociodemographic, environmental, support system, health status, functional status, and health service utilization characteristics of the patient” (CMS 2012).
OASIS has undergone several updates and refinements. OASIS-D version is the version of the OASIS data set that went into effect on January 1, 2019. It is the core data item set for collection on all adult home health patients whose skilled care is reimbursed by Medicare and Medicaid with the exception of patients receiving pre- or postnatal services only. Only a registered nurse (RN) or any of the therapies (physical therapist [PT], speech-language pathologist/speech therapist [SLP/ST], occupational therapist [OT]) can conduct the comprehensive assessment and OASIS data collection (CMS 2019).
A data collection instrument containing the data elements is used by those qualified to do so at various times such as the start of care or upon discharge from home care services. Submission of OASIS data is a CMS requirement if the agency participates in the Medicare program. The data are used in a variety of ways such as the assessment of the patient’s ability to be discharged or transferred from home care services or the creation of patient case mix profile reports used by state survey staff in the certification process. The CMS Home Health Compare website’s information on home health agency process and improvement outcome measures is based on OASIS data submitted by home health agencies to state repositories. Medicare provides this information to anyone who may have an interest in comparing home health agency ­performance.

Healthcare Effectiveness Data and Information Set
The Healthcare Effectiveness Data and Information Set (HEDIS), sponsored by the National Committee for Quality Assurance (NCQA), is designed to collect administrative, claims, and health record review data. HEDIS contains more than 90 standard performance measures. Included are data ­related to patient outcomes and data about the treatment process.
NCQA collects the data from health plans, healthcare organizations, and government agencies. HEDIS survey data and protocols standardize data about specific health-related conditions or issues to evaluate and compare the success of various treatment plans. These data form the basis of performance improvement (PI) efforts for health plans. HEDIS data also are important in the creation of physician profiles for use in positively shaping physician practice patterns by showing comparative clinical performance information to encourage quality improvement or utilization ­adjustments.
Once the standardized HEDIS data elements from health records are gathered, these data are combined with enrollment and claims data and ­analyzed according to HEDIS specifications. Healthcare purchasers and consumers can use the information to compare the performance of managed healthcare plans to help decide which plan to contract with or enroll in.

Uniform Hospital Discharge Data Set
The Uniform Hospital Discharge Data Set (UHDDS) is required by Department of Health and Human Services (HHS). This core set of data elements is collected by acute-care, short-term stay (usually less than 30 days) hospitals to report inpatient data elements in a standardized manner. It was developed through the National Committee on Vital and Health Statistics (NCVHS).
The 837I, the institutional standard healthcare claim format for electronic healthcare transactions, and Form CMS-1450, also known as the Uniform Bill UB-04, for paper claims, are the instruments for collecting UHDDS data elements. When diagnosis-related groups (DRGs) were implemented, UHDDS definitions were incorporated into the inpatient prospective payment system (PPS) regulations. For additional information on DRGs and the inpatient PPS, see chapter 15, Revenue Management and Reimbursement.
The UHDDS lists and defines a set of common data elements for the purpose of facilitating the collection of uniform and comparable health information from hospitals. Contained in the UHDDS’s data dictionary are the definitions of the core data elements to be collected along with each data element’s guidelines for use. For example, the UHDDS data element principal diagnosis is defined in the data dictionary as the condition, after study, to be chiefly responsible for occasioning the admission of the patient to the hospital for care. This element and its definition are used to determine a DRG.

Common Clinical Data Set
The Office of the National Coordinator for Health Information Technology (ONC) established a common set of data types and elements and associated standards for use across several certification criteria. The Common Clinical Data Set (CCDS) is the combination of these common sets of data types and elements and associated standards used across several certification criteria. The CCDS is used across inpatient and ambulatory care settings. Some but not all data types or elements have a standard attached to them. An example of a data element with a specified standard is smoking status. It must be reported with one of the following SNOMED CT identifiers:
Current everyday smoker. 449868002
Current some day smoker. 428041000124106
Former smoker. 8517006
Never smoker. 266919005
Smoker, current status unknown. 77176002
Unknown if ever smoked. 266927001
Heavy tobacco smoker. 428071000124103
Light tobacco smoker. 428061000124105
Released as a draft, the U.S. Core Data for Interoperability (USCDI) in meant to help achieve the goals in the 21st Century Cures Act. The USCDI takes the CCDS and adds clinical notes and provenance to the list of data classes. Table 5.5 lists the draft USCDI data classes, which include the CCDS.

Table 5.5 USCDI version 1 data classes
1. Patient name
2. Sex (birth sex)
3. Date of birth
4. Preferred language
5. Race
6. Ethnicity
7. Smoking status
8. Laboratory tests
9. Laboratory values/results
10. Vital signs
11. Problems
12. Medications
13. Medication allergies
14. Health concerns
15. Care team members
16. Assessment and plan of treatment
17. Immunizations
18. Procedures
19. Unique device identifier(s) for a patient’s implantable device(s)
20. Goals
21. Provenance
22. Clinical notes
Source: © AHIMA

Database of Clinical Terminologies, Classifications, and Code Systems
The number of clinical terminologies, classifications, and code systems in healthcare has grown substantially over the past few decades and some that have been around for several years have undergone revisions and updates expanding their size. Although consolidation in some instances may occur in the future, requirements for use are not limited to just one. With so many available and some of them being quite large, a centralized location is needed to maintain consistent terminology for implementation and use. One such centralized location of health and biomedical terminologies and standards is the Unified Medical Language System (UMLS).
Having access to terminologies, classifications, and code systems from a single source is made possible through the efforts of the NLM via the UMLS. According to the NLM, “the UMLS ­integrates and distributes key terminology, classification and coding standards, and associated resources to promote creation of more effective and interoperable biomedical information systems and services, including electronic health records” (NLM 2016a).
The UMLS is a multipurpose resource. It contains the Metathesaurus, Semantic Network, and SPECIALIST Lexicon and Lexical Tools, which make up the UMLS Knowledge Resources. In addition, the UMLS Terminology Services (UTS) provides UMLS access. The Metathesaurus contains the codes and terms from over 200 terminology, classification, and coding standards. Those found include terminologies designed for use in EHR systems (for example, SNOMED CT), disease and procedure classifications used for statistical reporting and billing (such as ICD-10-CM and HCPCS), and code systems such as LOINC. The UTS is a set of web-based applications that serves as the gateway to the UMLS Knowledge Sources and the site to download the UMLS data files.
The uses of UMLS are the following:
⦁ Linking health information, medical terms, drug names, and billing codes across different computer systems such as between the physician, pharmacy, and insurance company
⦁ Coordinating patient care among different hospital departments
⦁ Searching engine retrieval
⦁ Data mining
⦁ Reporting public health statistics
⦁ Researching terminology (NLM 2016b)

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