Unit 5 Ch 6: Nomenclatures and Classification Systems Tuesday, April 5 th at 8PM EST

1. Unit 5Ch 6: Nomenclatures and Classification SystemsTuesday, April 5th at 8PM EST HS 410 - 01Adrienne Palmer, BSPH, MHA, FACHE

2. Medical communications • Medical language • Greek and Latin derivations • Eponyms • Modern words • Overtime changes occur

3. Languages • Essential for accurate and consistent indications • Vocabulary • Clinical vocabulary • Nomenclature or terminology • Clinical terminology • Importance of standardization: • It is difficult to communicate electronically if variances in meaning exist.

4. SNDO • Standard classified nomenclature of disease (SNDO) • Published by the American Medical Association in 1933 • Classifies diagnostic terminology in order of localization (site) and etiology (Cause) • Use through 1961, then deemed to simplistic

5. SNOP • Systematized nomenclature pathology (SNOP) • Published by the American College of pathologists • classifies pathological specimens • Use since 1965, but its use gradually diminished as it did not cross fields of specialization

6. SNOMED • Systematized nomenclature of medicine (SNONET) • Published at American College of pathologists in 1977 • Expansion of SNOP • Crosses fields of specialization • Classifieds in multiple ways • Can be used with computers

7. CPT • Current procedural terminology (CPT) • Published by the American Medical Association • Conference of listing a medical terms and codes used to designate diagnostic and therapeutic procedures • Can be used with computers

8. Electronic communication • Unified medical language system • MEDLINE • MEDLARS • MeSH • UMLS purpose: • Helps computers understand medical meaning; therefore providers can retrieve biomedical information from various sources, including EMRs

9. Knowledge sources • UMLS Metathesauras – uniform, integrated distribution format • SPECIALIST lexicon – syntactic information for many terms, component words, and English words not in metathesaurus • UMLS semantic network – information about types or categories of meta-thesaurus concepts and relationships • Updated regularly • Available to the public at no cost

10. Classification systems • Taxonomies • Coding • ICD ( international classification of diseases) • ICD-9-CM • ICD-10

11. Updating the ICD • NCHS ( national Center for health statistics) • CMS ( centers for Medicare and Medicaid services) • American Hospital Association • American health information management Association

12. Coders • Apply classification systems to data • Must possess extensive knowledge of the number of related areas • Biomedical sciences • Information technology • Healthcare data content, structure, and systems • Reimbursement methodologies

13. ICD-9-CM • Volume 1 – tabular numerical listing of diagnosis codes • Volume 2 – alphabetic listing of diagnoses • Volume 3 – both tabular and alphabetic listings of procedures that are primarily used in a hospital setting • E-codes and V-codes

14. CPT • When a practitioner does when providing a performing medical services • Evaluation and management • Anesthesia and surgewillry • Pathology, laboratory, and radiology • Medicine • Can be complex and requires coder skills

15. DRGs • Diagnosis – related group (DRG) • In 1982, U.S. Congress passed TEFRA • In 1983, CMS introduce the PPS for inpatient hospital services • Medicare adopted the DRG model developed by Yale University to make PPS work

16. Role of DRGs • 1. Evaluate quality of care: Classify hospital stays in terms of what was wrong with the patient (major diagnosis) and what was done for the patient (resources used) • MDC– Major Diagnostic category • 25 MDCs cover over 500 diagnoses • 2. Calculate reimbursement: Reimbursement on these DRGs is on a flat rate basis • Adjustments on an annual basis • Adjustments for cost outliers, patient transfers, capital costs, and medical education • 3. Evaluate utilization of services

17. DRGs • Statistically consistent – patients grouped in a particular DRG consume similar amounts of resources as measured by length of stay and cost • Medically meaningful – patients grouped in a particular DRG possess similar clinical conditions or treatment

18. DRGs • Medicare PPS has been expanded • SNF PPS • OPPS • APC • HH PPS • HHRG • IRF PPS • CMG

19. HIM transformation • PPS and DRG have major impact • Becomes more complex, ties coded diagnosis and procedure to amount reimbursed and impacted focus on ethics and compliance. • Nosologists • Encoders • Groupers • Optimizing programs • Natural language processing encoding systems • Ethics and up-coding • Coding compliance program to prevent healthcare fraud and abuse

20. Other classification systems • SNOMED • CPT • HCPCS • RBRVS (resource-based relative value scale) • DSM-IV

21. Other classification systems • Classification systems for mental retardation or developmentally disabled • Nursing • Oncology • Injury, disabilities, and handicaps • Dental • Prescription drugs • Alternative billing codes (ABC) • Others address multiple specialties

22. Emerging issues • Case mix – type and volume of patients a healthcare organization treats. • Case mix management and analysis • Automation and impact on coders – potential for off-site coding and reduced costs; more of a oversight and quality assurance role for coders • Clinical data representation • Data mapping

23. Questions?