Clinical classification systems and clinical terminologies represent two distinct coding schemes that are used in healthcare. Healthcare terminology and classification systems can be used by consumers, healthcare providers, quality and utilization management personnel, researchers, and other administrative staff (accounting, billing, and coding personnel). It highlights the major events that influenced its development, current status, and future uses. Several classification systems (see Table 5-2) are commonly used in various healthcare settings. health as expanding consciousness a conceptual model of nursing formulated by Margaret A. newman which offers a paradigm based on the view of health as the undivided wholeness of the person in interaction with the environment. © 2019 AHIMA Foundation. To bring order among the various healthcare provision systems, various classification criteria have been proposed. “Payment by Results: Financial Implications of Clinical Coding Errors in Urology.”, Naran, S., A. Hudovsky, J. Antscherl, S. Howells, and S. Nouraei. The ICD-9-CM stands for the International Classification of Diseases, Clinical Modifications. The Systematized Nomenclature of Medicine (SNOMED) is the most widely recognised nomenclature in healthcare. The ICD coding system was originally created to code death certificates, but its use has expanded to encompass a wide range of statistical reporting. Clinical terminology systems as well as clinical classification systems were originally designed to serve different purposes and different users’ requirements. Close Staff Hospital: A closed hospital system is one in which all doctors are on staff, and also doctors that aren't on staff may not have access or privileges at said hospital. Hiring to Succeed. Additional examples can be found in Table 2. No other relevant models can replace the AHIMA’s DQM model in this capacity, making it a long-established health information standard. Furthermore, “the global scope of SNOMED CT reduces geographical boundary effects arising from the use of different terminologies or coding systems in different organizations and countries.”10. Also, ICD-10-CM is now used in place of ICD-9-CM for public health reporting (i.e., reporting the leading cause of death and morbidity on the national level). SNOMED CT is an automated system, which makes it convenient to be used at the point of care for generating clinical alerts and reminders, serve as a part of a clinical decision-support system, and link providers to medical knowledge and current publications that can be used for outcome measurement. In fact, we can think of SNOMED CT as a programing language; users utilize applications that apply SNOMED CT without knowing what is at work in the background. Currency: SNOMED CT in its current form was developed in 2007,50 while ICD-10 was first introduced in 1990s and has been used to collect mortality statistics in the United States. Abdelhak, M,. Information provided by such systems can be used to improve clinical, financial, and administrative performance by enabling effective payment systems, identifying potential fraud and abuse, and ensuring accurate reporting. Every year, it is mission critical for billers and coders to obtain the new versions of both these code sets to stay abreast of any changes to codes in either of these classification systems, otherwise they will risk denied claims and potential compliance issues. “Impact of Coding Errors on Departmental Income: An Audit of Coding of Microvascular Free Tissue Transfer Cases Using OPCS-4 in UK.”, Beckley, I. C., et al. Laboratory and diagnostic care 4. “An Audit of the Nature and Impact of Clinical Coding Subjectivity Variability and Error in Otolaryngology.”, Moar, K., and S. Rogers. In fact, the WHO, together with the IHTSDO, has been working on similar projects that will enable mapping between SNOMED CT and ICD-10 (the WHO version) as well as ICD-11. However, these mapping projects further emphasize the importance of future data infrastructure that encompasses characteristics of both systems to achieve the maximum benefits of information technology in healthcare. In this context, it is critical to distinguish between clinical terminologies and clinical classification systems, identify how both sets of systems are utilized in healthcare settings, and acknowledge individual contributions of each system to providing data infrastructure for clinical as well as administrative data uses in the healthcare delivery system. “A Proposed SNOMED CT Ontology-based Encoding Methodology for Diabetes Diagnosis Case-Base.”, Mikroyannidi, E., R. Stevens, L. Lannone, and A. Rector. The ICF is a multipurpose classification system designed to serve various disciplines and sectors — for example in education and transportation as well as in health and community services — and across Latest News. ICD is the standard international system of classifying mortality and morbidity statistics, and it’s used by more than 100 countries. Classifications are some of the most important, yet least-known products produced by WHO. patient data across the system • The American Health Information Community is aware of these issues as a result of its own investigations and the recent report from the President’s Commission on Systemic Interoperability 2 Healthcare Terminologies and Classification: Essential Keys to Interoperability Disease Groupings: What are They, How are They Used, and How Do They Compare Internationally? Coding using SNOMED CT is always automated: end users cannot view the codes assigned by the system. According to the World Health Organization (WHO), 70% of the world’s health care expenditures are allocated using ICD. Available at, Cornet, R., and N. Keizer. “A Systematic Literature Review of Automated Clinical Coding and Classification Systems.”, Nouraei, S., A. Hudovsky, J. Virk, P. Chatrath, and G. Sandhu. Also, classification systems can be used to support other applications in healthcare, including reimbursement, public health reporting, quality of care assessment… “Towards Converting Clinical Phrases into SNOMED CT Expressions.”, Stanfill, M. H., K. L. Hsieh, K. Beal, and S. H. Fenton. Furthermore, ICD-10-CM/PCS will be needed to constitute the foundation of reimbursement in the United States.102. These instructions are designed for professional coders and therefore make it hard for clinicians to adopt the system for direct care purposes.57–59 (See Table 5. Timeliness: SNOMED CT is designed to be used at the point of care by clinicians, while ICD-10-CM/PCS codes are usually assigned by professional coders after the patient’s episode of care is complete.79–84. Chicago: American Health Information Management Association (AHIMA). A classification is “a system that arranges or organizes like or related entities.”11 Classification systems are intended for classification of clinical conditions and procedures to support statistical data analysis across the healthcare system. SNOMED CT is a standardized healthcare terminology that was originally developed from a pathology-specific nomenclature called Systematized Nomenclature of Pathology. Classification Systems Medical vocabulary is a system of disease names with explanations of their meanings, and a medical classification system is an organization of medical terms into categories. This helps us diagnose disease, and are a great step forward from the four D’s , … “Automated Coding Workflow and CAC Practice Guidance (2013 Update).”, AHIMA. Each system is used for distinct clinical and administrative applications and has its own benefits and potential limitations. Therefore, caution is advised when administrative data are utilized for less common conditions, such as Down syndrome, eosinophilic esophagitis, congenital heart disease, genetic blood disorders, and surgery.66–70. AHIMA Work Group. “Forty Years of SNOMED: A Literature Review.”. For example, ICD-10-CM/PCS data are utilized for clinical documentation improvement initiatives to educate physicians on effective clinical documentation in EHR systems. The current version, ICD-10, features more than 68,000 codes for infections and parasitic diseases, neoplasms, and congenital malformations, as well as diseases of the digestive system, respiratory system, and nervous system. As DVMD President, Annett Mueller summed up, “Classification systems are important tools for the indexing of health information and for investigating specific areas of health. Available at, 54. The U.S. and other countries use the fourth edition and they were designed to provide a uniform data set that could be used to describe medical, surgical, and diagnostic services rendered to patients. Substance abuse treatment 5. The two HHCC taxonomies and their 20 Care Components are used as a standardized framework to code, index, and classify home health clinical nursing practice… Clinical coding constitutes one of the fundamental functions in the field of health information management. However, the first field test of ICD-10-CM was conducted in 2003. However, coding in SNOMED CT is different from conventional coding using ICD-10-CM/PCS. It involves the use of a health record as the source for determining code assignment..”3 Clinical classification systems and clinical terminologies represent two distinct sets of coding schemes that are used in healthcare. ICD-10-CM/PCS can also be used to assess clinical outcomes and improve quality of care provided for individual patients. A critique of both systems was presented in this article using AHIMA’s DQM model, using SNOMED CT and ICD-10-CM/PCS as examples of clinical terminologies and clinical classification systems, respectively. ICD, ICHI or ICF is essential to making non-standardized data available for analysis purposes and health statistics. However, essential elements distinguish a clinical terminology from a classification system. Many people think of primary care, outpatient care, and emergency care when they need an illness managed or are generally not feeling well. On Oct. 1, 2014, ICD-10 was implemented and replaced its predecessor, ICD-9-CM, as the standard coding system for the U.S. See our dedicated pages for more details.. SNOMED CT provides a unified language that can be used as a standard for communication among healthcare providers and across clinical applications. Rather than concluding which system is “best” to accommodate healthcare needs and data structure, a critique of both systems will be presented in this article using AHIMA’s Data Quality Management Model. Why Residency Programs Should Not Ignore the Electronic Heath Record after Adoption, Evidence-based Operations Management in Health Information Management: A Case Study, Developing and Implementing Health Information Management Document Imaging Productivity Standards: A Case Study from an Acute Care Community Hospital, An Exploratory Study Demonstrating the Health Information Management Profession as a STEM Discipline, Use of Health Information Technology among Patient Navigators in Community Health Interventions, Clinical Terminology and Clinical Classification Systems: A Critique Using AHIMA’s Data Quality Management Model. The AMA has implemented the CPT Editorial Panel, which meets three times a year, which reviews and discusses issues that are relevant to any new or upcoming technology and identified problems encountered with any procedure and how it relates to a specific code. In this system, individuals are either covered by their employers, covered by a private policy the policyholder purchases themselves or they go without coverage at all. International classifications are used to standardize health data, and lay the foundation for evidence-based healthcare. El-Sappagh, S., M. Elmogy, A. M. Riad, H. Zaghloul, and B. Farid. Thus, ICD-10-CM/PCS coding is semi-automated at best and requires human intervention to either assign or validate selected codes. CPT codes are five-digit alphanumeric codes and consist of five numbers and occasionally may have four numbers and letter, depending on the type of service. “Synergizing ICD-10: Integrating an ICD-10 Implementation into Other Compliance Programs Will Reduce Costs, Maximize Investments.”. The WHO defines coding as “the translation of diagnoses, procedures, co-morbidities and complications that occur over the course of a patient’s encounter from medical terminology to an internationally coded syntax.”85 In this definition, the WHO acknowledges the capability of the ICD system that is used for clinical coding and classification to enable international comparisons with respect to mortality as well as morbidity statistics. SNOMED CT is defined by the International Health Terminology Standards Development Organisation (IHTSDO) as “SNOMED CT is a comprehensive clinical terminology that provides clinical content and expressivity for clinical documentation and reporting. SNOMED CT is often described as a reference terminology. SNOMED CT and ICD-10-CM/PCS will be utilized as examples of clinical terminologies and clinical classification systems, respectively. If they want more detail, such as what muscle of the heart was involved, they will need SNOMED CT.”101 Therefore, both systems can be used in research and education depending on which degree of specificity is required by circumstances: SNOMED is a better choice for identifying rare diseases, while ICD-10-CM/PCS is more efficient for general reporting, such as collecting the top causes of mortality and morbidity at the national level. Today’s healthcare systems and their many facilities are complex and multi-faceted. The Medicare Severity Diagnosis Related Group (MS-DRG) system constitutes the foundation of Medicare’s Inpatient Prospective Payment System (IPPS), which is used to reimburse acute-care and short-term hospitals for services rendered to Medicare beneficiaries. ), Granularity: SNOMED CT is in general is more specific than ICD-10-CM/PCS.60 Furthermore, SNOMED CT has a unique characteristic that enables extensibility and creation of new concepts (post-coordinated expressions) by end users.61 In contrast, less common diseases in ICD-10-CM are grouped together in “catchall” categories (e.g., J15.8 Pneumonia due to other specified bacteria), which can lead to loss of information.62, 63, Precision: Concepts have the same values in SNOMED CT; studies have shown up to 93 percent precision of SNOMED CT for identifying clinical expressions.64, 65 However, the presence of some codes with unspecified (not specified in documentation) and other specified (present in medical record but not enough details to code it) can affect the ability of the ICD system to collect data related to certain conditions, such as rare conditions. However, because of the substantial differences between these coding schemes, it is not always possible to have one-to-one mapping. On October 12, 2012, OPM’s Dallas Oversight office accepted a classification appeal submitted through the agency on behalf of [appellant’s name]. © 2020 MedicalBillingAndCoding.org, a Red Ventures Company, Everything you need to get started in Medical Billing & Coding. These codes are used in conjunction with CPT (procedural) codes to record services rendered by a provider to a patient and is documented in the medical record and then reported to a payer for reimbursement. A classification system can be less detailed than a clinical terminology.100 Therefore, the lower specificity of ICD-10-CM/PCS is an intrinsic feature rather than a shortcoming; SNOMED CT is too detailed to replace ICD-10-CM/PCS in this context. 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