Medical classification coding vs clinical terminology coding

MEDICAL CLASSIFICATION CODE VS. CLINICAL TERMINOLOGY CODE

Dr SB Bhattacharyya

MBBS, MBA. FCGP

Member, National EHR Standardisation Committee, Moh&FW, GoI

Member, Health Informatics Sectional Committee (MHD-17), BIS

Hony. State Secretary (2015), IMA Haryana

President (2010 – 2011), IAMI

RECORDS – WHY KEEP THEM?

• For reuse

• As a source of historical data & information

• Information exchange among providers

• To anticipate future health problems

• As a record standard preventive measures

• To identify deviations from the expected

• As basis for clinical research – trials and observational

• As legal evidence

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Dr SB Bhattacharyya©

WHY CODE?

• Computers hold information as sequences of binary bits and work by matching strings all of which need precisely coded data

• Codes are needed and used by computers, not humans

• These are a sequence of symbols, usually digits or letters, which designate an object or concept for identification or selection purposes and is just an alternative name for something, an identifier, designed for computer processing

• All free-text data needs to be redacted during anonymisation/de-identification process, not the coded ones


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CLASSIFICATION & TERMINOLOGY: APPLES AND ORANGES OR CHALK

AND CHEESE?

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Dr SB Bhattacharyya© : Images as sourced from Internet

CLASSIFICATION & TERMINOLOGY SYSTEMS

Classification Systems

• Semasiological or meaning-based approach to building the code system

• Starting point is the word (term)

• Studying a term, the lexicographer ponders on its many meanings or the different concepts it reflects, i.e. the term’s point-of-view

Terminology Systems

• Onomasiological or concept-based approach to building the code system

• Starting point is the concept

• Studying a term, the terminologist ponders on the various terms that could best reflect a particular concept, i.e., the conceptual point-of-view

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POINTS OF DIFFERENCE


• Codes specific data items, e.g.,

• Diseases & diagnosis (ICD, ICD-O, DRG, etc.)

• Lab reports (LOINC)

• Procedures/services – for billing (CPT)

• Pharma products (RxNorm, ATC)

• Combination of codes required to query several items simultaneously

Terminology Systems

• Codes the entire domain, e.g. SNOMED CT covers terms from abscess to zygote

• Ability to function as a common reference code system that maps to others

• Using compositional grammar complex concepts can be coded and queried

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APPLICATION AREAS


• Statistical analysis

• Administrative

• Performance

• Activity Based Analysis

• Epidemiological studies

• Billing & Accounting

• Reporting

Terminology Systems

• Semantic interoperability

• Detailed analysis including those that classification can do

• Predictive analytics

• Personalised medicine

• Robust support for clinical trials and observational research

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EXAMPLES OF MEDICAL CLASSIFICATION CODE SYSTEMS – ICD

• ICD-10 Version : 2016

• I Certain infectious and parasitic diseases

• II Neoplasms

• III Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism

• IV Endocrine, nutritional and metabolic diseases

• V Mental and behavioural disorders

• VI Diseases of the nervous system

• VII Diseases of the eye and adnexa

• Certain infectious and parasitic diseases

• A00-A09 Intestinal infectious diseases • A00 Cholera

• A00.0 Cholera due to Vibrio cholerae 01, biovar cholerae

• A00.1 Cholera due to Vibrio cholerae 01, biovar eltor

• A00.9 Cholera, unspecified

• A01 Typhoid and paratyphoid fevers

• A02 Other salmonella infections

• A03 Shigellosis

• A04 Other bacterial intestinal infections

Dr SB Bhattacharyya© : Codes as sourced from the Internet

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EXAMPLES OF CLINICAL TERMINOLOGY CODE – SNOMED CT

• Infectious disease (disorder)

• Infectious disease

• Disease due to infection

• Infective disorder

• Disorder due to infection

• Infection

• Term fully defined as ...

• | is a | = disease

• (has a) pathological process = infectious process

• Infectious disease

• Acute infectious disease

• Bacterial infectious disease

• Chronic infectious disease

• Congenital infectious disease

• Disease caused by parasite

• Dust-borne infectious disease

• Fomite transmitted infectious disease

• Ill-defined infectious disease


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CONCEPTS

• Concepts are a clinical idea with a unique identifier that is machine-processable pseudo-random number.

• The Concepts (thought or idea) themselves are in people's heads, while the corresponding codes are its unique identifiers and is a unique numeric code representing a “unit of meaning” like “pain in right leg”


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CONCEPTS

• Based on the principle of ‘one code per meaning, one meaning per code’

• Unique concept identifiers are actually strings of machine-processable digits with lengths ranging from 6 to 18, although most commonly 8 or 9 digits


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CONCEPTS

Each clinical idea is called a concept

that has a concept ID (e.g. 195967001 | asthma |)

which is a pseudo-random number

Allows multiple names for the same clinical idea in many

languages (e.g. English, Spanish, Danish)

dialects of the same language (e.g. US English, UK English)

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MULTIPLE DESCRIPTIONS FOR EACH CONCEPT

• Some descriptions are what clinicians prefer to use while communicating, e.g. Myocardial Infarction

• Some descriptions are other names that can be used for the same thing, but are not the preferable term e.g. cardiac infarction, infarction of heart, heart attack

• SNOMED CT includes all these synonyms as distinct terms that are all related to the same concept

• Thus, anyone subsequently studying it would understand what clinical idea the author of the record had when making the entry

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Image courtesy IHTSDO

CODINGClassification & Terminology

15Dr SB Bhattacharyya©

LAPAROSCOPIC EMERGENCY APPENDECTOMY

ICD - 9 - CM (Year 2001 – WHO – International Classification of Diseases – Ninth Revision – Clinical Modification)

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Diagnosis Acute Appendicitis 541

with perforation 540.0

with peritoneal abscess 540.1

Dr SB Bhattacharyya© : As sourced from the Internet


International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)-WHO Version for 2016

Chapter XI : Diseases of the digestive system (K00-K93)

Diseases of appendix (K35-K38)

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K35 Acute appendicitis

K35.2 Acute appendicitis with generalized peritonitis

Appendicitis (acute) with generalized (diffuse) peritonitis following rupture or perforation

K35.3 Acute appendicitis with localized peritonitis

Acute appendicitis (with or without perforation or rupture) with peritonitis:

NOS

Localized

Acute appendicitis with peritoneal abscess

K35.8 Acute appendicitis, other and unspecified

Acute appendicitis without mention of localized or generalized peritonitis

K36 Other appendicitis

Incl.: Appendicitis:

Chronic

Recurrent

K37 Unspecified appendicitis

K38 Other diseases of appendix

K38.0 Hyperplasia of appendix

K38.1 Appendicular concretions :

Faecalith of appendix

Stercolith of appendix

K38.2 Diverticulum of appendix

K38.3 Fistula of appendix

K38.8 Other specified diseases of appendix

Intussusception of appendix

K38.9 Disease of appendix, unspecified

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CPT CODES (Year 2001 – AMA [Common Procedural Terminology])

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Laparoscopic Appendectomy 44970

Open Appendectomy 44950

Incidental Appendectomy-open 44955

Open Appendectomy for perforated appendicitis and

peritonitis44960



• Cannot write procedure as “laparoscopic emergency appendectomy” as such, which surgeons would normally prefer

• Procedure performed has to be entered using ICD-10 : K35.8 (Acute appendicitis without mention of localized or generalized peritonitis) –since no information about anything other than appendicitis is available – best guesstimate

• Procedure performed has to be entered using CPT : 44970 (Laparoscopic Appendectomy)

• Need TWO (2) separate entries – one for procedure name and another for billing purposes

• The fact that it was an emergency needs to be implicitly derived

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LAPAROSCOPIC EMERGENCY APPENDICECTOMY

• Difficult as the term “appendicectomy” is not available in either ICD or CPT code systems

• Needs to be implicitly understood that “appendicectomy” and “appendectomy” are synonyms

• Users need to be taught how to code correctly, not-so-easy to automate the coding activity

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SNOMED CT (US-English) :

174041007 | laparoscopic emergency appendectomy |

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Dr SB Bhattacharyya© : Sourced using CliniClue™

LAPAROSCOPIC EMERGENCY APPENDICECTOMY

SNOMED CT (GB-English):

174041007 | laparoscopic emergency appendicectomy |

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WHAT THE SURGEON RECORDS…

Procedure: (any one of the following)

laparoscopic emergency appendicectomylaparoscopic emergency appendectomyendoscopic emergency appendectomy endoscopic emergency appendicectomy

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WHAT THE GP SEES (ON REVIEW)…

Procedure performed: laparoscopic emergency appendicectomy

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HOW IT CAN HELP THE INSURANCE SECTOR?

Within medical records…

• More accurate terms for services rendered

• Consistent terms for diagnosis / procedure performed

• Robust support for fraud analysis and detection, even in real-time

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INTRODUCTION TO SNOMED CT BY DR SB BHATTACHARYYA AVAILABLE

AT• http://www.amazon.com/Introduction-SNOMED-CT-S-B-

Bhattacharyya/dp/9812878939/ref=sr_1_1?ie=UTF8&qid=1453269681&sr=8-1&keywords=introduction+to+snomed+ct – hardcopy only

• http://www.amazon.in/Introduction-SNOMED-CT-2016-Bhattacharyya/dp/9812878939/ref=sr_1_1?ie=UTF8&qid=1453269722&sr=8-1&keywords=introduction+to+snomed+ct – hardcopy only

• http://www.springer.com/gp/book/9789812878939 – ebook and hardcopy

• http://link.springer.com/book/10.1007/978-981-287-895-3 – chapter-wise online access only


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http://www.amazon.com/Introduction-SNOMED-CT-S-B-Bhattacharyya/dp/9812878939/ref=sr_1_1?ie=UTF8&qid=1453269681&sr=8-1&keywords=introduction+to+snomed+ct

http://www.amazon.in/Introduction-SNOMED-CT-2016-Bhattacharyya/dp/9812878939/ref=sr_1_1?ie=UTF8&qid=1453269722&sr=8-1&keywords=introduction+to+snomed+ct

http://www.springer.com/gp/book/9789812878939

http://link.springer.com/book/10.1007/978-981-287-895-3

[email protected]

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Medical classification coding vs clinical terminology coding

Health & Medicine

Transcript of Medical classification coding vs clinical terminology coding