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MEDICAL CLASSIFICATION
CODE VS. CLINICAL
TERMINOLOGY CODE
Dr SB Bhattacharyya
MBBS, MBA. FCGP
Member, National EHR Standar...
RECORDS – WHY KEEP THEM?
• For reuse
• As a source of historical data & information
• Information exchange among providers...
WHY CODE?
• Computers hold information as sequences of binary bits and work by
matching strings all of which need precisel...
CLASSIFICATION & TERMINOLOGY:
APPLES AND ORANGES OR CHALK
AND CHEESE?
4
Dr SB Bhattacharyya© : Images as sourced from Inte...
CLASSIFICATION & TERMINOLOGY
SYSTEMS
Classification Systems
• Semasiological or meaning-
based approach to building the
co...
POINTS OF DIFFERENCE
Classification Systems
• Codes specific data items, e.g.,
• Diseases & diagnosis (ICD, ICD-O,
DRG, et...
APPLICATION AREAS
Classification Systems
• Statistical analysis
• Administrative
• Performance
• Activity Based Analysis
•...
EXAMPLES OF MEDICAL
CLASSIFICATION CODE SYSTEMS – ICD
• ICD-10 Version : 2016
• I Certain infectious and parasitic
disease...
EXAMPLES OF CLINICAL
TERMINOLOGY CODE – SNOMED CT
• Infectious disease (disorder)
• Infectious disease
• Disease due to in...
CONCEPTS
• Concepts are a clinical idea with a unique identifier that is machine-
processable pseudo-random number.
• The ...
CONCEPTS
• Based on the principle of ‘one code per meaning, one meaning per
code’
• Unique concept identifiers are actuall...
CONCEPTS
Each clinical idea is called a concept
that has a concept ID (e.g. 195967001 | asthma |)
which is a pseudo-random...
MULTIPLE DESCRIPTIONS FOR
EACH CONCEPT
• Some descriptions are what clinicians prefer to use while
communicating, e.g. Myo...
14
Image courtesy IHTSDO
CODING
Classification & Terminology
15Dr SB Bhattacharyya©
SEVERE BURN BETWEEN 4TH & 5TH
LEFT TOE
ICD-10
• One cannot implicitly code
• One cannot explicitly code
• Nearest code:
T2...
LAPAROSCOPIC EMERGENCY
APPENDECTOMY
ICD - 9 - CM (Year 2001 – WHO – International Classification of Diseases – Ninth
Revis...
LAPAROSCOPIC EMERGENCY
APPENDECTOMY
International Statistical Classification of Diseases and Related Health
Problems 10th ...
LAPAROSCOPIC EMERGENCY
APPENDECTOMY
K35 Acute appendicitis
K35.2 Acute appendicitis with generalized peritonitis
Appendici...
LAPAROSCOPIC EMERGENCY
APPENDECTOMY
CPT CODES (Year 2001 – AMA [Common Procedural Terminology])
20
Laparoscopic Appendecto...
LAPAROSCOPIC EMERGENCY
APPENDECTOMY
• Cannot write procedure as “laparoscopic emergency
appendectomy” as such, which surge...
LAPAROSCOPIC EMERGENCY
APPENDICECTOMY
• Difficult as the term “appendicectomy” is not available in either ICD or
CPT code ...
LAPAROSCOPIC EMERGENCY
APPENDECTOMY
SNOMED CT (US-English) :
174041007 | laparoscopic emergency appendectomy |
23
Dr SB Bh...
LAPAROSCOPIC EMERGENCY
APPENDICECTOMY
SNOMED CT (GB-English):
174041007 | laparoscopic emergency appendicectomy |
24
Dr SB...
WHAT THE SURGEON RECORDS…
Procedure: (any one of the following)
laparoscopic emergency appendicectomy
laparoscopic emergen...
WHAT THE GP SEES (ON REVIEW)…
Procedure performed: laparoscopic emergency appendicectomy
26
Dr SB Bhattacharyya©
HOW IT CAN HELP THE INSURANCE
SECTOR?
Within medical records…
• More accurate terms for services rendered
• Consistent ter...
INTRODUCTION TO SNOMED CT
BY DR SB BHATTACHARYYA AVAILABLE
AT
• http://www.amazon.com/Introduction-SNOMED-CT-S-B-
Bhattach...
sbbhattacharyya@gmail.com
29
Dr SB Bhattacharyya©
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Medical classification coding vs clinical terminology coding

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Discussion on how medical classification and clinical terminology systems are coded and how they each may be used to enrich EHR/EMR systems and help enhance care delivery.

Published in: Health & Medicine
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Medical classification coding vs clinical terminology coding

  1. 1. 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
  2. 2. 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 2 Dr SB Bhattacharyya©
  3. 3. 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 Dr SB Bhattacharyya© 3
  4. 4. CLASSIFICATION & TERMINOLOGY: APPLES AND ORANGES OR CHALK AND CHEESE? 4 Dr SB Bhattacharyya© : Images as sourced from Internet
  5. 5. 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 5 Dr SB Bhattacharyya©
  6. 6. POINTS OF DIFFERENCE Classification Systems • 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 6 Dr SB Bhattacharyya©
  7. 7. APPLICATION AREAS Classification Systems • 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 7 Dr SB Bhattacharyya©
  8. 8. 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 8
  9. 9. 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 Dr SB Bhattacharyya© 9
  10. 10. 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” Dr SB Bhattacharyya© 10
  11. 11. 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 Dr SB Bhattacharyya© 11
  12. 12. 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) 12 Dr SB Bhattacharyya©
  13. 13. 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 13 Dr SB Bhattacharyya©
  14. 14. 14 Image courtesy IHTSDO
  15. 15. CODING Classification & Terminology 15Dr SB Bhattacharyya©
  16. 16. SEVERE BURN BETWEEN 4TH & 5TH LEFT TOE ICD-10 • One cannot implicitly code • One cannot explicitly code • Nearest code: T25.3 – burn of 3° ankle and foot • T31.0 to T31.9 – indicating %-age of burn (<10% to >90%) SNOMED CT • One cannot implicitly code • One can explicitly code as follows 284196006|Burn of skin|: 246112005|Severity|= 24484000|severe, 363698007|Finding Site|= (113185004|Structure of skin between fourth and fifth toes|: 272741003|Laterality|= 7771000|left) 16 Dr SB Bhattacharyya©
  17. 17. LAPAROSCOPIC EMERGENCY APPENDECTOMY ICD - 9 - CM (Year 2001 – WHO – International Classification of Diseases – Ninth Revision – Clinical Modification) 17 Diagnosis Acute Appendicitis 541 with perforation 540.0 with peritoneal abscess 540.1 Dr SB Bhattacharyya© : As sourced from the Internet
  18. 18. LAPAROSCOPIC EMERGENCY APPENDECTOMY 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) 18 Dr SB Bhattacharyya© : As sourced from the Internet
  19. 19. LAPAROSCOPIC EMERGENCY APPENDECTOMY 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 19 Dr SB Bhattacharyya© : As sourced from the Internet
  20. 20. LAPAROSCOPIC EMERGENCY APPENDECTOMY CPT CODES (Year 2001 – AMA [Common Procedural Terminology]) 20 Laparoscopic Appendectomy 44970 Open Appendectomy 44950 Incidental Appendectomy-open 44955 Open Appendectomy for perforated appendicitis and peritonitis 44960 Dr SB Bhattacharyya© : As sourced from the Internet
  21. 21. LAPAROSCOPIC EMERGENCY APPENDECTOMY • 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 21 Dr SB Bhattacharyya©
  22. 22. 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 22 Dr SB Bhattacharyya©
  23. 23. LAPAROSCOPIC EMERGENCY APPENDECTOMY SNOMED CT (US-English) : 174041007 | laparoscopic emergency appendectomy | 23 Dr SB Bhattacharyya© : Sourced using CliniClue™
  24. 24. LAPAROSCOPIC EMERGENCY APPENDICECTOMY SNOMED CT (GB-English): 174041007 | laparoscopic emergency appendicectomy | 24 Dr SB Bhattacharyya© : Sourced using CliniClue™
  25. 25. WHAT THE SURGEON RECORDS… Procedure: (any one of the following) laparoscopic emergency appendicectomy laparoscopic emergency appendectomy endoscopic emergency appendectomy endoscopic emergency appendicectomy 25 Dr SB Bhattacharyya© : Sourced using CliniClue™
  26. 26. WHAT THE GP SEES (ON REVIEW)… Procedure performed: laparoscopic emergency appendicectomy 26 Dr SB Bhattacharyya©
  27. 27. 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 27 Dr SB Bhattacharyya©
  28. 28. 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 Dr SB Bhattacharyya© 28
  29. 29. sbbhattacharyya@gmail.com 29 Dr SB Bhattacharyya©

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