Section B. Terminology in Use Today
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2 Section B Terminology in Today
3 Coding Systems International Classification of Diseases (9th ed.) Clinical Modifications (ICD-9-CM) ICD-10-CM and ICD-10-PCS (Procedure Coding System) Healthcare Provider Taxonomy Current Procedure Terminology (CPT ) National Drug Codes (NDC) RxNORM 3
4 Coding Systems SNOMED CT Healthcare Common Procedure Coding System (HCPCS) Logical Observation Identifiers Names and Codes (LOINC ) RadLex Unified Codes for Units of Measure (UCUM) HL7 Version 3 Vocabulary HL7 Version 2 Tables 4
5 Nursing Coding Systems North American Nursing Diagnosis Association International (NANDA) Nursing Interventions Classification (NIC) Nursing Outcomes Classification (NOC) The Omaha System The Clinical Care Classification System (CCC) 5
6 Proprietary Coding Systems MEDCIN First DataBank Medi-Span Multum 6
7 ICD-9-CM Publisher Number of codes International Classification of Diseases 9th Revision Clinical Modifications CDC (diseases) and CMS (procedures) Ambulatory and inpatient billing (diagnoses) Inpatient billing (procedures) Hierarchical Structured ~14,000 diagnoses and ~3,800 procedures Examples Acute myocardial infarction of anterolateral wall initial episode of care E880.0 Accidental fall on or from escalator V14.0 Personal history of allergy to penicillin Laparoscopic cholecystectomy 7
8 ICD-10-CM International Classification of Diseases 10th Revision Clinical Modifications CMS and NCHS Ambulatory and inpatient billing Hierarchical Structured Number of codes ~70,000 Examples I2109 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall W100xxA Z880 Fall (on)(from) escalator, initial encounter Allergy status to penicillin 8
9 ICD-10-PCS ICD-10-PCS CMS Inpatient billing (procedures) Hierarchical Structured Number of codes ~72,000 Examples 0FT44ZZ Resection of Gallbladder, Percutaneous Endoscopic Approach 9
10 Healthcare Provider Taxonomy Healthcare Provider Taxonomy National Uniform Claims Committee National Provider Classification with NPI Hierarchical Structured Number of codes ~1,000 Examples 208U00000X Allopathic & Osteopathic Physicians Clinical Pharmacology 207Q00000X Allopathic & Osteopathic Physicians Family Medicine 207QA0000X Allopathic & Osteopathic Physicians Family Medicine Adolescent Medicine 10
11 Current Procedure Terminology Current Procedure Terminology American Medical Association Procedure classification and ambulatory billing Hierarchical Structured Number of codes ~7,800 Examples Cholecystectomy Laparoscopy, surgical; cholecystectomy 11
12 Current Drug Terminology National Drug Codes ndc/ default.cfm FDA eprescribing and Claims Hierarchical Structured Number of codes ~75,000 Examples ACETAMINOPHEN AND CODEINE PHOSPHATE TABLETS 300;30MG;MG ACETAMINOPHEN AND CODEINE PHOSPHATE TABLETS 300;30MG;MG; 100 TABLETS/BOT 12
13 RxNORM RxNORM overview.html National Library of Medicine Clinical medications, CPOE Ontology Opaque Number of codes >850,000 Examples Acetaminophen 300 MG / Codeine Phosphate 30 MG Oral Capsule 13
14 LOINC Logical Observation Identifiers Names and Codes Regenstrief Institute Laboratory order, results, clinical documents and sections, form fields Ontology* Opaque Number of codes >30,000 Examples Hemoglobin A1c Summary of Episode Note Problem list 14
15 SNOMED CT SNOMED CT IHTSDO Clinical care Ontology Opaque Number of codes ~ 1,000,000 Examples laparoscopic cholecystectomy myocardial infarction acetaminophen + codeine Hemoglobin A1c measurement H1N left aortic arch 15
16 UCUM Unified Code for Units of Measure Regenstrief Institute Measurement units Grammar N/A Number of codes ~ 200 atoms, infinite codes Examples m/s 2 Meters per second squared mg/dl Milligrams per deciliter 16
17 HL7 Version 3 Number of codes Health Level 7 Version 3 Vocabulary welcome/ environment/index.html Health Level 7 International, Inc. Various Hierarchy Mnemonic? (more than 150 code systems) Examples EVN Event Mood (MoodCode) MTH Mother (RoleCode) 17
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