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
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Medical classification coding vs clinical terminology coding
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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
• 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
• 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”
• 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
• 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
• T31.0 to T31.9 – indicating %-age of burn (<10% to >90%)
SNOMED CT
• One cannot implicitly code
• One can explicitly code as follows284196006|Burn of skin|: 246112005|Severity|= 24484000|severe, 363698007|Finding Site|= (113185004|Structure of skin between fourth and fifth toes|:272741003|Laterality|= 7771000|left)
• 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
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