The practice of clinical documentation is varied and complex, requiring multiple standardized code sets and terminologies to support all of its use cases. Each system has a uniquely defined purpose related to the diagnosis and treatment of patients, as well as to reimbursements that correspond to their care. Additionally, the data captured during the care process is the foundation for research and analytic initiatives that will improve the future state of healthcare.
An introduction to the systems – identifying their purpose and content structure – provides a fundamental overview for those in the health sector who are not immersed in this content every day. This primer covers four of the most widely used standardized coding systems in the United States: ICD-10-CM, CPT®, SNOMED CT®, and LOINC, along with others like HCPCS and RxNORM®.
ICD-10-CM
The International Classification of Diseases (ICD) system has a long healthcare history dating back to the 1800s. Today, ICD continues its foundational role in the medical community, with codes representing clinical diagnoses for users worldwide.
What is the ICD-10-CM?
ICD-10 refers to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, which is maintained by the World Health Organization (WHO). The ICD-10-CM, or the International Classification of Diseases, 10th Revision, Clinical Modification, is a version of the ICD-10 adapted for use in the United States by the National Center for Health Statistics (NCHS) – part of the Centers for Disease Control and Prevention (CDC).
Why is the ICD-10-CM used in clinical documentation?
ICD-10-CM codes represent medical diagnoses and detailed clinical information, such as specifying that a patient had a heart attack at home while working outside. These standardized codes are integrated into electronic health records (EHRs), enabling critical tasks like generating healthcare analytics, monitoring quality outcomes, tracking mortality statistics, and creating billing claims. As part of the national coding system under the Health Information Portability and Accountability Act (HIPAA), ICD-10-CM codes play a vital role in healthcare documentation and data management.
How is ICD-10-CM maintained?
The ICD-10-CM Coordination and Maintenance Committee manages and updates the code system. The Committee holds meetings for members of the public to give input on new code updates and proposals twice a year. Typically, the effective date for corresponding changes is either April or October first. Usually, the October release holds the bulk of the year’s modifications.
What do ICD-10-CM codes look like?
CD-10-CM codes are seven-character, alphanumeric codes. The first character is a letter followed by two numbers that represent the category of injury or disease. This is followed by a decimal point and four more characters that can be either alphabetic or numeric.
What are z codes in ICD-10-CM?
Z codes belong to ICD-10-CM and capture factors influencing a patient’s health status or reasons for utilizing health services that are not classifiable elsewhere as diseases, injuries, or external causes. In short, Z codes help to illustrate a patient’s comprehensive health profile and the various factors driving their healthcare needs. They provide valuable context for treatment planning, prevention, and understanding healthcare utilization.
CPT
Current Procedural Terminology (CPT®) identifies healthcare procedures, technologies, and services – like surgeries or EKGs – that support a health system’s need for standardized data about medical procedures.
What is CPT?
Originally, CPT codes were designed to identify and standardize the documentation of various medical procedures and services in order to determine an appropriate work value. Today, they continue that function by helping providers to not only document procedures, but also secure appropriate reimbursements.
Why are CPT codes used in clinical documentation?
CPT codes are a primary method for healthcare providers to report patient services to the government and insurance companies for reimbursement. As part of the national coding system under HIPAA, these codes are essential for documenting medical services and ensuring accurate billing.
How are CPT codes maintained?
CPT codes are maintained by the CPT Editorial Board, a part of the American Medical Association (AMA). They are typically updated once a year. The new codes are released annually in November and go into effect on the following January first. The editorial board meets three times a year to review applications for new codes.
What do CPT codes look like?
CPT codes are five characters long and usually numeric, although some may be alphanumeric depending on the category into which they fall.
CASE STUDY
Learn how surgical terminology, accurately mapped to CPT® codes, helped Piedmont Healthcare optimize OR scheduling
SNOMED
SNOMED CT® is a clinical terminology designed to support the organization and retrieval of clinical data in a computerized standard format. It is used for numerous analytic and research initiatives.
What is SNOMED CT?
SNOMED CT stands for Systemized Nomenclature of Medicine – Clinical Terms. It is a standardized, international, and multilingual core set of clinical healthcare terminology that can be used in EHRs. It is maintained by the International Health Terminology Standards Development Organization (IHTSDO).
Why is SNOMED CT used in clinical documentation?
SNOMED CT is a system of coded terms used in EHRs to capture, record, and share clinical data, supporting the retrieval of meaningful information. It is widely used in healthcare and clinical research due to its granularity and became mandatory in U.S. EHR systems after 2013 to comply with Stage 2 of Meaningful Use.
How is SNOMED CT maintained?
SNOMED International, the organization under IHTSDO that manages the system, continuously updates content based on user needs and feedback. Updates to SNOMED CT International are released biannually on January 31 and July 31. The United States edition of SNOMED CT is updated by the National Library of Medicine twice a year, in March and September.
What do SNOMED CT codes look like?
SNOMED CT codes are numerical and at minimum six digits long. For instance, 271737000 is the unique code for the SNOMED concept “Anemia (disorder)”.
LOINC
LOINC originated as a structured system to facilitate the electronic exchange of medical laboratory data. Today, many healthcare systems rely on LOINC codes to transmit information about a range of clinical tests and assessments.
What is LOINC?
LOINC, which stands for Logical Observation Identifiers Names and Codes, is a system used to electronically transmit a vast amount of medical data. Originally, LOINC was designed to standardize information about clinical laboratory test orders and results. Since its inception in 1994, it has grown to incorporate codes representing other types of clinical assessments, such as medical imaging.
Why is LOINC used in clinical documentation?
Before LOINC was introduced in 1994, medical institutions used distinct codes for lab tests, making it difficult to share data between providers. LOINC now standardizes the exchange of lab results and other clinical data, enabling effective communication between healthcare organizations and insurance companies.
How is LONIC maintained?
LOINC was created and is maintained by the Regenstrief Institute, an Indiana-based nonprofit healthcare research organization. LOINC updates are released twice a year, in June and December.
What do LOINC codes look like?
LOINC code descriptions contain six parts, each with a specific meaning. They are alphanumeric and, unlike other code sets, have a more sentence-like structure.
HCPCS
HCPCS was developed to ensure uniformity in billing and coding for medical services and supplies. Today, healthcare providers and insurers use HCPCS codes to accurately document and reimburse a wide range of items, from medical equipment to outpatient procedures.
What is HCPCS?
HCPCS stands for Healthcare Common Procedure Coding System. It is a set of standardized codes created and maintained by the Centers for Medicare & Medicaid Services (CMS) that represent medical procedures, supplies, products, and services.
Why are HCPCS codes used?
These codes are used to streamline the billing process for Medicare and other insurers, covering services like drugs, ambulance transport, and durable medical equipment in outpatient settings.
How are HCPCS codes maintained?
CMS updates HCPCS codes quarterly, with new codes released in January, April, July, and October, and they take effect on the first of each month.
What do HCPCS codes look like?
HCPCS codes are five characters long and alphanumeric. They begin with a letter that corresponds with the chapter followed by four numbers.
- J9355: Injection, trastuzumab, excludes biosimilar, 10mg
- C1823: Generator, neurostimulator (implantable), non-rechargeable, with transvenous sensing and stimulation leads
RxNORM
RxNORM was created to provide a standardized naming system for medications, ensuring consistency across electronic health records. Today, RxNorm codes are widely used to facilitate accurate communication of prescription details, supporting medication-related information exchange between healthcare systems and pharmacies.
What is RxNORM?
RxNORM is a standardized system developed by the National Library of Medicine (NLM) to normalize drug names, ensuring consistency across different organizations. It eliminates confusion by providing uniform names for prescription and over-the-counter drugs, including generics and branded medications.
Why is RxNORM important?
RxNORM supports interoperability by ensuring that health IT systems, like EHRs, use standardized drug names, allowing seamless data exchange between facilities. This is crucial for maintaining continuity of care as patients move between providers.
What do RxNORM codes look like?
RxNORM assigns unique identifiers (RXCUIs) to drugs, grouping different names for the same medication under a single code. For example, RXCUI 198013 identifies 250 mg of Naproxen, regardless of variations in how it’s named in different databases. These codes are updated weekly to include newly approved drugs.
Conclusion
With so many clinical terminologies in use, each with its own frequent updates, it can be challenging for healthcare organizations to stay current and maintain data accuracy. However, IMO Health specializes in streamlining this complexity. By leveraging our advanced clinical terminology and data quality management solutions, we help ensure your organization stays up-to-date, enabling more accurate coding, smoother workflows, and better patient care.
Check out this article to learn what makes clinical terminology so challenging to maintain.
CPT is a registered trademark of the American Medical Association. All rights reserved.
SNOMED and SNOMED CT® are registered trademarks of SNOMED International.
RxNorm® is a registered trademark of the National Library of Medicine.
