NURSING

INFORMATICS Module 3
CURRENT PROCEDURAL TERMINOLOGY
DATA AND SYSTEM STANDARDS

Prepared by: Lianne S. Decano

OBJECTIVES

01 The student will understand the data and system

standards of Nursing Informatics.

02 To recognize the difference and application of CPT and

ICD-10 in the Nursing Profession.

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CURRENT PROCEDURAL TERMINOLOGY
CPT

❖ Standard vocabulary
for Hospital
terminologies
(procedure,
diagnostics exam, The CPT set code is
laboratory, anesthesia, copyright protected by the
basic services AMA.
rendered to patient in
the hospital.

❖ Created by American
Health Association
(AMA) - 1966
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 CPT
1. Evaluation and management (99201 - 99499)
E/M contains codes for the different services that the
CPT 6 Sections physician may perform on a patient. For example, the code
99251 would refer to the following description:

Inpatient consultation for a new or established patient

which requires these 3 key components: a problem
focused history; a problem focused examination;
and straightforward medical decision
making. Counseling and/or coordination of care with
other providers or agencies are provided consistent with
the nature of the problem(s) and the patient's and/or
family's needs. Usually the presenting problem(s) are
self-limited or minor. Physicians typically spend 20
minutes at the bedside and on the patient's hospital floor
or unit.​are pathways are also known as Clinical or
Critical pathways 4
 CPT
2. Anesthesia (00100 - 01999) – This set of codes would refer
to administration of anesthesia for patients requiring surgical
CPT 6 Sections procedures. For example, the code 01740 would refer to the
following description:

Anesthesia for open or surgical

arthroscopic procedures of the elbow;
not otherwise specified.

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 CPT
3. Surgery (10021 - 69990) – This set of codes would refer to
the surgical procedures that the patient may have underwent.
CPT 6 Sections For example, the code 33572 may refer to the
following description:​

Coronary endarterectomy, open, any

method, of left anterior descending,
circumflex, or right coronary artery
performed in conjunction with coronary
artery bypass graft procedure, each
vessel (List separately in addition to
primary procedure)..
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 CPT

4. Radiology (70010 - 79999) – This set of codes would refer to

the radiologic procedures that the patient has undertaken. For
CPT 6 Sections example, the code 76604 would refer to the following:​

Ultrasound, chest (includes

mediastinum), real time with image
documentation.

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 CPT
5. Pathology and Laboratory (80047 - 89398) – This set of
codes would refer to laboratory tests that have been ordered
for the patient. For example, the code 82550 would refer to
CPT 6 Sections
the following:​

Creatine kinase (CK), (CPK); total

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 CPT
6. Medicine (90281 - 99607) – Lastly, medicine would involve
procedures that would encompass all other clinical fields not
seen in the previous sections. It covers not only internal
CPT 6 Sections medicine, but likewise ophthalmology, dialysis, acupuncture,
among others.

ECG

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 The organization of CPT codes allows users to find codes through six methods:

1. The name of the procedure (ex. Electrocardiography)

2. Service by which the procedure was done (ex. Cardiology)
3. Eponym of the procedure
4. Anatomic location (Heart)
5. Medical abbreviation (ECG)
6.Diagnosis (Unstable angina)
 STRUCTURED DATA AND CPT

Having known the different sets of codes that are supported by the CPT, we can
now appreciate the value it brings to structured health data analysis. Structured health
data means that the terms, descriptions, and management options made available for
the patient are practice
Clinical organizedguidelines
into a finiteare
setstatements
of standardsthat
thatinclude
would enable further
recommendations
statistical analysistoand
intended research.
optimize If a doctor
patient care. would see a patient for 20 minutes, order
ECG, chest x-ray, creatine levels, and prepare for coronary arterial bypass procedure –
these terms altogether would create a huge possibility of disarray. The possibilities of
writing these procedures according to how the doctor would be accustomed to doing
will later on be inefficient in researching for how many patients have had a particular
diagnostic procedure. Hence, providing a standard such as CPT creates order in the
health information being entered and later on extracted from the patient’s chart.

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 CPT AND HCPCS

•It is not uncommon to find CPT information go hand-in-hand with HCPCS. HCPCS stands
for the Healthcare Common Procedure Coding System of the Center for Medicare and
Medicaid Services (CMS) of the United States. The CMS is the largest health insurance
provider in the US, and accounts for all privileges of those qualifying low-income
Clinical
individuals practice
(Medicaid) andguidelines
those whoare arestatements
older thanthat
65 include
years oldrecommendations
and some disabled
intended to optimize patient care.
persons (Medicare). In order for the CMS to know more about the trends regarding the
availing of healthcare services, an agreement was made with the AMA to allow the CMS in
using CPT codes inside the HCPCS. The HCPCS uses CPT codes for its level I
documentation, while using national codes for the level II (For purposes of this
courseware, level II codes will not be discussed anymore).
•As a whole, health standards enabled users to obtain reimbursement forms which have
a standard set of codes for both diseases (ICD) and procedural terms (CPT).
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 DATA SYSTEM STANDARDS
The Story:

❑ Stan the man. Stan is a fifty-five year-old Taxi driver, who has a fourty pack-year smoking history. Stan is a
heavy alcoholic beverage drinker averaging twenty four bottles of beer a week. He is a
diagnosed hypertensive maintained on Losartan (Cozaar) 50 mg once a day.
❑ Chief complaint: chest pain
❑ Three days Prior to Consult (PTC): Stan the man experienced mild shortness of breath after having
a drinking spree with his buddies.
❑ Two days PTC: Stan felt heaviness on his chest with generalized pain 7/10 in intensity lasting 1 minute.
❑ One day PTC: Stan attempted to have another drinking session with friends. On his second bottle,
Stan felt heaviness on his chest again this time accompanied by generalized pain 8/10 intensity and
lasting for an hour. Stan was eventually brought to the district hospital. ECG was done showing q
wave abnormalities, but no ST segment abnormalities. He was assessed with the possibility of having an
acute coronary syndrome and was given Aspirin. No radiologist was immediately available at the
hospital. Patient was advised to transfer to EHRI-Hospital for further assessment. Stan was stabilized for
the night and was scheduled for transfer the following morning. Hence consult.

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 DATA SYSTEM STANDARDS
The Situation:

• You are the health professional on duty at EHRI-Hospital - a 25-bed, multi-specialty center specializing in
management of complicated illnesses. The case was called in one day PTC at around 11:00PM. Because of
the agreed protocols between the district and EHRI hospitals, the transfer of information
was immediately put into action. Unfortunately, no Internet was available at the district hospital to
transfer the information, but the referring hospital was able to provide you with the patient ID that can
be used to track the patient using the EHRI hospital information system HarmoniMD. Patient was found
to have a record with the EHRI-hospital. You scheduled the patient for consult.
• As you search, view, and edit the patient's information, the fields that would contain the information
have already been mapped to corresponding terms that both the computer and the health
informatics professional can understand. For example, “Stan” as a first name is recognized appropriately
by the computer, and is not misunderstood as a type of diagnosis (Stable angina), a model
of fetal monitor, or some other thing. As humans, we can recognize the differences in meaning, but
computers have to be programmed in such manner that they, too, can recognize the differences.

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INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND
RELATED HEALTH PROBLEMS
ICD-10
❖ standard diagnostic tool
for epidemiology, health
management and
clinical purposes.

❖ World Health
ICD is designed as a health care
Organization (WHO) - classification system, including a system
1990 of diagnostic codes for
classifying diseases, symptoms,
❖ Under ICD-10, diseases and abnormal findings, complaints, social
other conditions are classified circumstances, and external causes of
into major categories of similar injury or disease..
disease or conditions. Each
element is assigned an
alpha numeric code of up to 7
characters. 15
ICD-10

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ICD-10

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ICD-11

ICD-11 will have definitions that give key descriptions in human readable terms -
to guide users through the coding process. This is an advancement over ICD-10,
which had only title headings. The Definitions have a standard structure according to
a template with standard definition templates and further features exemplified in
a “Content Model”. The Content Model therefore allows computerization (with links
to ontologies and SNOMED CT). Each ICD entity can be seen from different
dimensions or “parameters”. For example, there are currently 13 defined main
parameters in the Content Model to describe a category in ICD.

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ICD

Did you know?

ICD exists in 41 Languages in

electronic versions and its expression
in multiple languages will be
systematically pursued in ICD11.
ICD, how it is being used?

Processing of insurance claims

Diagnosing patient cases

Coding for the patient cause of death

2
0
This is ICD-10 looks like:

E-journals or electronic journals are scholarly

publications in digital form, which are
accessible on the web. In the Philippines, we
have the Philippine E-journals (ejournals.ph)
where you can find an online bibliographic
database & repository of academic journals in
different disciplines from various resources.

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This is ICD-10 looks like:

E-journals or electronic journals are scholarly

publications in digital form, which are
accessible on the web. In the Philippines, we
have the Philippine E-journals (ejournals.ph)
where you can find an online bibliographic
database & repository of academic journals in
different disciplines from various resources.

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ICD help improves health care system by:

1. Improves clinical communication

2. Supports care management, quality
measurement & analytics.
3. Understanding the risk and severity.
4. Provides more information
Standardized system used by health care providers to
code diseases and medical condition. Used in health
care setting in the US to report diagnosis. Designed for
inpatient to be more accurate and specific.
ICD-10 can be used by using,

❖ ICD-10 webpage
❖ Mobile application ( Apple, Android, and other mobile
operating system)
❖ Computerized hospital information systems provide, as part
of their service, a mechanism to search for ICD-10 codes
from within the computer terminals that access the
information system.

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 HISTORICAL SYNOPSIS

ICD started out way back when computers have come out of existence. The
first major attempt at classifying disease was accomplished by Dr. Jacques
Bertillon, a French physicians of the late 1800s in his treatise Bertillon
Classification
Clinicalof Causesguidelines
practice of Death, which was introduced
are statements at therecommendations
that include International
Statistical Institute
intended in Chicago
to optimize in 1893.
patient care.Subsequent updates included a synthesis
of German, English and Swiss medical classifications with a resulting 161
titles. The first international conference to revise ICD as it came to be known was
in 1900 with revisions happening every 10 years thereafter. Until the release of
ICD-6, most updates were minor in nature. The most common versions of ICD that
are being used today are ICD-9 and 10.
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 HISTORICAL SYNOPSIS ICD-9

At the 1975 meeting of WHO in Geneva, Switzerland, there was much debate about
the structure of ICD including the calls for more detail and the organization of conditions
based on the organs affected. Wikipedia reports: 'The final proposals presented to and
accepted by the Conference retained the basic structure of the ICD, although with much
Clinical
additional practice
detail at the levelguidelines
of the four are
digitstatements that
subcategories, include
and recommendations
some optional five
intended to optimize patient care.
digit subdivisions. For the benefit of users not requiring such detail, care was taken to ensure that
the categories at the three digit level were appropriate. For the benefit of users wishing to
produce statistics and indexes oriented towards medical care, the Ninth Revision included an
optional alternative method of classifying diagnostic statements, including information about
both an underlying general disease and a manifestation in a particular organ or site. This system
became known as the dagger and asterisk system and is retained in the Tenth Revision.'

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 HISTORICAL SYNOPSIS ICD-10

Work on ICD-10 started in 1983 and was approved in 1990 at the

43rd World Health Assembly with the latest version coming into use starting
in 1994. This classification allows for more than 155,000 different codes
and added many new diagnosis and procedures, a significant expansion of
the 17,000 code available in ICD-9. Interestingly, most of the world
adopted ICD-10 readily while the US remains mostly on ICD-9 with a
proposed change over date of October 1, 2013.

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 LIMITATIONS:

✓ ICD, whether its ninth or tenth edition, is limited only to classifying diseases
discussed and included in their respective versions. Because of the complexities of
other systems, such as dermatology, oncology, psychiatry, among others, only the
common and general term descriptions of diseases from the mentioned specialties
are included. There are special versions of the ICD which caters to
further classification of diseases for psychiatry and oncology, while there is
a Dermlex standard for further details on dermatological diseases. Notwithstanding
the intricacies of the different subspecialties, ICD is enough to cover the most
common diseases, as well as less common ones but only to a certain degree
of granularity.
✓ There are likewise disease terms unique to countries which are not necessarily
included in the ICD. Certain diseases from countries like the Philippines, furthermore,
have descriptions that are needed to be included in the terminology, but are not
necessarily included in the ICD. Because of this, the Philippines has decided to
produce an ICD-10 with Philippine modifications that would directly address the
need to further classify and organize information on certain diseases like
Tuberculosis.
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 LIMITATIONS:

✓ As of now, the Philippine modifications are still being used in the country,
and this immediately causes possible conflicts. For one, ICD-10 Philippine
codes cannot be compared to international health data. More than
that, incompatibilities may exist once ICD-11 is released. Patients may
have Philippine codes which may have a possible same ICD-11 code,
consequently affecting the management and could be detrimental to the health of
the patient. It is important that while the Philippine modification may address
the problems today, it could pose a very complex problem to solve in the future.

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