Imagine trying to have a conversation with someone who only speaks a foreign language and having no access to a translator. Tough to do, right? You’d need basic use and understanding of relevant words in the foreign language and your new friend would need the same for your language. Only then can you interact more meaningfully, with confidence that you’re both referring to the same things, referencing words in your own language to which you know the meaning. Welcome to medical coding! This is how the healthcare world removes as much ambiguity as possible and assures that all parties better understand the nuances of disease, procedures and even test results.
The most common coding systems are:
- ICD-10, or International Statistical Classification of Diseases and Related Health Problems, 10th Revision. ICD-10-CM (CM for Clinical Modification) is the version of ICD-10 used in the US. The codes in ICD-10-CM convey medical diagnoses and other information, such as associated conditions or manifestations, and even location and manner of an accident, for example. The codes are used for communication among the healthcare community as well as for research, billing and mortality statistics.
ICD-10-CM codes are alpha-numeric and up to seven characters in length. They are arranged in 22 chapters that correspond to specific disorders, organ systems, symptoms and other factors. ICD-10-CM contains over 72,000 codes that range from general or unspecified codes, meaning that little precision is documented or known, to very specific codes that convey nuances of the medical condition and related or causative elements. They are updated at least once per year in October but changes may also take effect in April.
ICD-10-CM codes help to communicate the complexity of a patient’s health status and, along with the provider’s documentation, assist in justifying medical necessity.
- CPT, or Current Procedural Terminology, is a set of codes used to identify procedures and services, and although there are three categories of CPT codes, Categories 1 and 2 are the most common in healthcare settings.
Category 1 CPT codes contain the majority of procedure codes from an office visit with your doctor or other healthcare practitioner, to surgeries, delivering a baby and associated activities, such as anesthesia, venipuncture and imaging services. Category 2 CPT codes are used for reporting and tracking healthcare outcomes and quality measures, such as your blood pressure readings, medication review post-hospital discharge, exposure to second-hand smoke and use of specific medications for certain conditions.
Many payors have implemented performance management systems that incentivize providers: to report Cat 2 codes; to achieve particular outcomes that contribute to wellness, lower healthcare costs and reduce probability of complications, such as diabetes control; and to perform wellness activities, such as screenings, that may or may not carry additional payment.
There are over 10,000 CPT codes, each five numeric-only or alphanumeric characters long, and they are updated annually in November for a January 1 effective date. Medical necessity is synthesized by the provider into the selection of some CPT codes. To help distinguish between ICD-10 and CPT, think “D” for diseases and “P” for procedures!
- The less well-known SNOMED CT, or Systematized Nomenclature of Medicine – Clinical Terms, is used more internationally and conveys a great deal more information in its codes, preferred especially in research settings.
There are over 350,000 SNOMED CT codes, or identifiers, that are described as unambiguous and devoid of “any ascribed human interpretable meaning.” At the core of SNOMED CT are concepts, descriptions and relationships. SNOMED CT takes into consideration clinical findings, body structure, organisms, procedures, causative elements, qualifying characteristics, even social contexts, plus relationships or hierarchies in a single code!
These codes are continuously updated but revised codes are released on January 31 and July 31 of each year.
Medical coding can seem like a lot of alphabet soup. But when you consider that providers need to communicate with each other and with payors, and to report medical data that will be understood by all parties, including other countries, you can see the critical need for universality of language.