Medical terminology is essential to understand and classify the patients’ records under the diverse range of medical conditions and procedural protocols.
Standardized Nomenclature of Disease (SND)
The standardized nomenclature of disease (SND) or basle nominaanatomica was developed during the annual meeting of the German Anatomic Society in Basel, Switzerland in 1895. The nomenclature was devised as a medical database where diseases were appropriately classified without duplication and confusion.
Systematized Nomenclature of Medicine (SNOMED)
Deriving from the Systematized Nomenclature of Pathology (SNOP) which had a four-axis system to define and classify the medical terminologies according to morphology and anatomical aspects of the disease, SNOMED was designed by Dr. Roger A. with Dr. Arnold Pratt and College of American Pathologists during 1973 to 1997 for better clinical administration.
While medical terminology is part of the nomenclature including the disease names and their explanations, under medical classification system they are divided into different categories
Current Procedural Terminology
CPT code is managed by the CPT editorial panel of the American Medical Association. The Current procedural terminology provides codes to classify medical, surgical and diagnostic services for an effective communication among physicians, coders, patients and payers and addressing the administrative norms for proper storage and retrieval of patients’ medical information.
Healthcare common procedural coding system is a standardized set of procedure codes associated with healthcare. It derives its basic structure from CPT manual of the American Medical Association.
International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM): It is the official Coding system revised the World Health Organization’s ICD-9 system. It is used to understand and code the medical diagnoses and procedures for inpatient and outpatient records for administrative and financial purposes.
International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10): For better health practices, this classification system uses mortality and morbidity data from different countries to understand the concurrence of diseases and devising proper codes for all medical purposes.
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM): A Coding system in practice in the U.S. to code and classify mortality data expanding on critical information such as managed care encounters.
International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS): ICD-10-PCS effectively replaced the volume 3 of the ICD-9-CM manual.
International Classification of Diseases for Oncology (ICD-O): Coding system to code and classify the registered tumor and cancer cases.
National drug codes (NDC): Under FDA guidelines, a coding system to identify and report drug products which is recognized universally.
Current dental terminology (CDT): A coding system specific to code and classify the dental treatment and procedures for administrative, analytical and financial purposes.
Diagnostic and Statistical Manual of Mental Disorders (DSM): A classification for mental disorders widely used and studied in the United States by the mental health professionals.
The National Center for Health Statistics: The NCHS is the U.S. agency associated with Federal Statistical System which collaborates statistical health data and improvise ICD codes by introducing clinical modifications.
Subcategory is defined in ICD codes after a decimal point commonly describing the nature and/or location of the medical condition.
The sub classification is defined in ICD codes following a subcategory, separated by a decimal point describing the gravity of the medical condition and/or any relevant information such as type of encounter.
A technical component describes the practical discretion of the procedure, not the diagnostic. Ex., This could be a frontal view x-ray but may not include the assessment such as the fracture type.
V-codes are used to code the patient encounters other than related to disease or injury but circumstantial in nature to avoid any medical or financial discrepancy in understanding the treatment and procedure.
The World Health Organization is responsible for monitoring the international health statistics and prevalence and also revises the ICD codes for its universal implementation.
In ICD-9-CM, z-codes are used to describe the patient visit based on other factors extraneous to his medical condition or injury.