Advances in technology have made it possible for healthcare practitioners to retrieve medical information. Such information is coded and entered into a database using coding systems, such as, ICD-10-CM, CPT, and HCPCS. The coding systems assist in administrative and statistical purposes.
The International Classification of Diseases, 10th revision, and its Clinical Modification, ICD-10-CM is a classification for diseases and conditions, diagnosis and the reasons for a visit to a health care facility (Green, Bowie & McGraw, 2011). It is based on the statistical classification ICD-10, published by the World Health Organization. Physicians and outpatient service providers use Current Procedural Terminology, CPT for coding procedures and services for reimbursement. Further, the Healthcare Common Procedure Coding System identifies products, services, and supplies that are not included in the CPT manual. The CPT coding is similar to ICD-10, except that it identifies the services rendered instead of the claim diagnosis. The ICD-10-CM also contains procedure codes for use only in the inpatient services.
Information is stored according to nomenclature and statistical classification. Nomenclature is a simple system of names while classification entails systemic organization of information into classes and a thesaurus with a design for indices and bibliographic database (Green et al., 2011). The classification incorporates similar clinical concepts and clusters them into limited categories to avoid big classifications. An example of classification is the ICD. Further, classification provides residual categories for “other” as well as “unspecified” conditions that lack a specific category in the specific classification. The ICD uses one chapter to group circulatory system diseases. Other clinical concepts under classification include auricular tachycardia, paroxysmal atrial tachycardia and nodal tachycardia.
Nomenclature, on the other hand has a separate listing and code for all clinical concepts. It is thus awkward for compiling health statistics. An example is the Systematized Nomenclature of Medicine, SNOMED. It allows indexing, storing, retrieval and aggregation of medical data across specialties and care sites in a consistent way (Green et al., 2011).