Healthcare Code Sets, Clinical Terminologies, and Classification Systems


In the EHR, multiple terminologies, vocabularies, and classification systems are used to create encoded data that users can access, combine, manipulate, and share. HIM professionals need to learn these key systems to prepare for the adoption of the electronic health record. "Healthcare Code Sets, Clinical Terminologies, and Classification Systems" explains the components comprising the infrastructure for electronic health records, taking you beyond the standard diagnosis and procedure code sets and how they interact with emerging code sets and data standards. Discover how new terminologies, vocabularies, and classification systems work together with HIPAA standard code sets in the identification and organization of clinical data.

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Table of Contents:

  • Preface
  • Introduction
  • Part I: Terminologies and Classifications Commonly Used for Administrative and Statistical Reporting
    • International Classification of Disesases (ICD)
    • Current Procedural Terminology (CPT)
    • Healthcare Common Procedure Coding System (HCPCS)
    • National Drug Codes (NDC)
    • Current Dental Terminology (CDT)
  • Part II: Other Vocabulary, Terminology, and Classification Systems
    • Systemized Nomenclature of Medicine Clinical Terms (SNOMED CT)
    • MEDCIN
    • Diagnostic and Statistical Manual of Mental Disorders (DSM)
    • Logical Observation Identifiers, Names, and Codes (LOINC)
    • Drug Terminology Systems
    • Terminologies Used in Nursing Practice
    • Specialty International Classifications
    • Other and Emerging Vocabulary, Terminology, and Classification Systems
  • Part III: Data Standards for Healthcare
    • Data Set Stndards
    • Data Interchange Standards
  • Part IV: Application of Vocabulary, Terminology, and Classification Systems
    • Database of Vocabulary, Terminology, and Classification Systems
    • Use of Vocabulary, Terminology, and Classification Systems

Includes exercises, glossary, bibliography and references, an in-book answer key, and index.

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Healthcare Code Sets, Clinical Terminologies,
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