Knowledge Activity: Classification and

Terminology Systems (Associate)

Student instructions
1. If you have questions about this activity, please contact your instructor for assistance.
2. You will review the chart of Zain Hamdan to complete this activity. Your instructor has
provided you with a link to the Classification and Terminology Systems (AS) activity.
Click on 2: Launch EHR to review the patient chart and begin this activity.
3. Refer to the patient chart and any suggested resources to complete this activity.
4. Document your answers directly on this activity document as you complete the activity.
When you are finished, you will save this activity document to your device and upload
this activity document with your answers to your Learning Management System (LMS).

Glossary
Classification system: a system “that arranges or organizes like or related entities.”
(Giannangelo, 2014). A classification system is used to classify clinical procedures and
conditions, enabling statistical data across the national and international healthcare systems.
Classification systems have other applications in healthcare, including research, performance
monitoring, reimbursement, public health reporting and quality of care assessment. (Alakrawi,
2016).
Some common classification systems (CDC, n.d.-a):
 International Statistical Classification of Diseases and Related Health Problems, 10 th
revision (ICD-10): Classification system used for systematic recording, analysis,
interpretation, and comparison of mortality and morbidity data from different countries
and to translate diagnoses, diseases and other conditions into codes. Implemented as
the standard coding system for classifying diseases and related health problems in the
United States on October 1, 2015. Implementation in Canada as ICD-10-CA began in
2001.

 International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-

CM): Coding system used to report diseases and conditions of US healthcare patients.

 International Classification of Diseases, 10th revision, Procedure Coding System (ICD-

10-PCS): Coding system developed to replace Volume 3 of the ICD-9-CM manual.

 Current Procedural Terminology (CPT): Coding system established by the American

Medical Association for coding of procedures and services.

EHR Go Knowledge Activity: Classification and Terminology Systems (Associate) HBK1001.3

Archetype Innovations LLC ©2022 1
Terminology system: a system characterized by “a set of concepts and relationships that
provide a common reference point for comparisons and aggregation of data about the entire
health care process, recorded by multiple different individuals, systems, or institutions.” (Imel,
M. & Campbell, J., 2003).
One of the most common terminology systems is the Systematized Nomenclature of Medicine -
Clinical Terms (SNOMED CT).
 SNOMED CT: a controlled, multilingual medical terminology system that healthcare
providers use for the electronic exchange of clinical health information, which provides
structured terminology to enable coding of an entire medical record. (Imel, M. &
Campbell, J., 2003).

The activity
EHR Go is an educational EHR used for educational purposes only and does not contain all
classification codes that might be found in an EHR in practice. EHR Go has ICD-10 and CPT
codes, but does not have SNOMED CT.

ICD-10
ICD-10 uses alphanumeric categories. ICD-10 codes allow for great specificity to identify disease
etiology, anatomic site, and severity.
ICD-10 Code Structure:
 Characters 1-3 – Category
 Characters 4-6 – Etiology, anatomic site, severity, or other clinical detail
 Character 7 – Extension
Character 7 for ICD-10 indicates:
A – Initial encounter
D – Subsequent encounter
S – Sequela
(Mitchell, D., 2014).
 Initial encounter: Patient’s initial encounter for active treatment of an injury. (CDC, n.d.-
a)

Example: A patient is seen in the Emergency Department for a displaced transverse

fracture of the left ulna. The ED applies ice and immobilization, but the fracture cannot
be managed immediately. Instead, the ED advises the patient to seek follow-up with an
orthopedic specialist. This ED encounter would be reported using S52.222A Displaced
transverse fracture of the left ulna, initial encounter for closed fracture. (Mitchell, D.,
2014).

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 Should the patient see an orthopedist the next day, and the orthopedist is able to
reduce the fracture, this would be considered initial active treatment for the fracture.
Because the ED was only able to provide comfort care, the encounter with the
orthopedist would be considered the first encounter of definitive care. Therefore, this
encounter would also be considered an initial encounter and S52.222A code would
again be used. (Mitchell, D., 2014).
 Subsequent encounter: “Encounters after the patient has received active treatment of
the injury and is receiving routine care for the injury during the healing or recovery
phase.” (CDC, n.d.-a)

“Examples of subsequent care are: cast change or removal, removal of external or

internal fixation device, medication adjustment and follow up visits following injury
treatment.” (CDC, n.d.-a)
 Sequela: “for use for complications or conditions that arise as a direct result of an injury,
such as scar formation after a burn. The scars are sequelae of the burn.” In other words,
sequela are the late effects of an injury. (CDC, n.d.-a)

Introducing SNOMED CT
SNOMED CT is a standard clinical terminology system with specific support for multi-lingual
translation. SNOMED CT can cross-map to other international standards and classifications.
(Alakrawi, 2016). For example:
SNOMED CT to ICD-10-CM Map
Knowing how to cross-map the coding systems is important for data collection, retaining the
value of the data when going from one database to another, limiting or preventing errors, and
controlling costs. U.S. National Library of Medicine. (n.d.).

Differences between SNOMED CT and ICD-10

 SNOMED CT coding is completely automated by the system, while ICD-10 coding is
usually performed manually by professional coders. Although coders may utilize
computer-assisted coding (CAC), human intervention is still required to validate the
coding.
 SNOMED CT has more specific clinical coverage than ICD-10, with 100,000 coding
concepts in SNOMED CT compared to 68,000 ICD-10 diagnosis codes. As a result, more
than one ICD-10 code may be needed to represent one concept in SNOMED CT.
 SNOMED CT is more clinician friendly. ICD-10 codes often include conventions used by
coders (e.g. initial encounter, subsequent encounter, sequela, etc.) that are irrelevant
and confusing for clinicians.
 ICD-10 is utilized by a wider spectrum of healthcare users and, unlike SNOMED CT, can
help provide patients with information on treatment options, costs and outcomes.

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  ICD-10 provides a much simpler system for the collection and reporting of data for
research, which, in turn, benefits consumers through improved reimbursement systems,
surveillance of public health and monitoring of administrative performance.
(Alakrawi, 2016).

EHR Go and SNOMED CT

There is not SNOMED-CT or a mapping system between ICD-10 terms and codes in the EHR Go
EHR. Users must select the appropriate codes manually. On the Problems tab of the patient
chart, after choosing the New button in the bottom right corner, users have the option to
search for and define problems using ICD-10, or a free-text “Add Other” option.

CPT Codes
Current Procedural Terminology (CPT®) codes provide healthcare professionals with a uniform
language for coding procedures and services. The uniformity of these codes allows for
increased accuracy, efficiency, and streamlined reporting across the healthcare system,
including administrative claims processing. This national coding set, which is the most widely
accepted medical nomenclature used across the United States, was designated under the
Health Insurance Portability and Accountability Act (HIPAA).
CPT codes are 5 digits; some are numeric and some alphanumeric. There are several categories
of CPT codes, including:
 Category I: These numeric codes have descriptors that correspond to a procedure or
service. Codes range from 00100–99499. Category I codes correspond to a service or
procedure performed. The CPT codes in EHR Go are Category I.
 Category II: Alphanumeric codes, used as optional supplemental codes for measuring
performance.
 Category III: Alphanumeric codes that are temporary for developing and new
procedures, services, or technology.
(American Medical Association, n.d.)

Billing codes in EHR Go

Assigning an ICD-10 diagnosis code or a CPT procedure code for billing purposes can be done
from the Account section of the chart under the Claims tab. Click the New button in the bottom
right to begin a new claim.

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To add a diagnosis code, users can click on the Add Diagnosis button under the Diagnosis or
Nature of Illness or Injury section of the claim.

To add a procedure code, users can click on the Add Procedure button under the
Procedure/Service/Supplies section of the claim.

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Apply your knowledge
Open the EHR for patient Zain Hamdan. Utilizing the information found in the patient’s chart
and the information provided above, answer the questions below.

Questions
Zain’s back pain has recently worsened because of a fall, and his problem of chronic pain needs
to be added to the problem list in his chart. Click on the Problems tab in Zain’s EHR. Click on
New in the bottom right corner. Look up the ICD-10 code for Chronic pain due to trauma by
selecting the ICD-10 option to the right of the Problem field and performing a search as
outlined above.
1. What is the ICD-10 code for Chronic pain due to trauma?
G89.21
Close out of the Problem Edit screen by clicking Cancel. Choose Don’t Save.

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 2. Zain has a problem of Primary pulmonary hypertension in his chart that is not classified.
What is the ICD-10 code for this problem?
I27.0
3. Zain has a problem entered in his chart for gastro-esophageal reflux disease that is not
coded using an ICD code. If an ICD-10 code needed to be assigned to this problem, what
additional information would be helpful to know regarding Zain’s gastro-esophageal
reflux disease?
To accurately code Zain’s gastro-esophageal reflux disease, it would be helpful to know
if he has complications, the severity of his symptoms, and whether the condition is
acute or chronic.
4. Spelling is important when searching for ICD codes. If a user was searching for an ICD-10
code for “gastroesophageal” or GERD (instead of gastro-esophageal”), what would they
discover? What does this tell you about search protocol for ICD codes?
When "gastroesophageal" instead of "gastro-esophageal," is searched it says “no
matches found” showing how important it is to use the correct spelling and format
when searching for ICD codes.
Zain was seen by his primary care provider a few weeks ago and then seen again today at the
pain clinic. Review the notes for each of these visits by clicking on the Notes tab and then
clicking on each note to read the visit details. Next, review the existing claim in the
Account/Claims section of Zain’s EHR for his previous visit a few weeks ago. Click to open and
review the details.
5. What is the ICD-10 code associated with this claim?
M54.5
6. What is the CPT code associated with this claim?
99213
7. What is the charge associated with the CPT code?
$275
8. This claim would have been coded inaccurately if the CPT code 99205 was used instead
of the CPT code listed in the claim. List two reasons why 99205 is not appropriate for
this visit. (Hint: refer to the oldest visit note on the Notes tab in his EHR.)
Using code 99205 would mistakenly categorize this visit as a new patient evaluation,
when it is actually a follow-up appointment.
9. If a claim was created for the patient’s visit today, which CPT code would be more
appropriate: 99202 or 99204? Explain your answer. (Hint: refer to the visit notes for
today’s visit on the Notes tab in his EHR.)
CPT code 99202 would be a better fit for today’s visit, because the notes show a
"problem-focused" history and exam, indicating a lower level of complexity than what’s
needed for code 99204.

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Imagine that it was determined that Zain has a dislocation of the left ankle after his recent fall.
As a result, the doctor is placing him in a short leg cast that will begin below his knee and go to
his toes. He will be allowed to walk with the cast on.
A new claim for his diagnosis and procedure would be needed. Click on the Account tab in
Zain’s chart and then choose the Claims tab. Select New in the bottom right corner. Refer to
instructions above for more detail on looking up a diagnosis code and CPT procedure code to a
claim. (Note: you only need to look up the appropriate codes and do not need to enter and save
them in the chart).
10. What is the ICD-10 code for the diagnosis of dislocation of the left ankle? (Hint: refer to
information about Character 7 for ICD-10 codes earlier in the activity.)
S93.05X
11. What is the procedure name and CPT code for this type of cast?
CPT code 27792 is used to describe the treatment of an ankle fracture. This code
specifically refers to the surgical procedure involved in repairing a fractured ankle.
12. In your opinion, how does the human factor (data entry, manual abstraction, human
error, etc.) impact the success of using classification systems? Provide details and
examples to support your answers.
Human errors, especially in data entry and manual abstraction, can seriously affect the
success of classification systems. These mistakes can cause incorrect results, reduce
accuracy, and weaken the reliability of the classified data. For example, misinterpreting
medical records during manual data handling can lead to wrong diagnoses in a clinical
classification system, which can affect treatment decisions.

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 Submit your work
Document your answers directly on this activity document as you complete the activity. When
you are finished, save this activity document to your device and upload this activity document
with your answers to your Learning Management System (LMS). If you have any questions
about submitting your work to your LMS, please contact your instructor.

Learning objectives
1. Explain the use of classification systems, clinical vocabularies, and nomenclatures (2)
2. Validate assignment of diagnostic and procedural codes and groupings in accordance
with official guidelines (3)
3. Describe components of revenue cycle management and clinical documentation
improvement (2)
4. Determine diagnosis and procedure codes according to official guidelines (5)
5. Evaluate revenue cycle processes (5)

References
Alakrawi, Z. M. (2016). Clinical Terminology and Clinical Classification Systems: A Critique Using
AHIMA’s Data Quality Management Model. Perspectives in Health Information
Management. Retrieved from: http://perspectives.ahima.org/clinical-terminology-and-
clinical-classification-systems-a-critique/

American Medical Association. (n.d.). CPT® overview and code approval. Retrieved from
https://www.ama-assn.org/practice-management/cpt/cpt-overview-and-code-approval
Centers for Disease Control and Prevention. (n.d.-a). ICD-10-CM FY2022 Guidelines. Retrieved
from https://www.cdc.gov/nchs/icd/icd10cm.htm

Centers for Disease Control and Prevention. (n.d.-b). International Classification of Diseases,
(ICD-10-CM/PCS) Transition – Background. Retrieved from
https://www.cdc.gov/nchs/icd/icd10cm_pcs_background.htm

Giannangelo, K. (2014). Healthcare code sets, clinical terminologies, and classification systems.
(3rd ed.). Chicago: American Health Information Management Association (AHIMA).

Imel, M., and J. R. Campbell. (2003). “Mapping from a Clinical Terminology to a Classification.”
AHIMA’s 75th Anniversary National Convention and Exhibit Proceedings, October 2003.
Retrieved from http://bok.ahima.org/doc?oid=61537.

Mitchell, D. Initial, Subsequent, or Sequela Encounter? April 1, 2014. American Academy of

Professional Coders. Retrieved from: https://www.aapc.com/blog/27096-initial-
subsequent-sequela-encounter/

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U.S. National Library of Medicine. (n.d.). Overview of SNOMED CT. Retrieved from
https://www.nlm.nih.gov/healthit/snomedct/snomed_overview.html

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