Key Issues Shaping Clinical Terminology and Classification

Editor's note: This article is an expanded version of "The Code Ahead: Key Issues Shaping Clinical Terminology and Classification" published in the July/August 2006 edition of the Journal of AHIMA.

Coding is changing quickly. HIM professionals can keep a step ahead by following eight issues shaping clinical terminology and classification.

Coded data go farther and do more than ever before, making it imperative that HIM professionals stay abreast of many rapid changes. One of the biggest changes is the expansion of coding from its traditional role of translating narrative clinical text into diagnosis and procedure codes. Coded data are now used for purposes such as severity adjustment, quality of care assessment, patient safety evaluation, public health surveillance, and decision support algorithm development. Coding must meet an emerging need to capture healthcare data in a standard format that has universal meaning and can be applied both at the individual and aggregate levels.

With this expansion come additional new responsibilities, such as entry of health information into a database and the need to understand how the quality and accuracy of the data are represented in code sets. HIM professionals are in a leadership position for the collection and reporting of healthcare data. They must plan now for transformational changes in clinical terminology and classification systems.

To this end, AHIMA's volunteer Clinical Terminology and Classification Practice Council identified key issues in clinical terminology and classification. They are:

  • Expanded uses of coded data
  • Compliance and reimbursement
  • State of traditional coding systems
  • Interoperability of the electronic health record (EHR) and the role of clinical terminologies
  • State of mapping
  • Computer-assisted coding
  • Work force
  • Education

These issues are summarized below.

Expanded Uses of Coded Data

Studies have found that coded data collected with a sole focus on reimbursement can adversely affect the use of the data for other purposes. For example, in a study conducted to assess the accuracy of hospital administrative data to serve as a risk-adjusted mortality predictor, Green and Wintfeld found that the observed differences in predicted hospital mortality reflected hospital-specific coding practices rather than hospital case-mix variation.1

While many individuals working within the healthcare industry only recognize coded data as the source for determining reimbursement, HIM professionals have always understood the myriad important uses of coded data. Historically, some uses of coded data included quality management activities, case-mix management, planning, marketing, administrative, and research activities.

In the last decade the uses of coded data have expanded. HIM practitioners must continue to monitor the many uses of coded data and must provide information of the highest quality for all reported information, not just for reimbursement-related data. Following are examples of the expanding uses of coded data.

Quality of Care Assessment

In 2001 the Agency for Healthcare Research and Quality (AHRQ) developed quality indicators that rely on hospital administrative data, including ICD-9-CM diagnosis codes, to construct a picture of the quality of medical care provided by a hospital and identify potential quality problems or success stories to be further investigated. Many state and regional hospital associations generate comparative data reports of these quality indicators as part of their quality programs and performance measurement systems.

An example of an AHRQ Inpatient Quality Indicator (IQI) is IQI 20, pneumonia mortality rate. This indicator monitors the number of deaths occurring for patients with a principal diagnosis of pneumonia. AHRQ selected the indicator because appropriate treatment with antibiotics is shown to result in reduced mortality rates from pneumonia.

Through the Joint Commission on Accreditation of Healthcare Organizations' ORYX initiative facilities report coded data used to assess the quality of care provided to patients and to compare performance on these core measures to other facilities.

Patient Safety Evaluation

AHRQ developed Patient Safety Indicators (PSIS) as a screening tool to identify areas where system or process changes could reduce preventable errors. Examples of PSI data tracked through coded data include obstetrical trauma in vaginal deliveries requiring instrumentation and cases of reclosure of postoperative disruption of abdominal surgical wounds. Currently PSI data are used by various state agencies for safety monitoring and confidential internal analyses.

Risk Adjustment

In order to provide a fair evaluation of outcomes data, many researchers are developing risk-adjustment methodologies. Many of the risk adjustment systems use ICD-9-CM data to classify patients into clinically meaningful groups and to further divide patients into severity-of-illness and risk-of-mortality subclasses. These risk adjustment tools are used to support a variety of data analysis efforts being conducted by individual healthcare facilities, state agencies, and hospital associations.

Pay-for-Performance Initiatives

Along with other care measures gathered through data abstraction, coded information is also being used for pay-for-performance initiatives. For example, in 2003 the Anthem Blue Cross and Blue Shield of Virginia Quality Insights Hospital Incentive Program began aligning financial incentives with achievement on specific objectives. As part of the program, hospitals are required to select two of a subset of nine AHRQ PSIs for monitoring and root cause analysis, when appropriate. The Centers for Medicare and Medicaid Services (CMS) are also currently piloting pay-for-performance initiatives with hospitals and physicians. These programs link bonus payments on a variety of measures. For hospitals, this includes two of the PSIs.

Public Health Surveillance

Coded data play a critical role in identifying and tracking disease outbreaks and in routine epidemiological monitoring. Recently the use of coded data for surveillance purposes is being explored more closely by public health specialists to detect and respond more effectively to bioterrorism threats.2

Clinical Decision Support

Healthcare data are being used to activate clinical alerts, prevention and chronic disease reminders, and in clinical decision support. This expanded application of healthcare data in the care provision has further increased the importance of the accuracy and timeliness of these data.

Coded and abstracted data from health record documentation also serves as the foundation for many clinical decision support algorithms. For example, a decision support tool developed to identify patients at high risk for developing deep vein thrombosis (and thus in need of prophylaxis) searches data for ICD-9-CM codes indicating a history of venous thrombosis or embolism, recent trauma or surgery, or current conditions such as venous insufficiency or obesity. ICD-9-CM coded data are also being used to develop patient profiles for proprietary clinical decision support systems to check if any of the patient's current medical conditions could have been caused by a drug included on the patient's current medication list.

Compliance and Reimbursement

The healthcare field is highly regulated by a complex statutory and regulatory scheme. Coded data play an important role in ensuring appropriate reimbursement for healthcare services rendered for institutional or provider claims. This importance continues to increase as prospective payments have evolved to include other treatment settings, such as inpatient psychiatric facilities. HIM professionals are uniquely qualified to interpret and implement policies that govern reimbursement. They can provide leadership within organizations to ensure that clinical documentation is accurate and appropriate to support the diagnoses and procedures selected for reimbursement.

Healthcare fraud is a major weakness in the US healthcare system, and it affects the ability to provide quality care and enhance patient safety.3 It is important to always consider the impact classification and terminology assignment has on both data quality and compliance to federal and state rules and regulations. In order to address the issue of healthcare fraud, a robust data quality and compliance program is of the utmost importance in the respective areas of classifications and terminologies.

AHIMA has provided important tools in this regard with medical coding guidelines and procedures at the national level. HIM professionals should continue to position themselves to play a significant role in the development and implementation of a quality program to meet the needs of all stakeholders, including compliance and appropriate reimbursement today and into the future.

State of Traditional Classification Systems

HIM professionals recognize that the medical code sets and classification systems are currently, and will continue to be, of significance to the profession. An understanding of CPT, ICD-9-CM, ICD-10-CM, ICD-10-PCS, HCPCS, and evaluation and management guidelines is essential to the coding body of knowledge. Whenever code sets and classification systems undergo revision, the work done by HIM professionals must change. Workflow and procedures developed for paper records are no longer relevant when electronic records are used. More terminologies and code sets are employed in the EHR so computers can process information accurately and completely. These terminologies and code sets have varied maintenance schedules. Version control and software updates become a challenge and can add overhead costs.


CPT provides a uniform language that accurately describes medical, surgical, and diagnostic services and thereby serves as an effective means for reliable nationwide reporting. Since 1966 CPT has undergone four revisions; it is currently in its fourth edition. The American Medical Association launched the CPT-5 project to ensure that CPT would be preserved and remain the authoritative source of correct physician and outpatient procedural coding in the industry while making improvements in the structure and process. From 2000 to 2002, CPT-5 recommendations were phased in, and the rollout was completed in the CPT 2003 edition.

As part of the drive to extend the function of CPT, two new categories were developed to extend its function. Category II (performance measurement) facilitates data collection of services and test results that are agreed upon as contributing to positive health outcomes and quality patient care. They are considered a set of optional tracking codes for performance measurement. Category III codes (emerging technology) facilitate data collection and assessment for new technology, services, and procedures in widespread use or in the FDA approval process.

Evaluation and Management Guidelines

Hospital Use

Since the inception of the Medicare hospital outpatient prospective payment system (HOPPS) in August 2000, hospitals have reported clinic and emergency department visits using the same CPT codes that physicians use for reporting health services. However, these evaluation and management (E/M) codes were designed to describe professional services, not the services provided by the facility. In response, CMS has allowed facilities to develop unique internal guidelines to report clinic and emergency department services by mapping them to the levels of effort represented by the existing CPT codes. As a result, each hospital has its own E/M method, although hospitals within the same health system may have the same or similar methods.

In its November 1, 2002, final rule for HOPPS, CMS called for an "independent expert panel" to develop consistent code definitions and guidelines to be used by Medicare and Medicaid for facility-based evaluation and management services. As a result, the American Hospital Association and AHIMA convened a panel of experts to develop standardized E/M code definitions and guidelines for use by facilities.

CMS believes that the panel has made much progress in its efforts to develop a set of national facility guidelines for emergency department and clinic visits. However, CMS feels that the guidelines require additional testing to provide hospitals with the least burdensome standard for achieving uniformity and to yield more accurate, meaningful information for appropriate payments. CMS will ultimately make the proposed standardized guidelines available through its Web site. The proposed guidelines will be disseminated once CMS is satisfied with the results of the testing and modifications have been made based on the testing results. CMS also promises to provide ample opportunity for public comment and to be considerate of the time necessary to educate the users of these guidelines and make modifications to hospital systems.

Physician Use

In 1994 CMS released documentation guidelines that divided each E/M code into key and contributory components. They are commonly referred to as the 1995 Documentation Guidelines. However, the guidelines were problematic for some specialties, and in 1997 CMS published a revision. Different problems were identified with the 1997 set. Presently, CMS allows use of either the 1995 or 1997 guidelines. Thorough understanding of both sets is essential for correct assignment and validation of E/M codes.

As of January 2004, the 1995 and 1997 guidelines remain in effect for evaluating documentation to support physician reporting of E/M service codes. CMS is committed to developing a more accurate method for consistently measuring levels of service, preferably one that does not involve counting. In 2002 CMS turned the E/M guideline project over to the American Medical Association, which works through its CPT editorial panel. The panel is revising the E/M code descriptors and hopes to enhance the functionality and utility of the codes so that separate documentation guidelines are not necessary for accurate code assignment.


ICD-9-CM is used in the United States to code and classify diagnoses for inpatient and outpatient records, other healthcare encounters, and inpatient procedures. Although diagnostic and procedural coding for statistics and research were the original functions of the system, ICD-9-CM also has been used for reimbursement since 1983.

Updates to ICD-9-CM are managed by the ICD-9-CM Coordination and Maintenance Committee, a federal committee established in 1985 and cochaired by representatives from the National Center for Health Statistics and CMS. Updates to ICD-9-CM are made each October 1. Regulatory provisions also allow updates every April 1, although this provision has not yet been used.

ICD-10-CM and ICD-10-PCS

ICD-10-CM is the US clinical modification of the World Health Organization's International Classification of Diseases, 10th revision (ICD-10). ICD-10-CM was developed as a replacement for volumes 1 and 2 of ICD-9-CM for diagnosis coding. The National Center for Health Statistics is responsible for the development of ICD-10-CM. ICD-10-PCS (procedure coding system) was developed to replace ICD-9-CM volume 3, used by hospitals to report inpatient procedures.

Legislation calling for the implementation of ICD-10-CM and -PCS in the United States by October 1, 2010, passed in the House of Representatives.

The healthcare industry's current dependence on coded data makes the transition from ICD-9-CM to ICD-10-CM/PCS more important than the 1979 transition to ICD-9-CM. Similar to HIPAA, the change to ICD-10-CM/PCS affects every healthcare provider, payer, and user of healthcare data. In addition to the logic behind software systems such as encoders, editors, compliance systems, and decision support systems all other software that uses coded data must be revised to accommodate ICD-10-CM and -PCS. Educating users of coded data will pose another major challenge.


CMS maintains Healthcare Common Procedure Coding System (HCPCS) Level II codes to identify products, supplies, and services not in the CPT code set maintained by the American Medical Association. However, in some instances there is overlap and duplication, leading to provider confusion about which code to use and difficulty comparing data across healthcare settings. The codes are used for billing items such as durable medical equipment, prosthetics, orthotics, supplies, and ambulance services. They are alphanumeric codes with a single alphabetic letter followed by four numeric digits. The national codes are published annually and become effective at the beginning of each year. Temporary HCPCS Level II codes are implemented quarterly

Medicare's voluntary program to report evidence-based, consensus quality measures-an important step toward supporting higher quality physician care-uses a dedicated set of HCPCS G-codes. These codes will supplement the claims data doctors currently submit to CMS with clinical data. These clinical data will then be used to measure the quality of services provided to Medicare patients. CMS anticipates that these G-codes will serve as an interim step until the electronic submission of data through EHRs replaces this process. CMS expects to collaborate with participating physicians to develop such electronic data submission methods.

Interoperability and the Role of Clinical Terminologies

For healthcare systems to be interoperable-to exchange data in a uniform format that can be integrated automatically-they require medical terms that are universally understood. Standardized clinical terminologies supply that framework. They represent the meaning of medical terms that can be uniformly understood by all users of EHR systems inside and outside of healthcare enterprises.

Interoperable EHR systems based upon standardized terminologies provide many significant benefits, including:

  • Instantaneous clinician access to critical health information at the point of care
  • Improved patient safety
  • Decreased healthcare treatment errors and costs

There are a number of initiatives driving the adoption of standardized, interoperable EHRs. The president has called for the availability of EHRs for all US citizens by 2014, and he created the Office of the National Coordinator for Health Information Technology. The Consolidated Health Informatics project brought together federal healthcare agencies to review clinical terminologies and recommend their use in standardizing many clinical domains. The agencies then adopt these standards into their EHR projects. One goal of this project is to help the private sector move toward standards-based information solutions based upon these adopted standards. In 1991 the Institute of Medicine recommended the elimination of paper-based records due to patient safety issues. It continues to push this effort still today.

Outside the federal government, health information exchange initiatives are working to network patient data so that complete and accurate information is available for treatment wherever and whenever the patient requires it. Improved data exchange can help identify bioterrorism and public health threats, facilitate outcome and quality improvement research, and provide ongoing information for clinical decision support. Work is under way to create regional health information organizations (RHIOs) and a nationwide health information network to serve as the framework for exchanging data. The RHIO framework will most likely consist of policies, procedures, and business rules for the information exchange, as well as a road map of technical standards, policies, procedures, and implementation guides.4 HIM professionals must be involved in the development of RHIOs and other health information exchange projects.

Other initiatives include the EHR Collaborative, a group of private-sector organizations moving to rapidly adopt information standards for healthcare. The Health Information Technology Standards Panel, working under a contract from the Department of Health and Human Services, has brought together US standards development organizations and other stakeholders to develop, prototype, and evaluate a harmonization process for achieving a widely accepted and useful set of health IT standards that support interoperability among healthcare software applications, particularly EHRs.

Messaging standards, content standards, and terminologies in EHRs today include:

  • The Continuity of Care Record (CCR), being developed by the American Society for Testing and Materials (ASTM). It contains a uniform healthcare summary of the patient's healthcare that is accessible to both clinicians and patients. The CCR will be exchanged whenever a patient is being transferred or treated by other clinicians. Benefits include greater continuity of care, reduced medical errors, and interoperability. ASTM also has other standards related to the content of the EHR.
  • Health Level Seven (HL7), which has been adopted as an EHR messaging standard for the transmission of consistent data between both the sender and receiver of the data. It has also been adopted to standardize immunizations, units of measure, and text-based documents. The HL7 Clinical Data Architecture has been adopted to standardize the structure and meaning of clinical text documents such as discharge summaries and progress notes. It ensures that the text document maintains the same content and structure when shared between healthcare entities. It uses coded vocabularies such as Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) and Logical Observation Identifiers, Names, and Codes (LOINC) to encode concepts in the documents. It is both machine and human readable. HL7 has also been tasked with developing a standardized functional model for EHR systems. The goal is to produce a standardized model for use by system builders to help accelerate adoption of EHR systems. The model requires that consistent terminologies be used to provide a standardized language for all EHR systems. EHR systems that use local terminologies will be required to map these to the specified standard terminologies.
  • LOINC provides a universal method to identify and encode laboratory and clinical observations for electronic exchange and pooling of results. It was adopted as the federal interoperability standard for lab test orders and drug label section headers. It provides a uniform means of sharing standardized lab test orders between healthcare entities, especially between facility-based and outsourced laboratories. It is also being used to encode other healthcare information, such as text document titles, mental health instruments, ventilator settings, and radiology exams.
  • SNOMED CT provides a common language for indexing, storing, retrieving, and aggregating clinical data across specialties and sites of care. It contains more than 993,000 descriptions for clinical concepts. The National Committee on Vital and Health Statistics recommended SNOMED CT as the standard for nonlaboratory interventions and procedures, laboratory test results, anatomical locations, diagnoses, problem lists, and nursing care. The National Library of Medicine purchased a license for SNOMED CT that allows its free use in the US. This purchase is intended to accelerate the adoption and interoperability of EHR systems.
  • National Council for Prescription Drug Programs (NCPDP) Script has been adopted as the standard for electronically transmitting prescription data between prescribers and pharmacies. CMS has mandated the use of NCPDP by all Medicare plans. It is also the official standard for HIPAA pharmacy claims. Benefits include reduced prescription errors and increased prescription legibility.

There are a number of barriers obstructing the development of standards-based EHRs:

  • Lack of adequate standards for all clinical domains (e.g., no standard acceptable yet for allergies)
  • Lack of open and "free-for-use" standards in the public domain
  • Lack of knowledge about and use of standards developed by standards development organizations
  • The high cost of systems, especially a factor for small clinician practices
  • Current fragmented use of technology with minimal interoperability

Standardized clinical terminologies are the data structures for the EHR, promoting data quality and enabling data to be uniformly understood by all internal and external users. HIM professionals must continue to learn about EHRs and the clinical terminologies that will be used to standardize the data since they have the clinical and coding expertise necessary to help adopt these standards in their organizations.

There are opportunities for using these standards to code and map their clinical data to other more commonly used classifications, such as ICD-9-CM, ICD-10-CM, and CPT. A potential new role for the HIM professional is that of clinical terminology manager. There are already a number of HIM professionals working in the areas of EHR and clinical terminology development and standardization.

State of Mapping

Mapping is the linking of content from one terminology or classification to another. It is a key element in maximizing the benefits of an EHR. As hospitals strive to maximize productivity, employing the clinical data being entered through automated coding practices will avoid duplication of data capture and increase productivity. Providing interoperability through mapping functions will also speed up the widespread use of SNOMED CT. Standardizing and codifying data provides for robust reporting capabilities for data mining and statistical analysis. Mapping of patient care data will prompt clinical decision support tools to alert caregivers to relevant patient information that will improve patient care.

Mapping activities are being actively developed in the US through the National Library of Medicine and SNOMED CT and in the United Kingdom by the National Health Service. Mapping SNOMED CT to US administrative code sets such as ICD-9-CM and CPT will provide a link from physician documentation to the billing process.

Harmonizing nursing terminologies to SNOMED CT allows for codification of nursing documentation and ability to report on outcomes management. Maps developed between terminologies and classifications are designed differently based upon the intended use of the mapped data. For example, the current SNOMED CT to ICD-9-CM map can be used for epidemiological purposes. However, in order to use a SNOMED CT to ICD-9-CM map for reimbursement purposes, several coding rule-based instructions would need to be incorporated. Furthermore, mappings for clinical decision support tools require links in the reverse direction, mapping from the external vocabulary or classification to the proprietary clinical decision support tools.

There will be many opportunities for HIM professionals around mapping proprietary records or terminologies to the standard reference terminologies. HIM roles will move from coding roles to reviewers of automated mapping, data analysis and data management roles, as well as that of clinical terminology manager. This role will include harmonizing terminologies (identifying and addressing overlaps in various terminology systems).

Computer-Assisted Coding

The healthcare industry is creating powerful tools to transform clinical data input into useful clinical data output. Clinical coding is approaching a tipping point where an increasing amount of work is done by machine, saving precious time and human resources for more complex coding and much-needed data analysis tasks.

Computer-assisted coding (CAC) is the use of computer software to automatically generate medical codes from clinical documentation. An increasing amount of routine clinical coding is done by machine, saving time and human resources for more complex coding and data analysis.

CAC affects management of the coding process, although the applications do not fully automate the coding process because human review is still necessary for final code assignment. CAC increases coder productivity and makes the process more efficient. It has a significant impact on coding workflow and the responsibilities of the coding staff, as the coding professional shifts from a production role to one of an expert editor. Clinical coding tasks will no longer include time-consuming, repetitive code assignment, instead concentrating on tasks involving critical thinking, such as interpretation and analysis of documentation or aggregate data.

As the transition to EHRs and the adoption of ICD-10-CM and ICD-10-PCS occurs in the US, the detailed and logical structure of these systems will increase the use of CAC tools across many different domains.

Work Force Issues

A multitude of interrelated issues affect the coding work force, including increased uses of coded data, advances in CAC, and anticipation of ICD-10. Thus, an adequate supply of qualified coders is critical to the success of each healthcare enterprise. CAC is projected to reduce the current shortfall of coders by allowing coders to focus only on specific codes flagged for review in the CAC process, thereby becoming more productive. Increased recognition of coding's importance and the need for trained, qualified, credentialed coders continues to fuel the demand for coders in excess of the current supply.

The shortage of qualified coders has led to an exploration of staffing alternatives such as remote coding, permanent outsourcing, and interim staffing. Questions exist. Do facilities that allow coders to work from home experience increased productivity and decreased turnover? What are the keys to success when outsourcing or interim staffing options are used to fill the coder shortage? Each healthcare enterprise should explore the issues surrounding these options in order to plan for adequate staffing of qualified coders.

The industry is addressing recruitment and retention challenges by adopting technology that allows coding professionals to work remotely, accessing medical records in electronic format. Since this is becoming a more common practice, AHIMA and its members must be involved to facilitate successful implementation of remote coding.

The areas that need to be addressed include:

  • Methods to determine if an individual is suited to work from home
  • Management considerations, concerns, and controls associated with work from home, including quality and quantity indicators
  • Necessary workflow changes
  • Data security and privacy
  • Training and education for at-home staff
  • Technological advances positioning, future classification changes, and the entire HIM professions transformation

HIM outsourcing can be either a permanent or interim solution for staffing shortages In either situation, it is important to:

  • Assure an accurate staffing agreement
  • Begin change management early
  • Transition in a willing manner
  • Partner with the outsourcer

Outsourcing is successful when communication is frequent and bidirectional, participants show flexibility, the outsource provider has expertise, and the client is a responsible stakeholder. A sound contract delineating responsibilities is essential.

It is equally important that both organizations be successful and that the client realizes that the outsourcer is a partner in providing solutions. It is important also for both parties to have adequate controls in place to ensure data quality. The HIM community must also be able to adequately assess the feasibility of offshore outsourcing alternatives. Information should be available to verify that training and credentials are equivalent to US expectations and that regulatory guidelines are adequately followed.


There will be a great demand for educational programs to assist HIM professionals in their transition to the many new roles described above. HIM professionals will need to conduct gap analyses of their existing skills to determine the education they require to stay abreast of the many changes within the coding, clinical terminology, and classification systems.

In order to meet this need AHIMA, academic institutions, and vendors will need to develop educational offerings in areas such as the mapping and the use of clinical terminologies in the EHR, new classification systems such as ICD-10-CM and ICD-10-PCS, data security, and integrity issues to be addressed during information exchange and how to work effectively with CAC tools. Educational offerings will need to take a variety of formats, such as new curriculum for new HIM professionals, in-person seminars, Web-based sessions, and published articles.

In order to prepare the graduates of HIM and health IT educational programs for this rapidly changing work environment, academic programs will also need to be vigilant in monitoring these changes, reinforcing their skills, and making appropriate revisions to curricula.

Future Issues

Healthcare data presented in a format that has universal meaning and can be applied at the individual level and in the aggregate healthcare delivery system are valuable assets. HIM professionals are in a leadership position for the collection and reporting of healthcare data because they understand the translation and categorization of data, regardless of the code sets or software applications. They are valuable because of their knowledge of the clinical care process and its relationship to wellness and disease. They are integral for the description of the time and effort of the care process in a few succinct codes that are machine readable for efficient automated storage and retrieval to meet multiple needs. Further, HIM professionals understand the structure and format of maintaining a legal health record that supports quality care.

HIM professionals must prepare for transformational changes in clinical terminology and classification systems. ICD-9-CM and HCPCS/CPT have been the current focus for coding professionals for more than 25 years because they are used for reimbursement from most healthcare plans, including the government-supported Medicare and Medicaid programs. Currently when the word "coding" is used, it refers to ICD-9-CM and HCPCS/CPT code assignment. The future will include additional new coding systems with different capabilities designed for uses other than claims processing.

HIM professionals currently work primarily with classification systems where the objective is to place the disease or procedure into the correct category like the Dewey decimal system. Other systems important to learn about for the future are better able to describe the clinical facts about an individual's disease because they are built to do so more like a nomenclature, such as SNOMED CT. Even the classification systems are evolving and becoming more sophisticated, such as ICD-10 and the International Classification of Functioning, Disability, and Health.

Technology, too, is an ever-changing landscape. Software is available now and will continue to develop to assist in automating the basic disease and procedure coding processes. The future will offer systems that abstract key symptoms, problems, disease statements, and procedures through natural language processing and present this profile for higher-level review and organization by a skilled HIM professional.

HIM professionals recognize that the EHR has great potential to be a rich data resource. Currently governmental agencies and healthcare organizations have come out in support of converting paper records to electronic formats. In the process HIM professionals need to take the longer view of the data and future patient care requirements. It may be expedient to create an electronic record that serves an individual healthcare provider's patients and allows the bill to be paid. However, taking a short-term view may not serve society and may totally derail the efforts to use data at a higher level to support longitudinal care for an individual, improve public health and the health of the community, and address major diseases and identify the most effective treatments.

Technology is available to create EHR systems that can be accessed by more than one healthcare provider and by the patient. People need to work together on the content that translates into data and on systems that interface with one another to allow health information exchange. Content and interface and exchange standards will support the code assignment process and use of standard data elements. Many technological applications can be developed to take the tedium out of tasks related to abstraction and organization of the data (e.g., coding, research, planning, disease management, and billing).

HIM professionals are in an excellent position to be major players and leaders in translating data into useful information about health, disease, and efforts to prevent and treat disease. Implementing EHR systems that rely on code sets as a data resource for patient care and all other potential uses of the data that will support the individual, the community, and the healthcare delivery system is very much a part of the HIM domain.


  1. Green J., and N. Wintfeld. "How Accurate Are Hospital Discharge Data for Evaluating Effectiveness of Care?" Medical Care 31, no. 8 (1993):719-31.
  2. Parks, Leticia I. "Homeland Security and HIM. Appendix B: Syndromic Surveillance Systems in Bioterrorism and Outbreak Detection." Journal of AHIMA 75, no. 6 (2004): Web extra.
  3. Foundation of Research and Education. "Report on the Use of Health Information Technology to Enhance and Expand Healthcare Anti-Fraud Activities." 2005. Available online in the FORE Library: HIM Body of Knowledge at
  4. Mon, Donald T. "An Update on the NHIN and RHIOs." Journal of AHIMA 76, no. 6 (2005): 56-59.


Delena C. Bidwell, MA, RHIA, CCP, CPUR
Sue Bowman, RHIA, CCS
Bonnie S. Cassidy, MPA, RHIA, FAHIMA
Cheryl A. D'Amato, RHIT
Kathy Giannangelo, RHIA, CCS
Gail L. Graham, RHIA
Matthew J. Greene, RHIA, CCS
Candace L. Hall, RHIT
Mary A. Hanken, PhD, RHIA, CHP
Laurie Johnson, MS, RHIA
Tammy J. Mathewson, RHIA, CCS-P
Kathryn M. Perron, RHIA
Rita Scichilone, MHSA, RHIA, CCS, CCS-P, CHC
Mary Stanfill, RHIA, CCS, CCS-P
Susan Wallace, MEd, RHIA, CCS
Ann M. Zeisset, RHIT, CCS-P, CCS


Julie Beinborn, RHIA
Rhonda Butler, CCS
Kathy Johnson, RHIA
Cesar M. Limjoco, MD, CCS
Melanie S. Loucks
Bernice C. Ulrich, RHIA

Article citation:
AHIMA Clinical Terminology and Classification Practice Council. "Key Issues Shaping Clinical Terminology and Classification ." Journal of AHIMA 77, no.7 (July/August 2006): extended online edition.