CPT® International
OVERVIEW
Purpose of the Terminology Management Component
Terminology management is of strategic importance to organizations that use Current Procedural Terminology (CPT®)[1] content as the clinical terminology to document and report patient services and procedures for clinical and administrative purposes. Terminology management involves leveraging CPT content and derivatives such as maps and subsets to efficiently and effectively achieve the goals of an organization including clinical documentation, patient safety, resource allocation, and remuneration.
Intended Audiences
This module is intended for all audiences.
Learning Objectives
After reviewing the content in the Terminology Management Component, the reader is expected to be able to:
- Understand the rationale and importance of terminology management.
- Describe the core components of terminology management.
Modules
The Terminology Management Component includes one module:
Module One: Terminology Management – Summarizes the key components of a terminology management strategy.
Each module is structured as follows. Note that some sections may not apply to a module.
Introduction – An introduction to the topic being discussed and why it is important.
- Intended Audience – The intended audience for the module.
- Learning Objectives – A list of learning objectives that will be covered in the module.
Main Module Content – The main content, which consists of five main sub-sections.
- Personnel – People who are involved in the topic.
- Tooling – Tooling and requirements that are required to apply the approach.
- Approach – The approach or methodology specific to a topic.
- Process – The interaction between personnel with other personnel and/or tooling.
- Challenges – Challenges associated with applying the approach.
Practical Use Example – An example of how the approach has been used.
MODULE ONE: Terminology Management
Introduction
Terminology management is of strategic importance to organizations that use CPT® content as the clinical terminology to document and report patient procedures and services for clinical and administrative purposes. Terminology management involves leveraging CPT content and derivatives such as maps and subsets to efficiently and effectively achieve the goals of an organization including clinical documentation, patient safety, resource allocation, and remuneration.
Intended Audience
This module is intended for all audiences.
Learning Objectives
After reviewing the content in this module, the reader is expected to be able to:
- Understand the rationale and importance of terminology management.
- Describe the core components of terminology management.
Terminology Management
The following are key components of a terminology management strategy.
Purpose
The purpose clearly states the reason for adopting and implementing CPT content, and the reason for terminology management. For example, the purpose of adopting and implementing CPT content is to facilitate the accurate, consistent, and comprehensive reporting of clinical procedures and services. The purpose of terminology management is to ensure formal processes are in place to support the use of CPT content.
Goals
Two sets of goals should be documented. First, the terminology use goals, which refers to the objectives of using CPT content. Examples include:
- To provide clinicians a uniform process for coding medical services that streamlines reporting and increases accuracy and efficiency
- To enable clinicians to communicate with colleagues, patients, hospitals, and insurers about procedures performed
- To facilitate administrative management purposes such as claims processing and developing guidelines for medical care review
- To facilitate medical education and research by providing a useful basis for local, regional, and national utilization comparisons
Second, the terminology management goals, which refers to the objectives of actively managing the core CPT content and the development and maintenance of derivative works of CPT content.
- To ensure new, changed, and inactivated CPT content is reviewed with each CPT content release.
- To ensure quality assurance principles are incorporated in the management of CPT derivatives.
- To ensure all CPT derivatives, including maps and subsets, are maintained.
Enumerating the goals are important as the processes and policies must support the goals.
Governance
Governance refers to the organizational entities involved, and the relationships and expected interactions between the entities. The role of each organizational entity must be clearly defined to ensure there is a clear demarcation of responsibilities.
Depending on the size of an organization, the organization may have three separate groups:
- A terminology management team comprised of health information management professionals, mapping and subsets specialists, and translators where applicable, and some clinicians. The terminology management team is responsible for identifying changes in each CPT content release and bringing it to the clinical advisory group to determine the clinical impact of the changes. This team is also responsible for managing CPT content derivatives such as maps and subsets.
- A clinical advisory group comprised of a multidisciplinary team of physicians/doctors, nurses, and other allied health care professionals that provides advice on clinical issues related to CPT content adoption and implementation. The clinical advisory group is responsible for reviewing changes in each CPT content release and providing advice on managing the clinical impact of the changes. This group can also make recommendations to apply for new CPT codes through the standard CPT Editorial Panel process.
- A technical advisory group comprised of systems analysts, software developers, and database managers that provide advice on technical issues related to CPT content adoption and implementation.
Policies and Processes
Policies and process must be well-documented to ensure all stakeholders and consumers of the terminology are aware of policies and processes. Examples include:
- Change Management – Guidance on how to prepare, support, and reinforce change.
- Use – Guidance on best practices for primary data use (eg, by clinicians for clinical documentation) and secondary data use (eg, research, resource planning).
- Education and Training – Education and training plan and materials for informing users and potential uses of the importance of CPT content and how to use CPT content in their electronic systems.
- Change Request – Processes that define how users request changes to CPT content, how the requests are evaluated and approved, and the action taken on the requests.
- Licensing – Ensuring the organization is properly licensed by the AMA for use of CPT content, and is in compliance with the terms of its license agreement with the AMA.
- Maintenance – Identifying new, changed, or inactivated CPT® content and ensuring derivatives such as maps and subsets reflect any changes from the core CPT content.
- Quality Assurance – Ensuring all CPT content derivatives undergo quality assurance checks before implementation. This should include a combination of automatic checks and manual review and focus on correctness, consistency, completeness, and non-redundancy.
APPENDIX: Terminology Management Principles
Source: Abrams K, Giannangelo K, Schneider S, et al. Learning more about terminology asset management trends, principles, and definitions. Journal of AHIMA 85, no.2 (February 2014): web extra.
Principles for managing healthcare terminologies address the following attributes:
- Holistic: Examining the situation from all aspects of terminology use
- Systematic: Assuring value of use through systems design and training of users
- Optimal: Finding the best value compromise between competing factors related to the use of terminology products that often arise in EHR systems
- Sustainable: Managing cost and performance. Terminology systems are an expensive but necessary asset to health care delivery and information sharing. A terminology asset manager guides the practice of data stewardship to maintain and improve the system over time.
- Integrated: Cooperating and leveraging other assets within the enterprise. Terminologies co-exist with other data management assets including classifications, registries, and a variety of software applications within the existing health information system(s)
Key elements are required to be successful in terminology management. These elements cover the five critical areas of support mentioned above for organizations and individuals. The elements are:
- Organizations must have a structure that facilitates implementation of essential principles
- Employees must have proper training and deep knowledge of health information management and essential knowledge of the health IT system hosting the terminology
- Organizations and employees must understand how to treat the use of standardized terminologies as assets to be managed and maintained
- To be an effective terminology asset manager, one must have a:
- Knowledge of all existing terminology systems within the health care entity
- Clear understanding of structure, authority, and responsibilities for the role
- Confirmed competence in data content and use of the select terminological resources
- Documented system information specific to the terminologies deployed
- Terminology asset management (TAM) policy statement
- Information and data governance awareness and/or training
- Competencies for terminology management employment include:
- Knowledge of terminology systems
- Ability to assess and develop concept representation for health data requirements appropriate for the work environment
- A keen sense of discernment, discretion, and judgment for deploying and managing the terminological resources included in the information system
- Familiarity with common terminology-related tools including terminology browsers, data mapping tools, and technology requirements and specifications
- Knowledge of data quality management principles and the ability to apply them consistently for collection, mapping, and analytics
- Ability to design data capture and collection processes involving the use of terminology systems
- Knowledge of release cycles for specific terminologies used in the information system
- Familiarity with the standards organizations developing and distributing the terminologies used by the employer
- Knowledge of certification, licensing, and conformance requirements for the systems and standards being used by the organization and vendors
- Knowledge of laws to address an extension or constraint of the standards
Source: Journal of AHIMA. AHIMA, 2020.
NAVIGATION
Component 3: Assessment of Feasibility
Component 7: Clinical Reporting
Component 9: Technical Requirements
Component 10: Educational Material
Component 11: Terminology Management