In many healthcare settings, ICD-9-CM/ICD-10-CM codes come to mind any time problem lists or diagnoses are discussed. That has now changed under the new stage of meaningful use. The Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT) is the terminology required for the capture of problem lists under Stage 2, causing some concern among clinicians and executives who have not previously considered how SNOMED will play a role in their IT strategies.
Healthcare organizations unaccustomed to recording in SNOMED must assess the current terminologies used for problem lists – as well as diagnoses – and how those terminologies might affect ongoing analytics and reimbursement. They also must consider the larger roles of SNOMED and ICD-10 in meeting the end goals of meaningful use.
After analyzing clinical documentation workflows, one option for easing the transition to SNOMED is the use of terminology conversion tools that can help providers accurately record in SNOMED and ICD-10, while still maintaining the unique data points of each code set. In the end, despite maintaining separate code sets, organizations will appreciate the granularity of SNOMED and ICD-10 in improving patient population care management, operational efficiency and reimbursement.
Problem lists have been around a long time. Historically, and in many outpatient offices and clinics today, physicians have maintained paper problem lists in the front of patient charts that are updated during each encounter. The problem list basically acts as a running record of the major or chronic conditions suffered by the patient.
By contrast, the diagnoses coded within a practice represent the conditions that prompted the services rendered during a visit. In other words, the diagnosis codes describe the ailments that justify billing for the procedures performed. After a visit, a physician typically marks the appropriate ICD-9 codes on a superbill and sends it to the billing staff.
When electronic health record (EHR) systems were first developed, it was easy for the technology to lump problem lists and diagnoses together using ICD-9 codes. However, the result of relying on those codes for problem lists is that physicians often end up without the exact information they need. Once the industry transitions to ICD-10, for example, a physician might see a code for: “Other fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing.” While the closed fracture and delayed healing detail is helpful, the fact that the patient was presenting for a subsequent visit does not belong on a problem list. Conversely, an ICD-10 code could be too general, such as: “Heart failure, unspecified,” a descriptor lacking clinical detail.
In comparison, the SNOMED codes required by Stage 2 meaningful use for documenting problem lists, family history, drug/allergy reactions, smoking status and hospital procedures include more of the clinical detail necessary for appropriate care, but omit irrelevant billing information. Moreover, SNOMED is a proven terminology. Created in 1965, the code set is owned, maintained and distributed by the International Health Terminology Standards Development Organisation (based in Denmark). SNOMED has a long history, international acceptance and strong organizational support and maintenance.
Organizations that have not yet implemented SNOMED for problem lists will need to assess their EHR system’s capabilities and determine how to convert current problem list terminology into SNOMED. This project could be incorporated into the ICD-10 implementation, as the two terminologies will need to be used concurrently.
Providers can update EHR and practice management systems for SNOMED capabilities, but can also investigate software tools that use provider-friendly terminology to help translate between the two code sets. With some conversion tools, for instance, ICD-10 codes easily can be dragged from an electronic superbill to the problem list and automatically translated to SNOMED.
Recording problem lists in SNOMED is required to meet meaningful-use criteria. More importantly, however, taking full advantage of the terminology can serve the best interests of patients.
Once all organizations are using SNOMED for problem lists and ICD-10 for diagnoses, the healthcare industry should experience improved operational efficiency and reduced costs as it moves toward providing greater patient safety and care. HMT
About the Author
Brian Levy, M.D., is senior VP and CMO for Health Language Inc. For more on Health Language Inc.: www.rsleads.com/304ht-211