Vol. 15 •Issue 20 • Page 22
Building a Bridge to EHRs ICD-10 and SNOMED-CT
ICD-10 and SNOMED-CT are building blocks to a complete EHR; developing a bridge of communication.
Have you ever watched the Miss Universe® pageant? During the final question competition, a translator is usually present on stage. A language barrier prohibits the English-speaking host from communicating directly with some of the contestants from around the world, so a translator is used to ease the flow of communication.Classification systems, such as ICD-10-CM and ICD-10-PCS (referred to as ICD-10), and standard clinical reference terminology, such as SNOMED-CT®, must coexist as translators for computer systems of electronic data to omit any language barriers between national and universal electronic health care systems.
Why must classification systems and reference terminology work together toward this goal? To enable implementation of a complete electronic health record (EHR) system, both ICD-10 and SNOMED-CT must be utilized to create a seamless link to payment classification systems and clinical information.
Establishing the Foundation
Because our health care system already uses ICD-9 as a classification system, updating to ICD-10–a more up-to-date and all-inclusive system—is natural.
But, it’s not necessarily easy, which is evident in the numerous setbacks to obtaining the preliminary rule for the tenth edition. “We’re still waiting for that preliminary rule,” explained Sheri Poe Bernard, CPC, CPC-H, national advisory board secretary for the American Academy of Professional Coders, Salt Lake City, and senior director of product management at Ingenix. “Am I surprised it’s taken this long? Yes. My hope would have been a 2007 implementation date, but now the earliest I see that happening is 2008.”
Linda Kloss, MA, RHIA, CAE, chief executive officer of the American Health Information Management Association (AHIMA), Chicago, testified before the U.S. House of Represen- tatives Committee on Ways and Means on July 27, 2005, on the specific concern of ICD-10 implementation. She stated, “Health care pro- viders, payers and vendors are waiting for a notice from the Department of Health and Human Services signifying the intent to implement ICD-10 in order to begin planning and preparing for an anticipated use date.”
Kloss explained in her address that an Oct. 1, 2008 implementation date of ICD-10 is essential. “This upgrade will affect all diagnoses coding, currently Volumes 1 and 2 of ICD-9-CM, as well as inpatient procedural coding, currently Volume 3 of ICD-9-CM,” she stated.
Today, there are currently 99 nations using ICD-10 for both mortality and morbidity, the U.S. started using ICD-10 for mortality in 1999. But to accomplish global comparability of data, the U.S. must implement ICD-10 for morbidity as well.
In doing so, ICD-10 will provide a more accurate portrayal of a physician’s clinical practices, resulting in precise reimbursement.
In addition to the classification system, once all health information becomes electronic—which currently is not the case—all detailed clinical notes and information will need to be electronic as well.
And that’s where SNOMED-CT comes in.
“The federal government has licensed SNOMED-CT to make it available at no charge as a reference terminology in EHRs,” Kloss explained in her testimony. SNOMED encompasses all of the detailed clinical data needed in patient records in terms of medical treatment and progress. Kloss also included in her address a brief background on SNOMED. “It is a comprehensive, precise clinical reference terminology, containing concepts linked to clinical knowledge to enable accurate recording of data without ambiguity. It’s specifically designed for use in an EHR and is incompatible with a paper-based health record system,” she explained.
Because SNOMED-CT is specifically designed for an EHR, making it an essential tool for the future of health care, it currently cannot stand alone.
Not all hospitals or health care facilities have fully functioning and all-inclusive EHRs, so until then, ICD-10 is necessary to code paper-based records.
“You need an EHR for SNOMED-CT to be of use,” emphasized Sandra R. Fuller, MA, RHIA, executive vice president and chief operating officer, AHIMA. “We simply don’t have many EHRs, and particularly we don’t have EHR capabilities for all the information in a patient record used to code an inpatient discharge,” she stated.
Another reason SNOMED-CT can’t stand alone is because the U.S. is part of a bigger picture.
“We’re part of the world community, and the world uses ICD-10,” Bernard explained. “We have to report our national health status statistics to the world community.”
The Miss Universe pageant would be a bust if it didn’t recognize the need for a translator, assuming all contestants could speak English. That’s what would happen if the U.S. adopted SNOMED-CT as its only coding system. But by using ICD-10, we are able to compare data around the world.
ICD-10 also plays an important role in billing. “If we solely used SNOMED-CT as our coding system by building groups of SNOMED-CT terms to use for payment, the codes would still need to be billed,” Fuller explained. “Those new groups would need to be promulgated around the country in a standardized way.”
So even though implementing ICD-10 is a huge undertaking, implementing new SNOMED-CT billing groups instead would become a world event rather than just a national one.
Bernard also mentioned that SNOMED-CT might be too detailed for all EHR functions. “It may not be necessary to have that level of detail in a coding system used mostly for reimbursement and outcome studies,” she continued. “For the purpose of keeping the hospitals running, SNOMED-CT might be too complex, that’s why both systems are needed.”
Linking ICD-10 and SNOMED-CT also provides a broader classification of the reference terminology. “The detailed information from SNOMED-CT can be classified into a broader group, making it usable for quality assurance, resource utilization and reimbursement,” assured Valerie J. M. Watzlaf, PhD, RHIA, FAHIMA, associate professor, department of HIM, School of Health and Rehabilitation Science, University of Pittsburgh.
When the two systems are used together, “You can really see a whole different slice of health care,” stated Susan Stanger, product manager for HIM solutions, QuadraMed, Alameda, CA. “When you map SNOMED-CT back into the other systems, it allows the entire record to talk,” she pointed out.
HIM, Part of the Team
“Talking” is an important function of an EHR; if it can’t “talk,” HIM professionals won’t be able to use the coding systems for various functions like coding and billing.
“HIM professionals understand the coding data, so their input is valuable and needed in regard to mapping ICD-10 and ICD-9 to SNOMED-CT,” explained Stanger.
According to Fuller, the map between SNOMED-CT and ICD-9-CM is not complete. “It’s available, and in fact, AHIMA is working with the National Library of Medicine to do a validation test on the map’s accuracy, but no one has stated that it’s a complete map yet,” she explained.
So HIM professionals need to get involved. “The mapping piece needs to take place across many HIM systems in the hospitals, so this entire process should become more common knowledge to HIM professionals,” stated Watzlaf.
And to fully understand the gamut of implementing ICD-10 and mapping it to SNOMED-CT, Bernard offered some impressive figures. “When coders work with ICD-9, they’re working with about 13,000 codes. When they’re working with ICD-10-CM the number of codes is almost 10-fold, increased to 120,000 codes. SNOMED-CT triples that number to 365,000 codes. So it’s important for coders to understand the scope of implementation. The changes are essential and monumental for both coders and clinicians,” she stated.
Costly to Wait
Even though the number of code changes seems intimidating, the longer the U.S. health care system waits, the more costly it will become.
“Right now coders are messaging reports back into ICD-9, they’re retro-fitting it back into an obsolete system under varying categories. The unorganized categories defeat the purpose of a classification system, increasing the amount of work when ICD-10 is implemented. It’s the same as waiting 10 years to build a bridge, it’s just going to cost more,” Stanger explained.
So what’s the hold up? Bernard thinks the momentum toward ICD-10 was lost because like anything else, you have to crawl before you walk. “The big focus in Washington, DC, has been the implementation of HIPAA regulations,” she continued. “It’s all a part of the grand scheme of things. But the ground work of HIPAA had to be laid for the EHR to really become a standard and before electronic claims could become a standard.”
So the next move toward that goal is changing code sets, because ICD-9 is obsolete. And with that, ICD-10-CM and SNOMED-CT together will move us forward.
“SNOMED-CT is a great thing for HIM professionals. The granularity it adds to ICD-10-CM will contribute to easing coding,” Bernard continued. “What SNOMED-CT is targeting is the improvement of physicians’ documentation, which is the biggest problem in coding and reimbursement, regardless of who you ask.”
Tricia Cassidy is an assistant editor at ADVANCE.