SNOMED CT vs ICD10 CM AAPC Austin Chapter

SNOMED CT vs. ICD-10 -CM AAPC Austin Chapter Presentation November 20, 2014 Michael Stearns, CPC, CFPC, MD CEO and Founder Apollo HIT

The Basics

Differences ØICD-10 -CM is a “classification system” Ø Codes may have multiple but similar meanings, forming a classification Ø SNOMED CT is a “reference terminology” ØVery specific codes that have one meaning Apollo HIT, LLC

ICD-10 -CM: Intended Purpose � Classification systems such as ICD-10 -CM: ◦ Group similar diseases and similar entities for easy retrieval. ◦ Allow granular clinical concepts captured by a reference terminology (e. g. , SNOMED CT) to be aggregated into manageable categories for secondary data purposes. ◦ Are typically used for external reporting requirements or other uses where data aggregation is advantageous: �Population Health �Resource Utilization �Processing claims for reimbursement Apollo HIT, LLC

ICD-10 -CM: Intended Purpose (2) ◦ Classification systems such as ICD 10 -CM: �Are not intended or designed for the primary documentation of clinical care �Are inadequate in a reference terminology role because they lack granularity and fail to define individual clinical concepts and their relationships. �Are by far the most common source of clinical data today (as a byproduct of the healthcare reimbursement process). � Reference: Bowman, Sue. "Coordinating SNOMED-CT and ICD-10: Getting the Most out of Electronic Health Record Systems. " Journal of AHIMA 76, no. 7 (July-August 2005): 60 -61. Apollo HIT, LLC

Terminology Challenges � Common dilemma associated with trying to extract clinical information from clinical documents: � “Each disease has, in many instances, been denoted by three or four terms, and each term has been applied to as many different diseases: vague, inconvenient names have been employed, or complications have been registered instead of primary diseases. ” � William Farr (England) 1839

Health. Care Challenges “Studies have shown that most health care is not based on clinical studies of what works best and what does not — be it a test, treatment, drug or technology. Instead, most care is based on informed opinion, personal observation or tradition” � NYTimes Op. Ed Article 10 -23 -08 ◦ Critical lack of data needed to improve the quality and efficiency of healthcare

Reference Terminology � Data captured and stored in a manner that supports: ◦ ◦ ◦ Clinical decision support Interoperability Clinical reporting Clinical Research Health Information Technology (HIT) research Public health (e. g. , “All health departments have real-time situational awareness of outbreaks”) This is what SNOMED CT was designed to do

SNOMED CT® Apollo HIT, LLC

Why SNOMED CT®? � SNOMED was originally developed by the College of American Pathologists to support a common language for pathology reporting � Clinical Terms (CT) was developed by the National Health Service to facilitate the capture of clinical data at a granular level. � These two were merged in 2001 to form SNOMED CT® Apollo HIT, LLC

SNOMED CT Content � Over 360, 000 concepts � Over 1, 000 synonyms � Over 1, 000 logical relationships between concepts � Content coverage includes anatomy, symptoms, observations, diseases, procedures, substances, organisms, modifiers and many other concepts used in healthcare Apollo HIT, LLC

SNOMED CT Content (2) � � � � Clinical finding/disorder Procedure/intervention Observable entity Body structure Organism Substance Pharmaceutical/biologic product Specimen Special concept Physical object Physical force Event Environmental of geographical location Social context Staging and scales Apollo HIT, LLC

Injury Codes Markedly Increased in ICD-10 -CM � W 56. 2 Contact with orca ◦ W 56. 21 Bitten by orca �W 56. 21 XA …… initial encounter �W 56. 21 XD …… subsequent encounter �W 56. 21 XS …… sequela ◦ W 56. 22 Struck by orca �W 56. 22 XA …… initial encounter �W 56. 22 XD …… subsequent encounter �W 56. 22 XS …… sequela ◦ W 56. 29 Other contact with orca �W 56. 29 XA …… initial encounter �W 56. 29 XD …… subsequent encounter �W 56. 29 XS …… sequela SNOMED CT: Orca (organism) + Animal bite with location Apollo HIT, LLC

Benign Rolandic Epilepsy � Most common form of primary childhood epilepsy � ICD-10 -CM ◦ No current specific code in ICD-10 -CM ◦ Use ICD-10 -CM G 40. 802 (other epilepsy, not intractable, without status epilepticus) � SNOMED CT ◦ Code 44145005 = Benign Rolandic Epilepsy � Content coverage in ICD-10 -CM overall is markedly less complete than ICD-10 -CM Apollo HIT, LLC

Synonyms (Descriptions) � Example ◦ Wilson’s Disease (SNOMED CT Code: 88518009) �Hepatolenticular degeneration �Hepatocerebral degeneration �Progressive lenticular degeneration �Neurohepatic degeneration �Westphal-Strumpell Syndrome �Cerebral pseudosclerosis �Copper storage disease �Kinnier-Wilson disease ◦ Each of these is a true synonym of Wilson’s disease ◦ Each has it own unique “description” ID but the same concept ID ◦ ICD-10 -CM has similar synonyms listed but there is no associated synonym ID Apollo HIT, LLC

SNOMED CT Structure � Strict hierarchies ◦ Bacterial meningitis is_a meningitis � Multiple (unlimited) levels supported ◦ Nervous system disorders �Infections of the nervous system �Bacterial infections of the nervous system �Bacterial meningitis �Streptococcal meningitis � Group A Strep meningitis Apollo HIT, LLC

SNOMED CT® Polyhierachy � Codes can have multiple “parents” ◦ Streptococcal meningitis is_a: 1. Disorder of the nervous system, and 2. An infectious disorder � ◦ Having the codes in more than one place greatly improves the retrieval of information. For example, if you were looking for all cases of streptococcal meningitis and it was only under the nervous system disorder hierarchy: � Searches under infectious disease would not retrieve the cases with strep meningitis Apollo HIT, LLC

SNOMED CT® Relationships � Concepts in SNOMED CT can be “defined” by linking them to other concepts ◦ Streptococcal meningitis: �Has location: meninges �Caused by: streptococcal organism �Has morphology: inflammation � Each of these concepts, meninges, streptococcal organism, and inflammation all are concepts in their own hierarchies � Most powerful feature of SNOMED CT but markedly underutilized Apollo HIT, LLC

SNOMED CT® - Current Use � Information is being captured in some EHRs as SNOMED CT codes and used for clinical operations: ◦ Problem lists ◦ Clinical decision support ◦ Reporting (e. g. , disease and immunization registries) ◦ Clinical research � SNOMED CT is currently an option to be use for problem lists in Stage 2 Meaningful Use.

National Committee on Vital and Health Statitics (NCVHS) 2003 Recommendations to the HHS � Recommended that the following terminologies be adapted as “reference” terminologies for storing patient medical record information ◦ SNOMED CT (clinical concepts) ◦ LOINC (laboratory values) ◦ For medications �Rx. Norm; �The representations of the mechanism of action and physiologic effect of drugs from NDF-RT; and �Ingredient name, manufactured dosage form and package type from the FDA

SNOMED CT®’s Impact on Coding � If your EHR system is using SNOMED CT: ◦ Information from the EHR may come to the practice management system in the form of SNOMED CT code ◦ These will need to be “translated” into ICD-10 -CM codes so they can be used for claims submission • Mapping tables from SNOMED CT to ICD 10 -CM are available but reportedly are not of high quality… Apollo HIT, LLC

ICD-10 -CM

Brief History of ICD � Started in 17 th century England with “London Bills of Mortality” ◦ 36% mortality rate before age 6 years ◦ John Graunt wanted to study causes of death in childhood ◦ Captured statistical information on causes of death

1665: Listed causes of death included “Bloody Flux, Griping in the Guts, Mortification, Rising of the Lights, and Teeth”

ICD History (2) � William Farr (England) ◦ England, 1839 ◦ Early attempt at disease classification ◦ Found current recording schemes lacking � Bertillon Classification of Causes of Death ◦ Paris, 1893 � International Lists of Causes of Death, 1890 s ◦ Designed for “the dead, not the living” � ICD-1 released in 1900 (fell under control of the WHO) � ICD-10 released in early 1990’s ◦ ICD-10 -CM scheduled for U. S. adoption in 2015

ICD-10 -CM Advantages over ICD-9 -CM � As per the CDC, specific improvements include: ◦ The addition of information relevant to ambulatory and managed care encounters; ◦ Expanded injury codes; ◦ The creation of combination diagnosis/symptom codes to reduce the number of codes needed to fully describe a condition; ◦ The addition of sixth and seventh characters; ◦ Incorporation of common 4 th and 5 th digit subclassifications; ◦ Laterality; ◦ Greater specificity in code assignment; ◦ A structure that will allow for greater expansion than was possible with ICD-9 -CM. Apollo HIT, LLC

Advanced Clinical Coding

Codifying Complex Expressions (1) � Simple expressions like appendicitis can be represented by one code and safely sent in a message ◦ As long as both systems are using the same code there is little risk of error ◦ This is generally all that is needed for billing purposes

Codifying Complex Expressions (2) � The safe transmission of clinical data between clinical systems requires much more complex expressions ◦ E. g. , Ruptured appendix resulting in peritonitis and sepsis ◦ Codes can be grouped in “clinical expressions” to represent this complex expression using 4 codes �Appendicitis code �Ruptured code (as modifier) �Secondary code + Peritonitis code �Secondary code + Sepsis code

Some Basic Informatics… � Post-coordination: ◦ Taking existing codes and putting them together to create a more complex expression � Pre-coordination: ◦ Grouping concepts that are commonly used together to create more complex concepts that are represented by one concept code �Insulin dependent diabetes mellitus Apollo HIT, LLC

Pre vs. Post-Coordination � Post-Coordination care) (assemble at point of ◦ Moderate + Aching + Right + Flank Pain ◦ Code 1 + Code 2 + Code 3 + Code 4 � Pre-Coordination ◦ “Moderate aching right flank pain” = one “clinical expression” made by putting the four codes together in advance �Information can be shared between applications �Documentation more efficient �One click instead of four �No need to search vocabulary for all four items

Codifying Complex Expressions � There is significant value in being able to codify as much clinical information as possible ◦ ◦ ◦ Accurate clinical documentation Clinical decision support Research Clinical reporting Interoperability � However, very little progress has been made world wide on using these advanced principles, but many centers are trying

Mapping from SNOMED CT to ICD-10 -CM and Vice Versa

SNOMED CT/ICD Mapping Methodology 0 = Unmappable. SNOMED CT concept cannot be assigned to an appropriate ICD-10 -CM code. 1 = One-to-one SNOMED CT to ICD map. The SNOMED CT and ICD-10 -CM concepts are identical. 2 = Narrow to Broad SNOMED CT to ICD map. The SNOMED CT concept is more specific than the ICD target code. 3 = Broad to Narrow SNOMED CT to ICD map. The SNOMED CT concept is less specific than the ICD target code. Additional patient information and rules are necessary to select an appropriate mapping. 4 = Partial overlap between SNOMED CT and ICD. Overlap exists between correlates, and additional patient information and rules are necessary to select an appropriate mapping.

Mapping Basics � Codes may arrive as SNOMED CT codes � Coding professionals will need to know how to convert these to ICD-10 -CM codes � Coding professionals may also need to know how to convert ICD-10 -CM codes into SNOMED CT codes ◦ E. g. , for clinical reporting and exchanging data with other facilities Apollo HIT, LLC

Magnitude of mapping challenge � Any concept in the following three SNOMED CT hierarchies ◦ Clinical finding ◦ Event ◦ Situation with explicit context � Total about 110, 000 concepts in scope Apollo HIT, LLC

Clinical Coding Example � Dx: Impetigo, Otitis Externa ◦ ICD-10 -CM �I 01. 00 Impetigo Unspecified �H 62. 41 Otitis externa in other diseases classified elsewhere ◦ The otitis may or may not be caused by the impetigo so a causal relationship cannot be established �SNOMED CT �[Otitis Externa] and [Causative Agent] and [Impetigo] ◦ The SNOMED CT relationship concept [Causative Agent] allows for the causal relationship to be defined. Apollo HIT, LLC

Clinical Coding Example (2) � Dx: Recurrent left kidney stone ◦ ICD-10 -CM �N 20. 0 Calculus of kidney ◦ SNOMED CT � 255227004: Recurrent � 7771000: Left laterality attribute � 444717006: Kidney stone – calcium oxalate � SNOMED CT allows for greater and more specific information to be stored about this condition � This would represent a mapping situation where the SNOMED CT codes together would be more specific than the ICD-10 -CM code Apollo HIT, LLC

Clinical Coding Example (3) � SNOMED CT concept: Thermal burns from lightning (disorder) : 242012005 � ICD-10 -CM Codes ◦ T 30. 0 Burn of unspecified region ◦ X 33 Victim of lightning Apollo HIT, LLC

Clinical Coding Example (4) �SNOMED concept: Pneumonia in aspergillosis (disorder): 111900000 �ICD-10 -CM ◦ Other pulmonary aspergillosis: B 44. 1 ◦ Pneumonia in mycoses: J 17. 2 Apollo HIT, LLC

Clinical Coding Example (5) � SNOMED concept: Pyloric stenosis (disorder): 367403001 � ICD-10 -CM concept ◦ Congenital hypertrophic pyloric stenosis: Q 40. 0 ◦ OR ◦ Adult hypertrophic pyloric stenosis: K 31. 1 Apollo HIT, LLC

Mapping Challenges � Excludes 1 ◦ A type 1 Excludes note is a pure excludes note. The code excluded should never be used at the same time as the code above the Excludes 1 note. (E. g. , use when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition). � Excludes 2 ◦ A type 2 Excludes note represents “Not included here”. An excludes 2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time.

Handling ICD “Excludes Notes” in SNOMED CT � Example: ◦ Two SNOMED CT codes are received by the billing department from the EHR �They are converted to ICD-10 -CM codes by the mapping table �Excludes 1: Software would need to recognize when codes cannot be used together – relatively straightforward �Excludes 2: Would need more sophisticated algorithms and in many cases it would require manual review �However, software would alert coder that there was a potential problem that could be reviewed Apollo HIT, LLC

The use of “and” in ICD-10 -CM � The word “and” should be interpreted to mean either “and” or “or” when it appears in a title ◦ ICD-10 -CM code R 10. 2 Pelvic and perineal pain ◦ SNOMED CT has a code for each of these alone or together �Perineal pain: 225565007 �Pelvic pain (acute): 314716005 �Pelvic and perineal pain: 274671002 � All of these SNOMED CT codes would map to R 10. 2 � Going the other way would be challenging, however… Apollo HIT, LLC

What’s the Bottom Line? Job Security! Apollo HIT, LLC

ICD-10 -CM Implementation Considerations Apollo HIT, LLC

ICD-10 -CM Implementation Guidance (in sites using SNOMED CT) (1 of 8 steps) � Step 1 ◦ Identify the ICD-9 -CM codes that are associated with greatest amount of total revenue in you organization today �These can be referred to as high value ICD-9 -CM codes �These may be low dollar per charge codes, but ones that are used frequently ◦ Identify the SNOMED CT codes that map to these ICD-9 -CM codes �There may be “many to one” and “one to many” relationships Apollo HIT, LLC

ICD-10 -CM Implementation (2) � Step 2 ◦ Identify the ICD-10 -CM codes that correspond to the high value ICD-9 -CM codes. ◦ These now become the high value ICD-10 -CM codes. ◦ The mapping from ICD-9 -CM to ICD-10 -CM is often not entirely straightforward, so this may require a significant investment of time. ◦ Mapping tables are available Apollo HIT, LLC

ICD-10 -CM Implementation (3) � Step 3 ◦ Develop policies around ICD-10 -CM code selection and submission that meet the requirements of each payer �They may be different ◦ Make sure that enough information is being captured by the SNOMED CT codes so that the requirements for reporting are being met �E. g. , laterality, congenital, active care vs. sequelae, etc. �Will frequently require review of the source documents, at least at first Apollo HIT, LLC

ICD-10 -CM Implementation (4) � Step 4 ◦ Update all systems that will be impacted by ICD-10 -CM at the earliest possible time (e. g. , practice management software, electronic health records, etc. ) to ICD-10 -CM. ◦ This may require updates to templates and other content used by clinicians at the point of care even if they are coded to SNOMED CT �Make sure that templates, even when using SNOMED CT, capture the information needed to meet the coding requirements (e. g. , laterality) Apollo HIT, LLC

ICD-10 -CM Implementation (5) � Step 5 ◦ Provide training to clinical and billing staff �Focus on codes that are relevant for the practice setting. �Focus in particular on the high value ICD-10 -CM codes �Help EHR stakeholders understand that value of having code come across with enough information to bill properly. Apollo HIT, LLC

ICD-10 -CM Implementation (6) � Step 6 ◦ Encourage clinicians and billing representatives to start submitting ICD-10 -CM codes or perform dual coding prior to October 1, 2015, as allowed by payers. ◦ Closely review the policies of all carriers you work with about their specific requirements for reimbursement �Focus on their policies regarding the high value codes Apollo HIT, LLC

ICD-10 -CM Implementation (7) � Step 7 ◦ Identify when high value ICD-10 -CM are denied or rejected and devote significant resources to understanding why and how this situation can be remedied. ◦ Contact the payer representative �Be persistent �Physician to physician communication may be needed �Excellent investment of physician time for high value codes and their associated procedures Apollo HIT, LLC

ICD-10 -CM Implementation (8) � Step 8 ◦ Incorporate the feedback from working denials into your practice's clinical workflow ◦ Create specific templates for payers who have different requirements, as allowed by your EHR system ◦ Create warning in your practice management system as allowed by your application Apollo HIT, LLC

The Future of ICD � WHO has agreed to modify ICD-11 to allow it to be more applicable for clinical activities and computer applications ◦ Incorporating SNOMED CT (not confirmed) ◦ Would have one coding system that was applicable for clinical and billing uses (in theory) � ICD-11 now scheduled for release in 2017 ◦ ICD-11 -CM not even in planning stages Apollo HIT, LLC

The Future of ICD-11 � However, many groups are lobbying for ICD 10 -CM not to be released next year ◦ E. g. , Texas Medical Association � Some chance of ICD-10 -CM being delayed � Slight chance that we will go right to ICD-11 CM ◦ It would allow us to be on par with the rest of the world that is going to ICD-11 in 2017 ◦ However, SNOMED CT would require significant work to meet the billing and fraud detection requirements of CMS. Apollo HIT, LLC

Conclusion � SNOMED CT may be present in your organization’s EHR and you be seeing or you may start seeing these codes come over… � Mapping from SNOMED CT to ICD-10 -CM is not straightforward, but having additional information available when making a coding decision will likely be necessary � Start preparing now for ICD-10 -CM � There is some uncertainty about ICD-10 -CM being required in the coming year, but given the amount of time needed to prepare, organizations cannot count on a last minute delay as to when ICD-10 -CM will be required. Apollo HIT, LLC

Us Feds Apollo HIT, LLC

Thank You! Contact Information ◦ Michael Stearns, CPC, CFPC, MD ◦ CEO and Founder, Apollo HIT ◦ Email: mcjstearns@gmail. com Apollo HIT, LLC