SNOMED CT vs. ICD-10-CM

Michael Stearns, CPC, CFPC, MDCEO and FounderApollo HIT

AAPC Austin Chapter PresentationNovember 20, 2014

The Basics

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SNOMED CT is a “reference terminology”Very specific codes that

have one meaning

DifferencesICD-10-CM is a

“classification system” Codes may have

multiple but similar meanings, forming a classification

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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

ICD-10-CM: Intended Purpose

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◦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.

ICD-10-CM: Intended Purpose (2)

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

Terminology Challenges

HealthCare 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 OpEd Article 10-23-08

◦ Critical lack of data needed to improve the quality and efficiency of healthcare

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”)

Reference Terminology

This is what SNOMED CT was designed to do

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SNOMED CT®

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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®

Why SNOMED CT®?

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Over 360,000 concepts Over 1,000,000 synonyms Over 1,000,000 logical relationships between concepts Content coverage includes anatomy, symptoms,

observations, diseases, procedures, substances, organisms, modifiers and many other concepts used in healthcare

SNOMED CT Content

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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

SNOMED CT Content (2)

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W56.2 Contact with orca◦ W56.21 Bitten by orca

W56.21XA …… initial encounter W56.21XD …… subsequent encounter W56.21XS …… sequela

◦ W56.22 Struck by orca W56.22XA …… initial encounter W56.22XD …… subsequent encounter W56.22XS …… sequela

◦ W56.29 Other contact with orca W56.29XA …… initial encounter W56.29XD …… subsequent encounter W56.29XS …… sequela

SNOMED CT: Orca (organism) + Animal bite with location

Injury Codes Markedly Increased in ICD-10-CM

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Most common form of primary childhood epilepsy

ICD-10-CM◦ No current specific code in ICD-10-CM◦ Use ICD-10-CM G40.802 (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

Benign Rolandic Epilepsy

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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

Synonyms (Descriptions)

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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

SNOMED CT Structure

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Codes can have multiple “parents”◦ Streptococcal meningitis is_a:

1. Disorder of the nervous system, and2. 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

SNOMED CT® Polyhierachy

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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

SNOMED CT® Relationships

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.

SNOMED CT® - Current Use

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

RxNorm; 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

National Committee on Vital and Health Statitics (NCVHS) 2003 Recommendations to the HHS

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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

SNOMED CT®’s Impact on Coding

• Mapping tables from SNOMED CT to ICD-10-CM are available but reportedly are not of high quality…

ICD-10-CM

Brief History of ICD Started in 17th 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, 1890s◦ 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

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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 4th and 5th digit subclassifications; ◦ Laterality; ◦ Greater specificity in code assignment;◦ A structure that will allow for greater expansion than was

possible with ICD-9-CM.

ICD-10-CM Advantages over ICD-9-CM

Advanced Clinical Coding

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 (1)

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

Codifying Complex Expressions (2)

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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

Some Basic Informatics…

Post-Coordination (assemble at point of care)◦ 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

Pre vs. Post-Coordination

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

Codifying Complex Expressions

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

Versa

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.

SNOMED CT/ICD Mapping Methodology

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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

Mapping Basics

Any concept in the following three SNOMED CT hierarchies◦ Clinical finding◦ Event◦ Situation with explicit context

Total about 110,000 concepts in scope

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Magnitude of mapping challenge

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Dx: Impetigo, Otitis Externa◦ ICD-10-CM

I01.00 Impetigo Unspecified H62.41 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.

Clinical Coding Example

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Dx: Recurrent left kidney stone◦ ICD-10-CM

N20.0 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

Clinical Coding Example (2)

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SNOMED CT concept: Thermal burns from lightning (disorder) : 242012005

ICD-10-CM Codes◦ T30.0 Burn of unspecified region◦ X33 Victim of lightning

Clinical Coding Example (3)

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SNOMED concept: Pneumonia in aspergillosis (disorder): 111900000

ICD-10-CM ◦Other pulmonary aspergillosis: B44.1 ◦Pneumonia in mycoses: J17.2

Clinical Coding Example (4)

SNOMED concept: Pyloric stenosis (disorder): 367403001

ICD-10-CM concept ◦ Congenital hypertrophic pyloric stenosis: Q40.0◦ OR ◦ Adult hypertrophic pyloric stenosis: K31.1

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Clinical Coding Example (5)

Excludes1 ◦ 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 Excludes1 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 excludes2 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.

Mapping Challenges

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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

Handling ICD “Excludes Notes” in SNOMED CT

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The word “and” should be interpreted to mean either “and” or “or” when it appears in a title◦ ICD-10-CM code R10.2 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 R10.2

Going the other way would be challenging, however…

The use of “and” in ICD-10-CM

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Job Security!

What’s the Bottom Line?

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ICD-10-CM Implementation Considerations

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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

ICD-10-CM Implementation Guidance (in sites using SNOMED CT) (1 of 8 steps)

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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

ICD-10-CM Implementation (2)

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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

ICD-10-CM Implementation (3)

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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)

ICD-10-CM Implementation (4)

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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.

ICD-10-CM Implementation (5)

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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

ICD-10-CM Implementation (6)

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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

ICD-10-CM Implementation (7)

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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

ICD-10-CM Implementation (8)

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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

The Future of ICD

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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.

The Future of ICD-11

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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.

Conclusion

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Feds

Us

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

Thank You!