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Module 7 – Clinical Vocabularies and Terminologies
A clinical vocabulary is a collection of words and phrases denoting clinical conditions and a
clinical terminology is a systematized and controlled vocabulary of clinically relevant
phrases. Both clinical vocabulary and terminology, used interchangeably, provide a precise
and sharable expression of clinical conditions to support clinical care. The most common
Clinical Vocabularies and Terminologies are SNOMED-CT, LOINC, and RxNorm reviewed
in this module.
Module 7 Objectives:
After completing this module, you should be able to:
•
o
1. Differentiate between clinical vocabularies and terminologies.
2. Select the most appropriate clinical term for describing a clinical
condition.
3. Conduct mapping among clinical vocabularies and terminologies.
4. Evaluate the role of clinical vocabularies and terminologies in health
information exchange and Interoperability
Module 7 Readings
1. Health Information Management: Concepts, Principles, and Practice Chapter 15 Clinical Classifications and Terminologies, pgs. 397-405.
2. Clinical Vocabularies: Essential to the Future of Health Information Management
3. [PDF] Clinical Terminology and Clinical Classification Systems: A Critique Using
AHIMA’s Data Quality Management Model | Semantic Scholar
4. SNOMED-CT: 5-Step Briefing
5. Health Terminologies and Vocabularies
6. Overview of SNOMED-CT
7. Introduction to SNOMED-CT
8. RxNorm Overview
9. What LOINC is
10. SNOMED International SNOMED CT Browser
11. SNOMED International determines global standards for health terms
12. Review Basics of Data Mapping PowerPoints
Assignment
Mapping between SNOMED-CT and ICD-10-CM
Note: For completing this assignment, use of the I-MAGIC tool (Interactive Map-Assisted
Generation of ICD Codes) is required. To access the I-MAGIC tool, click on the
following https://imagic.nlm.nih.gov/imagic/code/map)
Problems and diagnoses can be recorded in SNOMED CT in the EHR, while the cross mappings to ICD-10-CM can be used to assist the reimbursement process. For example, the
physician documents that a patient has congestive heart failure using a Lexicon linked to
SNOMED CT in the problem list. But when the HIM coding professional tries to code the
patient’s diagnosis, she sees in SNOMWED-CT concept mapped to ICD-10-CM. The coder
could now accept, reject, or modify the code list to be used for reimbursement purposes.
Your APA formatted assignment typed in 12-point Times New Roman (or 11- point Calibri)
excluding the Cover and Reference pages should be submitted by Tuesday midnight. Offer
minimum 2 credible sources to support your conclusions.
Discussion
Please kindly provide a response to the posts below.
POST 1
Systematized Nomenclature of Medicine Clinical Terms, known as SNOMED-CT was
specifically designed to be used as a standard for how electronic health information is to be
exchanged. It is “the most comprehensive, multilingual clinical terminology in the world,
encompassing more than 300,000 concepts, along with terms, synonyms, and definitions for
human and non-human concepts” (Davidson & Rawson, 2022). It is recommended for use in
EHR instead of ICD-10-CM and CPT 4.0 most notably for its granularity, comprehensiveness,
and can be used internationally. SNOMED-CT provides a higher level of clinical detail
compared to ICD-10-CM and CPT 4.0 codes because it captures a wider range of clinical
concepts. A few examples of Meaningful Use objectives that it supports include:
•
“Record patient family health history as structure data
•
Identify and report cancer cases to State cancer registries
•
Record patient smoking status” (National Institutes of Health, 2016).
ICD-10-CM and CPT 4.0 codes are primarily designed for billing and reimbursement purposes,
whereas SNOMED-CT is well-suited to capture and describe clinical concepts and the
relationships among them (NIH, 2016). Additionally, the system can remove language barriers
so that information can be exchanged globally (NIH, 2016). Because the system is a set standard
and is used consistently among healthcare settings, the risk of misinterpreting information is
significantly reduced.
The main reason that SNOMED-CT has not replaced ICD-10-CM and CPT 4.0 is because they
are all used for different, distinct purposes. Practice Fusion (2014) explains that SNOMED-CT is
“inherently more appropriate for clinical documentation of diagnoses in an EHR” and “due to its
use in medical billing, ICD is largely familiar to healthcare providers and was incorporated into
many EHRs as a way to capture clinical diagnoses.” Moreover, ICD-10 only contains 68,000
codes compared to SNOMED-CTs more than 100,000 unique concepts and codes (Practice
Fusion, 2014).
SNOMED-CT’s high level of comprehensiveness, accuracy, and attention to clinical detail
allows for more accurate and prompt reimbursement. The accurate representation of patient
conditions can potentially lead to higher reimbursement when coding with ICD-10-CM.
Essentially, SNOMED-CT’s purpose is to “support semi-automated generation of ICD-10-CM
codes from clinical data encoded in SNOMED-CT for reimbursement and statistical purposes”
(National Institutes of Health, 2021). The system also supports quality reporting and
performance measurement programs. Meeting quality metrics can have an impact on
reimbursement in value-based care models.
As a result of the importance, benefits, and significance SNOMED-CT has on the continuum of
care, interoperability, patient safety, and more, I would recommend it replace both ICD-10 and
CPT 4.0. To do this, there would need to be extensive and clear strategies, stakeholders involved,
and adequate training and education for staff. Throughout the implementation process, progress
should be monitored and evaluated regularly to make adjustments accordingly.
Citations:
Davidson, D., & Rawson, M. (2022, March 17). SNOMED CT: Why it matters to you.
Wolters Kluwer.
https://www.wolterskluwer.com/en/expert-insights/snomed-ct-why-it-matters-toyou#:~:text=How%20SNOMED%20CT%20is%20used,and%20social%20histories%20in%20E
HRs.
National Institutes of Health. (2016, October 14). Overview of SNOMED CT. U.S. National
Library of Medicine. https://www.nlm.nih.gov/healthit/snomedct/snomed_overview.html
National Institutes of Health. (2021, March 1). SNOMED CT to ICD-10-CM map. U.S. National
Library of
Medicine. https://www.nlm.nih.gov/research/umls/mapping_projects/snomedct_to_icd10cm.html
#:~:text=It%20is%20designed%20for%20use,for%20reimbursement%20and%20statistical%20p
urposes.
POST 2
SNOMED-CT is better suited for electronic health records due to its description logic based
creation with definitional relationships (SNOMED-CT International, 2021). The SNOMEDCT code set is extensive and able to link many different descriptions of the same issue or
diagnosis coming to one succinct selection. Many clinicians use different vocabularies to
document including different languages, SNOMED-CT can adapt to both of these tendencies.
Having this level of fluidity producing an interoperable function is ideal for EHR’s. This type
of system is also ideal in exchanging health information, streamlining the output makes it
more usable in analysis, comparison and reporting. SNOMED-CT is also updated bi-annually
to keep it up to date to new technologies and evidence-based practice (National Institutes of
Health, 2016).
Currently SNOMED-CT is not used for reimbursement because ICD-10-CM and CPT 4.0 are
managed by Centers for Medicare and Medicaid Services. SNOMED-CT is a global
classification of many pieces of medical care where ICD is just a classification of disease,
thus not completely lining up. With a lack of equal clinical modification, SNOMED-CT
would not be able to replace ICD-10 and CPT4.0 seamlessly. The clinical modifications are
specific to US healthcare billing requirements and not global inclusivity. Bowman (2014)
explained that SNOMED-CT is a input system for care documentation where ICD are
statistical, epidemiological research purposed. It took 8 years to build the clinical
modifications for ICD-10 and a total of 19 years before it was signed into final rule (Bowen,
2012). I don’t believe that switching to just SNOMED-CT is the way to go. The clinical
modifications for billing would be enormous as it is not just limited to diseases, however it
would offer a very comprehensive billing opportunity. The SNOMED-CT codes are also
updated twice a year, which would mean code expansions twice a year. The U.S. is not good
at being timely and keeping up. Although there are perks, I don’t believe moving to
SNOMED-CT is the correct move.
Bowman, Sue E.(12 June, 2014). “SNOMED, ICD-11 Not Feasible Alternatives to ICD-10CM/PCS Implementation” (Journal of AHIMA website). SNOMED, ICD-11 Not Feasible
Alternatives to ICD-10-CM/PCS Implementation (ahima.org)
SNOMED International. (12 January 2021). Tutorial: Introduction to SNOMED CT – Ian
Spiers and Jon Zammit (202069). [Video].
YouTube. https://www.youtube.com/watch?v=ELgXwo324pk
National Institutes of Health. (2016, October 14). Overview of SNOMED CT. U.S. National
Library of Medicine. https://www.nlm.nih.gov/healthit/snomedct/snomed_overview.html
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