AAPC Austin Chapter Presentation
November 20, 2014
Michael Stearns, CPC, CFPC, MD
CEO and Founder
Apollo HIT
ICD-10-CM is a
“classification system”
 Codes may have multiple
but similar meanings,
forming a classification

SNOMED CT is a “reference
terminology”
Very specific codes that have
one meaning
Apollo HIT, LLC

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
◦ Classification systems such as ICD10-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

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
“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”)
This is what SNOMED CT was designed to do
Apollo HIT, LLC



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




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
Apollo HIT, LLC















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

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
Apollo HIT, LLC


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
Apollo HIT, LLC

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

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

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

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

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.

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

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 ICD10-CM are available but reportedly are
not of high quality…
Apollo HIT, LLC

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”

William Farr (England)

Bertillon Classification of Causes of Death

International Lists of Causes of Death, 1890s


◦ England, 1839
◦ Early attempt at disease classification
◦ Found current recording schemes lacking
◦ Paris, 1893
◦ 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

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.
Apollo HIT, LLC

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

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

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

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

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
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.



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

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

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.
Apollo HIT, LLC

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
Apollo HIT, LLC


SNOMED CT concept: Thermal burns from
lightning (disorder) : 242012005
ICD-10-CM Codes
◦ T30.0 Burn of unspecified region
◦ X33 Victim of lightning
Apollo HIT, LLC
SNOMED concept: Pneumonia in aspergillosis
(disorder): 111900000
 ICD-10-CM
◦ Other pulmonary aspergillosis: B44.1
◦ Pneumonia in mycoses: J17.2

Apollo HIT, LLC


SNOMED concept: Pyloric stenosis (disorder):
367403001
ICD-10-CM concept
◦ Congenital hypertrophic pyloric stenosis: Q40.0
◦ OR
◦ Adult hypertrophic pyloric stenosis: K31.1
Apollo HIT, LLC

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.

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 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…
Apollo HIT, LLC
Job Security!
Apollo HIT, LLC
Apollo HIT, LLC

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

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

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

Step 4
◦ Update all systems that will be impacted by ICD10-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

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

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

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

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

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

However, many groups are lobbying for ICD10-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-11CM
◦ 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




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
Contact Information
◦ Michael Stearns, CPC, CFPC, MD
◦ CEO and Founder, Apollo HIT
◦ Email: mcjstearns@gmail.com
Apollo HIT, LLC