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SNOMED-CT to ICD-10: Who Assigns the Code?

October 21, 2013

With the deadline looming for transition from ICD-9-CM to ICD-10-CM on October 1, 2014, another deadline is around the corner as well – Meaningful Use.  The question of who is responsible for coding… i.e., should the providers be coding or a certified coder… looms larger now than ever.  A quick look at ICD transition and SNOMED-CT may make you think twice about what may been your historic norm.

Meaningful Use core measure #3, Stage 1 – Maintain an up-to-date problem list of current and active diagnoses.  How does your health center meet the criteria needed in your EHR/EMR?  The Medicare and Medicaid EHR incentive Programs do not specify the use of ICD-9 (soon to be ICD-10) or SNOMED-CT in meeting the measure for this objective.  However, the Office of the National Coordinator for Health Information Technology (ONC) has allowed providers to use either ICD-9 or SNOMED-CT to be used in the structure and made this a requirement for certified EHR technology.  Therefore, the eligible professional (EP… doctors, NPs, PAs, etc.) will have to maintain for each patient an up-to-date problem list of current and active diagnoses using ICD-9 or SNOMED-CT. In order to meet this objective, an ICD or SNOMED problem list MUST be the basis of the structured data as part of the certified EHR technology.  Even if a patient does not have any current or active diagnoses, an entry still has to be made to the problem list indicating no known problems.

An update to the problem list for patients is not required every time the patient is seen but must occur at least once during the EHR reporting period.  The eligible professional (EP) needs to use their judgment in deciding what further probing or updating may be required given the clinical circumstances.  The initial diagnosis can be in lay terms and later converted to standard structure data or can be initially entered using standard structure.  So you are saying – “What’s the problem?”  I can use ICD-9 (soon ICD-10) to meet this requirement.  However, Stage 2 and Health Information Exchange define a common dataset for all summary of care records which need to be in a specific format that includes the use of SNOMED-CT… not just ICD.  The problem lies that the SNOMED-CT is not widely adopted among providers and vendors, and Stage 2 will begin for hospitals in October 2013 and eligible professionals in January 2014.  Also, adopting SNOMED-CT codes for clinical documentation is a major feat… just as complex as ICD-10.  Some say that there are benefits to using SNOMED-CT, however if providers and vendors are not ready for it, they cannot satisfy meaningful use criteria… which means lost potential income.  So what is the provider to do?  Even if they are working now to be ready for Stage 2, they will probably end up reporting the clinical quality measures (CQMs) and attesting to meaningful use later than expected.   So where is your EMR vendor in this process?  We are racing to be ICD-10 compliant by October 2014 in order to be paid by our insurance carriers.  BUT, if we are not ready with SNOMED-CT data, say good-bye to meaningful use money.


SNOMED-CT is an acronym for Systematized Nomenclature of Medicine- Clinical Terms and considered the most comprehensive, multilingual clinical healthcare terminology in the world.  It is the creation of merging SNOMED RT (Reference Terminology) with CTV3 (Clinical Terms version 3) in 2002. SNOMED-CT is considered more clinically EHR/EMR suitable than other code sets, and that includes even ICD.  SNOMED-CT is not necessarily superior to ICD. However, each code set is designed for different purposes and should be used as such.

Differences between SNOMED-CT and ICD

  • SNOMED-CT has better clinical coverage than ICD – Number of codes
    • SNOMED-CT (clinical findings): 100,000
    • ICD-9-CM: 14,000
    • ICD-10-CM: 68,000
  • ICD is a statistical-based coding system.  It has less common diseases put together in “catch-all” categories e.g. E32.8 Other diseases of thymus where there could be a loss of information
  • SNOMED-CT is clinically-based where you can document whatever is needed for patient care.
  • SNOMED-CT is directly used by the providers during the patient care as opposed to ICD which is  used by coding professionals after the episode of care.
  • Some providers find the ICD terms are not “clinical user-friendly”.
  • There is a presumption that the user has knowledge of coding rules and conventions.

Since SNOMED-CT seems to be more “clinical user-friendly”, some providers believe that they can be trained in SNOMED-CT and have their systems generate the ICD-10-CM codes and allow coders to verify the ICD-10-CM codes. It is no secret that providers are having a hard time with ICD-10-CM transition.  It has long been debated – who should be providing the codes – providers or certified coders? At PMG, it has been our opinion that the provider should choose the ICD code.  Given the complexity of ICD-10-CM, maybe we should reconsider.  Providers understand clinical terminology but not about coding rules and conventions.   A health center with which I had the opportunity to discuss the transition to ICD-10-CM stated that their software vendor was working on SNOMED-CT integration in their EHR/EMR system to prepare them for meaningful use.  Could you be “killing two birds with one stone”? It has been stated that the implementation of SNOMED-CT in the EHR/EMR will not only help to improve the quality of data but also help transition to ICD-10-CM.  This may be true, however, providers still need training on ICD-10-CM not only for documentation requirements but also to relate to support staff, i.e., coders, billers, front desk, etc. It will be these support teams who will need to query the provider on his/her documentation for ICD-10-CM for clinical interaction with payers, diagnostic labs, pharmacies and the like.

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