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ACC going from READ codes to SNOMED CT

#1 User is offline   Alan Thomas 

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Posted 09 November 2018 - 11:54 AM

SNOMED CT (Systematized Nomenclature of Medicine -- Clinical Terms) is a standardized, multilingual vocabulary of clinical terminology that is used by physicians and other health care providers for the electronic exchange of clinical health information.

SNOMED CT provides the core general terminology for electronic health records. SNOMED CT comprehensive coverage includes: clinical findings, symptoms, diagnoses, procedures, body structures, organisms and other etiologies, substances, pharmaceuticals, devices and specimens.



Mapping from a Clinical Terminology to a Classification
by Margo Imel, RHIT, MBA, SNOMED International, and James R. Campbell, MD, University of Nebraska Medical Center

The paper discusses mapping and the relationships of SNOMED CT® to a statistical and administrative classification system such as ICD-9-CM. It explores the purpose and differences encountered in creating a mapping and provides a brief overview of SNOMED® and its evolution.


The Terminology- SNOMED CT®, an Evolving Clinical Reference Terminology
SNOMED® is the Systemized Nomenclature of Medicine. It is a controlled medical terminology (CMT). At its simplest, a SNOMED is a coded vocabulary of medical concepts and expressions used in healthcare. It is designed to provide the terminology needed to code the entire medical record. Controlled means that the content of the terminology is validated with careful quality assurance procedures in place to ensure that the terminology is structurally sound, biomedically accurate and consistent with current practice. SNOMED is a work of the College of American Pathologists (CAP), a medical specialty organization of Board-certified pathologists. Oversight of the "content" is provided by a multi-disciplinary editorial board with broad representation from clinical practice and academia.


What is a Clinical Reference Terminology?
A reference terminology is defined as "a set of concepts and relationships that provide a common reference point for comparisons and aggregation of data about the entire health care process, recorded by multiple different individuals, systems or institutions."

A reference terminology is an ontology of concepts and the relationships linking them. An ontology is a collection of terms, similar to a dictionary or glossary, that is organized by meaning rather than alphabetically. A reference terminology can allow the concepts to be defined in a formal and computer-processable way. For example, hierarchical relationships can be defined using the "is a" link to identify which concepts are included within broader concepts. Along with other relationships, a network of meaning is created that is useful for computer representation and processing that allows a computer to answer basic questions such as: "Is angina pectoris a type of heart disease?"

By creating computable definitions, a reference terminology supports reproducible transmission of patient data between information systems. It supports consistent and understandable coding of clinical concepts and so is a central feature for the function of computerized patient records.


Origins of SNOMED CT
Introduced in 1965, the Systematized Nomenclature of Pathology (SNOP) was the precursor to SNOMED. SNOP consisted of logically organized codes for the key terms that describe the pathology case:

  • Topography - The part of the body from which the specimen came
  • Morphology - The pathologic change documented in the report
  • Procedure - The method by which the specimen was obtained
In the mid-1970s, work began to expand the coded vocabulary beyond pathology and develop a terminology that would encompass the entire medical record. The first edition of the Systematized Nomenclature of Medicine (SNOMED) was published in 1977 and was soon followed by SNOMED II in 1980. This work was refined with another release, in 1993, of SNOMED International, which was updated annually through 1998. Work continued with the release of SNOMED RT version 1.0 in January 2001 and SNOMED RT 1.1 in July of 2001.

Is SNOMED only for pathology applications? While one of SNOMED CT's precursors focused mainly upon pathology, today's SNOMED CT has a broad scope that encompasses all of healthcare. SNOMED CT is the merger of SNOMED RT and the United Kingdom's CTV 3 terminology, formerly known as the Read codes. SNOMED CT's 19 hierarchies provide coverage in diseases, findings, procedures, body structures, pharmacy products and other health care concepts.

The hierarchical nature of SNOMED CT enables recording and documentation of clinical data at the appropriate level of detail that can later be analyzed from other perspectives and groupings.

The integration of a clinical terminology such as SNOMED CT into computer-based patient records provides a comprehensive and functional terminology for clinical care. SNOMED CT can be utilized to index, store and retrieve patient information for clinical purposes. SNOMED CT helps ensure comparability of data records between multiple practitioners, across diverse platforms and computer systems.


What is a Classification System?
A classification system has been defined as: A systematic arrangement into classes or groups based on perceived common characteristics; a means of giving order to a group of disconnected facts. The groups or classes may have similar or like characteristics or may even be synonymous.


The Classification ICD-9-CM
International Classification of Disease, Ninth Revision (ICD-9) was originally designed to classify patient morbidity and mortality for reporting. The clinical modifications provided a way to classify morbidity data for indexing of medical records, medical case reviews, and ambulatory and other medical care programs, as well as for basic health statistics, resulting in International Classifications of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). ICD-9-CM codes are commonly used for reporting, analysis, and payment of healthcare services.

ICD-9-CM employs multiple axes of classifications. Within individual chapters different axes are used in classifying different diseases. ICD-9-CM codes classify diseases or conditions that are similar which may or may not be synonymous. An example in which both diseases are both included in ICD-9-CM code 789.0x is:

  • Abdominal pain
  • Infantile colic



ICD-9-CM maybe described as a "closed" classification which means that each actual patient diagnosis is "bundled" into only one of the broad categories provided by the classification scheme.





Why Create a Map between SNOMED and ICD?



The purpose of mapping is to provide a link between one terminology and another in order to:

  • use data collected for one purpose for another purpose
  • retain the value of data when migrating to newer database formats and schemas
  • avoid entering data multiple times with the risk of driving up cost and errors



A map there is, therefore, created with a specific purpose in mind and must be refined for particular use cases and users in diverse settings.




Since classifications such as ICD-9-CM are widely used in health care for administrative purposes, SNOMED International provides mapping resources that allow a linking from SNOMED clinical concepts to codes used in other schemas and for other purposes. As an example, the purpose of the cross mapping to ICD-9-CM is to support the process of deriving an ICD-9 CM code from patient data.




While SNOMED provides an ICD-9-CM mapping, each enterprise needs to review the content to ensure consistency with local policies and practices before integrating into the enterprise's processes and tools.


Coding involves the use of clinician documentation and other clinical data contained in a particular patient health record as the source for determining the appropriate code assignment within a terminology, classification, or other controlled vocabulary. Coding conventions and guidelines are applied in determining code assignment.

Mapping is linking terminology content between two schemes. Unlike coding, it is not specific to a particular patient encounter. Coding selections may sometime depend upon the context of the patient record; context is not available for each patient when a mapping is developed.

Each mapping from source to target should have a purpose. The mapping begins with the development of heuristics and guidelines that support the use case or the purpose of the mapping, respecting the conventions of the source and target to preserve the granularity and flexibility of both.

Computer programs may use mapping files to translate codes and help automate the process. Full automation that takes into account the coding rules (e.g., such as disease during pregnancy) remains an elusive goal that requires knowledge-based software and some kind of human review.



So the good news is that ACC are adopting an information system that forces adherence to criteria thus avoiding individual staff members rationalising what they believed to be the problem based entirely upon their own intuition, common sense, critical reasoning and suchlike that has nothing whatsoever to do with the legislated criteria.
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#2 User is offline   MINI 

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Posted 10 November 2018 - 09:55 AM

Better be careful they just don't use their own way of getting to a certain answer as the do with AMA4(original) as they do now.

I am having another assessment after pulling them up on this exact point. They certainly didn't want me going to Review.



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#3 User is offline   doppelganger 

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Posted Yesterday, 04:16 PM

If they use this then the case manager should not need to be able to read Dumber case managers and Dumber persons in head office.

If one can not read one can not then use a computer so what is the use?
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#4 User is offline   doppelganger 

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Posted Yesterday, 04:22 PM

One would question as to why the article is not bee reported correctly


ICD-9-CM to ICD-10-CM Codes: What? Why? How?

The current diagnosis coding system used in the United States is International Classification of Diseases (ICD)-9-Clinical Modification (CM), which has an alphabetic index (Volume 2) and a tabular index (Volume 1). The ICD-9-CM system is used in all venues of healthcare to report diagnoses. ICD-9-CM is based on the official version of the World Health Organization's 9th Revision of the International Classification of Diseases (ICD-9). In 1977, a steering committee was formed by the National Center for Health Statistics (NCHS) to clinically modify ICD-9 for use in the United States. The term “Clinical” meant that the United States needed a useful tool to report diagnoses, to classify morbidity data for indexing, for medical care review, and to capture basic health statistics for all venues of healthcare.

Just an extract as the does not just on Diseases but also on all clinical modifications. This is used in NZ by the health Department and is free to any social organisation.

From 2013.
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#5 User is offline   Alan Thomas 

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Posted Today, 11:20 AM

In summary any types of statistical analysis for the purposes of coding or the use of coding in any way or form is solely for the statistical information of the ACC and is not to be confused with identifying the nature of an injury or the expected outcomes of such an injury. These codes simply do not go so far as to meet the standards required by legislation. Keep in mind that the information coming from your treatment provider must have its origins in what was taught in medical school so as to enable the doctor to acquire the appropriate qualification and authority to sign off on ACC documents used for entitlements. Read codes and subsequent codes do not fulfil the legislated criteria and as such can only be used by the ACC for statistical information and therefore no decision referencing redcoats And SNOMED CT Codes the merit for decision-making purposes concerning entitlements. Watch out for lazy ACC staff members or were still those who are belligerent and wilful to the extent that they disobey legislated criteria.
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