A recommendation earlier this week by a presidential advisory committee has the folks who developed the Snomed clinical terminology beaming and officials of a trade association of healthcare workers who deal with medical codes a bit concerned.
A subcommittee of the President's Information Technology Advisory Committee on Tuesday released a list of draft recommendations calling for broad federal support for healthcare IT, including one encouraging the government to perform a cost-benefit study of using Snomed Clinical Terms as an alternative to switching to International Classification of Diseases-10-Clinical Modifications coding systems.
In November, the National Committee on Vital and Health Statistics voted to recommend that HHS adopt ICD-10 to replace several of the decades-old ICD-9 code sets as the new transactions and codes sets under the Health Insurance Portability and Accountability Act of 1996.
A RAND Corp. study for the NCVH estimated the industrywide cost of upgrading to ICD-10 at $425 million to $1.5 billion, but the Blue Cross and Blue Shield Association put the price tag as high as $14 billion.
Snomed International, based in Northfield, Ill., which developed Snomed CT, is a division of the American College of Pathologists. The idea of the cost-benefit study of Snomed and ICD-10 intrigues several Snomed officials.
Experts generally agree the Snomed terminology is much far more complex and precise -- the term "granular" is commonly used to describe it -- than the ICD-9 codes now in use or even the ICD-10 codes, their proposed replacements. The argument, if there is one, is whether Snomed could fully substitute for ICD-10, as the presidential advisory committee's study recommendation implies.
Officials from both Snomed and the American Health Information Management Association of Chicago, a trade group representing 46,000 medical records professionals, agree that it cannot.
"It's something we ought to test," said Kent Spackman, M.D., chairman of the editorial board of Snomed and a professor of pathology and medical informatics at Oregon Health and Science University, Portland. "What this PITAC recommendation is saying is people are willing to take a look at where we're going and maximize our resources. That's a very positive direction."
Frank Elevitch, M.D., CEO of Healthcare Engineering, a Palo Alto consultancy specializing in healthcare information analysis, is chairman of the Snomed Authority, the board governing Snomed International. He said a government analysis would be good for healthcare and Snomed.
"It's going to push people to want to use Snomed," he said. "I think from the fed's perspective, Snomed has the granularity to weight reimbursement of claims based on acuity."
For example, Elevitch said, with ICD-10 it's difficult to get a good handle on duration of illness. "You do have some weighting of the co-morbidity attachments you can use, but it's not fine enough."
But Snomed is too fine, too granular for use as a reimbursement coding system, according to Dan Rode, AHIMA's vice president of policy and government relations.
"There's a misnomer that you can just put Snomed in and not do ICD-10 at all," Rode said. "You wouldn't want to adjudicate a claim in Snomed. It's way too gritty. You'd have thousands of things you'd have to consider."
"You'd still need a classifications system like ICD-10 or CPT," he said, referring to the Common Procedural Terminology code set owned by the AMA.
Rode also said the RAND study was a feasibility study and after it was completed, the NCVHS decided to go forward with ICD-10.
As a practical matter, Rode said he worries that HHS was delaying going forward with ICD-10, waiting for the presidential advisory committee to report, and any further delay for yet another study would be detrimental to the industry. As it is now, "we might not see ICD-10 until 2007 or 2008," he said.
Meanwhile, physicians are buying electronic medical records systems today not knowing which coding system will be used in the future. "There's going to be a lot installed that's going to have to be updated and modified," Rode said.
But, according to Spackman, it's not about apples or oranges, but about both.
"I'm a little concerned that what some people might assume that this recommendation is suggesting," Spackman said. "For example, they may assume that we're suggesting we do not have available ICD-10 codes in any fashion, and that's not where we're headed."
"There is value in keeping a separation between the codes you use to record clinical data and those that you use for reimbursement," he said. "Let's say the clinicians have a particular procedure and they say it's not specific; let's retire that code and replace it with two new one."
He used the example of open appendectomies, which have been leapfrogged by laparoscopic appendectomies.
"If that code is encumbered with reimbursement attachments, we end up not being able to change our recording of clinical occurrences because of the reimbursement coupling."
Spackman advocates using Snomed for clinical applications and building translations, or mapping systems, to the new billing codes. Snomed already is mapped to ICD-9, he said.
"In the United Kingdom, where the National Health Service is committed to using Snomed, they've begun mapping the clinical code to ICD-10," Spackman said. "Building that mapping is where I would see us to make some effort."
"People will have the clinical detail they need to manage healthcare in a more intelligent fashion," Spackman said. "With a reimbursement-based coding, we get distortions so that we can't properly manage healthcare. That's what people told us 10 years ago from Kaiser, who told us we really need a coding that can really help us. That's why they've put so much investment in it "
"That's what they're saying in the U.K. that's why they're using Snomed. My feeling is that it's better to record faithfully what you're seeing," he said. Then, he said, a computer could combine the many Snomed codes into fewer ICD-10 codes for public health and billing purposes.
"You have to think, who does the mapping. That's why a test case has to be done."