Diagnostic Code Sets (SNOMED-CT, ICD-10, ICD-9) in PCC’s Software and Services
PCC’s software and services include support for several diagnostic taxonomies.
How does PCC software support SNOMED-CT, ICD-10, and ICD-9?
SNOMED-CT: In the patient’s chart, clinicians record all diagnoses with SNOMED-CT. They select SNOMED terms during assessment or when updating a patient’s Problem List, for example. SNOMED is a detailed vocabulary that is ideal for charting and is required by industry standards. Programs such as PCMH and ARRA’s “Meaningful Use” prefer SNOMED-CT for the identification of patient diagnoses.
ICD-10: When billing for a visit, a practice must use ICD-10. Physicians select SNOMED-CT diagnoses in the chart, and PCC EHR can automatically select or suggest the appropriate ICD-10 codes for billing. Physicians can make additional coding choices (such as laterality) in the chart, and a practice’s biller or a billing service can also make adjustments when they review charges for the claim. Each practice can directly adjust the automatic mapping between SNOMED-CT and ICD-10 in order to meet their billing needs.
ICD-9: While ICD-9 is no longer an active or maintained code set, patient medical records may still contain ICD-9 descriptions and codes. ICD-9 may appear on old chart notes in PCC EHR, in billing records, and even on a patient’s Problem List. As you work with a patient’s chart, PCC recommends that you replace the ICD-9 Problem List entries with appropriate SNOMED descriptions.
Reporting: PCC’s reporting tools, including the customizable Report Library in PCC EHR, the Smart Report Suite, and your Practice Vitals Dashboard, all understand and report on both SNOMED and ICD-10 diagnoses. Some reports also support ICD-9 filtering. Consistent implementation of a coding taxonomy leads to excellent reporting. In addition to meeting requirements for insurance carriers, mandates, or incentive programs, consistent diagnosis language leads to improved patient recall and powerful tools for evaluating your practice’s clinical and financial health.
Look Up ICD-10 Codes for Patient Diagnoses
If you are filling out a form or need the ICD-10 code for a patient’s diagnosis, you can use the Diagnosis Flowsheet in a patient’s chart to quickly get the codes you need.
For more information, read the Look Up ICD-10 Codes for Referrals, DME, Requisitions, and Pre-Authorizations article.
Software and Configuration Considerations
As your office works with SNOMED-CT and ICD-10, here are some configuration topics you should consider. Feel free to contact PCC Support to discuss any of these issues.
Billing Configuration for PCC EHR: PCC EHR includes a diagnosis billing code mapping for common pediatric codes, but your practice can configure which SNOMED diagnosis descriptions map to which ICD-10 billing codes with the Billing Configuration tool. If you wish to review and update all of your common code mappings, you may find the Partner snomedmap report useful.
Charge Screens and Posting Charges: Your practice can customize PCC’s software and services to meet their workflow. For example, your practice may adjust both the electronic encounter form that appears in PCC EHR and the charge posting screens to make selection of appropriate codes faster and easier.
Custom Diagnoses Descriptions: The ICD-10 and SNOMED-CT lists on your PCC systems are a national standard (based on a broader, international standard) and can not be edited. However, your practice can select which alternative or preferred SNOMED description appears in your charts in the Diagnosis Configuration Tool.
Favorites: When you start to type a diagnosis in PCC EHR, it automatically searches for matching diagnoses to help you. First, it looks from a subset of the complete list, your practice’s diagnosis “Favorites” list. You can customize which diagnoses appear in this smaller Favorites list. Next, you can also right-click in a diagnosis field to search the entire SNOMED-CT list.
2015 Transition to ICD-10
As the medical industry moved away from ICD-9 and towards ICD-10 and SNOMED, PCC offered educational opportunities and created special tools to help practice’s handle the interaction between the different taxonomies. We now continue to offer web labs, videos, and coding classes to help your practice with your ongoing coding challenges.
Read the ICD-10 Resources article to learn more.
Call or e-mail PCC Support at any time to talk about SNOMED, ICD-10, and the specific needs of your practice.
We can work with your office to create custom solutions, provide additional training, and work with you to meet your coding needs.