Download DIAGNOSTIC CODING PRACTICAL INFORMATICS IS JUST THE

DIAGNOSTIC CODING
IS JUST THE BEGINNING
Stephen T. Pittenger, DVM, DABVP (Canine & Feline Practice)
PRACTICAL INFORMATICS
FOR PRIVATE PRACTICE
The American Animal Hospital Association (AAHA) released the Standardized Diagnostic Terms for Veterinary
Medicine in May 2010. This was a culmination of seven years of hard work by several groups of individuals. I was
fortunate to be one of the early contributors to this project during the genesis of the “mapping phase,” where we took
concepts known in veterinary medicine and began the arduous process of mapping that terminology to those
concepts contained in the Systematized Nomenclature of Medicine–Clinical Terms® (SNOMED-CT®). In 2002,
AAHA, supported by Hill’s Pet Nutrition, Inc., conducted the profession’s first study on compliance. The Path to
High Quality Care study report was published in 2003. While gathering data for the study, the researchers lamented
that a confirmed diagnosis, or even a list of differential diagnoses, was often lacking in the medical records they
reviewed for the study. Initially, the diagnosis coding project was envisioned to help support and rectify the
problems encountered during the initial compliance studies. It became clear to those appointed to the first task force
that the diagnosis coding project needed to be much more comprehensive than the suggested initial guidelines the
group received.
The earliest lists of diseases compiled were generally causes of death. These lists were refined in the international
community in the nineteenth century and were utilized, mostly in hospitals, as a way to statistically analyze why
patients expired and to allow for some standardization of death records. In the 1940s in the United States we began
to compile lists of diseases that caused morbidity as well as mortality. These lists were used by some voluntary
hospital insurance plans, large hospitals themselves, and some governmental projects. The lists allowed statistical
analysis to occur in patient populations, and they were some of the first to be accompanied by a “code” for each
term in the list. Widespread adoption of diagnosis codes occurred when the budding health insurance market needed
to use codes to calculate reimbursement amounts for policyholders. Once third-party payment became popular,
physicians needed to properly code the diagnoses (and treatments) that patients received in order to ensure proper
(and maximal) reimbursement for providing the described care. The monetary incentive to provide a diagnosis code
is an enormous driver in the human health-care arena—one that is virtually nonexistent in veterinary medicine.
In the arena of human health care, the diagnosis carries the same weight and importance that it does in veterinary
medicine. The diagnosis is the art or act of identifying a disease from its signs and symptoms. There are certainly
cases where a definitive diagnosis is not possible. In addition, there are abundant examples of cases where a
diagnosis can be made, but where the specificity of the diagnosis could potentially be defined further with additional
testing and/or time. This is often termed the “granularity” of a concept. SNOMED-CT concepts are organized in
hierarchies with multiple levels of granularity, and the Diagnostic Terms that have been mapped to them in
veterinary medicine have differing levels of granularity based on what was deemed appropriate by the task force and
editors as applied to veterinary medicine in the present day. What we have created is essentially a “Reference Set” in
which concepts (or descriptions) from SNOMED-CT are grouped and cross-referenced with commonly discussed
veterinary classifications.
There are three main components of SNOMED-CT:
1.
2.
3.
Concept Codes: numerical codes that identify clinical terms, some elemental or “primitive” and some very
defined and organized in hierarchies
Descriptions: the text descriptions of concept codes
Relationships: relationships between the concept codes that have related meanings
The “concepts” are described by a unique Fully Specified Name (FSN) and may also contain preferred term(s) and
other synonyms. Each concept has a unique code number and a unique FSN. All of these concepts are organized into
taxonomic hierarchies. For example:
Lung Disease
Pneumonia
Infectious pneumonia
Viral pneumonia
So, for the concept of Viral pneumonia (75570004), we can note that this is a component of Infectious pneumonia,
which belongs not only to the concept of Pneumonia, but also Infectious Diseases. Lastly, these are lung diseases at
the top level. We could go much deeper into the viral component with this disease, if possible. For example, all of
these types of Viral pneumonia have a specific concept code as well:
Adenoviral pneumonia (disorder) {41207000, SNOMED-CT}; Chickenpox pneumonia (disorder) {195911009,
SNOMED-CT}; Congenital viral pneumonia (disorder) {276692000, SNOMED-CT}; Cytomegaloviral pneumonia
(disorder) {7678002, SNOMED-CT}; Hantanvirus pulmonary syndrome (disorder) {123620007, SNOMED-CT};
Herpes simplex pneumonia (disorder) {233624006, SNOMED-CT}; Infectious mononucleosis pneumonia
(disorder) {233622005, SNOMED-CT}; Measles pneumonia (disorder) {195900001, SNOMED-CT}; Parainfluenza
virus pneumonia (disorder) {64917006, SNOMED-CT}; Pneumonia due to Human metapneumovirus (disorder)
{445096001, SNOMED-CT}; Pneumonia due to Respiratory syncytial virus (disorder) {195881003, SNOMEDCT}; Pneumonia due to Severe acute respiratory syndrome coronavirus (disorder) {441590008, SNOMED-CT};
Progressive pneumonia of sheep (disorder) {48722001, SNOMED-CT}; Viral pneumonia associated with AIDS
(disorder) {421508002, SNOMED-CT}
As you can see, there may be diseases in veterinary medicine that, like those specific disease-causing agents listed
above, we could identify and actually code at this level of granularity. At other times, we would be limited to the use
of a higher-level (less granular) FSN, such as Pneumonia.
Here is a sample list of pneumonia concepts provided in the Standardized Diagnostic Terms for Veterinary
Medicine:
Concept, Fully Specified Name
Fungal pneumonia (disorder)
Lobar pneumonia (disorder)
Bronchopneumonia (disorder)
Aspiration pneumonia (disorder)
Bacterial pneumonia (disorder)
Interstitial pneumonia (disorder)
Bronchoalveolar pneumonia
(finding)
Preferred Description
Fungal pneumonia
Lobar pneumonia
Bronchopneumonia
Bronchial pneumonia
Aspiration pneumonia
Inhalation pneumonia
Bacterial pneumonia
Interstitial pneumonia
Interstitial pneumonitis
Bronchoalveolar pneumonia
Synonyms
Fungal pneumonia
Lobar pneumonia
Bronchopneumonia
Bronchial pneumonia
Aspiration pneumonia
Inhalation pneumonia
Bacterial pneumonia
Interstitial pneumonia
Interstitial pneumonitis
Bronchoalveolar pneumonia
By using the concept code, we have a universal (international) language to denote a particular diagnosis or problem.
The mapping of common synonyms in veterinary medicine makes the finding and coding of a diagnosis much easier
for a particular patient. Use of terms that are common in veterinary medicine allows the clinician and staff to
continue to focus on medicine and surgery and not the arduous task of diagnosis coding to a specific level of
granularity. These lists will enable a practice to search its patient population for specific concepts and allow for
better tracking of patient outcomes and even for pooling of data from multiple practices or regions to determine
disease incidence.
Veterinarians and their staffs are encouraged to adopt the Standardized Diagnostic Terms for Veterinary Medicine
for their practices. The AAHA website contains the code list, and your practice management software provider has
been notified of the list and has also been given access to the code data. Once the codes are adopted into the
practice, the actual use of the codes, when an appropriate level of diagnosis has been achieved, is the final action
step.