Transcript Document

SNOMED Usage Guide for
Veterinary Systems:
Saying what we want to say.
AVHIMA
July 18, 2001
Boston, MA
Collaborators
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Bobbi Schmidt
Kathy Ellis
Dr. Penny Livesay
Dr. Kurt Zimmerman
Dr. Larry Freeman
Dr. Cynthia Wheeler (ACVO)
Usage Guide “Preamble”
• A (specific) medical record system provides the
context for the use of medical language.
• SNOMED provides semantic “values” that can
be used appropriately in medical record systems.
• No single Guide can guarantee appropriate use of
SNOMED for all medical records systems.
Usage Guide “Preamble”
• Both SNOMED and the medical record
system may influence the meaning of a
(end-user constructed) concept phrase.
• Both SNOMED and the medical record
system architecture may influence the
retrievability of a concept phrase.
Usage Guide “Preamble”
• SNOMED is concept-based not code-based.
– A SNOMED concept has a single meaning.
– SNOMED is not currently providing precise English
language-based definitions of concepts. Meaning can
be inferred from relationship-based definitions and
hierarchy position.
– Until additional features are added, selection of
concepts should be based (ONLY) on the fully
specified name of the concept.
Usage Guide “Preamble”
• SNOMED is hierarchy-based not code-based.
– The meaning of a particular concept name may only
be made clear by examining the position of a concept
in a hierarchy
– References to code “types” (D, M, F) does not confer
reliable information about appropriate uses of
concepts.
– Values sets for particular record fields or for concept
phrases should be evaluated critically. Specific
subsets of SNOMED can be derived for specific
purposes.
Usage Guide “Preamble”
• The use of SNOMED specified by this
document imposes certain fundamental
restrictions on any system:
– The system must support data storage and
transmission that maintains discrete code
phrases based on object-attribute-value triples.
– The system owner must own a valid license
for SNOMED.
Birth
• Type of Delivery (Dystocia)
– Delivery procedure vs. delivery diagnosis?
• Conditions affecting Newborn includes
maternal? (Whazzat?)
Biopsy
• A biopsy code is not assigned when a lesion
removed for therapeutic purposes is sent to
pathology for examination even though the term
biopsy may be used.
• Closed biopsies are sometimes performed even
though the operation itself is an open procedure.
In these cases, the open procedure is also coded.
(i.e. Laparotomy with needle biopsy of liver; code
both the laparotomy and the biopsy)
– VMDB Coding guideline draft (6/20/2001).
Biopsy
• So, if I do an open procedure and add a closed
biopsy, I code the biopsy. If I do an open
procedure and I do an open biopsy, I don’t code
the biopsy?
– Sounds very much like a policy decision, not a
“retrieval-criterion-based” decision.
– State an unambiguous definition for “biopsy”
• is it the intent to gather diagnostic information by tissue
submission (it is to me)?
– OR
• is it an administrative category based on the specific
procedures employed to deliver the diagnostic sample to the
laboratory?
Colic
• Code Colic (F-50820) in addition to the
Final Diagnoses listed, if it is the reason
for admission.
– VMDB Coding guideline draft (6/20/2001)
Colic
• Reason for admission and diagnosis should be
two different fields.
– Inconsistent capture of “reason for admission” in
diagnosis field.
• Why does Equine Colic deserve special attention?
– Addition of Colic to a diagnosis field DOES NOT
identify the Colic as reason for admission.
• Partly BECAUSE Colic is also used as “the diagnosis”
Colic
Colic
• F-50820 is the “finding” called abdominal pain.
• Equine clinicians elevate the “finding” to the
level of disorder.
• We still need to capture vague colic (resolved
spontaneously, no other diagnosis rendered).
– Is F-50820 “Abdominal colic (finding)” adequate for
this purpose?
• Does the medical record system sanction the use
of clinical signs as final diagnosis?
– Is this decision made on a disease-by-disease basis
(policy decision) ?
Complications (Postoperative)
• Use codes in DD-66000 category (hierarchy) –
Complications of surgical procedure
• Choose the most specific applicable. Always
– Mechanical – complications which result from some
failure of an internal device, implant, or graft, such as
a displacement or malfunction. This term includes
such things as catheters.
– Nonmechanical/Postoperative - Abnormal reactions to
the presence of a device, implant, or graft that is
functioning properly are coded to the appropriate
complication code.
• VMDB Coding guideline draft (6/20/2001).
Complications (Post-procedure)
• If there is no structural or philosophical
difference in approach, all procedure
complications should be managed the same way.
– “…includes such things as catheters”
• Complication of procedure (disorder) DD-60002?
• I THINK this also extends to adverse drug
reactions if therapy was administered.
• It will be difficult to maintain accuracy at the
“Mechanical” non-mechanical level.
– Better to support this with free text elsewhere in the
document? (is this worth recording in an abstract?)
Clinical Scenario
• Patient is presented to ophthalmology
service for evaluation
• Prior diagnosis of diabetes mellitus is
present in previous records (from
“reliable” referring DVM).
• Diagnosis of diabetic cataract is made.
Diabetic cataract
• When there is a causal relationship
between the diabetes and a complicating
condition, the type of diabetes is coded
first, followed by the type of diabetic
manifestation and the code to identify the
complication.
– VMDB Coding guideline draft (6/20/2001)
Diabetic Cataract
• DB-61010 - Insulin dependent diabetes
mellitus
• DB-61510 - Ophthalmic manifestations of
diabetes
• DA-73840 - Diabetic cataract
Diabetic Cataract DA-73840
Is a
Cataract
62795009
DA-73500
Is a
Diabetic
oculopathy
25093002
DB-61510
Associated
morphology
Cataract
128306009 M-54510
Associated
topography
Crystalline
lens
78076003
T-AA700
Diabetic Cataract DA-73840
• Already inherits (is a) Diabetic Oculopathy
(Ophthalmic manifestations of diabetes )
• In SNOMED-CT, will inherit
– HAS_ASSOCIATED_ETIOLOGIC_FINDING
• Diabetes mellitus (DB-61000)
Diabetic Cataract DB-61010
• Other general concerns with approach:
– The coding ORDER (in the system) does not control
the association between the concepts.
• Relationship between codes must be made EXPLICIT in the
medical record system.
– Diabetic Cataract is ALWAYS Associated with Insulin
dependency?
– What if insulin dependency is established in diagnoses
rendered prior to the cataract? Is this coded whether
or not the secondary provider confirms the diagnosis
(administrative decision)?
– This is a specialized case of “secondary” disease
described differently in the document.
Due to
• When coding a diagnosis “due to” or “secondary to” another
diagnosis, code the causative / principal condition first followed by
the resulting / secondary condition. Use DF-00150 with the
secondary diagnosis. (Example: Seizures due to fever. Use the Dcode with the code for seizures.) Use only if not included/implied in
the diagnosis code description in SNOMED (i.e. secondary
cataracts).
• Exception: Do not use the DF-00150 codes for conditions due an
external cause/injury; i.e. HBC, poisoning, etc.
• **Need to discuss on Forum what codes to use**
– VMDB Coding guideline draft (6/20/2001)
Due to
• HAS_ASSOCIATED_ETIOLOGIC_FINDING
(Relationship)
– To distinguish from “complications of
procedure”
• How much flexibility (expressiveness) do
you expect for “value set” used in this
relationship?
– Single codes? Code phrases?
Fracture
• Fractures should be coded with the appropriate D-code
by site followed by an M-code for fracture type if
specified. A T-code can be used if necessary to specify
the site more fully. Do Not use combination codes for
multiple fractures (e.g. fracture of radius and ulna). Use
individual codes for each site/bone.
• Any fracture that is not specified as open is coded as
closed. Open indicates that the bone has punctured the
skin; a closed fracture has not penetrated the skin.
Closed fractures are described by a variety of terms, such
as comminuted, depressed, green stick, impacted, simple
and spiral. Open fractures include compound, infected,
missile, puncture, and with foreign body.
– VMDB Coding guideline draft (6/20/2001)
Fracture
• Fractures should be coded:
– D-code by site
– M-code for fracture type if specified.
• comminuted, depressed, green stick, impacted, simple and spiral,
compound, infected, missile, puncture, and with foreign body.
– A T-code can be used if necessary to specify the site more fully.
• Do Not use combination codes for multiple fractures (e.g.
fracture of radius and ulna). Use individual codes for
each site/bone.
• Open vs closed should only be included if specified.
Default use of “closed” when closed or open is not
specified should be an system-specific internal rule
(administrative decision).
Grafts of Bone or Skin
• Code the P code for “Excision / Harvesting of the
bone or skin for graft”. For Bone Grafts, if you
can not obtain a code that specifically lists the
bone you are harvesting from, then use the P110332 and a T code for the bone. For Skin
Grafts, use P1-40D04 and a T code for where the
skin is removed.
– VMDB Coding guideline draft (6/20/2001)
Grafts of Bone or Skin
• Code the P code for “Grafting of bone or
skin by ‘site’ ” and code for type of graft
(Autograft or Allograft). If code by site is
not available, use P1-10D00 (bone graft) or
P1-40D00 (Skin graft) and T code for
where graft was placed.
Grafts of Bone or Skin
• When a fully specified (topography
included) procedure code does not exist,
select the most specific parent available
– Pedicle graft
– Myocutaneous graft
• Additional modifiers
– Graft types (layers)
– Graft morphologies (slit grafts)
Disorder secondary to adverse
drug reaction.
• If a condition is caused by properly
administered medications and is diagnosed
as iatrogenic, code DD-64800 + C code if
stated + Iatrogenic condition.
– VMDB Coding guideline draft (6/20/2001).
Iatrogenic hypothyroidism
• What distinguishes “iatrogenic” disease from
other adverse drug reactions?
• Is it:
– Hypothyroidism
• Has associated etiologic finding
– Adverse drug reaction
» Associated etiology:Methimizole
• Is it:
– Iatrogenic hypothyroidism
• Associated etiology Methimazole?
Late Effects
• A late effect is the residual effect that
remains after the termination of the acute
phase of an illness or injury. Complete
coding of late effects usually requires two
codes: 1) Residual condition or nature of
late effect; 2) Cause of the late effect.
The residual condition is sequenced first
followed by the cause of the late effect.
– VMDB Coding guideline draft (6/20/2001).
Late Effects
• Late effects of trauma have a relatively
rich hierarchy and seem somewhat logical.
• Late effects of diseases do not.
Leukemia
• Code with the appropriate D-code
specifying the type of leukemia and the Mcode for the morphological type of
Leukemia. Exception: Feline Leukemia
code as DE-36030.
– VMDB Coding guideline draft (6/20/2001).
Leukemia
• What makes this special? (Needs to be handled
in the neoplasia section – we’ll figure it out there
)
• Feline leukemia is not an exception, it just has its
own code. We need to make sure that the feline
leukemia “model-definition” is accurate. (It’s
just a very specific “kind-of” leukemia).
– The DE-36030 concept is only “cat is infected”. We
need additional concept(s) for manifestation of
disease.
– New concepts should be added to the leukemia
hierarchy.
Limb Sparing
1) Code the P code for “Excision of lesion from the ‘bone’
” and/or “Partial resection/ostectomy of ‘bone’ ” and
the T-code for the bone you are removing.
2) Code the P code for “Excision / Harvesting of the bone
for graft”. If you can not obtain a code that specifically
lists the bone you are harvesting from, then use the P110332 and a T code for the bone.
3) Code the P code for “Grafting of bone by ‘site’ ” and
code for type of graft (Autograft or Allograft)
4) Code chemotherapeutic implant if performed.
– VMDB Coding guideline draft (6/20/2001).
Limb Sparing
• Limb sparing really serves as a specific
example for “multiple-surgery” procedure
groupings.
• Administrative or medical category?
• Is there an “organ sparing” category?
Lipoma
• Code with the appropriate D-code
specifying site and M-88500 (Lipoma).
• VMDB Coding guideline draft (6/20/2001).
– Children of “Lipoma (clinical disorder)” D1F2800?
– Code like ANY other benign neoplasm?
Lipoma
Luxation / Subluxation
• Luxations and Disarticulations are to be
coded as “Dislocations” except for when
the problem is listed only under Luxation
(i.e. lens or patellar).
• For Subluxations use the appropriate code
under “ Subluxation.”
– VMDB Coding guideline draft (6/20/2001).
Luxation / Subluxation
• Disarticulation is a procedure
• Patellar luxation (disorder) IS A joint
dislocation
– Examine the hierarchy not the text string.
Mass
• Masses should be coded with the
appropriate D-code specifying site. If
there is no D-code available then code
Localized Mass M-03000 AND the
appropriate T-code.
– VMDB Coding guideline draft (6/20/2001).
Mass
Mass
• appropriate D-code specifying site
– e.g., Abdominal mass (disorder) D5-02004
• Or, most specific disorder
– e.g., Disorder of abdomen
• Fold these into tumors / neoplasms ?
Neoplasm / Tumors
• Neoplasms should be coded with the appropriate
D-code based on anatomical site (e.g.
Benign/Malignant Neoplasm of the spleen)
followed by an M-code (e.g. Hemangiosarcoma)
and a G-code for histologic grading,
differentiation, and behavior. G-F505 should be
entered if differentiation is not determined. Other
clinical staging G-codes are optional.
– VMDB Coding guideline draft (6/20/2001).
Neoplasm / Tumors
• If the site is unknown, then use D code of
Neoplasm of unspecified site. If
morphology is not specified to cell type
then use M-8000* (e.g. Malignant
Neoplasm, Benign Neoplasm)
– VMDB Coding guideline draft (6/20/2001).
Neoplasm / Tumors
• The following neoplasms should be coded with the appropriate Dcode based on morphology type (e.g. Lymphoma of cervical lymph
nodes) followed by the proper
• M-code and G-code
– Hemangioma, Leukemia (See Leukemia), Lipoma (See Lipoma),
Lymphoma / Lymphosarcoma (use key term Lymphoma), Mast Cell
Tumors – Malignant use M-97403, Benign use DC-47000 and M97401, Melanoma (of the skin only), Multicentric Lymphoma – If
neoplasm is not of skin and is Stage 3 or 4, then it is considered
multicentric.
• Wart/Papilloma (See Wart/Papilloma)
– VMDB Coding guideline draft (6/20/2001).
Neoplasm / Tumors
• Tumors should be coded with the appropriate Dcode for Neoplasm of Uncertain Behavior by site
with M-80001.
• Use the Chemotherapy procedure code P267010 for oncology cases only.
– VMDB Coding guideline draft (6/20/2001)
• P2-67010 is parent for chemotherapies that ARE
NOT for treatment of malignant disease
– it doesn’t mean “cancer chemotherapy”
Neoplasm / Tumors
• We got work to do!
Normal Patient / Wellness Exam
• For a patients with a diagnosis of Normal /
Healthy with NO EXAM PERFORMED (e.g.
Mare with Foal, Boarding, etc.) use F-00001 –
Normal Patient Condition for the diagnostic
code.
• For a Wellness Exam or Healthy Patient with an
EXAM PEFORMED use – F-06800 – Wellness
State for the diagnostic code.
• Note: Do not use these codes if another
diagnosis is listed on the record.
– VMDB Coding guideline draft (6/20/2001)
Normal Patient / Wellness Exam
• F-00001 – Normal Patient Condition for the
diagnostic code.
• F-06800 – Wellness State for the diagnostic
code.
– These two codes are not distinguished on the basis of
the examination performed (or lack thereof).
– Wellness state is (probably) a group header for the list
of wellness states that can be used as values here.
(Well adult, etc.)
• Does a physical exam result (Normal Patient
Condition) belong in the diagnosis field?
Open wounds without
complications
• Open wounds should be coded as Open wound by site
(Concept: Open wound and/or crushing injury - DD30000). Also code the M code to identify the type of
wound:
• M-14400 Laceration, M-14120 Avulsion/Degloving, M14300 Puncture Wound, M-14374 Bite Wound, M-145**
Gunshot Wound, M-14700 Abrasion
• **Note: If there is no code by site available, then use
DD-30010 for Open wound without complication and
specify the site with a T code.
– VMDB Coding guideline draft (6/20/2001)
Open wounds with
complications
• Open wounds are coded as being complicated when any
of the following circumstances are associated with them.
Use M codes to describe the complication and the type of
wound (see list above):
• Delayed healing (M-78330), Delayed treatment, Foreign
Body in wound (M-30400 + substance code), Major
Infection, Sequestrum / Necrosis
• **Note: If there is no code by site available, then use
DD-30020 for Open wound with complication and specify
the site with a T code.
– VMDB Coding guideline draft (6/20/2001)
Open wound with infection
• Infection
– Has associated etiologic finding = wound
• Open wound
– Has associated complication = infection
• These two are the same “concept? ”
• Can we construct and retrieve either or
both?
Poisoning / Ingestion / Toxicity
• Conditions caused by drugs, medicinal substances, and other
biological substances due to animal’s exposure to the substance are
classified as poisonings when the substance involved is not used in
accordance with a clinician’s instructions. Such as:
– Wrong Medication given or taken, Wrong dosage given or taken ,
Overdose, Intoxication, Toxic Effects of non medicinal substances,
Ingestion or other exposure of a substance
• Adverse effects resulting from the proper administration of the
correct substance (prescription drug for patient) are excluded from
poisoning. Under these circumstances, code as an adverse effect or
reaction (DD-64800).
– VMDB Coding guideline draft (6/20/2001)
Poisoning / Ingestion / Toxicity
• Language needs to reconcile with “Adverse drug
reaction”
– “when the substance involved is not used in accordance with a
clinician’s instructions”
– “If a condition is caused by properly administered medications”
• There are additional perspectives on “wrong medication”
– Administrative (Drug A was ordered, Drug B delivered)
– Medical (Drug A was ordered, it was the wrong drug)
– Medical (Drug A was ordered, it was the right drug, the patient
didn’t tolerate the usual dose).
Procedure
• Therapy administered to the patient should
be indicated with the appropriate P code.
Use the most specific code available to
describe the procedure. You may need to
add an additional P code, topography (T),
morphology (M), Chemical (C) or Device
(A) code(s) to fully describe a procedure.
– VMDB Coding guideline draft (6/20/2001)
Procedure
• Procedures are much more difficult to
compose than are findings.
• “Procedure” hierarchy has generated much
discussion lately and it’s not completely
resolved.
Rechecks
• For Rechecks of a previous medical diagnosis,
previously listed in the medical record of the
institution holding the record, use G-1001 (prior
diagnosis) as a modifier for the diagnosis/disease
being rechecked. Confirmation of a diagnosis at
a referral institution would be considered the
original diagnosis and not a recheck.
• For a surgical recheck, use F-06030 (postop
status).
– VMDB Coding guideline draft (6/20/2001)
Rechecks
• Confirmation of a diagnosis at a referral
institution would be considered the original
diagnosis and not a recheck.
– Is diabetes mellitus (established by a referring vet) a
“prior” diagnosis when part of an ophthalmology
record?
• F-06030 (postop status).
– Postop status is for the immediate post-op period. Not
for evaluation of the ultimate success or failure of the
procedure.
Rechecks
Rule Outs / Differential
• Do not code Rule Out or Differential diagnoses or code
them in conjunction with modifier code G-1006. Multiple
Rule outs for the same symptoms code at the coder’s
discretion. Also, code diagnoses listed as “vs another
diagnosis” as rule outs
• When Signs/Symptoms are diagnosed with several Rule
outs listed, code the Sign/Symptom independently and
then code the Rule out Diagnoses with G-1006.
• Example: Ataxia rule out poisoning or encephalitis.
Code Ataxia without the G-code, then code Poisoning and
encephalitis with the G code.
– VMDB Coding guideline draft (6/20/2001)
Rule Outs / Differential
• Rule-outs / Differential lists SHOULD NOT be
coded in a final diagnosis field.
• The structural relationship between signs and
symptoms and either individual rule-outs or
differential lists cannot be solved through coding
schemes alone.
• The medical record system must be structurally
capable of managing these relationships.
Suspected
• For Suspected, Possible and Probable diagnoses,
code diagnosis in conjunction with the
appropriate modifier G code. Diagnoses listed
with a “?”, code as Suspected – G-2001.
• Code Signs/Symptoms that are manifested
independently without the G code, then code the
“suspected diagnoses” with the G code.
– VMDB Coding guideline draft (6/20/2001)
Suspected
• Administrative decision again
– The secret forms of communication used
between clinicians and medical records
personnel are not the purview of this
organization…
•?
• ? Vs ??????
• ;-)
Third Eyelid / Nictitans
• Do not code the diagnosis to conjunctiva.
Use topography code T-AA980 for third
eyelid of animal (nictitating membrane).
– VMDB Coding guideline draft (6/20/2001)
Third Eyelid / Nictitans
• This problem will take care of itself when
we create appropriate disorder codes.
• Ophthalmologists are helping with a real
nomenclature committee.
– Encourage yours to Participate?
Acknowledge? Use?
Warts / Papilloma
• For all warts/papillomas in Bovines, use
DE-32A31 and the T-code for the site.
• For all other species, use a D code for
benign neoplasm by site; M code for wart
or papilloma; T-01747 (Animal skin wart)
and G-F505.
– VMDB Coding guideline draft (6/20/2001)
Warts / Papilloma
• We need to make sure that Bovine
Wart/Papilloma integrates well with others.
What to do…
• VMDB-sponsored nomenclature party.
– At Virginia Tech
• Dr. Livesay, Dr. Freeman and I are already there.
• I’d suggest peak fall foliage season!
– Break into 3 – 5 working groups of 2-3 people.
• Could invite experts to lead working groups?
– Surgeon, oncologist, cancer registry manager
– Use Virginia Tech tools to create subsets
– Use Virginia Tech tools to create examples