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The Clinical Documentation Conundrum

   February 01, 2017

SNOMED CT, a standard way of exchanging clinical documentation such as problem lists, has proven to be a more precise way of describing the clinical narrative in a structured way than ICD-10, and the good news is software developers are making progress at mapping natural language technology, taking speech or clinical notes as input, into specific SNOMED codes. In addition, ICD-10's eventual successor, ICD-11, will be derived from SNOMED, Hersh says.

"The best attribute of SNOMED is that it's extensible, so you can build more complex terms from simpler ones," Hersh says.

Another provider likens today's CDI to a kind of arms race in which algorithms suggest that more intricate diagnoses replace simpler diagnoses in order to maximize fee-for-service revenue.

"A lot of things that we do around billing, coding, and case-mix index are dependent on how you talk about a situation," says Sameer Badlani, MD, FACP, chief health information officer and vice president at Sutter Health, a 24-hospital system based in Sacramento, California. "If I were to write 'congestive heart failure,' I would get paid less versus if I say 'decompensated systolic heart failure,' which is a technical term for congestive heart failure. To a physician they mean the same thing. I would provide the same level of care, but there is a marked difference in the level of reimbursement that allows you to get paid better. So we're constantly playing this cat-and-mouse game where people are trying to document appropriate care in the best possible sequence of terms to get adequately compensated for the care they provide. And that is not the way we should be practicing medicine. If we were truly in a value-based system, you wouldn't care what I wrote in my documentation. You would care about the patient outcome."

Moreover, a fundamental challenge as clinical documentation pivots from volume to value is the continuing need to code in both old and new styles in order to satisfy requirements of Medicare and other payers, says Alistair Erskine, chief informatics officer at Geisinger Health System, the Danville, Pennsylvania-based system that serves more than 3 million residents throughout 45 counties in central and northeastern Pennsylvania and also in southern New Jersey with AtlantiCare.

Scott Mace is the former senior technology editor for HealthLeaders Media. He is now the senior editor, custom content at H3.Group.

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