The College of American Pathologists (CAP) appreciates this opportunity to present a written statement to the National Committee on Vital and Health Statistics on the standards for the electronic exchange of health claims attachments as specified in the administrative simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191. The CAP is a medical specialty society representing more than 15,000 physicians board certified in anatomic and/or clinical pathology. College members practice their specialty in community hospitals, independent clinical laboratories, academic medical centers, and federal and state health facilities.
As you are well aware, the purpose of the HIPAA administrative simplification provisions is to facilitate the transfer of electronic health information. The HIPAA administrative simplification provisions are expansive, reaching far beyond administrative transactions to encompass all activities in the clinical environment. Implicit in the legislation is the development of an effective information linkage between the administrative and clinical health care environments.
Today, claims for reimbursement of health services are based on ICD-9-CM and CPT-4 – administrative code sets that identify diseases/diagnoses (ICD) and medical procedures (CPT). ICD and CPT are classification systems that place all medical diseases and procedures into predetermined categories. As such, they do not identify or explain the individual details of a particular patient’s illness or medical case.
Claims attachments support the insurance claim for reimbursement by extracting relevant information from the medical record that demonstrates the reason for performing the service. By its nature, a claims attachment is often essentially a subset of the medical record. An effective standard for the electronic submission of claims attachments should specify what information from the medical record is needed and require that it be submitted in a standardized format.
When looking at the specific items that should be linked between payment and the clinical environment, the CAP believes that a limited code set, such as that identified by the joint HL7-X12 working group, is appropriate. At this time, however, the CAP believes it is premature for the scope of the discussion on claims attachments to expand to include the question of the specific code sets to be used for the entire medical record.
The CAP presents to the NCVHS what it considers to be a realistic approach to the development of standards for the electronic transmission of claims attachments. The CAP recommends an approach in which claims attachments requiring coded clinical data are limited to a set of well-defined claims attachment templates utilizing a standardized coded clinical nomenclature that can clearly capture any clinical information contained in the medical record. Specifically, the CAP believes this approach can be most effectively implemented using SNOMED (Systematized Nomenclature of Human and Veterinary Medicine) as the source of clinical codes, which can be formatted according to the coding system in a HL7 message standard specifications and which in turn can beformatted message standard packaged and transmitted using the X12 standard.
A Description of the Systematized Nomenclature of Human and Veterinary Medicine (SNOMED)
While the CAP recognizes that no single code setsystem captures all clinical concepts, independent studies have demonstrated SNOMED to be pragmatically one of the most complete works used today in the clinical environment.1,2 SNOMED, copyrighted and published by the CAP, is a comprehensive nomenclature designed to encompass all of the terms used in medicine, including procedures and diagnoses. SNOMED is cross-referenced to ICD-9-CM and can readily be cross-referenced to other classification systems such as CPT-4. Therefore, SNOMED and classification systems are compatible. SNOMED provides a mechanism to capture the detail needed to support classification systems and much more.
SNOMED can codify all the activities within the patient medical record including: medical diagnoses and procedures, nursing diagnoses and procedures, patient signs and symptoms, occupational history, the many causes and etiologies of diseases including such things as infectious conditions, and the physical causes of injury. In contrast, classification systems such as ICD and CPT represent only pieces of the medical record.
The CAP has more than 30 years of experience with SNOMED. Today, SNOMED International, the third edition of SNOMED, has gained wide acceptance internationally and is being endorsed by both the private and public sectors.
One of the advantages of SNOMED is its ability to adapt to multi-purpose coding. For example, SNOMED has been selected by the Digital Image and Communications in Medicine (DICOM) as the standard for representing anatomical and other concepts in the reports that accompany images in electronic messages. In cooperation with the American Dental Association (ADA), SNOMED will integrate the ADA’s nomenclature with the SNOMED structure while ensuring lack of overlap. This cooperative effort also permits the ADA wide latitude in determining the content of dental diagnoses contained in SNOMED. Similarly, working with the American Nurses Association, nursing vocabulary will be integrated into SNOMED. We are also working closely with LOINC to harmonize its clinical and laboratory codes with SNOMED.
There are several professional medical organizations, in addition to those previously mentioned, with which the CAP is working to improve the detail and clinical content coverage of SNOMED. A major initiative currently underway is a project with the Kaiser Permanente Medical Group that will significantly enhance the ability of SNOMED to represent clinical data. These enhancements will form the basis of the next generation of SNOMED, SNOMED RT. A range of software vendors and individual organizations across the U.S. have integrated/adopted SNOMED for their systems. The CAP is committed to continuing these many efforts to meet the needs of the users of clinical vocabulary.
While the CAP recognizes the potential benefits of a national health information system, we remain concerned about the standards that will be adopted to accomplish this goal. Adoption and implementation of inappropriate standards has the potential to produce undue burdens on both health care providers and patients and thereby negate the Congressional intent of HIPAA; to improve the efficiency and effectiveness of the electronic exchange of health information.
Electronic submission of claims attachments depends upon an effective coded nomenclature that can represent all aspects of patient care documented in the medical record. SNOMED was developed for this specific purpose. As stated previously, credible studies have established thatThere is no other clinical nomenclature in existence today that is more ascomprehensive than asSNOMED. In these studies SNOMED ranks as the most comprehensive.
The CAP recognizes the importance of terminology for the future of health care and believes in the role of SNOMED in encoding the patient medical record. In a move to demonstrate its commitment to the future of SNOMED, the CAP Board of Governors recently approved an aggressive five-year strategic plan for the continued development and maintenance of SNOMED.
A separate operating unit has been created within the CAP to support the enhancement, maintenance and distribution of SNOMED. The efforts of the SNOMED Editorial Board are being will beaugmented by collaboration with the addition ofnumerous medial health care organizations representing physicians, nurses, dentists, allied health professions and others.specialty groups, all focused on terminology content development.
Oversight of all SNOMED activities, including the SNOMED Editorial Board, iswill be the responsibility of the SNOMED Authority, a member/staff team reporting directly to the CAP Board of Governors. A newly established SNOMED Advisory Panel, consisting of leaders in health care informatics, will provides the Authority with a valuable source of guidance on the future development of SNOMED. In addition, the CAP is examining the requirements of ANSI accreditation as a way to make the SNOMED nomenclature more open to the needs of clinical users.
As the NCVHS turns its focus to standards to facilitate the electronic exchange of claims attachments, the CAP recommends that the committee take into consideration the relationship between the medical record and claims attachments. In this regard, the CAP believes that the NCVHS will recognize the value of a nomenclature for claims attachments that can capture all the clinical data contained in the medical record.
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