Attn: Coders, Physicians, CDIs-Need help with terminology for CPOE Physician Problem List
Typo on the last one sorry...
CDIs are trying to get in early since reading Dr. Robert Gold's blog on meaningful use. We are contacting those responsible for implementing CPOE to see if the problem list can be expanded so that diagnoses give codeable choices. As in heart failure, first an acuity choice, then a specificity choice.
We got word that the problem list was being based on SNOMED terminology. Here is the link: http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html
Is this at all close to ICD-9-CM terminology? The problem list I saw was very basic with no specificity or acuity.
It is my feeling that to have the problem list give codeable choices as well as unspecified/unknown for each category would help reinforce the terminology that is needed to accurately reflect the patient's SOI/ROM, medical necessity, LOS and withstand scrutiny by RACs etc.
CDIs are trying to get in early since reading Dr. Robert Gold's blog on meaningful use. We are contacting those responsible for implementing CPOE to see if the problem list can be expanded so that diagnoses give codeable choices. As in heart failure, first an acuity choice, then a specificity choice.
We got word that the problem list was being based on SNOMED terminology. Here is the link: http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html
Is this at all close to ICD-9-CM terminology? The problem list I saw was very basic with no specificity or acuity.
It is my feeling that to have the problem list give codeable choices as well as unspecified/unknown for each category would help reinforce the terminology that is needed to accurately reflect the patient's SOI/ROM, medical necessity, LOS and withstand scrutiny by RACs etc.