The pMD Blog

Welcome to the
pMD Blog...

where we cover interesting and relevant news, insights, events, and more related to the health care industry and pMD. Most importantly, this blog is a fun, engaging way to learn about developments in an ever-changing field that is heavily influenced by technology.

From Paper Charts to EHRs: Standardized Code Sets and Their Impact on Providers

Electronic Health Records have greatly benefited health care. However, the wide adoption of EHRs did not come without certain drawbacks, especially for providers.  Do you remember what it was like to go to the doctor 15 years ago? You’d walk in and immediately see a lifetime supply of manila folders behind the front desk staff. When the provider entered the room, they were able to sit in front of you and have an engaging conversation. Today, a majority of providers are having to type into a computer in order to meet electronic documentation requirements. Although EHRs have propelled health care forward in many ways, unfortunately, they’ve added a new burden for providers: having to code from their patient visits with standardized code sets.

What are standardized code sets?

Providers are expected to document within different sets of billing and clinical terminologies. Simply put, these are standardized vocabularies that allow representation of the same health concepts between different health information systems. You can think of health care terminologies as the building blocks that support the entire health care documentation process. They allow patient data to be transferred in a way that can be understood and consumed universally, which is necessary not only for individual patient records but also for public health reporting, statistics, and billing.

ICD-10 and SNOMED-CT

You may be wondering: why is this a problem for providers? To dive in, let’s focus on two code systems often used by providers: 

ICD-10 (International Classifications of Diseases, 10th Edition) is often used for the backbone of diagnoses. The issue is that the coding hierarchy was built for billers and therefore is not provider-friendly. A lot of the terms aren’t expressed in everyday provider language (ie - “myocardial infarction” instead of “heart attack”), and there aren’t enough codes to capture the specificity of many clinical concepts. In general, ICD-10 is appropriate to be used as the backbone for billing but lacks the specificity needed for clinical documentation. 

SNOMED-CT (Systematized Nomenclature of Medicine – Clinical Terms) is a clinical term that includes diseases, clinical findings, etiologies, procedures, and health outcomes. It was the terminology required to meet Meaningful Use Stage 2 certification standards back in 2014 and is what providers typically use to document clinically in the EHR. Although this is a more comprehensive, clinical-based terminology, it still forces providers to document using the language of the code system rather than being able to document using their everyday language. There are several complexities to each code set - such as having to post-coordinate on a term to make it more clinically specific. 

This is burdensome because providers are, on top of their growing list of patient responsibilities, now tasked with learning multiple coding languages - which was something that was previously handled exclusively by billers and coders. With the wide adoption of EHRs, it moved the clerical task of coding to the providers, which shows that EHR technology is not assisting the providers, but rather the providers are assisting the technology. Why make providers learn all of these different code languages instead of allowing them to document clinically in the way they were trained?

Are there any solutions?   

Thankfully, there are solutions that help to ease this new coding burden on providers. Here at pMD, we accomplish this on the charge capture side by making the diagnosis and charge lists extremely customizable - not only to each practice but down to the individual provider. We can rename ICD-10 and CPT terms based on the provider’s preference, float important terms to the top, and delete terms that are not necessary. By offering a highly customized pick list, we eliminate the need for providers to memorize multiple coding languages. 

There are also clinical interface terminology solutions that serve as a bridge between code sets and providers. These companies offer expansive clinical vocabularies that have multiple synonyms and ways of documenting each term (ie - “type 2 diabetes,” “t2dm” and “diabetes, type II” would all be options for documenting the clinical concept of type II diabetes mellitus). They are very helpful to providers documenting in the EHR where more in-depth documentation is required. Overall, EHRs have helped propel health care forward, but pMD helps to take the coding burden back away from providers. 

 

To find out more about pMD's suite of products, which includes our charge capture and MIPS registrysecure messagingclinical communication, and care navigation software and services, please contact pMD.

5G ACA Account Management ACI adoption Advancing Care Information AHCA AHRQ AI Alternative Payment Model Amazon S3 Android API Apple appointment reminders Artificial Intelligence arts Audit Bay Area BCRA Best Place to Work Best Practices Big Data bootcamp BPCI BPTW Bundled Payments Business relationships Care Communities care coordination Care Navigation Care Team Career Fair CDC Charge Capture Charge Capture App Charge Capture Software Charge Capture Solution Charge Capture Statistics Charge codes Charge Lag CHIP CIO Clinical Communication clinical data Clinical Data Registry Clinically integrated network Cloud CMS cms regulations Collaboration Communication Company Culture Conferences Connected Health Record contact practice Coronavirus COVID-19 COVID19 CPT codes Cross-functional culture custom reports Customer Interaction customer relations customer service customer success customer support Customers Cyber Security cybersecurity Developer DHHS Diagnosis codes Dialysis discharge instructions EHR elderly Electronic Charge Capture Encryption epidemic Expansion FDA FHIR Flu fundamentals GI GI Outlook Goals group messaging Health Care Health Care Technology Health Care Web health data Health Information Exchange Health Record Healthcare healthcare interface healthcare interface integration healthcare software HIE HIPAA hipaa compliant communication hipaa compliant communication platform HIPAA-Compliant HL7 Holidays Home dialysis Hospital Census Hospital Communication humanity IA ICD-10 ICD-11 Implementation Improvement Activities in-app calling injury rehabilitation Instant capture Integration interface interoperability iOS iOS 8 iOS7 iPad iPhone iPhone 6 Lead Generation length of stay Long Term Care LTC Machine learning MACRA Medaxiom Medical Billing Medical Errors Medical Software Medicare Mental Health Mentorship Messaging Messaging with Patients MGMA MIPS MIPS Registry mobile Mobile App Mobile Charge Capture Mobile EHR Mobile Health Mobile Messaging Mobile security Mobile Technology Modern Healthcare Native App Network new feature new features news NIH OCM onboarding Oncology Care Model operations opioid crisis Pandemic Parenting partnerships Patient Patient access Patient App Patient Care Patient Chat Patient chat routers Patient Communication patient data Patient Engagement patient experience Patient Generated Health Data Patient Handoff Software Patient Information Patient Messaging Patient payments patient portal Patient Safety Patient satisfaction patient support Patient Visits Patient-Centric PCP Performance bonus PHI pmd pMD Pro pMD Team population health Population Health Management PQRS Product Development Productivity products Promoting Interoperability Protected Health Information QCDR QPP quality reporting Quality Scoring RCM Recruiting Recruitment Reimbursement remote jobs Remote Work reports Residents Responsibility revenue cycle management ROI Rural communities Sales Secure Communication Secure Data Secure Messaging Secure Messaging Video Secure Text Messaging Secure Video Secure Video Chat Security Audit self care seniors SF Biz Times SMB SNF SNOMED-CT SOC 2 software vendor Specialty Care success support TCM Team culture Teamwork technology telehealth Telemedicine telemedicine in long term care Telemedicine skilled nursing facilities Teletherapy Text Messaging texting Thanksgiving time-based billing training Travel Upgrades UX Design VA vaccination records vaccinations Value-based care Video Calling Video chat video communication video conferencing Virtual Care Virtual Visit voice calling voice memos Wearable Device wearing many hats Web App wellness wfh Wireless Work From Home Work Life Balance