ICD-10 Use of Intelligent Medical Objects, SNOMED CT, and the Electronic Medical Record for Accurate Coding By Valerie Fernandez, MBA, CPC, CPC-H, AHIMA ICD-10 Trainer ntelligent Medical Objects (IMO) refers to utilizing specific medical terminology used by clinicians in their documentation to conduct searches within the electronic medical record or utilize associated code sets to link a medical term with a diagnosis. IMO Inc. is a privately held company that has been instrumental in the development of this technology and holds the trademark for developing, marketing, licensing, and distributing the medical vocabularies. This technology can assist physicians and nonphysician practitioners in assessing a series of patients who may be suffering from the same disorder in order to conduct research that will ultimately improve outcomes or offer opportunity for advancing THE JOURNAL OF THE HEALTHCARE BILLING AND MANAGEMENT ASSOCIATION 29 evidence-based clinical care. Additionally, IMO can be used along with natural language processing to conduct a documentation search to enable selection of accurate coding for services rendered. If an appeal is then necessary, the same approach can be utilized to find specific documentation to support the appeal to the insurance carrier. Quality reporting initiatives can also be promoted with the use of IMO. It is through the uniformity of the terminology that standardization can occur regarding all communication within institutions and physician offices and across insurance carriers. IMO interacts with SNOMED CT, or the Systematized Nomenclature of Medicine Clinical Terms, as well as with the ICD-9 and ICD-10 code sets, to offer comprehensive use of the electronic medical record and the capability of participation in numerous electronic data interchanges. SNOMED uses clinical terms along with synonyms that might be used by a layperson in determining a final code for the service rendered based on documentation. The core components of SNOMED include concepts, relationships, descriptions, and reference sets for cross mapping. SNOMED was published in September 2012 in preparation for Meaningful Use Stage 2 compliance. SNOMED CT is the most comprehensive, multilingual clinical healthcare terminology in the world. SNOMED is complementary to coding systems and provides a set of descriptive terms for use in healthcare. SNOMED is a set of terms representing the system of concepts of a particular subject field; it’s a clinical terminology for use of clinical words, names, and symbols. It contains more than 300,000 concepts with unique meanings. Like ICD-10, SNOMED is granular and specific. It uses concepts, descriptions, and relationships to build a reference set that is cross mapped and cross targeted, and is used with software applications to code, retrieve, and analyze clinical data. SNOMED ensures medical consistency and is used with ICD-10 CM and ICD-10 PCS to create a standard language for communication. The clinical terminology, SNOMED, is linked to the classification system, ICD10-CM and ICD10-PCS. SNOMED CT enables provider access to a rapid exchange of information. It enables tracking of allergies, testing, medications, reactions, and interactions. SNOMED enables implementation of standards to promote policies I SNOMED ensures medical consistency and is used with ICD-10 CM and ICD-10 PCS to create a standard language for communication.
Billing_MarApr15
To see the actual publication please follow the link above