Introduction to SNOMED CT
Systematized Nomenclature of Medicine- Clinical Terms (SNOMED CT) is a universal, structured clinical coding format which, unlike ICD-10 and CPT codes, are used exclusively for clinical documentation, not for billing. SNOMED CT codes were developed out of a need for a universal coding system for clinical terms specific for documentation and are now the clinical coding standard required by the U.S government for electronic exchange of health information. SNOMED CT will also be used as a part of the enhanced medication therapy management (MTM) program. Center for Medicare and Medicaid will be collecting MTM encounter data, including SNOMED CT codes, to monitor quality and performance of services.
SNOMED CT codes can be used to describe a wide range of health-related information including medication history information, impression of a patient’s condition, medication-related problems, conditions, lab data, procedures, and treatment recommendations. SNOMED CT codes can be used to document the steps outlined by the Joint Commission of Pharmacy Practitioners for pharmacist patient care process. To document assessment, SNOMED CT includes the seven main drug related problems: unnecessary drug therapy, needs additional drug therapy, medication not effective, dose too low, adverse drug reaction, dose too high, noncompliance.
There are over 311,000 codes in the library maintained by the National Library of Medicine and 300 codes relate to MTM. Using SNOMED CT codes in documentation of MTM allows for pharmacists to easily communicate with other healthcare providers. SNOMED CT can be used to measure outcomes, evaluate quality and cost of care, and monitor patient outcomes. Using SNOMED CT in MTM documentation can allow pharmacists to demonstrate their value as a part of the healthcare team.
Recently, a multi-stakeholder group convened to develop a standardized framework for SNOMED CT codes related to MTM services. This group defined terms relating to MTM to create a consistency when using SNOMED CT codes. Value sets of codes were created and gaps in existing terms where identified. The complete report of definitions, suggested additions of SNOMED CT codes, and future goals can be found at http://www.amcp.org/SNOMEDFramework/.
SNOMED CT is coming to the world of pharmacy due to the enhanced MTM program. It is essential that pharmacists understand the use of this system and how it can be used to prove the value of a pharmacist on the healthcare team.
References:
Spiro S. SNOMED CT Is Coming to Pharmacy: A Primer on Systematized Nomenclature of Medicine–Clinical Terms—Documentation (for Pharmacist and Pharmacy Services). Pharmacy Times. http://www.pharmacytimes.com/news/snomed-ct-is-coming-to-pharmacy-a-primer-on-systematized-nomenclature-of-medicine-clinical-terms-documentation-for-pharmacist-and-pharmacy-services. Published January 27, 2016. Accessed October 14, 2016.
Medication Therapy Management Services Clinical Documentation: Using a Structured Coding System – SNOMED CT. Booklet published by Pharmacy Health Information Technology Collaborative.
Documenting Comprehensive Medication Management in Team-Based Models Using SNOMED CT Codes. Booklet published by Pharmacy Health Information Technology Collaborative. Published August 1, 2014.
Guidance for Use of SNOMED CT in Transitions of Care Documentation. Booklet published by Pharmacy Health Information Technology Collaborative. Published July 18, 2016.
Image from: http://jcpp.net/patient-care-process/
AUTHORED BY
Abigail Buchman
Doctor of Pharmacy Candidate 2017
Southern Illinois University Edwardsville, School of Pharmacy
Rotation Student with Starlin Haydon-Greatting 11/01/2016
Email: abuchma@siue.edu
Starlin Haydon-Greatting, MS, BSPharm, FAPhA, CDM
IPhA Director of Clinical Programs & Population Health
ASHP SACP CPS & MM SAG MEMBER
Pre-Diabetes, Diabetes & CV Health Patient Self-Management Programs
Email: sh.greatting@comcast.net