Canadian Institute for Health Information (1 of 2)

Mapping for Interoperability: Modernizing Physician billing using SNOMED CT and ICD-11

Americas

Clinical Practice, Implementation, Innovation, Mapping, Tooling

This work explores the potential of leveraging a primary care health concern value set developed using SNOMED CT CA as the basis for modernizing primary care data collection and physician billing processes in Canada. The value set is mapped to ICD-10-CA for aggregated secondary reporting and to ICD-9, which is still the standard most commonly required for patient level physician billing (PLPB). The central aim of this analysis is to assess the feasibility of using the value set to support the migration from ICD-9 to ICD-11 to enhance primary care data capture and modernize physician billing. By looking at how this value set works across different classifications and uses, this work aims to help plan for a future transition to the joint use of SNOMED CT CA and ICD-11 to modernize Canada's primary care data and physician billing.

Description

ICD-9, a classification system developed in the 1970s, continues to be used for PLPB. ICD-9 has not been updated in decades and no longer reflects current clinical language, emerging health conditions, or evolving models of care. As Canada moves towards greater digital health integration and interoperability, there is a clear need to modernize the way we capture and report primary health concerns in electronic medical records and reciprocal billing systems.

The Case for Change

As directed by their provincial ministries of health, physicians across Canada use a variety of provincial billing schedules that draw on code sets mainly derived from ICD-9. This legacy approach contributes to significant variability and inconsistency in how diagnoses and health concerns are captured and reported across the country. In a time where precise data capture, digital health and interoperability are becoming increasingly important, Canada needs a more modern, consistent and clinically relevant approach.

The Opportunity: Mapping SNOMED CT CA to ICD-11

SNOMED CT is a comprehensive, clinician-friendly terminology designed for the collection of detailed clinical documentation in electronic health and medical records (EHR/EMRs). In contrast, ICD, the International Classification of Diseases, traditionally has been used for collecting and grouping diagnostic data to support statistical reporting and reimbursement.

The Canadian Institute for Health Information (CIHI) has developed a curated subset of health concern terms commonly used in primary care to support clinical documentation and interoperability, whilst addressing a national data reporting gap. The pan-Canadian Health Concern Value Set (PHCVS) is a standardized list of clinical terms, derived from SNOMED CT CA, that are mapped to ICD-10-CA for health system use and ICD-9 for PLPB. The PHCVS is recommended in the Canadian Core Data for Interoperability (CACDI), a subset of the Pan-Canadian Health Data Content Framework, to capture health concern data.

As provinces in Canada consider updating physician billing systems from ICD-9, there is an opportunity to explore how the SNOMED CT CA terms in the PHCVS subset, captured at point of care, can be leveraged, through a mapping process, to evaluate the benefits and feasibility of adopting ICD-11, the eleventh and latest version of the ICD. The use of the postcoordination feature in ICD-11 can be beneficial to capturing additional specificity, which could help support the improvement of primary healthcare data and serve to replace ICD-9. This migration would allow clinicians to continue documenting health concerns using SNOMED CT CA terms found in the PHCVS, while billing systems and administrative datasets could receive the corresponding (mapped) ICD-11 code to meet PLPB requirements and enhance clinical utility. The abstract additionally provides insights into the level of equivalent terms available in SNOMED CT CA that are found in the ICD-11 Foundation. The results of this work will inform planning for the envisaged joint use of SNOMED CT CA and ICD-11 to enhance Canada's health information infrastructure.

Scope

SNOMED CT is a globally accepted terminology available for use in electronic medical record systems. As the terms are expected to be what a physician wants to record at the point of care, the PHCVS was developed using the most common SNOMED CT CA clinical terms found in primary care to support the capture of health concern data in the Canadian Core Data for Interoperability (CACDI).

How SNOMED CT will be used

SNOMED CT CA terms (source clinical terminology) currently used in the PHCVS can be linked to corresponding ICD-11 stem/extension codes (target classification codes). This project aims to bridge a curated set of SNOMED clinical terms documented at the point of care in primary care EMRs, to corresponding ICD-11 codes for physician billing purposes. These terms are drawn from the PHCVS, which was developed based on the most frequently used SNOMED CT CA concepts in primary care setting and reflects physician documentation practices at the point of care.