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WHY CODE VETERINARY RECORDS (April 30, 2004)

WHY CODE VETERINARY RECORDS (April 30, 2004). W. Kathleen Ellis, RHIT, RN, BS University of Illinois Veterinary Teaching Hospital and VMDB HIM Consultant wkellis@uiuc.edu. Thanks to the following for their contributions: Dr. Allen Hahn (University of Missouri)

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WHY CODE VETERINARY RECORDS (April 30, 2004)

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  1. WHY CODE VETERINARY RECORDS (April 30, 2004)

  2. W. Kathleen Ellis, RHIT, RN, BSUniversity of Illinois Veterinary Teaching Hospitaland VMDB HIM Consultantwkellis@uiuc.edu Thanks to the following for their contributions: • Dr. Allen Hahn (University of Missouri) • Margaret Neterer, RHIA (Michigan State University) • Dr. Art Siegel (University of Illinois)

  3. In Veterinary Medicine there are no reimbursement reasons for coding! Why Code at All?

  4. Research Teaching activities Grant proposal support Disease prevalence trends Caseload data Comparisons with similar institutions Publication or presentations (especially for tenure needs) Intern papers and vet student papers Board certification data Business Management Why then?

  5. Standardization and Consistency • Retrieval purposes • Data exchange and transmission

  6. Clinicians often say the same thing but in different ways • Hairy heel wart vs bovine digital dermatitis vs Mortellaro Disease • Or, use the same terminology but have different meanings • Peg Leg, is it osteomalacia or muscle rigidity?

  7. For optimal retrieval purposes what is being said needs to be standardized and consistent so the information may be interpreted appropriately

  8. Example of A Problem: • Dr. Smith and Dr. Brown collect patient data on tumors. • The data is not collected using a nationally recognized standardization.

  9. Dr. Smith leaves the clinic to take another position. • The CEO of the clinic wishes to locate all tumor cases seen at the clinic. • This is not possible. Some of Dr. Smiths cases are located, but many are not as there is no standardized mechanism by which to find them.

  10. Sharing Data • In this day and age of heightened awareness of bioterrorism and the spread of new infectious diseases, there is a greater need to be able to capture information consistently in order to share data with external agencies

  11. SNOMED CT • This goal becomes more realized when using a standard nomenclature such as SNOMED CT • And, SNOMED CT has been sanctioned for use in veterinary medicine by the AVMA

  12. Human Medicine • With the issues of Homeland Security, there may be a need to share data with human medicine • SNOMED CT is currently mapped to ICD

  13. Free Text • Many systems now utilize pull-down lists and controlled vocabularies • SNOMED CT may be mapped to the free text dictionary in the background which makes using free text a controlled language • If mapping free text, a context expert should be involved • Note that capturing billing information by mapping does not allow one to obtain data based on diagnoses or findings, nor certain procedural information such as internal fixations, fabellar suture procedures, etc.

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