WHY CODE

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WHY CODE VETERINARY RECORDS (April 30, 2004)
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W. Kathleen Ellis, RHIT, RN, BSUniversity of
Illinois Veterinary Teaching Hospitaland VMDB
HIM Consultantwkellis_at_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)

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Why Code at All?

• In Veterinary Medicine there are no
• reimbursement reasons for coding!

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Why then?

• 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

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Standardization and Consistency

• Retrieval purposes
• Data exchange and transmission

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• 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?

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

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Example of A Problem

• Dr. Smith and Dr. Brown collect patient data on
  tumors.
• The data is not collected using a nationally
  recognized standardization.

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• 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.

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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

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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

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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

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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.