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Advance for Health Information Professionals • January 2017

8 ADVANCE FOR HEALTH INFORMATION PROFESSIONALS / CODING Documentation codes transform information typically written or typed as progress notes into discrete data points structured to describe the care provided to an individual patient. medications and laboratory results. However, much of the clinical story is not recorded. The importance of codified clinical documentation has been underscored by national initiatives to modernize the health IT infrastructure in the United States. The Meaningful Use program served as a launching pad, incentivizing hospitals and health care providers to adopt certified electronic health records (EHRs). Meaningful Use requirements include implementing standards for exchanging patient data with other providers and reporting clinical quality measures to the Centers for Medicare and Medicaid Services (CMS). Clinical documentation using standardized coding terminologies is the foundation for achieving these goals. Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) is a coding terminology used for clinical documentation and a federally recognized standard for health information technology in the United States.1 SNOMED CT codes are standardized terms used to document findings, problems, interventions and outcomes. Codes are organized into value sets, or unique groups of codes, to aid implementation into electronic systems and support effective health information exchange and quality reporting.2 Healthcare providers are most likely familiar with billing codes. Current Procedural Terminology (CPT) and International Statistical Classification of Diseases and Related Health Problems (ICD-9/10) have been mainstays in the healthcare system for years and attached to claims for reimbursement. Meaningful Use and quality payment programs drive providers to document additional clinical information to fulfill data reporting requirements. These programs require clinical information using SNOMED CT and other vocabulary standards and have stimulated clinical documentation beyond billing codes. How- JANUARY 2017 Who Are the Data Classification Experts? AHIMA Certified Coding Specialists (CCSs®)! Are you skilled at coding inpatient and outpatient records? Earn the AHIMA CCS credential to let the world and potential employers know it. CCSs classify medical data from patient records in hospital settings to ensure reimbursement of expenses and for use by researchers and public health officials to describe health outcomes, monitor patterns, and explore new interventions. Prepare to sit for the exam with the CCS virtual exam prep session—always available on your schedule. Four on-demand webinars and one virtual interactive learning session explore each of the test’s domains, provide study tips and test-taking skills, and present an enlightening Q&A session with a coding expert! Learn more at ahima.org/certification/CCS 2006.16


Advance for Health Information Professionals • January 2017
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