Standard Terminologies and Codes
Clinical terminologies are structured, encoded vocabularies of clinical concepts, organized in hierarchies, and used to describe clinical information accurately and in a standardized manner. Healthcare providers use clinical terminologies to capture information for treatment planning, for coordinating care with other providers, for billing, for quality improvement, and for a number of other purposes.
When used with electronic health information systems that interpret clinical data encoded in standard terminologies, standard terminologies can:
- Enhance communication
- Reduce errors
- Help ensure accurate data recording
- Improve the quality of information available to clinicians
- Aid in knowledge-building activities like public health monitoring, research, and development of evidence-based practices
Currently, there are three standard terminologies used in US dentistry: the dental subset of SNOMED-CT® known as SNODENT®, the Code on Dental Procedures and Nomenclature (CDT), and the International Classification of Disease, Clinical Modification, Release 9 (ICD-9-CM).
SNODENT is a clinical terminology for dentistry. It is also a fully interoperable, recognized subset of the Systematized Nomenclature of Medicine, or SNOMED®. As such, it may be used in connection with the Center for Medicare and Medicaid Services (CMS) Electronic Health Records (EHR) Meaningful Use Incentives programs. It contains over 7000 distinct concepts, of which 64 percent are clinical findings and disorders.
CDT is ADA intellectual property whose purpose is to achieve uniformity, consistency, and specificity in accurately reporting (i.e., documenting) dental treatment. One use of the CDT Code is to populate patient health records, both paper and electronic; another is to enable efficient processing of dental claims. The CDT Code was first published in 1969 as the Uniform Code on Dental Procedures and Nomenclature in The Journal of the American Dental Association. Since 1990, the CDT Code has been published in the American Dental Association’s reference manual entitled Current Dental Terminology (CDT). The dental professions, and other sectors of the dental community, are most familiar with this code taxonomy.
ICD-9-CM and its successor, ICD-10-CM, are disease classification taxonomies developed and maintained by the World Health Organization (WHO). Since 2003, ICD-9-CM codes have been the standard for reporting diagnoses on HIPAA electronic transactions such as electronic institutional and professional claims. Dentists and dental specialists who file medical professional claims will be familiar with use of ICD-9-CM codes for billing purposes. On Jan. 1, 2012, the electronic dental claim acquired the capability to report a diagnosis using ICD-9-CM codes in limited scenarios in which the payer may offer an additional benefit for services that mitigate health risks associated with a patient’s systemic health condition.
The U.S. Department of Health and Human Services has published a regulation that will require the use of ICD-10-CM beginning Oct. 1, 2015. The rule also requires HIPAA covered entities to continue to use ICD-9-CM through Sept. 30, 2015. Both ICD-9-CM and ICD-10-CM are available at no cost from the Centers for Disease Control and Prevention (CDC).