HIM 215 Module Six Worksheet (2)

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Feb 20, 2024

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HIM 215 Module Six Worksheet In this worksheet, you will practice using a mapping tool. Read the instructions for setting up and using I- MAGIC. Look up the following terms and provide the codes for SNOMED-CT and ICD-10, and provide a description of the information that was observed while determining the codes. For example, is it possible to refine your code? 1. Composite hemangioendothelioma a. SNOMED-CT 403984006 b. ICD-10 D48.1 c. What do you find when mapping the codes?  Neoplasm of uncertain behavior, of connective and other soft tissue  2. Second-degree burn of foot, initial encounter a. SNOMED-CT 62537000 b. ICD-10 T25.229A c. What do you find when mapping the codes?  Clarify - SNOMED CT has more than 100 terms that might be relevant! Here are some of them. Please choose the appropriate SNOMED CT concept from the list, if it is there, or clarify on the following entry blank.  Changed information to “Burn of second degree of unspecified foot, initial encounter,” same result. I reduced the information to “Burn of foot,” and I was given options where I chose “initial encounter” for “Burn of unspecified degree of unspecified foot.”  After deciding to start over and select the option “Partial thickness burn of foot,” I discovered the ICD-10 code that was associated, was described as “Burn of second degree of unspecified foot (initial encounter).” From there, I could refine Laterally, to describe either the left or right foot.  3. Sleep apnea a. SNOMED-CT 73430006 b. ICD-10 G47.30 Sleep apnea, unspecified c. What do you find when mapping the codes?  TBD (Further information is required before mapping)  Refinement by age, underlying condition, and type were suggested.  4. Herniated urinary bladder, male, 54 years old a. SNOMED-CT 410070006 b. ICD-10 N32.89 Other specified disorders of bladder c. What do you find when mapping the codes?  Would one of the following diagnoses apply? Choose the most specific one:  Male cystourethrocele  Congenital hernia of bladder

 Cystocele co-occurrent with incomplete uterovaginal prolapse  Cystocele and rectocele co-occurrent with complete uterovaginal prolapse  The above choices are not applicable  5. Atrophic scar a. SNOMED-CT 239172000 b. ICD-10 L90.5 Scar conditions and fibrosis of skin c. What do you find when mapping the codes?  No further refinement needed 6. Carcinoma, in situ, breast a. SNOMED-CT 189336000 b. ICD-10 D05.90 Unspecified type of carcinoma in situ of unspecified breast c. What do you find when mapping the codes?  Lateral refinement suggested 7. Mild depression a. SNOMED-CT 310495003 b. ICD-10 F32.A Depression, unspecified c. What do you find when mapping the codes?  Problem refinement  Would one of the following diagnoses apply? Choose the most specific one:  Mild postnatal depression  Recurrent mild major depressive disorder co-occurrent with anxiety  Mild major depressive disorder co-occurrent with anxiety single episode  Mild recurrent major depression  Mild major depression  The above choices are not applicable 8. Failure to gain weight a. SNOMED-CT 36440009 b. ICD-10 R62.51 Failure to thrive (child) c. What do you find when mapping the codes?  Because an age was not specified, the mapping automatically chose the ICD-10 code for a child.  Problem refinement  Would one of the following diagnoses apply? Choose the most specific one:  Childhood failure to gain weight  The above choices are not applicable  Replace the original problem with the more specific diagnosis  R62.51 Failure to thrive (child)  Age refinement  Please provide the patient's date of birth, in the format YYYY - MM - DD. Answer the following:

1. What does SNOMED mean? SNOMED stands for Systematized Nomenclature of Medicine - Clinical Terms. It is a comprehensive, multilingual clinical healthcare terminology that provides standardized codes for representing clinical concepts and relationships between them (Vuokko, Vakkuri, & Palojoki, 2023). 2. Why is it important? SNOMED provides a common language for healthcare professionals, researchers, and health information systems to exchange and share clinical information. It promotes standardization and interoperability by ensuring that clinical terms are consistently used and understood across different healthcare settings and systems. SNOMED facilitates accurate and detailed clinical documentation in electronic health records (EHRs). It allows healthcare providers to capture and communicate clinical information with specificity, which improves patient care, clinical decision-making, and continuity of care. 3. Why is it important for mapping to be accurate? Accurate mapping ensures that the correct codes are assigned for billing and reimbursement purposes. When mapping is done inaccurately, it can result in coding errors, leading to incorrect billing, reimbursement denials, or underpayment. Inaccurate mapping can also impact data analysis, research, and decision-making processes that rely on accurate coding and classification of clinical information.

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References Vuokko, R., Vakkuri, A., & Palojoki, S. (2023, February 6). Systematized Nomenclature of Medicine–Clinical Terminology (SNOMED CT) Clinical Use Cases in the Context of Electronic Health Record Systems: Systematic Literature Review . U.S. National Library of Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9941898/#:~:text=The %20Systematized%20Medical%20Nomenclature%20for,clinical%20information %20captured%20by%20clinicians.