American Hospital
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Hospitals

June 4, 2004

Jonathan C. Javitt, :MD, MPH
Co-Chair Health Care Delivery and IT Subcommittee
President's Information Technology Advisory Committee
C/o National Coordination Office for Information Technology
Researchand Development
4201 Wilson Boulevard, Suite ll-405
Arlington, VA 22230
Dear Dr. Javitt:
The undersigned organizations are writing to express our concern with the recent draft
recommendation of the President's Information Technology Advisory Committee (pITAC),
Health Care Delivery and IT Subcommittee, calling for the adoption of SNOMED-CT as analternative to ICD-IO-CM. In particular, we call your attention to the draft recommendation
calling for a "cost-benefit study" of upgrading the nation's diagnosis and procedure coding
systems from ICD-9-CM directly to SNOMED-CT. We urge the PIT AC Subcommittee torework this recommendation.
The draft recommendation wrongly implies that SNOMED-CT is a viable alternative to ICD10-CM and ICD-IO-PCS (collectively referred to as ICD-IO), or for that matter, CPT-4. We
believe that ICD-I 0 must move forward first. SNOMED-CT is a reference terminology andICD-IO is a classification system. Both can exist together. When ICD-I 0 is completed, it
can be mapped to SNOMED-CT. ICD-IO is a preferred coding classification system for data
analysis and reimbursement and can be implemented fairly quickly.
-~---The National Committee on Vital and Health Statistics (NCVHS), the advisory body to theSecretaryofHHS, has studied these coding issues since the 1980s, and in November 2003
recommended that the Secretaryissue a proposed rule to replace the ICD-9-CM codingclassification with ICD-l O. This would not affect the use of other code sets for otherpurposes under HIP AA, such as CPT-4 and Level II HCPCS (Heal~care Common Procedure
Coding System). During this period, the NCHVS had also considered SNOMED-CT as analternative coding system and concluded, after numerous hearings, that the nation needs tomove forward with the adoption ofICD-10. They recognized the importance ofICD-10 for
statistical data analysis, such as epidemiological analysis or trending of diseaseincidence, aswell as for reimbursement.

It becameclearduring the NCHVS hearingsthat SNOMED-CT,while well designedfor thesupportof the electronichealthrecord,containstoo manytermsto feasiblycollapsethem forstatistical analysis and reimbursement systems. Further, using SNOMED-CT to define allclinical conceptscontained in the medical record -discharge summary, operative report,
pages and pages of progress notes -can only lead to a cumbersome and inefficient process.

Reimbursementsystemswould be difficult to designusing SNQMED-CTbecauseof its
extremegranularitythat oftenlendsitself to redundancyof codes. On the otherhand,ICDlO-CM and ICD-l O-PCSprovide for a morepreciseselectionof codesfor summarizingthe
patient'srecord.
The NCVHS determined that the benefits of adopting ICD-IO far outweigh the costs. They
also noted the following expectedbenefits: improvements to tlile quality of care and patient
safety; fewer rejected or questionable reimbursementsof claim~; improved information for
diseasemanagement;more accurate reimbursementrates for emerging technologies; andbetter understanding of the value of new procedures
Initiating another cost-benefit study will only delay the implementation of ICD-l 0, andprolong the continuation of an obsolete ICD-9-CM coding system. No one system meets thecomplex needs of data capture and retrieval for the various uses outlined above. Together,
these controlled terminologies provide the data structure required to move towards a fully
functional electronic health record. We urge the PIT AC subcommittee to recommend
expedited implementation oflCD-lO and further research into making SNOMED-CT afunctional language for the electronic medical record with mapping from lCD-tO.

We look forward to working with you andthe Secretaryto resolve anyremainingissuesandto implementICD-I O-CMandICD-1O-PCS.If you have anyquestions,pleasecontactNelly
Leon-Chisenat the American HospitalAssociationat 312-422-3396.

Advanced Medical Technology Association
American Hospital Association
American Medical Association
Federation of American Hospitals

Cc

Membersof the PITAC
Membersof the NCVHS
TommyG. Thompson,Secretary,U.S. Departmentof HealthandHumanServices