Representing Patient Medical Encounter Diagnosis

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Type Standard / Implementation Specification Standards Process Maturity Implementation Maturity Adoption Level Federally required Cost Test Tool Availability
Standard
Final
Production
Rating 4
Yes
Free
N/A
Standard
Final
Production
Rating 4
No
Free
N/A
Limitations, Dependencies, and Preconditions for Consideration Applicable Value Set(s) and Starter Set(s)
  • Use of SNOMED CT® codes should generally be chosen from three axes: Clinical finding, Situation with explicit context, and Event.
  • The use of these standards may be further constrained by other standards and implementation specifications found elsewhere in the ISA.
  • Systems should be able to process (or at minimum display) data coded using the older ICD-9-CM standard, as this legacy content still exists and may be used for analysis/decision support/quality measurement needs, where retroactive analysis is often required, but ICD-9 should not be collected for new entries.
  • A mapping from SNOMED CT® to ICD-10-CM is available from the National Library of Medicine to support semi-automated generation of ICD-10-CM codes from clinical data encoded in SNOMED CT for reimbursement and statistical purposes.
  • Problem urn:oid:2.16.840.1.113883.3.88.12.3221.7.4 (SNOMED CT® code system)
  • Recommended starter set: CORE Problem List Subset urn:oid: 2.16.840.1.113762.1.4.1018.240

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