Problems

Information about condition, diagnosis, or other event, situation, issue, or clinical concept that is documented.

Submitted By: Joel Andress / Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
Data Element Information
Rationale for Separate Consideration	The current concept of problems/diagnoses is included in USCDI v1. This submission is to recommend expansion of the applicable standards to include both SNOMED and ICD-10-CM.
Use Case Description(s)
Use Case Description	Diagnosis/condition information defined by ICD-10 terminology is used extensively in CMS quality measures across programs including IQR, QPP, PAC, and Promoting Interoperability to define measurement populations. This concept is widely defined by SNOMED and ICD-10-CM terminology. ICD-10 is mandated for CMS billing and is reviewed and audited for those purposes, and therefore is an accurate source of condition information and a preferred source of condition data for many use cases.
Estimated number of stakeholders capturing, accessing using or exchanging	More than 4,000 hospitals and 1 million providers currently capture, access and exchange diagnosis data using ICD-10 terminology. ICD-10 is mandated for CMS billing, and therefore used by all stakeholders interfacing with Medicare and Medicaid beneficiaries. In addition to CMS mandate, On January 16, 2009, the U.S. Department of Health and Human Services (HHS) released the final rule mandating that everyone covered by the Health Insurance Portability and Accountability Act (HIPAA) implement ICD-10 for medical coding. eCQI resource center, includes measure specifications for CMS program eCQMs: https://ecqi.healthit.gov/ecqms CMS and HHS regulation: https://www.cms.gov/Medicare/Coding/ICD10/Statute_Regulations
Link to use case project page	https://ecqi.healthit.gov/ecqms
Use Case Description	Problems/diagnoses defined by ICD-10 codes are also used extensively for clinical care, care decision support, and exchanged for patients across the continuum of care. ICD-10 terminology is an accepted and frequently used terminology for this type of clinical exchange of data using C-CDA.
Estimated number of stakeholders capturing, accessing using or exchanging	ICD-10 for medical coding is required for everyone covered by HIPPA, and also required for CMS billing, and therefore is widely used/captured by all stakeholders. ICD-10 data is also electronically exchanged with patients and payers. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=492 https://bluebutton.cms.gov/
Link to use case project page	http://www.hl7.org/implement/standards/product_brief.cfm?product_id=492
Use Case Description	This use case was submitted by Holly Miller, MD, MedAllies. Either pushed or queried interoperable messages from one provider or organization to the next caregiver for the patient will include both ICD and SNOMED codes for problems/diagnoses to support semantic interoperability across systems and prevent errors that might occur from different systems disparate mapping methodologies. Current State Provider in system A documents a patient's problem/diagnoses using ICD 10 codes and links each element in the plan of care to the specific diagnosis that it is related to. In the background, system A maps the ICD 10 code to a SNOMED code using their preferred mapping processes. Provider in system B who is next taking care of the patient is either pushed or queries for an interoperable message that includes the SNOMED problem/diagnosis codes. In the background, system B maps each problem/diagnosis SNOMED code to the corresponding ICD 10 codes using system B’s mapping methodology resulting in some differences among the original and reconciled ICD 10 codes received from system A. Future State Provider in system A documents a patient's problems/diagnoses using ICD 10 codes and links each element in the plan of care to the specific diagnosis that it is related to. In the background, system A maps the ICD 10 codes to the corresponding SNOMED codes using their preferred mapping processes. Provider in system B who is next taking care of the patient is either pushed or queries for an interoperable message that includes both the original ICD 10 codes documented in system A as well as the SNOMED problem/diagnosis codes that were mapped by system A. The correct ICD 10 codes are reconciled and the linked treatment plan elements to each code can be retained. The received SNOMED codes are also stored by system B.
Estimated number of stakeholders capturing, accessing using or exchanging	Estimate the number of stakeholders who would capture, access, use or exchange this data element or data class: Level 2 All providers in the United States that document their patients' problems/diagnoses using ICD CM codes in their EHRs (the vast majority).
Healthcare Aims	Improving patient experience of care (quality and/or satisfaction) Improving the health of populations Reducing the cost of care Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s)	ICD-10 https://icd.who.int/browse10/2019/en https://vsac.nlm.nih.gov/welcome http://hl7.org/fhir/us/core/STU3.1/ValueSet-us-core-condition-code.html https://icd.who.int/browse10/2019/en
Additional Specifications	Many technical specification use/allow use of ICD-10 terminology to define diagnoses including: HL7 FHIR US Core Implementation Guide STU3 based on FHIR R4, Condition Profile, specifically can use ICD-10 terminology for encounter diagnoses (https://www.hl7.org/fhir/us/core/StructureDefinition-us-core-condition.html ) HL7 FHIR QI Core Implementation Guide STU4 based on FHIR R4, Condition Profile http://hl7.org/fhir/us/qicore/StructureDefinition-qicore-condition.html CMS Quality Data Model (QDM) version 5.5 Guidance (https://ecqi.healthit.gov/sites/default/files/QDM-v5.5-Guidance-Update-May-2020-508.pdf) HL7 C-CDA Release 2.0 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=492)
Current Use	This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders
Supporting Artifacts	ICD-10 terminology is mandated for CMS billing, and therefore used by all stakeholders interfacing with Medicare and Medicaid beneficiaries; ICD-10 for medical coding is also required for everyone covered by HIPPA and therefore used at scale between multiple different production environments. It is also widely available in EHR systems. https://fhir.cerner.com/millennium/r4/general-clinical/condition/#terminology-bindings https://fhir.epic.com/Specifications?api=949 https://open.epic.com/Interface/FHIR https://mydata.athenahealth.com/fhirapidoc https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Quality-Programs https://ecqi.healthit.gov/ecqms https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Quality-Programs
Number of organizations/individuals with which this data element has been electronically exchanged	5 or more. This data element has been tested at scale between multiple different production environments to support the majority of anticipated stakeholders.
Supporting Artifacts	ICD-10 terminology to define diagnoses is electronically exchanged for quality measurement used across CMS programs—it is exchanged electronically from EHR systems via QRDA files as well as in claims. ICD-10 codes are also routinely electronically exchanges with external organizations via C-CDA to support the continuum of care and with patients via CMS. https://ecqi.healthit.gov/qrda http://www.hl7.org/implement/standards/product_brief.cfm?product_id=7 https://ecqi.healthit.gov/qrda
Potential Challenges
Restrictions on Standardization (e.g. proprietary code)	No challenges anticipated. This terminology has been in use for many years and is widely used.
Restrictions on Use (e.g. licensing, user fees)	None
Privacy and Security Concerns	This data, like any patient data, should be exchanged securely. Current processes exist, governed by CMS and ONC, to securely transfer this data.
Estimate of Overall Burden	No burden estimated—terminology in use across the entire stakeholder community.
Other Implementation Challenges	N/A