A medical dictionary is a tool – essentially like a reference table – that tells users how clinical documentation links to administrative codes. Clinical documentation is exactly what it sounds like – the words and phrases providers use to record a patient’s medical history, which is comprised of conditions, diagnoses, procedures, lab orders, medications, and more. Conversely, administrative codes come from the standardized medical coding systems, like Current Procedural Terminology® or ICD-10-CM, that help facilitate tasks such as billing and regulatory reporting.
Therefore, at its core a healthy dictionary works to support an organization’s core functions like quality reporting, reimbursement, and patient care. It’s also the starting point for successful downstream initiatives – like healthcare data analytics and interoperability initiatives.
So, what classifies this tool as healthy or unhealthy? For starters, a healthy dictionary’s clinical language is comprehensive, complete, and up to date. Healthy dictionaries also map this subject matter to the appropriate terms and codes within current industry standard code sets. Unhealthy dictionaries, though? Check out some of the symptoms below:
Symptoms of an unhealthy dictionary
When providers can’t find the clinical terminology they need, it’s a struggle to accurately document a patient’s condition. Oftentimes the workaround means using more generic terms, such as flu-like symptoms to describe a patient infected with a specific virus.
The outbreak of Zika virus highlighted the types of issues that can arise when terms are missing from a medical dictionary. The need for the term Zika virus arose in Texas in February of 2016, when the virus first appeared in the United States. However, many medical dictionaries didn’t have this clinical terminology at the time – meaning the words for this condition weren’t available to clinicians. Even dictionaries derived from code systems weren’t immune, as Zika virus disease A92.5 first appeared in ICD-10-CM in the October 1, 2016 release, and LOINC codes for Zika virus testing didn’t arrive until June of the same year.
For all the nuances within clinical terminology, there’s still a fair degree of ambiguity and overlap in what terms mean. For example, the term “cervical lesion” can refer to an abnormality in a person’s neck or the uterine cervix. Without context, clues, or other indicators to clarify which condition is present, this type of uncertainty may lead to incorrect term mappings and therefore inaccurate records.
Terms inadequate for proper documentation
Healthy dictionaries support documenting all clinical details – no matter how granular and nuanced they may be. If dictionary terms are lacking, or are too generic, the level of detail in clinical documentation will be lacking, and the appropriate industry-standard codes may not be correctly linked to a provider’s record. Other infection associated with device is an example of a term lacking clinical specificity, and one that is likely too vague to ultimately be helpful for initiatives like data analysis.
Outdated or incorrect code maps
Industry standard terminology and code sets have routine content updates. ICD-10-CM updates become effective every October 1, whereas Current Procedural Terminology releases its updates January 1. Because of this, dictionary content must be constantly refreshed in order to reflect these changes and remain healthy. If the dictionary remains untouched, the content is considered aged, and risks linking to outdated or deleted codes.
The presence of any one of these four symptoms can significantly impact a dictionary’s health. To learn more about how IMO helps support healthy dictionaries, click here.