Improved Coding of the Primary Reason For Visit to the Emergency Department Using
SNOMED
James McClay, MD, Assistant Professor, Section of Emergency Medicine, Department of
Surgery, University of Nebraska Medical Center, Omaha, NE
James Campbell, MD, Professor of Internal Medicine, University of Nebraska Medical Center,
Nebraska Health System, Omaha, NE
Abstract
There are over 100 million visits to emergency
departments in the United States annually that could
be a source of data for multiple uses including
disease surveillance, health services research, quality
assurance activates, and research. The patients'
motivations for seeking care or the reason for visit
(RFV) are recorded in every case. Efforts to utilize
this rich source of data are hampered by inconsistent
data entry and coding. This study analyzes ICD-9-
CM, SNOMED-RT, and SNOMED-CT encoding of
the RFV for accuracy.
Each encoded reason for visit was compared to the
text entry recorded at the time of visit to determine
the closeness of fit. Each coded entry was judged to
be an exact lexical match, a synonym, a broader or
narrower concept or no match. SNOMED-CT was a
lexical match or synonym for 93% of the text entries,
while SNOMED-RT matched 87%, and ICD-9-CM
matched 40%. We demonstrate that SNOMED
coding of the RFV is more accurate than ICD-9-CM
coding.
Introduction
In 1999 there were approximately 102.8 million visits
to emergency departments (ED) in the United States
(1). This volume of patients makes the estimated
4,800 EDs in the United States well positioned to
provide data for public health surveillance However,
variations in the way data are entered in different ED
record systems impede the use of ED records for
disease and injury surveillance and deter their reuse
for multiple secondary applications.
People present either voluntarily or involuntarily to
the emergency department for assistance in dealing
with health problems. For every person we record a
primary reason for his or her seeking care. The
patient's stated reason for visit attempts to capture
what motivated the patient to seek care. This reason
for seeking care is variously termed the chief
complaint or the reason for visit (RFV). The Joint
Commission on Accreditation of Health Care
Organizations (JCAHO) requires all EDs to record
the RFV in logs of patient visits. The usual and
customary method for recording this information is
free text in the patient's own words either by hand in
a logbook or in the computerized medical record (2).
AMIA 2002 Annual Symposium Proceedings
The RFV is useful for analyzing demand for health
care services, evaluating quality of care and
performing risk adjustment (3). However, many
authors have pointed out that a codified RFV based
upon a standard terminology would better support
such applications as computerized records (4), health
services research (5), quality assurance (6), case
finding and disease surveillance (3). Despite the
importance of standardized terminology for
supporting ED data utility, Massachusetts recently
passed legislation requiring a thirty-character free
text field for recording the reason for visit (7).
Any system for encoding patient data must adhere to
basic features of maintenance, reliability, and
administrative control to provide for compatibility of
the data set over time (8). Currently RFV coding
schemes are driven by national administrative needs
that do not necessarily support disease and symptom
surveillance. We maintain that coding systems must
be able to support multi-site, community based,
uniform data collection of sufficient accuracy and
resolution to detect disease and injury trends. Recent
threats to national and personal health have
emphasized the importance of surveillance and the
ED is central to any plan for early detection of
bioterrorist or epidemic health care events.
The Department of Health and Human Services
requires use of ICD-9-CM (9) coding for the RFV on
outpatient claims (10). Little attention has been
focused on the appropriateness of this mandate for
ICD-9-CM in support of the uses of RFV data we
have discussed above. ICD-9-CM originated as an
epidemiologic reporting tool for population mortality,
and was never intended to provide full expression for
a patient's symptoms. Studies of other health care
contexts comparing ICD-9-CM to comprehensive
coding schemes such as the Read codes of the United
Kingdom, or SNOMED International have
demonstrated that the expressiveness of ICD-9-CM is
too limited to completely represent a patient's
symptoms (8, 11). Studies have shown that
SNOMED-RT is better than ICD9-CM for diagnostic
coding (13) but no published studies have validated
ICD-9-CM for RFV coding.
In keeping with basic tenets of computerized record
design, we at Nebraska Health System have
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implemented diagnosis and problem list coding in our for its match to the original RFV text field entered at
central computerized patient records employing the time of the patient visit. The text strings were
SNOMED-RT standard terminology. While judged to be either an exact match in which the terms
maintaining the essential clinical focus of the are the same but the word order may be different (a
diagnostic coding, we support billing and lexical variant); a synonym where the meaning was
administrative uses of the- data by extensive mapping determined to be the same (such as short of breath
to ICD-9-CM. It is our hypothesis that the finer and dyspnea); as no match where there wasn't an
granularity and enhanced clarity of SNOMED would anatomic or symptomatic relationship; or as a partial
more accurately represent the RFV and support better match. The partial matches were judged to be either a
disease surveillance. We undertook this project to broader concept (such as limb pain instead of foot
compare the clinical expressiveness of SNOMED- pain) or a narrower concept (pharyngitis instead of
RT, and the newly released SNOMED-CT, with ICD- sore throat). There determinations were performed by
9-CM in the representation of RFV recorded in our a clinician (JM) with 12 years experience reviewing
emergency facilities. and coding emergency department charts.
Methods
The Nebraska Health System (NHS) maintains a 700 Type of Description Example
bed tertiary care hospital admitting 30,000 patients match
annually as well as a network of community Lexical The terms included Low back pain
outpatient facilities supporting half a million Variant are the same vs. Pain in low
outpatient visits. All enterprise health services (Exact although the word back
employ the same computerized patient information match) order may vary
system, LastWordg developed by IDX Systems Synonym The terms have the Throat pain and
corporation. NHS serves metropolitan Omaha and is same meaning as sore throat
a trauma referral center for Eastern Nebraska and judged by the
Western Iowa. The emergency department staffs reviewer
three facilities seeing about 60,000 cases a year. Partial The coded concept A chief
When a patient visits any of our emergency match: encompasses the complaint of
departnents the reason for visit is typed into a text broader RFV text but the foot pain coded
field in the registration screen as free text. After the includes other as limb pain
visit the charts are submitted to the ED coding office possibilities
where an ICD-9 code is chosen for the reason for Partial The coded concept Back pain
visit. The RFV coding is performed by professional Match: is a subset of the encoded as
medical record coders in the employ the emergency narrower RFV text. Lumbar pain or
department. These ICD-9 codes then becomes a Typically the sore throat
searchable field in the database. Missing and complaint is coded encoded as
incorrect codes are flagged during the billing process as a diagnosis pharyngitis
and returned to the coders for review. The coders' No Match There isn't an
performance is regularly audited for compliance. obvious
Complete records for two days of ED visits were relationship.
extracted from the hospital information system. ICD- Table 1: Definition of Terms used in the Scoring
9-CM coding of the chief complaint was performed the Type of Match between the Text field, the
in the customary manner by the hospital billing ICD-9-CM Code and the SNOMED codes.
department. Each reason for visit was then further
coded using NHS custom browsing tools in Results
SNOMED-RT. SNOMED-CT first release was made Of 314 cases submitted in the two day period, one did
available March 1, 2002. Using the CLUE® browser not have a RFV entered and was eliminated.
available for this release, the SNOMED codings were Seventeen did not have corresponding ICD-9 codes
updated to create a third data set representing the entered and were removed from analysis. These 17
SNOMED-CT codification of the original RFV. records had not completed the coding process when
These coded records were reviewed and verified by the extract was taken. The distribution of the most
one author (JRC) who is an expert in SNOMED common ICD-9 codes assigned to the cases is listed
coding technology. The text strings from the original in Table 2 and is typical for emergency departnent
RFV entries were then tabulated with ICD-9 and the visits.
SNOMED representations. Each coded text
descriptor was scored, using the scheme in Table 1,

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Of the remaining 296 visits the author (JM) reviewed
the ICD-9, SNOMED-RT and SNOMED-CT 314 total visits
encoding of each RFV. Each entry was judged as an 313 with chief complaint recorded
exact lexical variant, a synonym, a partial match 296 with ICD-9 code recorded
where the concept was either broader than or Type of ICD-9 CM SNOMED- RT SNOMED-CT
narrower than the RFV, or no match as noted in match num num (percent) Num (percent)
Table 1. (percent)
Exact 80 (27%) 213 (72%) 261 (88%)
Thirty of the free text reason for visit entries were Synonym 39 (13%) 44 (15%) 14 (5%)
judged to represent multiple concepts of various Broader 88 (30%) 17 (6%) 5 (2%)
types and two linked SNOMED codes were used to concept
represent these entries. Although, this is the Narrower 49 (17%) 12 (4%) 9 (3%)
mechanism utilized in the NHS problem list system concept
there isn't an analogous ICD-9-CM linking
mechanism. We analyzed these entries to check for No 37 (13%) 6 (2%) 3(1%)
match
the effect. Twenty entries were multiple complaints ________I_ _I

such as cough and fever. Ten entries had a modifier Table 3: Summary Results of Analysis of 296 RFV
added to the complaint. Four of these modifiers codes.
indicated a status such as "possibly" reflective of a
degree of certainty. Three entries had a mechanism of Breaking out the complaints listed above with
injury along with a complaint (Motor vehicle multiple concepts; SNOMED-RT coding was exact
accident with leg pain). Three entries had localization for 28/30; ICD-9CM coding did not match for 8 of
terms (Left, Right). the 30; was broader than for 6 and narrower for 16.
Therefore allowing two ICD-9 codes may have
improved the score for the 16 codes that were of a
narrower focus. At most this would change the exact
match from 80 (27%) to 96 (32%).
789 ~BDOMINAL PAIN .24 17.5%
SNOMED-CT coding of the chief complaint
186 DYSPNEAJRESPIRATORYABN 19 |60 reflected the free text entry more accurately with
786.5 CHEST PAIN 18 5.6% 88% of the entries judged an exact match.
729.5 PAIN IN LIMB 17 15.3%
............................ ......................................................................................................................................... ........................... ...................... Discussion
780.6 FEVER 18 5.0% The distribution of cases noted in Table 2 is typical
787 NAUSEA AND VOMITING 13 .1% of most emergency departments (12). Proper coding
of the reason for visit should encompass these types
185.9 ACUTE URI NOS 8 2.5% of complaints in detail. This study demonstrates that
SNOMED encoding of the stated RFV is more
T9A PAIN INJOINT 8 2.5% precise than the current ICD-9 coding. The
z.

184 iHEADACHE SNOMED-RT coding provided an exact match or

synonym for the reason for visit for 88% of the cases
88.2 COUGH 12.5% Use of SNOMED-CT improved the match to 93%.
58.3 ATTEN-SURG DRESSNG/SUTUR 7 2.2% The standard ICD-9 coding matched only 40% of the
complaints.
379.9 EYE DISORDERS NOS 7 .2% There were a number of consistent flaws in the ICD-9
388.7 OTALGIA* 7
,............................ ....... .............................. ..................... ....................... .. ..... ..................................... ....... ..........................
2.2% coding that were dealt with by the SNOMED coding.
.................. .........
For example there isn't an ICD9-CM code for flank
724.5 BACKACHE NOS .1.9%/O pain so renal colic patients have their chief complaint
780.4 DIZZINESS AND GIDDINESS 5 1.6% coded as "ABDMNAL PAIN OTH SPCF ST"
(789.09). For general gastro-intestinal symptoms the
Table 2: Top fifteen ICD-9 CM codes assigned to ICD-9-CM code is 787.9. In order to specify
the RFV and their frequency. diarrheal symptoms alone the code becomes 787.91.
Since our coders are performing this service for
billing to generate an APC code rather than
surveillance reasons they code the more general term.
This may be a source of reduced quality in the ICD-9

501
coding. The ICD-9 code is often a diagnosis rather
than a symptom. For instance Sore throat is coded as
"ACUTE PHARYNGITIS" (462). Encoding of a
chief complaint of rash seemed particularly
problematic and was sometimes coded as nonspecific
skin eruption (782.1), as Varicella (059.0) or as
Urticaria (708.9). Coding the RFV involves access to
the entire emergency department record. Therefore
the coders may alter their coding of the chief
complaint for cases where the chief complaint given
to the triage nurse differs from the computerized
entry.
The emergency department does not utilize the
existing central diagnosis and problem list coding
system at Nebraska Health System (NHS). Free text
entries entered during the registration process should
therefore not be biased by pre-existing codified
language from NHS. As noted in the introduction,
this study is a step in the process of incorporating
reason for visit coding into the existing NHS standard
terminology.
SNOMED is a compositional coding scheme by
design. We were purposefully sparing in using the
compositional features since the billing department
personnel were not instructed to deliver multiple
ICD-9-CM codes, creating an unfair comparison.
Although the ICD-9 encoding may have improved
with the use of multiple codes our assessment is that
this would not have changed the nature of the results.
In fact, local statutes - such as legislation in
Massachusetts - allows only one text entry for the
reason for visit for each emergency department visit
and at this time there is no provision for the use of
multiple ICD-9 codes to describe the reason for visit.
To assess the issue of imnpact, we performed a
separate analysis of those RFV statements that were
compound complaints. If multiple ICD-9 codes were
utilized then the 20 complaints with multiple
concepts may be better coded even though ICD-9-
CM does not contain modifiers for localization or
status. We found the maximum improvement in ICD-
9 coding would be 5%.
This retrospective study involved an analysis of
existing methodologies for coding patients' stated
reason for visit to the emergency department. The
ICD-9 coding is conducted by the hospital coding
department during the billing process. As such the
ICD-9 codes are not utilized for surveillance at this
time. The SNOMED coding that we employed was
created using a user interface currently used
throughout NHS by clinical and clerical personnel.
Our studies have shown that this interface is accurate
and reliable for capturing clinical concepts.
Although the procedures are creating the coding
502
records were fundamentally different and could
represent a bias, both schemes are currently used by
department clerical personnel. Rating of the quality
of concept matching was performed by only one
reviewer and thus inter-rater reliability was not
assessed and could also represent a source of bias.
We believe that improving standardization of reason
for visit coding is a necessary first step for automated
surveillance systems. It is also a path to improved
decision support and quality improvement in the ED
and health care enterprise. In this paper we
demonstrated that SNOMED, and in particular
SNOMED CT, can encode the reason for visit in a
more accurate and granular fashion than the ICD-9-
CM coding now sanctioned nationally. It should be
strongly considered as a better system to standardize
and report patient reason for visit.
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