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In general terms — with some exceptions — medical coders use the three code sets when submitting medical claims to report the following: CPT ®  codes:  What the provider  did HCPCS codes:  What the provider  used ICD-10-CM:  Why  the provider 'did' and 'used'.  An  example can make it more clear.  If a urologist diagnoses a patient with bladder cancer and performs a bladder instillation of 1 mg of Bacillus Calmette-Guerin (BCG) to treat the tumor, the medical coder might assign: CPT ®  codes ( did ):  51720  Bladder instillation of anticarcinogenic agent (including retention time) HCPCS Level II code ( used ):  J9030  BCG live intravesical instillation, 1mg ICD-10-CM code ( why ):  C67.9  Malignant neoplasm of bladder, unspecified A. HCSPCS level I and II HCPCS Level I: Current Procedural Terminology, Fourth Edition: Procedures and services provided by physicians and other allied healthcare professional...

A.  Since SNOMED CT is a clinical terminology, it is inherently more appropriate for clinical documentation of diagnoses in an EHR than other terminologies or classifications, such as ICD-9. SNOMED CT is not necessarily superior to ICD-9 or 10; they were created for different reasons. Using a standard medical terminology to capture and store diagnosis (and other medical terms) in an EHR ensures consistent expression of similar concepts which can be leveraged for decision support, reporting, and analytics, while ensuring consistent communication across the healthcare community — all of which leads to better care. Due to its use in medical billing, ICD is largely familiar to healthcare providers and was incorporated into many EHRs as a way to capture diagnoses. The primary limitation with this strategy is the lack of clinical coverage available in ICD-9, which contains approximately 14,000 unique concepts. SNOMED CT, on the other hand, has more than 100,000 unique concepts and many m...