The College of American Pathologists has developed the Systematized Nomenclature of Medicine, Reference Terminology (SNOMED RT) for use in the electronic health record. SNOMED RT is more granular and provides more detail than traditional codes. More than 190,000 terms with associated concepts and relationships help document information on: diagnoses; procedures (including all clinical actions); social context; causes of injury or disease; anatomy; drugs, medical specialties; and demographics. SNOMED codes also support findings, conclusions and assessments (such as a patient’s mental state or functional capabilities).

CPT and ICD codes are used in health records for billing purposes, but many healthcare enterprises are not yet using a clinical reference terminology in addition to these billing codes. Using a clinical reference terminology with billing codes may actually increase reimbursement because the physician can document a more complete picture of a patient’s condition and the procedures used to treat him or her, and thus select the most appropriate CPT or ICD code.

SNOMED RT complements standard billing codes by providing a more detailed description of the patient encounter with consistent coding for clinical terms and concepts. The hierarchies and relationships of SNOMED RT expand functionality for complete and consistent retrieval of information, making data more accessible wherever and whenever it is needed.