In the operating room, nurses and doctors rely on codes with good reason: It’s a lot cleaner to input “45381" than “Flexible colonoscopy with directed submucosal injection, any substance". Coding conditions and procedures is the best way to uniformly collect data. The number 45379 can be catalogued, sorted and tracked, easily and accurately, while hard-to-spell words like “colonoscopy” and “submucosal” can easily be entered incorrectly and lost in a sea of words within electronic health records (EHR).

Why do we have so many different sets of codes in the OR?

Codes have the power to simplify data collection and dissemination. But, because there are multiple codes in play in our ORs, they can also confuse us.

Depending on where the code is coming from (patient referral in or outside your health care facility) and what the code is used for, it may match any one of these medical code sets:

1. CPT® - Data from CPT (Current Procedural Terminology) codes is shared with the government and insurance companies. CPT codes are maintained by the American Medical Association and typically updated once per year. CPT codes are used for claims processing and billing purposes.
2. ICD-10-PCS - ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th Revision) has CM (Clinical Modification) and PCS (Procedure Coding System) subsets, maintained by the World Health Organization. These codes enable healthcare providers to input data later used to cull major healthcare analytics and create benchmarks for better patient outcomes.
3. SNOMED-CT® - Systemized Nomenclature of Medicine – Clinical Terms (SNOMED-CT) is an international and multilingual set of clinical healthcare terminology that can be used globally in EHRs. It is maintained by the International Health Terminology Standards Development Organization (IHTSDO) and updated twice per year.

If your EHR is churning on multiple code sets, confusion can ensue, and your risks and costs increase.

The AORN Syntegrity® Standardized Surgical Procedure list can be integrated with most EHR systems – with minimal support from your information technology (IT) team. It provides access to more than 2,900 world class surgical procedures, all of which are referenced to CPT, ICD-10-PCS and SNOMED-CT medical codes.

This cross-referencing reduces confusion and increases the speed with which your OR team can identify and execute surgical procedures. The results? Nurses can work efficiently and spend more time taking care of patients.

This OR patient safety solution is updated quarterly to stay inline with all three major code sets. Schedule a free consultation to learn how AORN Syntegrity can help your team streamline procedure scheduling, improve patient safety and save money.