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EZCodes: A diagnostic terminology as the foundational step of quality for the
dental profession
Kalenderian-Groenewegen, E.
Publication date 2013
Link to publication
Citation for published version (APA):
Kalenderian-Groenewegen, E. (2013). EZCodes: A diagnostic terminology as the foundational step of quality for the dental profession.
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C
HAPTER
2
Standardized Dental Diagnostic Codes Are a Fundamental
Public Health Tool
E. Kalenderian*1, R. Ramoni*2, A. AbdulRahiman1, O. Tokede1, J.M. White3, M.F. Walji4, A.J. Feilzer5
1 Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, MA, USA
2 Center for Biomedical Informatics, Harvard Medical School, Boston, MA, USA 3
Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California, San Francisco, CA, USA
4
Department of Diagnostic and Biomedical Sciences, University of Texas Health Science Center School of Dentistry at Houston, Houston, TX, USA
5 Academic Centre for Dentistry Amsterdam (ACTA) University of Amsterdam and
VU University, Amsterdam, The Netherlands
Abstract
Public health efforts in medicine have long benefited from the International Classification of Disease (ICD), which was adopted in 1900 as an international standard for describing diagnosis. ICD underpins core public health activities – including the analysis of the general health situation of population groups, monitoring the incidence and prevalence of diseases, classifying diseases, enabling storage and retrieval of diagnostic information for epidemiological and quality purposes, and resource allocation decision making by countries. Dental public health and quality improvement activities have not enjoyed the same benefits of ICD as medicine has due to the limited representation of oral health diagnoses in ICD. The advent of electronic health records (EHRs) has served as a catalyst to fill this knowledge representation gap in dentistry, and standardized dental diagnostic terminologies are in their early days of broader adoption. Within the clinical setting, dental practitioners are key stakeholders in the consistent documentation of oral health diagnoses: documentation of ICD diagnoses in medicine is nearly ubiquitous in part because medical billing required documentation of diagnosis. In the dental setting, where documentation of diagnosis is not currently a requirement for billing, practitioners perceive both motivations for and barriers against the adoption and use of this foundational population health tool.
Introduction
In medicine, the International Classification of Diseases (ICD)1 underpins core public health and health services research activities – including the analysis of the general health situation of population groups, monitoring the incidence and prevalence of diseases, classifying diseases, enabling storage and retrieval of diagnostic information for epidemiological and quality purposes, and resource allocation decision making by countries.5 Israel said it well: “A major purpose for gathering descriptive
statistics is to allow comparisons of data over time and among different places. In the case of public health it has been particularly important to make such comparisons utilizing diagnostic information. Without a standard measuring tool which remains fixed for periods of time and which is applied uniformly from place to place, meaningful comparative analyses of diagnostic information would not be possible.”2
In dental public health, diagnostic terms are an underutilized but powerful tool. Diagnostic terms would allow epidemiologists to consistently evaluate disease patterns, treatment patterns, and disease outcomes; health services researchers could use the terms to study risk-adjusted, cross-sectional, and temporal variations in access to healthcare, healthcare quality, costs of care, disparities, and treatment effectiveness.3 Further, being able to capture information about diagnoses in a standardized way is essential to compare outcomes of varying treatments of the same diagnosis (evidence-based care); to compare the trajectory of a patient with a given diagnosis relative to the population with the same diagnosis; to enhance communication with the patient; to better tailor care to diagnosis; to more efficiently audit the appropriateness of a treatment for a given diagnosis; to determine the cost-effectiveness of treatments for a given diagnosis; and to report, compile, and compare data consistently. One of the reasons that dental public health has not been able to take advantage of standardized dental diagnostic terms is that ICD has not had sufficiently broad coverage of specific oral health diagnoses.4 In the absence of terms describing specific diagnoses, one must often resort to selecting catch-all terms to capture those diagnoses ‘not otherwise specified.’ Recognizing the importance of specific diagnostic terms to clinical care and public health, the EZCodes dental diagnostic terminology was created in 2009 and since then has undergone two revisions. Today, 15 dental academic centers in the United States and Europe; as well as Willamette Dental Group, a set of 54 practices in the Pacific Northwest of the United States, are benefiting from this shared diagnostic terminology.
For an explanation of the definitions used throughout this paper, please see Box 1.
History of Standardized Diagnostic Terminologies
While standardized diagnostic terminologies are now an integral part of medical care, their development and acceptance had many false starts, beginning 250 years ago. In 1763, François Bossier de Lacroix (aka Sauvages) published Nosologia
methodica the first published classification system of diseases,5 inspired by the classification of plants. Twenty-two years later, the charismatic William Cullen (1710-1790) published his own classification of disease under the title Synopsis nosologiae
methodicae: Cullen’s classification was the most broadly used in the early 1800s. In
1837, William Farr (1807-1883), the first medical statistician in the General Register Office for England and Wales, found that Cullen’s classification did not meet his needs because it had not kept up with advances in the understanding of disease and it fragmented diagnoses into too many categories to be useful from a statistical point of view. In the first Annual Report of the Registrar General,6 Farr outlined the principles that should underpin a statistical classification of disease and advocated for the adoption of a uniform classification:
“The advantages of a uniform statistical nomenclature, however imperfect, are so obvious, that it is surprising no attention has been paid to its enforcement in Bills of Mortality. Each disease has, in many instances, been denoted by three or four terms, and each term has been applied to as many different diseases: vague, inconvenient names have been employed, or complications have been registered instead of primary diseases. The nomenclature is of as much importance in this department of inquiry as weights and measures in the physical sciences, and should be settled without delay.”
In 1853, Farr and Marc d’Espine, of Geneva, were called upon by the first International Statistical Congress to create an internationally applicable uniform classification of causes of death. Alas, this classification and its subsequent revisions were never universally accepted. The first generally adopted set of standardized diagnoses was the Bertillon Classification of Causes of Death, created in 1893 by Jacques Bertillon under the auspices of the International Statistical Institute, the successor to the Congress. In 1898, the American Public Health Association (APHA) recommended the adoption of the Bertillon Classification by registrars of Canada, Mexico, and the United States of America. The APHA also recommended the implementation of a revision process every decade. Consequently, the first
international conference to revise the International Classification of Diseases (ICD) or International List of Causes of Death, as it was then called, convened in 1900. In 1948, the World Health Organization (WHO) took responsibility for the now renamed International Classification of Diseases, Injuries, and Causes of Death with the sixth edition.
Development of a Standard
Standards are greatly beneficial for human societies, which is perfectly represented by the International System (SI) or metric system of weights and measures. Allowing every country or state to develop its own system would result in enormous redundancy and loss in productivity.
There are four primary paths for standards development:
(1) Consortium (Ad hoc): A group of interested people and organizations agree on an informal standard specification, which is accepted as a standard through this mutual agreement.
(2) De facto: One stakeholder controls a large enough market share to make its product the standard.
(3) Government mandate (de jure standard): A government agency, such as the National Institute for Standards and Technology (NIST) develops a standard and legislates its use. A de jure standard can be enacted by law or regulation, i.e. the Health and Insurance Portability and Accountability Act (HIPAA) of 1996 mandated how medical information is shared. As a result the Accredited Standards Committee X12, accredited by the American National Standards Institute (ANSI) developed Form 5010 for the electronic transaction of dental claims for Medicaid patients.7
(4) Consensus: A set of volunteer stakeholder representatives participate in an open process to create a standard. Most health-care standards are produced by this method. An example is the Health Level 7 (HL7) standard for the interchange of clinical data.8 Sometimes specific organizations are formed to create standards, i.e. American Society for Testing Material (ASTM).9
On its path to maturity, a standard will generally go through several versions. The first attempts at implementation are often challenging as stakeholders may have different interpretations of the standard and as areas not addressed by the standard are identified. As the standard evolves to address early challenges, there must be attention paid to backward compatibility. During the course of maturation, an implementation guide may be produced to help new adopters benefit from the experience of early adopters. As illustrated in the History of Standardized Diagnostic Terminologies
section, early acceptance and adoption rate are critical to the success of a standard. Accredited standards bodies, governments, other major stakeholders, and the marketplace may influence this process. In the case of a standardized dental diagnostic terminology, these parties would include payors (insurance companies), government agencies, academic institutions, dental electronic health record vendors, professional organizations (responsible for the oversight of the profession), dental providers and care team members, and informed patients (consumers). After the early stage, the maintenance and promulgation of the standard are essential to ensure widespread availability and continued value. It is also important to have agreement among stakeholders about how rules will be enforced in order to assure adherence to the standard (conformance).
In some cases, standards are developed by organizations that required the standard to execute their principal functions; in others, coalitions are formed for the purpose of developing a particular standard. In addition, there are standards organizations whose sole purpose is to develop and promote standards.10 In the US, the American National Standards Institute (ANSI) administers the only government-recognized system for establishing American National Standards. ANSI does not create standards; instead, it guides standards developers and users to reach consensus. ANSI also represents U.S. interests in international standardization, serving as the U.S. voting representative on the International Standards Organization (ISO). The ISO was established as a membership organization to provide a focal point for all international standards with one member for each country. Its Vienna agreement describes how disagreements between different standards should be handled.11
With the development of the European Union, the European Committee for Standardization (Comité Européen de Normalisation, CEN) was developed as the major provider of European Standards and technical specifications. Just as ISO, CEN is a membership organization and counts thirty-three countries as its members. CEN signed the Vienna agreement with ISO in 1991.
ISO and CEN follow a strict workflow, which can take years, in order to arrive at an international standard.12 Adding new items to an existing standard or adopting a standard from another organization may fall under the “Fast-track procedure” in which “a document with a certain degree of maturity is available at the start of a standardization project.” In this case the document can be submitted directly for approval as a Draft International Standard (DIS) or final DIS (FDIS, if developed by an international standardizing body recognized by the ISO Council), skipping many stages of standard development.13 ISO approval of standards is important since a number of countries have laws that require the use of ISO standards if they exist.
Table 2.1: Standards Development Process
Development Methods9
De facto method: A group of interested people and organizations agree on an informal standard specification through mutual agreement. These "marketplace" standards often are developed more quickly than standards developed in a more formal process.
Consortia (Ad-hoc) method: Companies agree to work together to solve a specific market need. Membership often requires a substantial financial contribution.
Government-mandate (de jure) method: A government agency creates a standard and legislates its use.
Consensus method: Industry professionals from both the public and private sectors work in an open process to create a standard. The voluntary process requires full cooperation by all parties and depends upon data gathering and compromises among a diverse range of stakeholders.
Phases of Standard Maturation35
Identification stage: Awareness that a standard is needed for some domain and that there is technology that can support such a standard.
Conceptualization stage: The characteristics of a standard are defined, e.g., scope, purpose, format.
Discussion stage: An outline of content, critical issues, and timeline are created. The author states that basic concepts are usually heated topics of discussion.
Writing of a draft standard: Written by a small group of vendors. An open policy is followed with an open balloting process.
Comments and recommendations invited.
Critical Success Factors
Backward compatibility: allows the use of previous versions of the standard. Early implementation
Acceptance
Rate of Implementation
Conformance: compliance with the standard and usually includes specific agreements among users of the standard, who affirm that specific rules will be followed.
Certification: a neutral body certifies that a vendor’s product complies and conforms to the standard.
Current Representation of Oral Health Conditions in Standardized Diagnostic Terminologies
Diseases of the oral cavity were codified in the early revisions of ICD. However, ICD codes for oral diseases were not sufficiently subdivided and were difficult to use due to the scattered arrangement of codes throughout the ICD volume. Consequently, the ICD-DA, or the Application of the International Classification of Diseases to Dentistry and Stomatology was added at the time of the Eighth revision of the ICD in 1965. Despite these efforts, ICD’s coverage of oral and dental diagnoses remains insufficient.13-15 E.g. ICD does not distinguish between primary and recurrent caries, the two stages of enamel caries or three levels of dentinal caries. ICD does also not include diagnoses that encompass the need for tooth restoration or tooth replacement, such as a biologically unacceptable restoration.16 In the U.S. the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) developed the ICD-10 Clinical Modification (ICD-10-CM) for classifying diagnoses, medical coding and reporting for billing purposes. The ICD-10-CM is based on the ICD-10, the statistical classification of disease published by the World Health Organization (WHO), which replaces ICD-9. There are approximately 68,000 ICD–10–CM codes.17 There is more information and detail within these codes than its American predecessor ICD–9–CM. As such, the oral health component of ICD-10-CM is a bit more granular that ICD 10.
SNOMED was developed in 1965 by the College of American Pathologists (CAP) as SNOP (Systematized Nomenclature of Pathology), and later extended into other medical fields. In 1999, through collaboration with the National Health Service (NHS) SNOMED Clinical Terms (SNOMED CT) was developed. SNOMED CT is a comprehensive, multilingual clinical healthcare terminology for use in the EHR. Developed as a reference terminology, it contains more than 311,000 unique terms organized into hierarchies. In 2007 the International Health Terminology Standards Development Organization (IHTSDO) acquired SNOMED CT (and the rights to all older versions). IHTSDO, a healthcare standard development organization (SDO), is similarly to ISO and CEN a membership organization, and has eighteen countries participating as members as of 2012.18 SNODENT, a Systematized Nomenclature for Dentistry, was devised by the American Dental Association (ADA) in the early 1990’s (DIOC 2009). In 1998, the ADA entered into an agreement with CAP, licensing them to incorporating SNODENT into SNOMED. In 2012, SNODENT was incorporated into the SNOMED CT medical code set, thanks to a licensing agreement with IHTSDO. SNODENT is composed of diagnoses, signs, symptoms and complaints and
currently includes over 7700 terms. Up until its inclusion into SNOMED CT, SNODENT was only available by license and was maintained by the ADA’s Advisory Committee on Dental Electronic Nomenclature, Indexing and Classification (ACODENIC), a group comprised of representatives from each recognized dental specialty. As a result SNODENT has not yet been implemented in the dental profession.
Table 2.2: Selected Diagnostic Terminologies Relevant to Oral Health
Terminology Focus
International Classification of Diseases (ICD)
First published in 1893 and revised at 10-year intervals. The coding system consists of a core classification of three digit codes that are the minimum required to report mortality statistics to the WHO. A fourth digit provides an additional level of detail. ICD-9-CM is compatible with ICD-9 and provides extra levels of detail in many places by adding fourth-digit and fifth-digit codes. Most of the diagnoses in the United States are coded in ICD-9-CM allowing
compliance with international treaty (by conversion to ICD-9) and supporting billing requirements.
Systemized Nomenclature of Human and Veterinary Medicine Clinical Terms (SNOMED-CT)
In 1996, SNOMED changed from a multi-axial structure to a more logic-based structure called Reference Terminology.36,
37
In 1999, the College of American Pathologists and the NHS merged their products into SNOMED-CT38 containing terms for 344,000 concepts. Despite the broad coverage of SNOMED-CT, it continues to allow users to create new ad hoc terms through post coordination of existing terms. SNODENT Since the early 1990s, the American Dental Association
(ADA) has led the creation of SNODENT, the Systematized Nomenclature for Dentistry. SNODENT is composed of diagnoses, signs, symptoms and complaints, and currently includes over 7,700 terms. However, SNODENT is not available for use by the general practitioner or any dental schools. In June 2012 The ADA signed a licensing agreement with the International Health Terminology Standards Development Organization (IHTSDO) to allow for the integration of SNODENT into the SNOMED CT medical code set.
The EZCodes Dental Diagnostic Terminology
To meet the need for a comprehensive yet concise set of dental diagnostic terms, a happy medium between ICD sparseness and SNOMED enormousness, an academic workgroup came together in 2009 to create and implement the EZCodes dental diagnostic terminology. This work was funded by a National Institutes of Health grant R01 DE021051. The team is made up of dental clinicians/faculty, epidemiologists, informaticians and cognitive scientists from academic institutions in the US and Europe led by the Harvard School of Dental Medicine (Boston, Massachusetts). The workgroup charge and guiding principles in the creation and revision of the EZCodes dental diagnostic terminology have been published.4 Briefly they are based on the belief that diagnosis should precede treatment, that diagnoses should be documented consistently and in a standardized way, and that structured documentation of a diagnosis in an electronic health record should be easy and error free.
Since 2009, the EZCodes terminology has undergone 2 major revisions and has been adopted by 15 academic dental institutions in the U.S. and Europe, one hospital-based academic dental clinic and one large group practice with 54 clinics in three states, with additional institutions in line to begin using it in the near future. The EZCodes dental diagnostic terms have been validated16 and mapped to SNOMED, ICD 9, ICD 10 and ICD 10-CM, as well as the American and Dutch treatment coding classifications (CDT19 and UPT,20 respectively). These mappings were performed to assist in the administrative functions associated with payment and to keep pace with the American requirements for EHR functionality.21 The EZCodes’ usability, utilization, relevance and implications for dental education have been reported earlier.22-25 The EZCodes have already been a boon to health services research, as the standardization of diagnosis has enabled the pooling of clinical data across four dental institutions representing over one million patient visits in the United States.
The EZCodes were built upon existing best practices. EZCodes has incorporated the description and sub-classification of periodontal terms following the American Academy of Periodontology format.26 This format tackles the biggest challenges of previous classification attempts27-29 unique to the classification of periodontal disease such as the lack of sufficient knowledge to separate truly different diseases (disease heterogeneity) from differences in the presentation/severity of the same disease (phenotypic variation). It also adopted the recommendations of the American Board of Endodontics30 to classify diagnosis in two dimensions – symptomaticity and reversibility – both of which have implications for the clinical
management of patient presentation. The EZCodes terminology includes the American Academy of Pediatric Dentistry’s caries risk assessment procedure for assessing caries risk. This is especially important in informing a clinician whether or not to institute specific interventions. Following the principles of the International Caries Detection and Assessment System (ICDAS), the EZCodes dental diagnostic terminology follows best practices in caries diagnoses, which require an indication of the extent of decay. Lastly, the 2012 version of the EZCodes terminology contains terms relating to removable prosthodontics – an important sub-discipline in dentistry. These terms were the fifth most commonly utilized23 and are not available in ICD 10-CM, although analogous terms are available in ICD10-CM for complications/failures of cardiac and joint prostheses.
With 1355 terms, the EZCodes dental diagnostic terminology is developed as an interface terminology with SNOMED CT as its reference terminology. An interface terminology is a “bridge” which allows the user to describe the diagnosis using natural language, which is then mapped to the reference terminology using formal language. Once medical/dental information is captured with the interface terminology, it is mapped on the backend to ICD and SNOMED CT, the two relevant reference terminologies. In the context of an EHR, the usability of an interface refers to how easy it is for providers to interact with the terminology as represented in the EHR.31 Usability increases when the terminology is enhanced with attributes that improve the efficiency of selecting terms.32,33 These attributes include (1) presence of additional relevant medical/dental information (providing other more general facts about a concept, which is called assertional knowledge: e.g. when hovering over the diagnostic term “lichen planus”, a box will pop up that includes the following information: Oral lichen planus (OLP); reticular form (Wickham’s striae) – often bilateral and asymptomatic, bullous form, erosive forms (Atrophic LP & Ulcerative LP) – symptomatic, multiple areas of the mouth; affect middle age adults, female/male ratio is 3:2, rare in children.) (2) presence of adequate synonyms; (3) a balance between enough terms to pick from a list (pre-coordination) and the ability for the provider to create new terms by adding two or more terms together while using the electronic health record (post-coordination); and (4) mapping to terminologies having formal concept representations, such as ICD and SNOMED. The EZCodes terminology contains a fair quantity of these attributes with concrete steps to expand in this area over the next revisions. Specifically, the EZCodes include a full set of synonyms and descriptions for each term as part of the 2013 EZCodes terminology version.
Box 2.2 documents EZCodes terms that are currently not represented in ICD-10-CM and a suggested place they could be inserted. The list is longer for ICD 10, as that is a
less granular terminology. Although SNOMED CT is the reference terminology for the EZCodes, a number of EZCodes terms were developed that were not represented in SNOMED CT (mainly the removable partial denture terms as displayed in Box 2.2). We have successfully been able to submit those to IHTSDO for inclusion into SNOMED CT.
Barriers to the Adoption of a Standardized Diagnostic Terminology in Dentistry
In Fall 2012, three years after the implementation of the EZCodes, the researchers held a national conference to discuss the barriers against the broad adoption of standardized dental diagnostic terms. Participants included representatives from electronic health record vendors, insurance companies, government, dental professional organizations, dental academic centers and large dental group practices. Common concerns about implementing standardized dental diagnostic terms centered on cultural barriers, ease of use, return on investment, and technical issues, in particular:
Cultural inertia is a barrier to adoption. Moving to documenting diagnosis in standardized terms would represent a significant cultural change in a profession that tends to focus on procedures.
Fear of a loss of autonomy is a barrier to adoption. Some dentists may fear that the implementation of dental diagnostic terms will lead to more rigorous and inflexible oversight of the appropriateness of care, which may lead to the denial of insurance claims.
Fear of usability problems. If a standardized dental diagnostic terminology is difficult to use or disrupts the workflow, this will be a huge barrier to adoption. If terms are implemented in EHRs, users must be able to enter data with a minimum of effort.
Fear of adopting a terminology that would become outmoded. Given that dentistry has not, to date, widely agreed upon a single standardized diagnostic terminology, there is a hesitance to adopt a terminology that may not end up being broadly adopted.
Unclear utility. From the individual practitioner perspective, it may not be clear how using standardized diagnostic terms will improve their practice.
Not required for insurance reimbursement. Because they are not yet required for billing purposes, some dentists may not see the value in using standardized dental diagnostic terms.
Technological barriers to adoption. It would be a barrier to adoption if the EHR or billing system does not come pre-loaded with standardized dental diagnostic terms. Dentists who are still in paper-based settings may feel that standardized terms do not translate well to paper.
Relevance to Dental Public Health
There are great public health benefits to standardize the documentation of diagnoses in dentistry as enumerated and discussed earlier. To do so effectively, a basic requirement must be that all participants follow a standard, mainly because it “permits two or more disassociated people to work in some cooperative way”.34 In a
world with multiple code sets, the one set of terms that will be universally accepted is the one that integrates into electronic health systems in a way that is intuitive and usable for the provider, and cross-maps to standards like ICD-10 and SNOMED CT.
An early example is the development of the first dental data repository through a grant of the National Library of Medicine (NLM G08LM010075). Four American dental schools pooled structured de-identified clinical EHR data, including diagnosis in the form of EZCodes terms. This database now holds one million unique patients with, for the first time, information about diagnosis and treatment. It thus allows for the development of relevant research questions that can start exploring questions such as:
How often do crowns fracture/fall off due to inadequate preparation (inadequate crown length or inadequate ferrule)?
Does documenting a diagnosis of caries risk assessment impact the rate of caries over time?
Does the incidence of peri-implantitis differ by region, age?
Does the treatment for irreversible pulpitis differ by geographic region, by age?
Conclusions
Our medical counterparts have been capturing the causes of death for centuries. In 21st century dentistry, we do not capture why a tooth becomes non-vital or why teeth are extracted, much to the detriment of public health and quality improvement efforts. The EZCodes dental diagnostic terminology interfaces to the rich yet complex characterization available in SNODENT, is freely available and is gaining traction both in the United States and internationally. Building incentives to adoption and
overcoming the barriers to the routine use of this standardized dental diagnostic terminology would yield a powerful instrument in the dental public health toolbox.
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40. Clinical Information Modeling Initiative Category:Reference Terminology. 2013.http://informatics.mayo.edu/CIMI/index.php/Category:Reference_Termin ology. Accessed 4/26/2013.
41. Clinical Information Modeling Initiative Category:Precoordinated Concept. 2013.http://informatics.mayo.edu/CIMI/index.php/Category:Precoordinated_Co ncept. Accessed 4/26/2013.
42. Clinical Information Modeling Initiative Category:Postcoordinated Concept. 2012.http://informatics.mayo.edu/CIMI/index.php/Category:Postcoordinated_C oncept. Accessed 4/26/2013.
43. Alarcón R, Sierra G, Bach C. Developing a Definitional Knowledge Extraction System. http://www.upf.edu/pdi/dtf/carme.bach/docums/poloniafinal.pdf. Accessed 4/26/2013.
44. Lievens F, Coetsier P, De Fruyt F, De Maeseneer J. Medical students' personality characteristics and academic performance: a five-factor model perspective. Med Educ 2002;36(11):1050-6.
Box 2.1: Explanation of Terms
Interface Terminology: A set of terms designed to be compatible with the natural
language of the user, used to mediate between a user’s colloquial conceptualizations of concept descriptions and an underlying reference terminology.39
Reference Terminology: A terminology where each term has a codable,
computer-usable definition to support retrieval and data aggregation.40
Usability: The ease (e.g., speed, level of comfort, accuracy) with which its users can
accomplish their intended tasks (e.g., documentation of patient care)31
Pre-coordination: A process by which a concept is defined in terms of two or more
other concepts from a terminology and assigned a unique identifier.41
Post-coordination: A process by which a concept is defined in terms of two or more
other concepts from a terminology, e.g., "leg" plus "has laterality" plus "right" to represent the concept of right leg. A post-coordinated concept does not have a
predefined unique identifier within the given terminology. Post-coordination can avoid the need to create large numbers of predefined concepts within the terminology set, but many systems can only accept pre-coordinated concept, or structural representations of post-coordinated concepts.42
Backward compatibility: Compatibility of a new version of a terminology with
previous versions, usually accomplished through mapping between the new and previous versions.
Conformance: Specific agreements among users of the standard, who affirm that
specific rules will be followed and as such agreeing to compliance to the standard.
Assertional knowledge: explains a term by providing nuance and context without
specifically defining it. It can do so by adding relevant synonyms, associated
diagnoses, common symptoms, usual modifiers, and describing prevalence in a given patient population.31 Assertional knowledge in an interface terminology may be more relevant to clinical users than definitional knowledge.
Definitional knowledge: the author explicitly defines the term43
Synonym: adding a synonym allows for more expressivity and accuracy. Synonyms
include:
alternate phrases (e.g., "dyspnea" and "shortness of breath") acronyms (e.g., SOB for "shortness of breath")
definitional phrases (e.g., "a sensation of not getting enough air during breathing") eponyms (name of a person)
Box 2.2: EZCodes terms currently not in ICD-10-CM
E83.3 Odontohypophosphatasia
K00.5 Agenesis of enamel
K00.5 Enamel dysplasia
K00.6 Deviation in eruption sequence K07.3/K00.6 Ectopic eruption (buccal) K07.3/K00.6 Ectopic eruption (lingual)
K00.6 Eruption sequestrum
K00.2 Supernumerary cusp
K02. Recurrent caries - Enamel
K02. Recurrent caries - DEJ
K02. Recurrent caries - (< 1/2 distance to the pulp) K02. Recurrent caries - (> 1/2 the distance to the pulp) K02. Recurrent caries - (to the pulp)
K02. Rampant caries
K02. Pre-eruptive caries
S02.5 Incomplete tooth fracture
K03.8 Insufficient anatomical crown height K03.8 Insufficient clinical crown length
K03.8 Abfraction
K03.8 Non carious cervical lesion
K03.8 Vertical tooth fracture with pulp involvement
K03.8 Concussion of tooth
Z91.89 Caries risk low
Z91.89 Caries risk medium
Z91.89 Caries risk high
Z91.89 Caries risk extreme
Z91.89 Bacterial challenge low
Z91.89 Bacterial challenge medium
Z91.89 Bacterial challenge high
K04.0 Widened PDL
K04.0 Healthy Periodontium with attachment loss
K05.00 Plaque induced gingival disease without local contributing factors K05.00 Plaque induced gingival disease with local contributing factors
K05. Leukemia associated gingivitis
K05. Puberty associated gingivitis
K05. Gingival lesions-Foreign body reaction K05. Gingivitis associated with Candida
K05. Gingivitis associated with erythema multiforme K05. Gingivitis associated with histoplasmosis K05. Gingivitis associated with lichen planus
K05. Gingival Disease modified by Gingivitis associated with Neisseria gonorrhea K05. Gingivitis associated with pemphigoid
K05. Gingivitis associated with pemphigus vulgaris K05. Gingivitis associated with Treponema pallidum K05. Gingivitis associated with varicella zoster K05. Gingivitis hereditary gingival fibromatosis K05. Gingivitis with linear erythema of fungal origin
K06. Gingival reactions attributable to chewing gum additives K06. Gingival reactions attributable to foods and additives
K06. Gingival reactions attributable to mouth rinses and mouthwashes K06. Gingival reactions attributable to toothpastes and dentifrices
K06.2 Chemical injury - gingiva
K06.2 Physical injury - gingiva
K06.2 Thermal injury - gingiva
K05.5 Refractory Periodontitis
K05.21 Rapidly Progessive Periodontitis K05.22 Prepubertal Periodontitis
K05.22 Post adolescent Periodontitis
K05.3 Periodontitis associated with Acquired neutropenia K05.3 Periodontitis associated with Chediak Higashi syndrome K05.3 Periodontitis associated with Cohen syndrome
K05.3 Periodontitis associated with Down Syndrome
K05.3 Periodontitis associated with Ehlers Danlos syndrome (Types IV and VIII) K05.3 Periodontitis associated with Familial and cyclic neutropenia
K05.3 Periodontitis associated with Glycogen storage disease K05.3 Periodontitis associated with Histocytosis syndrome K05.3 Periodontitis associated with Hypophosphatasia
K05.3 Periodontitis associated with Infantile genetic agranulocytosis K05.3 Periodontitis associated with Leukemias
K05.3 Periodontitis associated with Leukocyte adhesion deficiency syndrome K05.3 Periodontitis associated with Papillon Lefevre syndrome
A69.0 Necrotizing ulcerative periodontitis (NUP)
K05.2 Gingival abscess
K05.2 Pericoronal abscess
K05.5 Combined periodontic-endodontic lesion
K06.8 Abnormal gingival color
K08.8 Decreased vestibular depth
K06. Insufficient biological width
Q87.0 Bilateral Hemifacial microsomia - Left predominant Q87.0 Bilateral Hemifacial microsomia - Right predominant
Q87.0 Hemifacial microsomia
Q87.0 Hemimaxillofacial dysplasia
M27.8 Gardner's syndrome
M27.8 Other giant cell lesions of the jaw
D18.0 Hemangioma of bone
D16.4 Unspecified benign nonodontogenic tumor D16.5 Focal cemento-osseous dysplasia
D16.5 Periapical cemento-osseous dysplasia
K09. Basal cell nevus syndrome
K09.1 Buccal bifurcation cyst
K14.8 Cyst of the Tongue
K09. Focal osteoporotic bone marrow defect K12.2 Infraorbital space infection
K12.2 Ludwig's angina
M62.8 Masseter hypertrophy
K12.2 Masseteric/submasseteric space infection Q36.0 Cleft lip, bilateral - with cleft alveolus Q36.0 Cleft lip, bilateral - without cleft alveolus Q36.1 Cleft lip, median - with cleft alveolus Q36.1 Cleft lip, median - without cleft alveolus Q36.9 Cleft lip, unilateral - with cleft alveolus Q36.9 Cleft lip, unilateral - without cleft alveolus
Q87. Stickler syndrome
K06.1 Drug-induced gingival hyperplasia K06.1 Hormone-modified gingival hyperplasia K06.1 Leukemia-induced gingival hyperplasia K06.8 Ossifying fibroma, peripheral
K05.1 Nonspecific hyperplastic gingivitis
M87.180 Bisphosphonate related osteonecrosis of the jaw (BRONJ) M87.1 Osteonecrosis of the jaw (ONJ)
C08 Central mucoepidermoid carcinoma
C90 Plasma cell neoplasm
K12. Denture Mucositis
J32. Dental structure displaced into sinus
D18.0 Kaposiform hemangioendothelioma
K05.1 Plasma cell gingivitis
K14.3 Strawberry tongue
K11.6 Cystic lesion of salivary gland
K11.8 Hemangioma of salivary gland
K11.3 Parotid gland abscess
K11.3 Submandibular gland abscess
R23 Skin macule
R23 Skin papule
R23 Skin nodule
R23 Skin wheal
J39. Upper airway resistance syndrome
K12.1 Allergic stomatitis
K13.2 Focal hyperkeratosis
K13.2 Hereditary benign intraepithelial dyskeratosis
K13. Snuff dipper's pouch
G50. Atypical neuralgia
K11.7 Post-irradiation xerostomia
R43 Radiation taste impairment
G44./G45. Eagle's syndrome
T75.89 Electrogalvanism
K00. Erupting tooth
F41. Dental anxiety or fear or concerns
F41. Frankl behavior rating scale 1 - completely uncooperative F41. Frankl behavior rating scale 2 - uncooperative, very reluctant
F41. Frankl behavior rating scale 3 - cooperative, but somewhat reluctant/shy F41. Frankl behavior rating scale 4 - completely cooperative
F98.8 Harmful oral hygiene habits
F98.8 Jaw jutting
F98.8 Lip licking
F98.8 Lip sucking
F98.8 Object biting
F98.8 Tongue thrusting
K07.2 End-to-end molar relationship
M26.2 Mesial-step primary occlusion
M26.2 Flush terminal plane primary occlusion M26.2 Distal-step primary occlusion
M26.3 Ectopic eruption (labial) M26.3 Ectopic eruption (lingual)
M26.4 Nonfunctional tooth
K08. Adhesive failure (tooth/material failure) K08. Cohesive failure (material/material failure) K08. Chipped/fractured veneering material K08. Loss of implant access hole filling
K08. Implant screw fracture
K08. Implant screw loosening
S02.5 Enamel and Dentine fracture
S02.5 Enamel and Dentine fracture - vertical without pulp involvement S02.5 Enamel and Dentine fracture - vertical with pulp involvement S02.5 Horizontal root fracture (cervical)
S02.5 Horizontal root fracture (mid-root) S02.5 Horizontal root fracture (apical) S02.5 Vertical root fracture
K07.6 Spontaneous TMJ condylar dislocation M62.4 Myostatic masticatory muscle contracture M62.4 Myofibrotic masticatory muscle contracture
M62.83 Masticatory muscle myospasm
M62.8 Localized masticatory muscle soreness
M79.2 Centrally mediated myalgia
S03.4 Acute TMJ trauma
M26.69 Retrodiscitis
M26.69 Stylomandibular ligament inflammation
M26.69 Temporal tendonitis
M79.1 Myogenous TMD pain (“Tendomyalgia”) ≤ 6 months M79.1 Myogenous TMD pain (“Tendomyalgia”) > 6 months R25.2 Limited mouth opening with a myogenous origin M26.69 Other internal derangements of the TMJ
T85.6 Complete denture loss of occlusal relationship T85.6 Complete denture loss of retention
T85.6 Complete denture loss of stability T85.6 Complete denture loss of tooth
T85.6 Complete denture loss of VDO, Vertical Dimension of Occlusion
T85.6 Complete denture increased VDO
T85.6 Complete denture not esthetic
T85.6 Defective mandibular complete denture T85.6 Defective mandibular overdenture T85.6 Defective maxillary complete denture T85.6 Defective maxillary overdenture
T85.6 Excessive pressure/over extension complete denture
T85.6 Fractured complete denture
T85.6 Defective mandibular removable over partial denture T85.6 Defective mandibular removable partial denture T85.6 Defective maxillary removable over partial denture T85.6 Defective maxillary removable partial denture
T85.6 Excessive pressure/over extension removable partial denture T85.6 Fractured removable partial denture
K08.4 Partially edentulous mandible K08.4 Partially edentulous maxilla
T85.6 Removable partial denture broken clasp
T85.6 Removable partial denture inadequate coverage - area T85.6 Removable partial denture inadequate coverage - full mouth T85.6 Removable partial denture loss of occlusal relationship T85.6 Removable partial denture loss of retention
T85.6 Removable partial denture loss of stability T85.6 Removable partial denture loss of tooth
T85.6 Removable partial denture increased VDO, Vertical Dimension of Occlusion T85.6 Removable partial denture not esthetic
