The promise and the problem of data: Four questions for healthcare leaders

The promise and the problem of data: Four questions for healthcare leaders How would you rate the data integrity of your EHR? Does your data support compliance? Is your data improving quality and patient safety? Is your data protecting your revenue? Executive summary Health care in the United States today is under a very public microscope. Healthcare costs consume a significant portion of the GDP, yet outcomes often rank lower than other nations that spend less. 1 At the center of this public scrutiny are healthcare providers, who live in an era of unprecedented reform and regulation that require them to adopt information technology (IT), specifically electronic health record systems (EHRs). Like other paper-based media, the paper medical record is disappearing from the healthcare scene at every level, from the large integrated networks to even small physician practices, replaced by EHRs of all sizes and complexities. These EHRs have in turn created volumes of data on a scale never seen before. In 2007, researchers at the RAND Corporation forecasted that health information technology (HIT) could save the U.S. $81 billion annually. The American Recovery and Reinvestment Act (ARRA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act followed in 2009 as the federal government offered financial incentives for providers to adopt EHRs and use them in meaningful ways. The government s goal with meaningful use (MU) was to promote patient safety and interoperability between and within healthcare systems. Hospitals large and small have implemented EHRs and received incentive payments. 2 Fast forward to January 2013: RAND issued a press release announcing a new study that essentially admits the promise of healthcare IT has not yet been realized. The study cites legitimate reasons why: sluggish adoption of health IT systems, coupled with the choice of systems that are neither interoperable nor easy to use; and the failure of health care providers and institutions to reengineer care processes to reap the full benefits of health IT. 3 Industry observers acknowledge that EHR technology has presented a new set of challenges, ranging from user interfaces and templates that some say are not physicianfriendly or workflow-enhancing to drop-down menus and copy-and-paste functions that may result in incorrect clinical documentation and inaccurate medical record coding. This paper poses four key questions for healthcare leaders to consider. The discussions around each question are intended to start conversations within your organization that can lead to improved use of IT and a full realization of EHR benefits.

How would you rate the data integrity of your EHR? For all its shortcomings, the paper medical record was relatively simple, straightforward and easy to use. The same is not always true of the EHR today, yet EHRs do offer some deceptively simple functions such as prescribed treatment templates, drop-down diagnosis menus, etc. that were designed to increase physician productivity but may make it difficult to capture accurate, complete and compliant data about the patient s condition and the care delivered. The old IT adage of GIGO garbage in, garbage out still applies and can definitely pose a threat to the data integrity of your EHR. In a blog on the topic of EHRs and compliance, 4 Ann Chenoweth, RHIA, senior director of industry relations with 3M Health Information Systems, cites several key factors in the data integrity area. Government initiatives The same initiatives that brought us accountable care organizations (ACOs), pay-for-performance (P4P), quality measures reporting, and ICD-10 are now showing healthcare leaders that their recently implemented EHRs may contain unreliable data. As a result, Chenoweth has observed that the C-suite is frequently turning to the health information management (HIM) professionals and asking them to: Evaluate the impact of poor EHR design on physician documentation Help design templates and queries that enhance physician workflow and support documentation and compliance requirements Spearhead copy-and-paste guidelines to maximize patient safety and improve compliance Deploy software tools that can identify documentation patterns and detect copy-and-paste issues that could lead to inaccurate coding and compliance issues Billing and coding risks Besides the patient safety concerns related to unreliable data in the EHR, billing and coding risks can also increase exponentially. Recent reports of record cloning and upcoding, which some investigators say has cost Medicare and Medicaid billions of dollars, 5 have aimed the spotlight on EHRs and compliance. Today, patient data is captured from across the continuum of care and subsequently used for clinical decision support, data mining, analysis, and reporting. With so much at stake, the codes generated by ambulatory clinics, physician offices, and home health matter now more than ever before. An HIM director whose hospital is participating in an ACO shared with me a recent scenario where a patient was seen for CHF [congestive heart failure] across multiple care settings: primary care physician, specialist, hospital, and home health, Chenoweth explains. Each location assigned a different CHF code, even though the diagnosis was the same. Scenarios like this have resulted in this HIM director being elevated to an information governance role, and the ACO is now in the process of hiring additional HIM professionals to focus on data integrity and compliance across the continuum. Lack of interoperability Perhaps the most visible challenge to EHR data integrity is the lack of interoperability between EHRs and other information systems, as witnessed by the recent formation of the CommonWell Health Alliance. 6 If your systems are not talking to each other accurately and completely, how can your data enhance clinical decisions and improve compliance? 2 3M Health Information Systems

To date, laboratory data has been relatively easy to exchange because good standards such as the Logical Observation Identifiers Names and Codes ( LOINC ) exist and are widely accepted. But such is not the case with other important clinical information such as problem lists and medication lists, which are not easily transmitted because existing standards have not been uniformly adopted. Because EHRs are generating incredible volumes of data, health care needs information governance to help assure data integrity. Coding The complexity of managing data The calculations shown in these graphics clearly demonstrate three healthcare industry facts of life: 1. Coding is complex 2. Auto-coding adds to the complexity 3. Regulatory updates change hundreds of codes, modifiers, and edits each quarter, resulting in an exponential increase in coding complexity Considering these average statistics, the question becomes not only whether an EHR or other vendor s system can 1. Deliver an accurate code out of millions of codes, and 2. Auto-suggest codes out of thousands of negations, deletions, etc., but 3. Can the system and the vendor also deliver an accurate code month after month, year after year, given all the changes to thousands of codes each quarter? Industry Hospital Average 8,154 * Discharges per Year 4,022 AHD Total Hospitals (Non Gov, Short Term) Industry Hospital Average 32,794,168 Total Discharges *This discharges-per-year figure has been rounded and was calculated according to publicly available AHD numbers (http://www.ahd.com/state_ statistics.htm) of hospitals and discharges as of January 10, 2013. A vendor s ability to maintain the codes is just as important as the ability to surface codes. The process requires substantial investment, expertise, and a long-term commitment to R&D. 32,794,168 Total Discharges 3.16 Codes per Discharge 103,629,571 Total Codes Generated per Year Auto Suggest Average Inpatient Visit Contains 22 16,000 Context Variations Applied Final Codes 28 Documents 224 Sections Processed 22,000 Negation Variations Applied (for 1 inpatient visit) Coding Complexity Maintenance Diagnosis Codes > 14,000 Procedures Codes > 4,000 Edits > 43,085 Help Message > 1,693 Modifiers > 450 Updates Add / Delete / Modify: 545 Codes 423 HCPCS Codes 50 Help Messages 300 Edits www.3mhis.com 3

Does your data support compliance? A quick scan of the headlines in any given week reveals that the Recovery Audit Contractors (RACs) and Medicare Administrative Contractors (MACs) are active, and with the publication of the Office of Inspector General (OIG) 2013 Work Plan, 7 no one should seriously doubt that an audit can happen to their organization. Playing the odds of not being audited is never a good idea. According to a recent article in Medical News, the errors and fraud in Medicare fee-for-service billings alone make it well worth the OIG s time to aggressively investigate and prosecute. In FY 2011, OIG audits and investigations resulted in: Banning of 2,662 individuals and entities from participation in federal healthcare programs Bringing 723 criminal actions and 382 civil actions, including suits for false claims, civil monetary penalty settlements and administrative recoveries related to provider self-disclosure matters 8 Donna Smith, a project manager and senior consultant with 3M Consulting Services, has seen plenty of examples of potential trouble spots in the data that hospitals hire her to evaluate and report on. In a recent blog entitled Documentation and Compliance Risk: Top Areas to Watch, 9 Smith points out that as health care moves to more automated record-keeping, organizations absolutely need to concentrate on accurate, complete and compliant coding before billing codes are assigned. Government auditors will take the same approach, looking for evidence that organizations may be using IT to game the system. Smith acknowledges that when it comes to coding, technology has been helpful but not always. Consider the following: Problem lists. EHRs have made the problem list a convenient method of documenting all health conditions for the patient, but there are drawbacks, especially when the diagnosis itself is selected from a drop-down menu entry that in turn triggers the assignment of a code. Key questions to consider: Who entered the documentation? A licensed provider? Someone else? The software? Who is responsible for updating the list as problems are resolved? Copy/Paste. This technology is a routine practice in all care settings, but is perhaps most commonly used in EHRs. The results? Incorrect information multiplies exponentially throughout the record and subsequent records It is difficult to distinguish between what is new or different with the patient today as compared to previous days Besides the manual process of copying one note and pasting it into the next, some EHRs automatically populate certain parts of the record. The risk is that the copied information may come from a different admission or an outpatient visit. There may be diagnoses that are listed in this documentation that are not valid for the current inpatient stay; if these diagnoses are selected for the final billed record, you have an inaccurately coded record. Compliant queries. AHIMA and ACDIS have collaborated to produce an AHIMA practice brief entitled, Guidelines for Achieving a Compliant Query Practice. 10 While not a regulatory document, the practice brief essentially represents best practice guidance for the industry. Leading queries in which the physician is asked outright if a diagnosis should be documented top the list of issues, but the document does list examples of appropriate situations and even sample wording. A compliant query should: Include clinical documentation to support the request Be written so the practitioner is not led to a specific diagnosis Supports the ultimate goal of preserving the integrity of healthcare data Computer-assisted coding. Technology can now streamline data capture by using natural language processing (NLP) to read through the record and identify code-able diagnoses and procedures. Computers can also be taught to follow some of the rules and regulations surrounding coding, thus eliminating those types of errors. However, there still needs to be a human element that validates the computer s findings. Smith s bottom line: Hospitals should clearly define and communicate their stance on how their IT resources will be used to ensure that only complete, accurate, and compliant diagnoses and procedures are reported. 4 3M Health Information Systems

The problem with problem lists Scenario: A patient is prescribed antibiotics for a urinary tract infection in an outpatient clinic, and the diagnosis of UTI is placed on the patient s problem list. Several weeks later, the same patient is admitted to the hospital for elective surgery. Although the UTI is resolved, it still appears as an active diagnosis on the problem list that is pulled into the current inpatient record. The coding and CDI staff now must try to figure out if this UTI still exists. The risk is that it could get coded into the patient record. Problem lists can also become inaccurate as a result of poorly designed drop-down menus in the EHR. If a physician cannot locate the precise diagnosis on the dropdown, he or she may become frustrated and select a less-than-accurate diagnosis code to assign. Data integrity and HIPAA compliance No discussion of compliance and data would be complete without considering HIPAA. It is essential that your own organization s processes as well as those supported by your IT vendors help protect both the privacy and security of your data. The HIPAA Omnibus Rule 11 adds obligations to your IT vendors who qualify as business associates. The rule requires those who interact with your data to follow the same security requirements that you do and restrict uses and disclosures. Both providers and their IT vendors/business associates must have policies that safeguard electronic protected health information (PHI) from improper alteration, destruction or distribution. This technical safeguard for data integrity within the original HIPAA Security Rule is at the heart of most required security standards. Complying with HIPAA security meets the goals of both the government and the healthcare industry for achieving confidentiality, integrity and availability of patient data. Always measure your revenue cycle indicators before implementing a new compliance procedure and after, too. If you see a negative impact to your revenue cycle, scrutinize the process to see if technology or real-time procedures can accomplish your goal without compromising your compliance results. Terri McCubbin, director, 3M Consulting Services www.3mhis.com 5

Key questions to ask all of your IT vendors If your EHR or any other IT vendor tells you this: The EHR will handle all the coding for your physicians automatically Computer-assisted or automated coding mean you don t need coders any more Coding an outpatient record isn t that difficult it s the perfect task for a computer to handle The EHR will store all of the data you need for analytics and provide all the reports you need, too Our natural language processing (NLP) technology is more accurate and consistent than any human coder Be sure to ask the vendor this: 1. Exactly what code sets does the software handle (e.g., CPT, ICD-9 and ICD-10, LOINC, SNOMED, RxNorms, etc.)? 2. Can the system accommodate pharmacy data or other local terminologies used in individual facilities? 3. What part of the software/system will be assigning these codes? 4. Who in your organization is responsible for programming that codeassignment software and ensuring its accuracy? What are their credentials for performing coding work? 5. How often is your coding logic and content updated to reflect regulatory changes federal and state? 1. How is coding accuracy validated if there is no human intervention? 2. Is there an audit trail generated? If so, how defensible is it if there is a RAC or MAC audit or an OIG investigation? 3. How does the system flag diagnoses considered present on admission (POA) and hospital-acquired conditions (HACs)? 1. How is medical necessity checking performed and by whom? 2. Are the users warned when an ABN is required? 3. How often is the software updated to include the most current national and local coverage determinations (NCDs and LCDs)? 4. Does the software support the application of National Correct Coding Initiative (NCCI) edits? 1. How do I access the data from unstructured text in the EHR? 2. Can I get longitudinal patient data across all care delivery sites from the EHR? 3. Does the EHR store data that can help me identify avoidable care? 4. Can the EHR data help us manage our compliance risk? 1. How does your NLP learn coding rules? 2. How does your NLP train itself on new rules and regulations? CPT is a registered trademark of the American Medical Association. 6 3M Health Information Systems

Is your data improving quality and patient safety? It will take a while to measure the influence of EHRs and healthcare IT on quality and patient safety. However, the healthcare industry is beginning to discuss EHRs from the perspective of VOI (value of investment) and not just the traditional ROI (return on investment). In addition, studies are beginning to emerge from pay-for-performance (P4P) initiatives that are encouraging. Recently, the State of Maryland reported some impressive reductions in both costs and hospital-acquired conditions (HACs) as a result of a P4P program. In just two years, this program reduced HACs state-wide by 15.26% and achieved $110 million in cost savings. 12 Maryland s HAC reduction program used a riskadjusted, rate-based approach and measured a broad range of potentially preventable conditions. Individual hospital performance is compared to the statewide average, with financial rewards or penalties determined by this comparison. Hospitals must submit diagnosis and procedure data to the state s discharge database the same database used for the state s prospective payment system. To improve quality and receive appropriate payment, hospitals must: Completely and accurately code the patient s conditions Correctly report POA for all the patient s conditions, including all secondary diagnoses Any incomplete or inaccurate data would affect the hospital s performance measure, its financial reward or penalty and ultimately, the safety of its patients. Ongoing audits, reviews, and screening processes check the accuracy of the hospital data. The bottom line: Data inaccuracy definitely poses a risk to patient safety and revenue. When healthcare IT lets you access data in real time (vs. retrospective analysis), you can often identify quality and patient safety issues as they are unfolding and target interventions, thus improving both quality and patient safety. And, while your organization s quality and patient safety can be exemplary, if the data doesn t reflect this reality, you will receive poor quality scores and performance report cards. In the real world, clinical performance determines patient outcomes, but the data used to describe outcomes is ultimately derived from a hospital s clinical documentation, coding, abstracting, and reporting functions. Whether or not it accurately reflects the quality of care delivered, outcomes data can definitely decide an organization s performance ratings, reputation and reimbursement. www.3mhis.com 7

Is your data protecting your revenue? Compliance is on everyone s mind, from the board of directors and healthcare executives to the compliance and coding directors to the individual employees who review charts and address compliance focus areas. So how does a healthcare organization keep its compliance activities from disrupting its revenue cycle workflow? Consider these very typical compliance areas and activities: CMS investigates the EHR copy/paste functions that could lead to overpayments Auto-coding and use of problem lists Recent focus on 1-2 day admission length of stays as well as re-admissions Recovery Audit Contractors (RACs) and their ever-expanding authority Commercial payers increasing their own audit activities The increase in review of leading queries The OIG investigation of admissions with conditions coded as present on admission (POA) Increased scrutiny of quality issues Use of analytics to look for areas above industry performance All of these activities can impact your organization s ability to get a bill out the door in a timely manner. To offset their risk, many facilities have implemented bill holds to give compliance, coding or internal auditing processes a chance to review cases before the final bill is dropped. While such an approach can help reduce risk, it can also impede the revenue cycle workflow and increase your accounts receivable. According to Terri McCubbin, RN, director of 3M Consulting Services, compliance plans and activities should be top-of-mind on a daily basis, but activities should be performed concurrently when possible so corrections can be made during admission or at the point of care for encounters. But how feasible is this approach? McCubbin points out that internal measures can be in put in place to alert coding staff, CDI personnel, case management, utilization management and compliance officers of the rules/regulations that drive many of the investigations. When such alerts are implemented, there is ample time for interventions and corrections before billing. Besides the common risk areas already discussed (EHR copy/paste, problem lists, etc.), McCubbin believes there are several other factors that can save the day with your data integrity without jeopardizing your revenue: Up-to-date, on-time releases of coding software with built-in edits around risk areas to alert coders as they code Analytics for early awareness Internal audit plans Education as a first line of defense Staying on top of your performance against industry focus areas 8 3M Health Information Systems

Updated coding software Coding impacts many compliance focus areas and the coding system you use in your facility should first and foremost be updated on time. Many compliance issues can be avoided by following the edits, alerts and guidance built within the software. Quarterly updates are critical to complying with changing regulations, so make sure your coding vendor consistently provides those updates on time. What happens if your coding software is not updated on time? Delayed updates mean the coding staff must review and remember all regulatory changes, the dates the regulations went into effect, and also remember to override the non-updated codes in their software. Analytics Facilities should have analytical dashboards or work lists to identify high risk target areas from the RACs, OIG and QIO quality issues. These tools should operate both in real-time, transactionalbased mode as well as provide retrospective summary information at the end of the month. Potential solution: Establish and monitor analytics focused on target areas from RAC, OIG and QIOs. Establish real-time, pre-bill processes to cross-review high risk claims prior to dropping the bill. Internal audits Ongoing quality assurance is a must. Daily real-time and pre-bill audits should occur along with random and focused audits on a monthly basis based on analytical results that reveal performance above peers. Auditing results will drive your internal education needs and create process changes that allow you to put pre-bill activities in place to correct identified risk areas. McCubbin suggests that you establish a real-time, pre-bill and retrospective auditing schedule for high risk areas and have your compliance and legal team oversee the audits. Use technology as much as possible to prevent excessive manual review. Continued on next page > www.3mhis.com 9

Education is your first line of defense Educate, educate, educate. The more informed your medical, billing, coding, case management, utilization management and CDI staff, the fewer mistakes you will see. Establish regularly scheduled meetings to discuss recent AHA Coding Clinic directives, RAC focus areas, OIG information releases of other investigations, findings from audit activities and your own dashboard analytics that suggest your performance exceeds peer groups. Monitor results over time to see if your efforts are changing your results. Keep detailed records of the claims you audit and associated factors/attributes you are finding in the audits. For example, if your facility is a referral center from multiple SNFs and rehab centers, that may well explain the high aspiration pneumonia volumes present on admission and help explain actions taken. Stay informed on industry focus areas Industry focus areas should be a priority and also provide a means for self-measurement. Understanding how you compare to the industry on such key indications as volume of hospital-acquired conditions (HACs), patient safety indicators (PSI), complications, LOS, denials, etc., also help you identify your own compliance risk areas. McCubbin suggests a facility convene a group of physicians, coders, compliance staff and clinicians to review the quality indicators and determine how quality will be reported and managed. Develop a process to review PSI, HACs and potentially preventable complications (PPCs). Set up a review process before reporting a diagnosis that could be identified as a quality indicator to see if the documentation is correct. For example, consider how you would verify the accuracy of a POA when reviewing a HAC case. Compliance and legal staff should consider the ramifications of over- or undercoding as well as under-reporting these conditions. And McCubbin s final suggestion? Always measure your revenue cycle indicators before implementing a new compliance procedure and after, too. If you see a negative impact to your revenue cycle, scrutinize the process to see if technology or real-time procedures can accomplish your goal without compromising your compliance results. 10 3M Health Information Systems

Conclusion: The ultimate question becomes, Is your data accurate and compliant? The common theme through all these questions centers on a basic issue of trust trust in the integrity of the data you are working so hard to collect, aggregate and analyze. Like the foundation of a skyscraper, you must be certain that your data is solid, stable, accurately laid out and meets code if you are going to build any worthwhile structure upon it. So, can you rely on your data for all the work you need it to do? Consider just a few of the tasks your data supports: Decision support of patient care and treatment Resource allocation and business planning Reimbursement calculations and projections Projection of an accurate representation of your organization in public report cards Defensibility of your practices during routine and special auditing processes HIM professionals can lend their voices and expertise and take leadership roles in making sure patient conditions are accurately coded, which goes a long way in governing the integrity of your coded data. This requires that your organization as a whole and the HIM department especially cultivate a culture of compliance, applying the same official coding guidelines, conventions, and definitions consistently each and every day. EHRs, computer-assisted coding, natural language processing and clinical documentation improvement software are all powerful tools, but to fulfill their potential to improve health care, they need complete, accurate content while physician documentation remains key to minimizing compliance risk and audit exposure, it is just one piece of the puzzle. Successful EHR implementations, the transition to ICD-10, adaptation to P4P and any other industry change that comes along will all require the integrated efforts of clinical teams and HIM leaders. All stand to benefit from data integrity. As Rhonda Butler, a 3M senior clinical research analyst and ICD-10 expert, recently noted, ICD-10 is only the beginning of a stronger data foundation. Data is only as good as the methods and people that create it. Collaboration is at the core of success; it comes down to how HIM leaders and clinical teams can make the most of the data they have. www.3mhis.com 11

Footnotes 1 Calculators of healthcare expenditures as a percentage of GDP are available online from the World Bank ( http://data.worldbank.org/indicator/sh.xpd.totl.zs ) and the World Health Organization ( http://apps.who.int/nha/database/predataexplorer.aspx?d=1 ), but a commonly quoted figure is that U.S. healthcare costs in 2010 consumed 17.6 percent of GDP ( http://www.pbs.org/newshour/rundown/2012/10/health-costs-how-the-us-compares-with-other-countries.html ). 2 In April 2012, payouts to organizations that had met meaningful use (MU) standards exceeded $5 billion ( http://www.fierceemr.com/story/meaningful-use-payouts-exceed- 5-billion/2012-06-05 ). The figure was taken from a Centers for Medicare & Medicaid Services (CMS) report ( http://www.cms.gov/regulations-and-guidance/legislation/ EHRIncentivePrograms/downloads/Monthly_Payment_Registration_Report_Updated.pdf ). However, on April 25, 2013, an article in ModernHealthcare.com s HITS e-newsletter put the figure for EHR incentives at $12.7 billion. 3 Arthur L. Kellermann and Spencer S. Jones, What It Will Take to Achieve the As-Yet-Unfulfilled Promises of Health Information Technology, Health Affairs 32:1 (Jan. 2013), 63-68. 4 To read and comment back to Ann Chenoweth s blog, EHRs and Compliance: Is HIM at the Table, published on January 31, 2013, visit http://3mhealthinformation.wordpress.com/2013/01/31/ehrs-and-compliance-is-him-at-the-table/#more-3661. 5 Center for Public Integrity, Cracking the Codes: How doctors and hospitals have collected billions in questionable Medicare fees, September 15, 2012, http://www.publicintegrity. org/health/medicare/cracking-codes. 6 The CommonWell Health Alliance was announced on March 4, 2013, at the HIMSS Conference. The founding member companies AllScripts, AthenaHealth, Cerner, Greenway, McKesson, and RelayHealth are aligned around the goal of... developing, deploying and promoting interoperability for the common good ( http://www.commonwellalliance.org/ ). 7 Download the 2013 OIG Work Plan at https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/work-plan-2013.pdf. 8 Cindy Sanders, OIG 2013 Work Plan Puts Providers On Notice, Medical News, December 13, 2012, http://www.medicalnewsinc.com/oig-2013-work-plan-puts-providers-on-noticecms-461. 9 To read and comment back to Donna Smith s blog, visit http://3mhealthinformation.wordpress.com/2013/02/25/documentation-and-compliance-risk-top-areas-towatch/#more-3734. 10 A web-version of the practice brief and full Journal of AHIMA citation can be found at http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050018. hcsp?ddocname=bok1_050018. 11 Camille Cohen, compliance officer for 3M Health Information Systems, commented on the HIPAA Omnibus Rule in a blog on February 18, 2013. To read and comment back, go to http://3mhealthinformation.wordpress.com/2013/02/18/should-we-be-concerned-about-the-new-hipaa-omnibus-rule/#more-3713. 12 Sule Calikoglu, Robert Murray, and Dianne Feeney, Hospital Pay-For-Performance Programs in Maryland Produced Strong Results, Including Reduced Hospital-Acquired Conditions, Health Affairs 31:12 (Dec. 2012), 2649-2653. Full text available temporarily at: http://content.healthaffairs.org/cgi/content/full/31/12/2649?ijkey=uk3xzz1ejdij6&keytype=ref&sitei d=healthaff. Health Information Systems 575 West Murray Boulevard Salt Lake City, UT 84123 U.S.A. 800 367 2447 www.3mhis.com 3M is a trademark of 3M Company. The International Statistical Classification of Diseases and Related Health Problems Tenth Revision (ICD-10) is copyrighted by the World Health Organization, Geneva, Switzerland 1992 2008. Microsoft and Excel are registered trademarks of Microsoft Corporation in the U.S. and other countries. CPT is a registered trademark of the American Medical Association. LOINC is a registered U.S. trademark of Regenstrief Institute, Inc. SNOMED and SNOMED CT are registered trademarks of the International Health Terminology Standards Development Organisation. Please recycle. Printed in U.S.A. 3M 2013. All rights reserved. Published 06/13 70-2009-9231-4