Uprise Code Systems and Terminology

Uprise utilizes standard coding terminology to document and communicate EHR information.  Moreover, this standard terminology allows Uprise EHR patient data exchange to occur between providers and patient portals.  Furthermore this standard terminology is government mandated, HIPAA compliant and allows MIPS certification. The standard coding systems are CPT, SNOMED CT and ICD-10.

  • CPT (Current Physicians Terminology)-codes used to document and bill physician services.  (exams, testing, procedures, lenses) 
    • Used in Uprise EHR in orders, special testing/procedures and coding 
    • Paired with and ICD-10 code can be used to generate insurance claim or invoice 
  • SNOMED CT (Systematized Nomenclature of Medicine — Clinical Terms)-codes using standardized clinical descriptions to document signs, symptoms, findings, and conditions.  SNOMED CT is required for electronic exchange of clinical health information.   
    • Used in Uprise EHR in Chief Complaint, Physical exam findings and Assessment 
    • Can be used to further define ICD-10 codes especially useful in “non specified” or “other” ICD codes.   
      • Use case:   ICD 10 H18.51X Endothelial corneal dystrophy. Can be further defined as 193839007 - Fuchs' corneal dystrophy (disorder) 
  • ICD-10 (International Classification of Disease 10th modification)- codes designed  to bill insurance companies paired with CPT codes.  They are commonly used to communicate a diagnosis in Assessment.  Ultimately will be phased out and replaced with SNOMED CT clinical terminology for EHR communications leaving ICD 10 for insurance billing.   
    • Used in Uprise EHR in Physical exam findings, Problems, Assessment, Special testing/procedures and coding 
    • Paired with CPT code can be used to generate insurance claim or invoice 
  • Findings (Versus Diagnosis) =  
    • typically incidental and likely won’t see again. 
    • they are often related to another diagnoses.  
    • Could also be used to label variants of normal that are not necessarily discussed with the patient 

 

The benefit of Uprise is ICD-10 diagnoses, assessments, and treatment plans are created together in one place. After findings and diagnoses (with severity) are selected, the appropriate assessments and default treatment plans will automatically drop in, as well as potential special tests that may want to be scheduled or ordered and documented related to those assessments, and applicable patient education that can be shared with the patient.