600 Maryland Avenue, SW, Suite 100 West
Washington, DC 20024-2571
April 15, 1997

Testimony by:
Lois M. Hoskins, PhD, RN, FAAN
Member, ANA Steering Committee on Databases to Support Clinical Nursing Practice
Associate Professor, Nursing, Catholic University of America, Washington, D.C. 20064



Registered nurses as users of medical/clinical classifications for claims processing and other administrative purposes reflect only a small group(1) who have formal preparation to practice in advanced nursing positions: clinical nurse specialists, nurse practitioners, nurse midwives, and nurse anesthetists. Legislation varies state by state and operates under a medical framework controlling who has prescriptive authority and can submit billing claims. Nurses licensed with this authority are the only ones with HCFA provider identification numbers.

The following responses are patterned upon the questions submitted by your committee. The item numbers correspond to the numbers of those questions addressed.

1. Medical/clinical codes and classification used, strengths and weaknesses.

· Nurses primarily use the ICD diagnostic codes and CPT and ICD-PCS procedural codes. These codes are inadequate for capturing nursing practice data.

Anecdotal comments from school nurse and pediatric nurse practitioners include: "Some things are not there and it is a struggle to make others fit." From a nurse psychotherapist who uses DSM-IV and ICD-PCS, "The DSM provides more information and makes selection more accurate." She treats eating disorders and stated that if she used ICD she would have to code anorexia and bulimia under an appetite code.

2. Given the time frame of HIPAA, what codes and classifications do we recommend as an initial standard; specific suggestions regarding coding and classification.

· We are on record with NCVHS as supporting a single procedure classification code.

3. If some version of ICD is used, which should it be?

· We understand that some of the revisions in ICD-10-CM will provide more codes useful to nursing. Presently we have insufficient information to comment on this.

5. Ongoing maintenance of medical/clinical code sets, public domain vs in the private sector.

Anecdotally, nursing only began developing its vocabulary in the 1970's. It's most well-known vocabulary, that of the North American Nursing Diagnosis Association (NANDA), was in the public domain until 1992. During that twenty year period it became widely integrated into nursing education, and recognized throughout this country and abroad. It is now copyrighted primarily to command income from licensing to publishers and vendors.

6. Resource implications of changing from the current coding and classification systems, costs and benefits of such changes.

In conclusion, the current systems for coding health conditions, diagnoses, services, and procedures do not do a good job of representing the nursing discipline. The data captured from the medical perspective accounts for only a small portion of the variance in outcomes. Policy decisions based on current billing codes that do not account for nursing interventions lack comprehensiveness. We would like to have more of our vocabulary incorporated into the system which will become a standard. We have a nursing diagnosis vocabulary and a nursing intervention vocabulary included in SNOMED International, and we have ANA-recognized vocabularies in the UMLS. UMLS is the only system that cross-walks nursing terms.

(1) 6.3% of the 2.5 million registered nurses in the U.S. in March 1996 were estimated to have formal preparation to practice in advanced nursing positions (Advance Notes II from the National Sample Survey of Registered Nurses March 1996, Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration, HHS).