HIT 114 Chapter 5

Which of the following is the standard for clinical lab test results? a. RxNorm b. LOINC c. HCPCS d. CPT

b. LOINC

True or false: UMLS includes terminologies but excludes classifications

false

True or false: data elements specified in OASIS-C1 are collected on long-term care patients.

false

In SNOMED CT, the _____________________ is the unique text assigned to a concept that completely describes it

fully specified name (FSN)

___________________ is when health information is electronically traded between providers and others with the same level of interoperabilility

health information exchange

HCPCS level ____ is made up of CPT

I

Which type of HCPCS level II code is not published by CMS? a. dental procedures b. durable medical equipment c. vision and hearing services d. drugs administered other than by oral method

a. dental procedures

Which of the following is the standard for supplies under HIPAA? a. RxNorm b. LOINC c. HCPCS d. ICD-10-PCS

c. HCPCS

RxNorm names for clinical drugs contain information on which of the following? a. manufactured drug c. route c. ingredients d. packaged produced

c. ingredients

A system where related entities are organized together is called a _______________________

classification

_______________ are the key to secondary data use

classifications

_________________ is a set of terms representing the system of concepts for the medical field

clinical terminology

An accumulation of numeric or alphanumeric representations or codes for exchanging or storing info is a __________________

code system

A list of recommended data elements with uniform definitions is a ______________

data set

ICD-10-CM contains ______ to ______ character codes and descriptions for patient conditions

3, 7

CPT codes are the ___________ character identifiers that represent the service or procedure the individual receives from a healthcare provider.

5

ICD-10-PCS codes contain ______characters

7

Which of the following is the standard for drugs under the Meaningful Use program? a. RxNorm b. LOINC c. HCPCS d. ICD-10-PCS

A. RxNorm

The purpose of _________________is to provide a uniform language that allows for accurate descriptions of medical, surgical an diagnostic services

CPT

The most widely accepted nomenclature for the reporting of physician procedures and services under government and private health insurance programs is....

Current Procedural Terminology

The ____________________ is the standard medical classification for mental disorders

Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

True or false: If data granularity is the goal of collecting the data, clinical terminologies is the best choice

False

True or false: Nursing terminologies are used for reimbursement of nursing care for Medicare patients

False

True or false: The Core Clinical Data Set definitions are incorporated into the inpatient prospective payment system

False

True or false: The common clinical data set is used in home healthcare settings

False

True or false: The three main core components of SNOMED CT are the SNOMED CT identifier, concepts and descriptions

False

____________ is made up of two code systems: Level I and level II

HCPCS

CMS requires physicians to use ________________ to report services provided to Medicare and Medicaid patients

HCPCS Level II

The ________________ is designed to collect administative, claims and health record review data

HEDIS

The purpose of __________ is to provide a classification of diseases for morbidity

ICD-10-CM

_____________ is used to provide a system for classifying procedures performed on hospital inpatients

ICD-10-PCS

_________________ is a derived classification based on ICD that classifies diseases for oncology, a branch of medicine that focuses on tumors

ICD-O-3

Category ____________ CPT is used for performance measurement

II

HCPCS level __________ standardizes the reporting of professional services, procedures, products and supplies

II

Category _________ CPT is used for emerging technologies, services and procedures

III

________________ classifies functioning, disability and health

International Classification of Functioning, Disability and Health (ICF)

_______________ is a universal code system for tests, measurements and observations

Logical Observation Identifiers, Names and Codes (LOINC)

The primary purpose of HCPCS level II is to meet the operation needs of _____________and __________ reimbursement programs

Medicare, Medicaid

_______________ refers to the structure and form of the neoplasm

Morphology

____________ is a standardized data set designed to provide the necessary data items to measure both outcomes and patient risk factors of medical beneficiaries who are receiving skilled services from a medical certified home health agency

OASIS

_________________ is the standard nomenclature for clinical drugs and a semantic interoperability tool

RxNorm

The drug name and all of its synonyms represent a single concept, which is an ______________________________

RxNorm concept unique identifier (RXCUI)

______________________ is a comprehensive clinical terminology that provides clinical content and expressivity for clinical documentation and reporting

SNOMED CT

_________________ is the unique integer assigned to each SNOMED CT component

SNOMED CT identifier

True or False: The SNOMED CT preferred term includes the semantic tag

True

True or false: Category I CPT includes E/M, anesthesia, surgery radiology, pathology and laboratory and medicine

True

____________ is a core set of data elements collected by acute care, short term stay hospitals to report inpatient data elements in a standardized manner

UHDDS

_____________ is a centralized location of health and biomedical terminologies and standards

UMLS

The process of assigning numeric or alphanumeric representations to clinical documentation is called ______________________

coding

The common set of data types and elements and associated standards for use across several certification criteria is called the __________________

common clinical data set

_________________ are unique units of knowledge or thoughts created by a unique combination of characteristics

concepts

A ________________ classification is one based on a reference classification such as ICD or ICF by adopting the reference classifications structure and categories and providing additional detail or thorough rearrangement or aggregation of items from one or more reference classifications

derived

There are two major groups of LOINC content______________ and __________________

laboratory, clinical

The state of being diseased including illness, injury or deviation from normal health is called __________________

morbidity

___________________ are a system of terms that follow pre-established naming conventions

nomenclatures

The purpose of ___________________ is to represent clinical information generated and used by nursing staff

nursing terminologies

The __________________in SNOMED CT is the description or name assigned to a concept that is used most commonly

preferred term

A __________________ in HIT domain is a set of concepts and relationships that provide a mutual understanding for clinical decision support and for exchanging data with meaning about the healthcare course

reference terminology

___________________ are a type of connection between two concepts

relationships

_____________________ define the meaning of a concept in a manner that allows a computer to process it

relationships

The mutual understanding of the meaning of data exchanged between information systems is called ___________________

semantic interoperability

_______________ refers to the anatomical site of neoplasm's origin

topography

True or false: HEDIS collects standardized data from health records in clinics and hospitals

true