Clinical Terminologies, Classifications, and Code Systems

Terminolgy

A code set to describe standards to support interopherability.

Vocabulary

A list of collection of clinical words or phrases with their meanings.

Data set

A list of recommended data elements with uniform definitions that are relevant for a particular use.

Nomenclature

A recognized system of terms that follows pre-established naming conventions.

Relationships SNOMED CT

A type of connection between two concepts.

Concept

A unique unit of knowledge or thought created by a unique combination of characteristics.

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 are not published by the Center for Medicare and Medicaid Services

SNOMED CT identifier

AKA SCTID A unique integer that includes an item identifier, a partition identifier, and a check-digit.

Which of the following developed the Diagnostic and Statistical Manual of Mental Disorders?

APA American Psychiatric Association

The UHDDS's core data elements were incorporated into the _______ prospective payment system.

Acute inpatient

Is the data use following granular or aggregate data, and clinical terminologies, classifications, or code systems? To allow collection and reporting of basic health statistics

Aggregate, classification systems, code systems

Is the data use following granular or aggregate data, and clinical terminologies, classifications, or code systems? To provide data that are used in designing payment systems and determining the correct payment for healthcare services

Aggregate, classification systems, code systems

Is the data use following granular or aggregate data, and clinical terminologies, classifications, or code systems? To provide data that are used in monitoring public health and risks

Aggregate, classification, code systems

Is the data use following granular or aggregate data, and clinical terminologies, classifications, or code systems? To provide data to consumers on costs and outcomes of treatment options.

Aggregate, classification, code systems

AMA

American Medical Association

ANA

American Nurses Association

APA

American Psychiatric Association

Code Set

An accumulation of numeric or alphanumeric codes.

Code System

An accumulation of terms and codes for exchanging or storing information.

Code

An identifier.

Category I CPT includes which of the following? A. HCPCS Level II B. Surgery C. Drugs D. Durable medical equipment

B. Surgery

The RxNorm semantic clinical drug term type contains information on which of the following? Manufactured drug, route, ingredients, packaged product

C, the semantic clinical drug term type includes ingredients plus strength plus dose

The _______ is responsible for the publishing and maintaining HCPCS Level II.

CMS

HCPCS is made up of which code systems?

CPT and HCPCS Level II

1065F is an example of what?

Category II of the CTS

0345T is an example of what?

Category III of the CTS

CMS

Centers for Medicare and Medicaid Services

If data aggregation is the goal of collecting the data, ______ are the best choice.

Classifications

Who's responsibility is it to assign the CPT code based on the healthcare provider's documentation of the medical services or procedures provided?

Coder

The ___________ originated from federal reporting requirements tied to certification criteria found in the Meaningful Use regulations.

Common Clinical Data Set

CCDS

Common Clinical Data Set combination of theses common sets of data types and elements and associated standards used across several certification criteria.

The __________ is a core component of SNOMED CT.

Concept

The SNOMED CT identifier is assigned to _________

Concepts, descriptions, relationships

The _________________ is a core component of SNOMED CT

Concepts, descriptions, relationships

CPT

Current Procedural Terminology Identifies the services rendered rather than the diagnosis on the claim.

Granular level

Data consisting of small components or details at the lowest level.

Aggregate Data

Data extracted from individual health records and maybe combined to form deidentified information about groups of patients that can be compared and analyzed.

DSM

Diagnostic and Statistical Manual of Mental Disorders

Name the 6 main sections of Category I CPT.

Evaluation and Management, Anesthesia, Survey Radiology, Pathology and Laboratory, Medicine

True or False: LOINC is standard for drugs under the promoting interoperability program

False, RxNorm is the standard for drugs under the promoting interoperability program

True or False: The Common Clinical Data Set definitions are incorporated into the inpatient prospective payment system.

False, the UHDDS was incorporated in to the inpatient prospective payment system

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

False. The preferred term is the description or name assigned to a concept that is used most commonly in a clinical record or in literature for a specific language or dialect.

True or False: Nursing terminologies are used for reimbursement of nursing care for medicare patients

False: Nursing terminologies are used to represent clinical information generated and used by nursing staff.

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

False: The three main core components of SNOMED CT are: Concepts, descriptions, and relationships

Which symbol is used to combine two stem codes in ICD-11-MMS

Forward slash /d

The ICD-11 ___________ allows for an entity to be classified in more than one location

Foundation component

The SNOMED CT _______ includes the semantic tag.

Fully specified name

Is the data use following granular or aggregate data, and clinical terminologies, classifications, or code systems? To allow many different sites and different providers the ability to send and receive medical data in an understandable and usable manner, thereby speeding care delivery and reducing duplicate testing and duplicate prescribing

Granular data, clinical terminologies, code systems

Is the data use following granular or aggregate data, and clinical terminologies, classifications, or code systems? To allow the computer to manipulate standardized data and find information relevant to individual patients for the purpose of producing automatic reminders or alerts

Granular data, clinical terminologies, code systems

Is the data use following granular or aggregate data, and clinical terminologies, classifications, or code systems? To facilitate electronic data collection at the point of care with terms familiar to the user.

Granular data, clinical terminologies, code systems

Is the data use following granular or aggregate data, and clinical terminologies, classifications, or code systems? To allow the computer to manipulate standardized data and find information relevant to individual patients for the purpose of producing automatic reminders or alerts

Granular, clinical terminologies, code systems

HCPCS

Health Care Common Procedure Coding System

HIPAA

Health Insurance Portability and Accountability Act

Health Information Exchange

Health information is electronically traded between providers and others with the same level of interoperability.

Descriptions

Human-readable representations of concepts

The __________ is a system for classifying the topography and morphology of neoplasm.

ICD-0-3

WHO defines ___________ as a reference classification.

ICF

Preferred term

In SNOMED CT, the description or name assigned to a concept that is used most commonly; in the UMNDS classification system, a representation of the generic product category, which is a list of preferred concepts that name devices

Reference terminology

In the HIT domain it's a terminology designed to provide common semantics for divers implementations.

ICD-10-PCS is a classification of

Inpatient procedures

ICD

International Classification of Diseases Identifies the diagnosis

ICD-11-MMS

International Classification of Diseases 11th Revision for Mortality and Morbidity Statistics Linearization of the ICD-11 foundation componentd ex

ICF

International Classification of Functioning, Disability, and Health one of the three reference classifications approved by the WHO Family of International Classification Classifies states of functioning, disability, and health

What is Category II of CPT for?

It is used for performance measurement.

The SNOMED CT identifier consists of ________.

Item identifier, partition identifier, check-digit

The standard for clinical lab observations is??

LOINC

What is the standard for clinical lab test observations under the promoting interoperability program?

LOINC

LOINC

Logical Observation Identifiers Names and Codes

Observation

Measurement, tests, or simple assertion

LOINC would be found in the UMLS ____________.

Metathesaurus

LOINC would be found in the UMLS ________________?

Methathesaurus

SNOMED CT

Most comprehensive, multilingual clinical healthcare terminology in the world

Semantic Interoperability

Mutual understanding of the meaning of data exchanged between information systems.

The ___________ is responsible for the maintenance of RxNorm.

NLM

NLM

National Library of Medicine

NOC

Nursing Outcomes Classification

ONC

Office of the National Coordinator for Health Information Technology

Derived Classification

One based on a referenced classification such as ICD or ICF by adopting the reference classification structure and categories and providing additional detail or through rearrangement or aggregation of items from one or more reference classifications.

OASIS

Outcome and Assessment Information Set

Home health agency process and improvement outcome measures are based on data from the _______.

Outcomes and Assessment Information Set (OASIS)

Morphology

Pertains to cell type or histology and the neoplasm's biological activity or behavior.

The _________________ in SNOMED CT is the description assigned to a concept that is used most commonly in a clinical record or in literature for a specific language or dialect.

Preferred term

Topography

Refers to the anatomical site of a neoplasm's origin

If you were looking for a code for a medication taken orally, in which system is it found?

RxNorm

RXCUI

RxNorm concept unique identifier

Which standard is attached to the data element smoking status contained in the Common Clinical Data Set?

SNOMED CT

Interoperable health IT enviroment

Seamless health information exchange is possible across different EHR systems and the information is understood and shared with those in need of it at the time it is needed.

Clinical Terminologies

Sets of standardized items and their synonyms that record patient findings, circumstances, events, and interventions with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement.

Morbidity

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

Functioning

The umbrella term for Body Functions, Body Structures, Activities and Participations

Disability

The umbrella term for impairments, activity limitations, and participation restrictions.

FSN Fully specified name

The unique text assigned to a concept that completely describes it, and the synonym is an alternative way to describe the meaning of the concept in a specific language or dialect.

What is the purpose of ICD-10-CM?

To provide a classification of diseases for morbidity

What is the purpose of ICD-10-PCS

To provide a system for classifying procedures performed on hospital inpatients

What is the purpose of CPT?

To provide a uniform language that allows for accurate descriptions of medical, surgical, and diagnostic services.

What is the purpose of nursing terminologies?

To represent clinical information generated and used by nursing staff

What is SNOMED CT's purpose?

To standardize clinical phrases, making it easier to produce accurate electronic health information

True or False: Data elements specified in OASIS-D are collected on long-term care patients

True

True or False: HCPCS Level II is standard for supplies under HIPAA

True

True or False: If data granularity is the goal of colleting the data, clinical terminologies are the best choice.

True

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

True

axioms

True statement

Unified Medical Language System

UMLS, multipurpose resource that includes concepts & terms from many different source vocabularies developed

UMLS

Unified Medical Language System

URI

Uniform resource identifier A unique character string for each entity

Tubular list

alphanumerical list of codes divided into chapters based on body system or condition.

Oncology

branch of medicine dealing with tumors

Stem Code

standalone code and can be a single entity or combination of clinical data

Extension code

starts with a X, adds detail to the stem code, and must be used with it.

Linearization

subset of the foundation component; once created the subset becomes the Tubular list