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