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