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Questions and Answers
If data granularity is the goal of collecting the data, clinical terminologies is the best choice.
If data granularity is the goal of collecting the data, clinical terminologies is the best choice.
False
The SNOMED CT preferred term includes the semantic tag.
The SNOMED CT preferred term includes the semantic tag.
True
The three main core components of SNOMED CT are the SNOMED CT identifier, concepts, and descriptions.
The three main core components of SNOMED CT are the SNOMED CT identifier, concepts, and descriptions.
False
Category I CPT includes E/M, anesthesia, surgery, radiology, pathology and laboratory, and medicine.
Category I CPT includes E/M, anesthesia, surgery, radiology, pathology and laboratory, and medicine.
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Nursing terminologies are used for reimbursement of nursing care for Medicare patients.
Nursing terminologies are used for reimbursement of nursing care for Medicare patients.
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What does ICD-10-CM stand for?
What does ICD-10-CM stand for?
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What does ICD-10-PCS refer to?
What does ICD-10-PCS refer to?
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What does ICF stand for?
What does ICF stand for?
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What does ICD-O-3 classify?
What does ICD-O-3 classify?
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What is DSM-5?
What is DSM-5?
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Which of the following is standard for drugs under the Meaningful Use program?
Which of the following is standard for drugs under the Meaningful Use program?
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Which of the following is standard for supplies under HIPAA?
Which of the following is standard for supplies under HIPAA?
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Which of the following is the standard for clinical lab test results?
Which of the following is the standard for clinical lab test results?
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Which type of HCPCS Level II code is not published by CMS?
Which type of HCPCS Level II code is not published by CMS?
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What information do RxNorm names for clinical drugs contain?
What information do RxNorm names for clinical drugs contain?
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The Core Clinical Data Set definitions are incorporated into the inpatient prospective payment system.
The Core Clinical Data Set definitions are incorporated into the inpatient prospective payment system.
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Data elements specified in OASIS-CI are collected on long-term care patients.
Data elements specified in OASIS-CI are collected on long-term care patients.
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HEDIS collects standardized data from health records in clinics and hospitals.
HEDIS collects standardized data from health records in clinics and hospitals.
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The UMLS includes terminologies but excludes classifications.
The UMLS includes terminologies but excludes classifications.
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The Common Clinical Data Set is used in home healthcare settings.
The Common Clinical Data Set is used in home healthcare settings.
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If data aggregation is the goal of collecting the data, ______ are the best choice.
If data aggregation is the goal of collecting the data, ______ are the best choice.
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The SNOMED CT _________ includes the semantic tag.
The SNOMED CT _________ includes the semantic tag.
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The ___________ is a core component of SNOMED CT.
The ___________ is a core component of SNOMED CT.
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___________ is a nursing terminology.
___________ is a nursing terminology.
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Category I CPT includes which of the following?
Category I CPT includes which of the following?
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A ___________ is a set of terms representing the system of concepts for the medical field.
A ___________ is a set of terms representing the system of concepts for the medical field.
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ICD-10-PCS is a classification of _________.
ICD-10-PCS is a classification of _________.
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Which organization developed the Diagnostic and Statistical Manual of Mental Disorders?
Which organization developed the Diagnostic and Statistical Manual of Mental Disorders?
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A classification provides clinical data to ______________.
A classification provides clinical data to ______________.
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The ___________ is responsible for the development and maintenance of ICD-10-CM.
The ___________ is responsible for the development and maintenance of ICD-10-CM.
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The _________ is a system for classifying the topography and morphology of neoplasm.
The _________ is a system for classifying the topography and morphology of neoplasm.
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WHO defines ___________ as a reference classification.
WHO defines ___________ as a reference classification.
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An accumulation of numeric or alphanumeric representations or codes for exchanging or storing information is a ___________.
An accumulation of numeric or alphanumeric representations or codes for exchanging or storing information is a ___________.
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Which of the following is the standard for clinical lab test results under the Meaningful Use program?
Which of the following is the standard for clinical lab test results under the Meaningful Use program?
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HCPCS is made up of which code systems?
HCPCS is made up of which code systems?
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If you were looking for a code for a medication taken orally, in which system is it found?
If you were looking for a code for a medication taken orally, in which system is it found?
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The _______ is responsible for development and maintenance of RxNorm.
The _______ is responsible for development and maintenance of RxNorm.
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One of the two major groups of LOINC content is _________.
One of the two major groups of LOINC content is _________.
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The ___________ is responsible for the publishing and maintaining HCPCS Level II.
The ___________ is responsible for the publishing and maintaining HCPCS Level II.
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The ________ originated from federal reporting requirements tied to certification criteria found in the Meaningful Use regulations.
The ________ originated from federal reporting requirements tied to certification criteria found in the Meaningful Use regulations.
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Home health agency process and improvement outcome measures are based on data from the _____.
Home health agency process and improvement outcome measures are based on data from the _____.
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The standardized HEDIS data elements are collected by _________.
The standardized HEDIS data elements are collected by _________.
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The UHDDS's core data elements were incorporated into the ___________ prospective payment system.
The UHDDS's core data elements were incorporated into the ___________ prospective payment system.
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Which standard is attached to the data element smoking status contained in the Common Clinical Data Set?
Which standard is attached to the data element smoking status contained in the Common Clinical Data Set?
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LOINC would be found in the UMLS ____________.
LOINC would be found in the UMLS ____________.
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Study Notes
Clinical Terminologies and Classifications
- Data granularity is not achieved through clinical terminologies but is best served by classification methods.
- SNOMED CT includes preferred terms with semantic tags, providing essential contextual information.
- Core components of SNOMED CT are relationships, concepts, and descriptions, not just identifiers and concepts.
- Category I CPT codes encompass various medical service types including evaluation and management (E/M), anesthesia, surgery, radiology, pathology, and laboratory services.
- Nursing terminologies are not associated with the reimbursement processes for Medicare patients.
ICD and Other Classification Systems
- ICD-10-CM refers to mental morbidity and focuses on diagnosing conditions while ICD-10-PCS pertains to inpatient procedures classification.
- ICF is defined as classifying states of functioning, aiding in understanding health-related states.
- ICD-O-3 serves specifically for oncology-related diseases, facilitating cancer diagnosis classification.
- DSM-5 is a standard reference for mental disorders, supporting clinical assessments.
Standards and Code Systems
- RxNorm is the standard for drug-related information under the Meaningful Use program, detailing clinical drug names and ingredients.
- HIPAA standards for supplies are primarily managed through HCPCS.
- Clinical laboratory test result standards are governed by LOINC, essential for interoperability in healthcare data reporting.
Core Data Sets
- The Core Clinical Data Set is specifically tailored for inpatient and ambulatory settings, not home healthcare.
- OASIS-CI data elements are collected from adult home health patients, clarifying care assessments.
- HEDIS collects standardized data from health records in clinics and hospitals, vital for quality assessment in healthcare services.
Terminology and Coding Components
- The Common Clinical Data Set and various terms are often integrated into classifications to enhance data collection and reporting efficiencies.
- Clinical terminology represents a systematic collection of concepts pertinent to the medical field, aiding in communication and data exchange.
- The National Center for Health Statistics (NCHS) is responsible for the development and maintenance of ICD-10-CM classifications.
Key Organizations and Processes
- The American Psychiatric Association developed the DSM, establishing a foundational reference for mental health disorders.
- The National Library of Medicine (NLM) oversees RxNorm, ensuring continuous updates and relevance.
- CMS is the authority responsible for publishing and maintaining HCPCS Level II, ensuring compliance with healthcare reporting standards.
Miscellaneous
- The standardized HEDIS data elements are gathered from acute care hospital records, providing critical insights into healthcare quality.
- Smoking status data in the Common Clinical Data Set is standardized under SNOMED CT, indicating a unified approach to health data reporting.
- LOINC is housed within the UMLS Metathesaurus, emphasizing its role in the broader clinical vocabulary and data exchange framework.
Studying That Suits You
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Description
Test your understanding of clinical terminologies, classifications, and code systems with this quiz based on Chapter 5. Challenge yourself with true or false questions that explore important concepts in clinical data management.
