Questions and Answers
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.
True
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.
Signup and view all the answers
Nursing terminologies are used for reimbursement of nursing care for Medicare patients.
Signup and view all the answers
What does ICD-10-CM stand for?
Signup and view all the answers
What does ICD-10-PCS refer to?
Signup and view all the answers
What does ICF stand for?
Signup and view all the answers
What does ICD-O-3 classify?
Signup and view all the answers
What is DSM-5?
Signup and view all the answers
Which of the following is standard for drugs under the Meaningful Use program?
Signup and view all the answers
Which of the following is standard for supplies under HIPAA?
Signup and view all the answers
Which of the following is the standard for clinical lab test results?
Signup and view all the answers
Which type of HCPCS Level II code is not published by CMS?
Signup and view all the answers
What information do RxNorm names for clinical drugs contain?
Signup and view all the answers
The Core Clinical Data Set definitions are incorporated into the inpatient prospective payment system.
Signup and view all the answers
Data elements specified in OASIS-CI are collected on long-term care patients.
Signup and view all the answers
HEDIS collects standardized data from health records in clinics and hospitals.
Signup and view all the answers
The UMLS includes terminologies but excludes classifications.
Signup and view all the answers
The Common Clinical Data Set is used in home healthcare settings.
Signup and view all the answers
If data aggregation is the goal of collecting the data, ______ are the best choice.
Signup and view all the answers
The SNOMED CT _________ includes the semantic tag.
Signup and view all the answers
The ___________ is a core component of SNOMED CT.
Signup and view all the answers
___________ is a nursing terminology.
Signup and view all the answers
Category I CPT includes which of the following?
Signup and view all the answers
A ___________ is a set of terms representing the system of concepts for the medical field.
Signup and view all the answers
ICD-10-PCS is a classification of _________.
Signup and view all the answers
Which organization developed the Diagnostic and Statistical Manual of Mental Disorders?
Signup and view all the answers
A classification provides clinical data to ______________.
Signup and view all the answers
The ___________ is responsible for the development and maintenance of ICD-10-CM.
Signup and view all the answers
The _________ is a system for classifying the topography and morphology of neoplasm.
Signup and view all the answers
WHO defines ___________ as a reference classification.
Signup and view all the answers
An accumulation of numeric or alphanumeric representations or codes for exchanging or storing information is a ___________.
Signup and view all the answers
Which of the following is the standard for clinical lab test results under the Meaningful Use program?
Signup and view all the answers
HCPCS is made up of which code systems?
Signup and view all the answers
If you were looking for a code for a medication taken orally, in which system is it found?
Signup and view all the answers
The _______ is responsible for development and maintenance of RxNorm.
Signup and view all the answers
One of the two major groups of LOINC content is _________.
Signup and view all the answers
The ___________ is responsible for the publishing and maintaining HCPCS Level II.
Signup and view all the answers
The ________ originated from federal reporting requirements tied to certification criteria found in the Meaningful Use regulations.
Signup and view all the answers
Home health agency process and improvement outcome measures are based on data from the _____.
Signup and view all the answers
The standardized HEDIS data elements are collected by _________.
Signup and view all the answers
The UHDDS's core data elements were incorporated into the ___________ prospective payment system.
Signup and view all the answers
Which standard is attached to the data element smoking status contained in the Common Clinical Data Set?
Signup and view all the answers
LOINC would be found in the UMLS ____________.
Signup and view all the answers
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
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
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.
