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HITT 1301 > Ch 5 Clinical Terminologies, Classifications And Code Systems > Flashcards

Ch 5 Clinical Terminologies, Classifications And Code Systems Flashcards

1
Q

True or false: category I CPT (Current Procedural Technology) includes E/M, anesthesia, surgery, radiology, pathology and laboratory, and medicine.

A

True

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2
Q

True/false: the three main core components of SNOMED CT are the SNOMED CT identifier, concepts, and descriptions.

A

False

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3
Q

True or false: the SNOMED CT preferred terms include the semantic tag.

A

False

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4
Q

True or false: nursing terminologies are used for reimbursement of nursing care for Medicare pts

A

False

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5
Q

True or false: if data granularity is the goal of collecting the data, clinical terminologies are the best choice.

A

True

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6
Q

Match the term: ICD-10-CM

A

External causes

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7
Q

Match the classification: ICD-10-PCS

A

inpatient procedures

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8
Q

Match the classification: ICF

A

States of disability

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9
Q

Match the classification: ICD-O-3

A

Morphology of tumors

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10
Q

Match the classification: ICD-11-MMS

A

Chinese medicine disorders

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11
Q

The standard for clinical lab observation is

A

LOINC (Logical, Observation, Identifiers, names and codes)

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12
Q

The RXnorm semantic: clinical drug term type contains information on which of the following?

A

ingredients

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13
Q

True or false: HCPCS level 2 is standard for supplies under HIPPA

A

True

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14
Q

True or false: LOINC is standard for drugs under the promoting interoperablility program

A

False

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15
Q

Which type of HCPCS level 2code is not published by CMS

A

dental procedures

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16
Q

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

A

True

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17
Q

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

A

False

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18
Q

LOINC would be found in the UMLS_____

A

Metathesaurus

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19
Q

The _____is a core component of SNOMED CT.

A

Concept

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20
Q

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

A

Preferred term

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21
Q

Nomenclature

A

Recognized system of terms that follows a pre established naming conventions

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22
Q

Classifications

A

Clinical vocabulary, term, or nomenclature that lists words or phrases with their meaning

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23
Q

Code system

A

Accumulation or nomenclature that lists words or phrases with their meanings

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24
Q

Code set

A

Any set of codes used to encode data elements, like tables of terms medical concepts, med diagnostic or procedure codes.

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25
Q

Granular level

A

Data consisting of small components or details at the lowest level, example: SNOMED CT

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26
Q

Semantic interoperability

A

The mutual understanding of the meaning of data exchange between information systems

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27
Q

SNOMED Clinical terms

A

Most comprehensive, multilingual clinical health care terminology in the world

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28
Q

SNOMED CT identifier

A

A unique integer that includes an item identifier, a partition identifier, and a check digit

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29
Q

Concepts

A

A unique unit of knowledge or thought created by a unique combination of characters

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30
Q

Axioms

A

True statements based on logic

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31
Q

Fully specified name

A

The unique text assigned to a concept, that completely describes it

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32
Q

Synonym

A

An alternative way to describe the meaning of the

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33
Q

Preferred term

A

The description or name assigned to a concept that is most commonly used in a clinical record

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34
Q

ICD-10

A

International Statistical classification of diseases and related health problems, tenth edition

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35
Q

ICDM-10-CM

A

Identifies the diagnosis established by the provider. Can be updated twice a year, definitely in October and only when necessary in April

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36
Q

Purpose of ICDM-10-CM

A

Provides a classification of diseases for morbidity

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37
Q

Morbidity

A

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

38
Q

Structure of ICD-10-CM

A

3 to 7 character codes and descriptions for patient conditions, such as symptoms, syndromes, diseases and other reasons for pts requiring health services

39
Q

Linearization

A

A subset of the foundation component, once created becomes the tabular list

40
Q

The____ is a component of ICD-10-CM

A

Index to External causes

41
Q

The____ established the Common Clinical Data Set

A

ONC (office of the National coordinator for health information technology

42
Q

According to CMS, who is qualified to collect the OASIS data?

A

Registered nurse

43
Q

What is a system of terms that follows pre established naming conventions?

A

Nomenclature

44
Q

HCPCS is made up of which code systems? (Healthcare common procedure coding system)

A

CPT (Current Procedure terminology) AND HCPCS LEVEL II

45
Q

Which chapter of HCPCS would you find drugs administered intravenously? (Healthcare common procedure coding system)

A

J codes

46
Q

LOINCL would be found in the UMLS___(Unified medical language system)

A

Meta thesaurus

47
Q

Which of the following is the standard for clinical lab test observations under the promoting interoperability program?

A

LOINC

48
Q

The uniform Hospitals Discharge Data Set’s core data elements are collected by ____

A

Acute care, short term stay hospitals

49
Q

The SNOMED CT______Includes the semantic tag.

A

Fully specified name

50
Q

The _____ is a core component of SNOMED CT.

A

Concept

51
Q

If you were coding a pt with the diagnosis of congestive heart failure, which classification would you use?

A

ICD-10-CM

52
Q

The fully specified name of an observation in LOINC contains which of the following parts?

A

Kind of property

53
Q

Which symbol is used to combine 2 stem codes in LCD-11-MMS?

A

Forward slash /

54
Q

A list of recommended data elements with uniform definitions is a _____

A

Data set

55
Q

The SNOMED CT identifiers is assigned to ____

A

Concepts, descriptions and relationships

56
Q

Nursing terminologies are _____

A

Used to direct pt care given by nursing staff

57
Q

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

A

ICD-O-3

58
Q

The UHDDS’S core data elements were incorporated into the ____ prospective payment system.
(Uniform hospital discharge data set)

A

Acute inpatient

59
Q

The ____ is a derived classification of the WHO Family of International Classification.

A

ICD-O-3

60
Q

In SNOMED CT _____ are a type of connection between two concepts.

A

Relationships

61
Q

The _____ is responsible for the maintenance of RXNorm

A

NLM (National Library of Medicine)

62
Q

WHO defines ____ as a reference classification.

A

ICF (International Classification of fuctioning, disability and health

63
Q

______ is a nursing terminology.

A

Clinical Care Classification

64
Q

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

A

Classifications

65
Q

ICD-10-PCS is a classification of ______

A

Inpatient procedures

66
Q

The string BA01/BD10.0&XS7A is an example of a ______

A

Stem code, extension code, and stem code

67
Q

The string 9B10.02&XK9K is an example of a ______

A

Stem code and extension code

68
Q

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

A

American psychiatric association

69
Q

One of the required descriptions for a SNOMED CT concept is _______

A

Preferred term

70
Q

if you were coding a pt with the diagnosis of congestive heart failure, which classification would you use?

A

ICD-10-CM

71
Q

Which system includes ICD-10-CM codes to assist with meeting administrative requirements?

A

DSM-5
(Diagnostic & statistical manual of mental disorders)

72
Q

The objective of RxNorm is to normalize names of generic and branded drugs and attach a _____to that name.

A

RxNorm concept unique identifier

73
Q

The ICD-11 ______allows for an entity to be classified in more than one location.

A

Foundation component

74
Q

One of the two major groups of LOINC content is _______

A

Clinical observatioins

75
Q

Which of the following is a clinical terminology?

A

CPT (current procedural terminology)

76
Q

The fully specified name of an observation in LOINC contains which of the following parts?

A

Kind of property

77
Q

The ______is a derived classification of the WHO Family of International Classifications.

A

ICD-O-3

78
Q

The OASIS-D data elements originate from a _______

A

Medicare certified home health agency

79
Q

The ______is responsible for the publishing and maintaining HCPS Level II

A

CMS (Centers for Medicare and Medicaide)

80
Q

The UHDD’s core data elements were incorporated into the _____prospective

A

Acute inpatient

81
Q

the SNOMED-CT______are a type of connections between two concepts.

A

Relationships

82
Q

The _____of ICD-11 is used to build a country specific modification.

A

Foundation component

83
Q

Healthcare effectiveness data and information set (HEDIS)

A

A set of standardized performance measures used to evaluate the quality of care provided by health plan and providers

84
Q

Minimum data set (MDS)

A

A standardized assessment tool used primarily in long term care facilities (nursing homes) to evaluate the functional capabilities and needs of residents

85
Q

Outcome and assessment information set (OASIS)

A

a standardized toll used primarily in home health care to collect data on pt outcomes and assess their needs.

86
Q

Uniform hospital discharge data set (UHDDS)

A

standardized set of data elements used for collecting information on hospital discharges in the US. Ensures consistency in data reporting

87
Q

Common clinical data set (CCDS)

A

Standardized set of health information elements established by the Office of the National Coordinator for health information technology

88
Q

Data elements for an Emergency department information system (EDIS)

A

specific pieces of information that help in the effective management of patients in emergency settings

89
Q

Bridgette works in the home health division of Acme Health Care. She has to enter data elements collected like ADL’S meds, and care management in the Home Assessment Validation and Entry (HAVEN) system. The info is then used to monitor outcomes assess quality and reimbursements

A

Outcomes and assessment information set

90
Q

Nurse at Ocean View SNF is collecting the functional status cognitive patterns and customary routine preferences along with bladder and bowel issues swallowing status and mood of a new resident. These are used to determine the level of care & appropritate care plan for the resident

A

Minimum data set (MDS)

91
Q

A 58 yo female came to the ER with chest pain that happens after meals in the last week. The chest pressure was intense today & did not ease. The pt came in, the dr ran a troponin level and cardiac enzyme labs & had an EKG performed. Th pt was diagnosed with GERD and discharged to follow up with PCP

A

Data elements for Emergency department systems

HITT 1301 (8 decks)

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