Ch 5 Clinical Terminologies, Classifications And Code Systems Flashcards
True or false: category I CPT (Current Procedural Technology) includes E/M, anesthesia, surgery, radiology, pathology and laboratory, and medicine.
True
True/false: the three main core components of SNOMED CT are the SNOMED CT identifier, concepts, and descriptions.
False
True or false: the SNOMED CT preferred terms include the semantic tag.
False
True or false: nursing terminologies are used for reimbursement of nursing care for Medicare pts
False
True or false: if data granularity is the goal of collecting the data, clinical terminologies are the best choice.
True
Match the term: ICD-10-CM
External causes
Match the classification: ICD-10-PCS
inpatient procedures
Match the classification: ICF
States of disability
Match the classification: ICD-O-3
Morphology of tumors
Match the classification: ICD-11-MMS
Chinese medicine disorders
The standard for clinical lab observation is
LOINC (Logical, Observation, Identifiers, names and codes)
The RXnorm semantic: clinical drug term type contains information on which of the following?
ingredients
True or false: HCPCS level 2 is standard for supplies under HIPPA
True
True or false: LOINC is standard for drugs under the promoting interoperablility program
False
Which type of HCPCS level 2code is not published by CMS
dental procedures
True or False: data elements specified in OASIS-D are collected on long term care patients.
True
True or false: The common Clinical Data Set definitions are incorporated into the inpatient prospective payment system.
False
LOINC would be found in the UMLS_____
Metathesaurus
The _____is a core component of SNOMED CT.
Concept
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
Nomenclature
Recognized system of terms that follows a pre established naming conventions
Classifications
Clinical vocabulary, term, or nomenclature that lists words or phrases with their meaning
Code system
Accumulation or nomenclature that lists words or phrases with their meanings
Code set
Any set of codes used to encode data elements, like tables of terms medical concepts, med diagnostic or procedure codes.
Granular level
Data consisting of small components or details at the lowest level, example: SNOMED CT
Semantic interoperability
The mutual understanding of the meaning of data exchange between information systems
SNOMED Clinical terms
Most comprehensive, multilingual clinical health care terminology in the world
SNOMED CT identifier
A unique integer that includes an item identifier, a partition identifier, and a check digit
Concepts
A unique unit of knowledge or thought created by a unique combination of characters
Axioms
True statements based on logic
Fully specified name
The unique text assigned to a concept, that completely describes it
Synonym
An alternative way to describe the meaning of the
Preferred term
The description or name assigned to a concept that is most commonly used in a clinical record
ICD-10
International Statistical classification of diseases and related health problems, tenth edition
ICDM-10-CM
Identifies the diagnosis established by the provider. Can be updated twice a year, definitely in October and only when necessary in April
Purpose of ICDM-10-CM
Provides a classification of diseases for morbidity
Morbidity
The state of being diseased including illness, injury or deviation from normal health
Structure of ICD-10-CM
3 to 7 character codes and descriptions for patient conditions, such as symptoms, syndromes, diseases and other reasons for pts requiring health services
Linearization
A subset of the foundation component, once created becomes the tabular list
The____ is a component of ICD-10-CM
Index to External causes
The____ established the Common Clinical Data Set
ONC (office of the National coordinator for health information technology
According to CMS, who is qualified to collect the OASIS data?
Registered nurse
What is a system of terms that follows pre established naming conventions?
Nomenclature
HCPCS is made up of which code systems? (Healthcare common procedure coding system)
CPT (Current Procedure terminology) AND HCPCS LEVEL II
Which chapter of HCPCS would you find drugs administered intravenously? (Healthcare common procedure coding system)
J codes
LOINCL would be found in the UMLS___(Unified medical language system)
Meta thesaurus
Which of the following is the standard for clinical lab test observations under the promoting interoperability program?
LOINC
The uniform Hospitals Discharge Data Set’s core data elements are collected by ____
Acute care, short term stay hospitals
The SNOMED CT______Includes the semantic tag.
Fully specified name
The _____ is a core component of SNOMED CT.
Concept
If you were coding a pt with the diagnosis of congestive heart failure, which classification would you use?
ICD-10-CM
The fully specified name of an observation in LOINC contains which of the following parts?
Kind of property
Which symbol is used to combine 2 stem codes in LCD-11-MMS?
Forward slash /
A list of recommended data elements with uniform definitions is a _____
Data set
The SNOMED CT identifiers is assigned to ____
Concepts, descriptions and relationships
Nursing terminologies are _____
Used to direct pt care given by nursing staff
The ____ is a system for classifying the topography and morphology of neoplasm.
ICD-O-3
The UHDDS’S core data elements were incorporated into the ____ prospective payment system.
(Uniform hospital discharge data set)
Acute inpatient
The ____ is a derived classification of the WHO Family of International Classification.
ICD-O-3
In SNOMED CT _____ are a type of connection between two concepts.
Relationships
The _____ is responsible for the maintenance of RXNorm
NLM (National Library of Medicine)
WHO defines ____ as a reference classification.
ICF (International Classification of fuctioning, disability and health
______ is a nursing terminology.
Clinical Care Classification
If data aggregation is the goal of collecting the data____ are the best choice.
Classifications
ICD-10-PCS is a classification of ______
Inpatient procedures
The string BA01/BD10.0&XS7A is an example of a ______
Stem code, extension code, and stem code
The string 9B10.02&XK9K is an example of a ______
Stem code and extension code
Which of the following developed the Diagnostic and Statistical Manual of Mental Disorder?
American psychiatric association
One of the required descriptions for a SNOMED CT concept is _______
Preferred term
if you were coding a pt with the diagnosis of congestive heart failure, which classification would you use?
ICD-10-CM
Which system includes ICD-10-CM codes to assist with meeting administrative requirements?
DSM-5
(Diagnostic & statistical manual of mental disorders)
The objective of RxNorm is to normalize names of generic and branded drugs and attach a _____to that name.
RxNorm concept unique identifier
The ICD-11 ______allows for an entity to be classified in more than one location.
Foundation component
One of the two major groups of LOINC content is _______
Clinical observatioins
Which of the following is a clinical terminology?
CPT (current procedural terminology)
The fully specified name of an observation in LOINC contains which of the following parts?
Kind of property
The ______is a derived classification of the WHO Family of International Classifications.
ICD-O-3
The OASIS-D data elements originate from a _______
Medicare certified home health agency
The ______is responsible for the publishing and maintaining HCPS Level II
CMS (Centers for Medicare and Medicaide)
The UHDD’s core data elements were incorporated into the _____prospective
Acute inpatient
the SNOMED-CT______are a type of connections between two concepts.
Relationships
The _____of ICD-11 is used to build a country specific modification.
Foundation component
Healthcare effectiveness data and information set (HEDIS)
A set of standardized performance measures used to evaluate the quality of care provided by health plan and providers
Minimum data set (MDS)
A standardized assessment tool used primarily in long term care facilities (nursing homes) to evaluate the functional capabilities and needs of residents
Outcome and assessment information set (OASIS)
a standardized toll used primarily in home health care to collect data on pt outcomes and assess their needs.
Uniform hospital discharge data set (UHDDS)
standardized set of data elements used for collecting information on hospital discharges in the US. Ensures consistency in data reporting
Common clinical data set (CCDS)
Standardized set of health information elements established by the Office of the National Coordinator for health information technology
Data elements for an Emergency department information system (EDIS)
specific pieces of information that help in the effective management of patients in emergency settings
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
Outcomes and assessment information set
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
Minimum data set (MDS)
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
Data elements for Emergency department systems
