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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
Granular level
Data consisting of small components or details at the lowest level, example: SNOMED CT
26
Semantic interoperability
The mutual understanding of the meaning of data exchange between information systems
27
SNOMED Clinical terms
Most comprehensive, multilingual clinical health care terminology in the world
28
SNOMED CT identifier
A unique integer that includes an item identifier, a partition identifier, and a check digit
29
Concepts
A unique unit of knowledge or thought created by a unique combination of characters
30
Axioms
True statements based on logic
31
Fully specified name
The unique text assigned to a concept, that completely describes it
32
Synonym
An alternative way to describe the meaning of the
33
Preferred term
The description or name assigned to a concept that is most commonly used in a clinical record
34
ICD-10
International Statistical classification of diseases and related health problems, tenth edition
35
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
36
Purpose of ICDM-10-CM
Provides a classification of diseases for morbidity
37
Morbidity
The state of being diseased including illness, injury or deviation from normal health
38
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
39
Linearization
A subset of the foundation component, once created becomes the tabular list
40
The____ is a component of ICD-10-CM
Index to External causes
41
The____ established the Common Clinical Data Set
ONC (office of the National coordinator for health information technology
42
According to CMS, who is qualified to collect the OASIS data?
Registered nurse
43
What is a system of terms that follows pre established naming conventions?
Nomenclature
44
HCPCS is made up of which code systems? (Healthcare common procedure coding system)
CPT (Current Procedure terminology) AND HCPCS LEVEL II
45
Which chapter of HCPCS would you find drugs administered intravenously? (Healthcare common procedure coding system)
J codes
46
LOINCL would be found in the UMLS___(Unified medical language system)
Meta thesaurus
47
Which of the following is the standard for clinical lab test observations under the promoting interoperability program?
LOINC
48
The uniform Hospitals Discharge Data Set’s core data elements are collected by ____
Acute care, short term stay hospitals
49
The SNOMED CT______Includes the semantic tag.
Fully specified name
50
The _____ is a core component of SNOMED CT.
Concept
51
If you were coding a pt with the diagnosis of congestive heart failure, which classification would you use?
ICD-10-CM
52
The fully specified name of an observation in LOINC contains which of the following parts?
Kind of property
53
Which symbol is used to combine 2 stem codes in LCD-11-MMS?
Forward slash /
54
A list of recommended data elements with uniform definitions is a _____
Data set
55
The SNOMED CT identifiers is assigned to ____
Concepts, descriptions and relationships
56
Nursing terminologies are _____
Used to direct pt care given by nursing staff
57
The ____ is a system for classifying the topography and morphology of neoplasm.
ICD-O-3
58
The UHDDS'S core data elements were incorporated into the ____ prospective payment system. (Uniform hospital discharge data set)
Acute inpatient
59
The ____ is a derived classification of the WHO Family of International Classification.
ICD-O-3
60
In SNOMED CT _____ are a type of connection between two concepts.
Relationships
61
The _____ is responsible for the maintenance of RXNorm
NLM (National Library of Medicine)
62
WHO defines ____ as a reference classification.
ICF (International Classification of fuctioning, disability and health
63
______ is a nursing terminology.
Clinical Care Classification
64
If data aggregation is the goal of collecting the data____ are the best choice.
Classifications
65
ICD-10-PCS is a classification of ______
Inpatient procedures
66
The string BA01/BD10.0&XS7A is an example of a ______
Stem code, extension code, and stem code
67
The string 9B10.02&XK9K is an example of a ______
Stem code and extension code
68
Which of the following developed the Diagnostic and Statistical Manual of Mental Disorder?
American psychiatric association
69
One of the required descriptions for a SNOMED CT concept is _______
Preferred term
70
if you were coding a pt with the diagnosis of congestive heart failure, which classification would you use?
ICD-10-CM
71
Which system includes ICD-10-CM codes to assist with meeting administrative requirements?
DSM-5 (Diagnostic & statistical manual of mental disorders)
72
The objective of RxNorm is to normalize names of generic and branded drugs and attach a _____to that name.
RxNorm concept unique identifier
73
The ICD-11 ______allows for an entity to be classified in more than one location.
Foundation component
74
One of the two major groups of LOINC content is _______
Clinical observatioins
75
Which of the following is a clinical terminology?
CPT (current procedural terminology)
76
The fully specified name of an observation in LOINC contains which of the following parts?
Kind of property
77
The ______is a derived classification of the WHO Family of International Classifications.
ICD-O-3
78
The OASIS-D data elements originate from a _______
Medicare certified home health agency
79
The ______is responsible for the publishing and maintaining HCPS Level II
CMS (Centers for Medicare and Medicaide)
80
The UHDD's core data elements were incorporated into the _____prospective
Acute inpatient
81
the SNOMED-CT______are a type of connections between two concepts.
Relationships
82
The _____of ICD-11 is used to build a country specific modification.
Foundation component
83
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
84
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
85
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.
86
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
87
Common clinical data set (CCDS)
Standardized set of health information elements established by the Office of the National Coordinator for health information technology
88
Data elements for an Emergency department information system (EDIS)
specific pieces of information that help in the effective management of patients in emergency settings
89
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
90
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)
91
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

HITT 1301 (10 decks)

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