Chapter 5 - Clinical Terminologies, Classifications, and Code Systems

Question 1

axioms

Answer 1

a statement or proposition which is regarded as being established, accepted, or self-evidently true

Question 2

clinical terminology

Answer 2

a set of standardized terms and their synonyms that record patient findings, circumstances, events, and interventions with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement

Question 3

granular level of data

Answer 3

data consisting of small components or details at the lowest level

Question 4

nomenclature

Answer 4

the devising or choosing of names for things, especially in a science or other discipline

Question 5

data set

Answer 5

a list of recommended data elements with uniform definitions

Question 6

derived classification

Answer 6

a classification based on a reference classification such as ICD or ICF; it is made by adopting the reference classification structure and categories and it either provides additional detail or it rearranges or collects items from one or more reference classifications

Question 7

extension code

Answer 7

a code that starts with an X, adds detail to the stem code, and must be used with it

Question 8

fully specified name (FSN)

Answer 8

In SNOMED CT, the unique text assigned to a concept that completely describes that concept

Question 9

functioning

Answer 9

In ICF, the umbrella term for body functions, body structures, activities, and participation

Question 10

SNOMED CT

Answer 10

also called SNOMED Clinical Terms; it is a collection of medical terms and codes used worldwide in the creation of electronic health records; there are three main categories of terms and codes: concepts, descriptions, and relationships

Question 11

International Classification of Functioning, Disability, and Health (ICF)

Answer 11

one of the three reference classifications approved by the World Health Organization Family of International Classification (WHO-FIC) Network; it classifies states of functioning, disability, and health

Question 12

stem codes

Answer 12

a standalone code and can be a single entity or a combination of clinical detail

Question 13

preferred term (PT)

Answer 13

In SNOMED CT, the description or name assigned to a concept that is used most commonly; in the UMNDS classification system, a representation of the generic product category, which is a list of preferred concepts that name devices

Question 14

constituent

Answer 14

[adjective] (1) being a part of a whole; (2) being a voting member of a community or organization and having the power to appoint or elect

Question 15

WHO reference classification

Answer 15

three internationally agreed upon standards for reporting medical information; they are ICD, ICF, and ICHI

Question 16

International Classification of Health Interventions (ICHI)

Answer 16

a system of classifying procedure codes currently being developed by the World Health Organization (not yet released)

Question 17

ICD-O

Answer 17

acronym for International Classification of Diseases for Oncology; it is a derived classification used for classifying tumors

Question 18

Unified Medical Language System (UMLS)

Answer 18

A set of files and software that brings together many health and biomedical vocabularies and standards to enable interoperability between computer systems.

Question 19

dental codes

Answer 19

these are the D codes within HCPCS Level II, published and maintained separately by the American Dental Association (ADA)

Question 20

RxNorm

Answer 20

a system of US-specific terminology in medicine that contains all medications available on the US market; it’s purpose is to allow computer systems to efficiently and unambiguously communicate drug-related information between hospitals, pharmacies, and other organizations

Question 21

Outcomes and Assessment Information Set (OASIS)

Answer 21

the patient-specific, standardized assessment used in Medicare home health care to plan care, determine reimbursement, and measure quality

Question 22

Healthcare Effectiveness Data and Information Set (HEDIS)

Answer 22

a tool, created by the NCQA, designed to collect administrative, claims, and health record review data for the sake of improving healthcare

Question 23

National Committee for Quality Assurance (NCQA)

Answer 23

an organization in the United States that works to improve health care quality through the administration of evidence-based standards, measures, programs, and accreditation

Question 24

Uniform Hospital Discharge Data Set (UHDDS)

Answer 24

this is required by the Department of Health and Human Services (HHS). It is data collected by acute-care, short-term stay (usually less than 30 days) hospitals to report inpatient data elements in a standardized manner.

Question 25

Common Clinical Data Set (CCDS)

Answer 25

a common set of data types and elements and associated standards for use across several certification criteria; it has things like name and date of birth

Question 26

Value Set Authority Center (VSAC)

Answer 26

A repository and authoring tool for standard lists of codes and terms from biomedical vocabularies.

Question 27

Universal Medical Device Nomenclature System (UMDNS)

Answer 27

a standard international nomenclature and computer coding system for medical devices