Representing Medical Procedures Performed

Type	Standard / Implementation Specification	Standards Process Maturity	Implementation Maturity	Adoption Level	Federally required	Cost	Test Tool Availability
Standard	SNOMED CT® U.S. Edition	Final	Production		Yes	Free	N/A
Standard	CPT®	Final	Production		Yes	$	N/A
Standard	HCPCS	Final	Production		Yes	Free	N/A
Standard	ICD-10-PCS	Final	Production		No	Free	N/A
Standard	LOINC®	Final	Production	Feedback Requested	Yes	Free	N/A

Limitations, Dependencies, and Preconditions for Consideration	Applicable Value Set(s) and Starter Set(s)
ICD-10-PCS is primarily a billing code used only in inpatient settings. CPT and HCPCS are codes used to report procedures and services in outpatient procedures. ICD-10-PCS is named in the 2015 Edition certification rules as an optional code set for procedures. SNOMED CT U.S. Edition procedure codes can be used to describe treatment in any clinical setting and is not tied to billing but can be cross-mapped to corresponding ICD-10-PCS and CPT/HCPCS codes. LOINC: A Procedure Note records the indications for a non-operative procedure and, when applicable, post-procedure diagnosis, pertinent events of the procedure, and the patient's tolerance of the procedure. A Pathology Report Narrative contains a consulting specialist's interpretation of the pathology report.	LOINC: Procedure Note (LOINC code 28570-0)

Limitations, Dependencies, and Preconditions for Consideration

Applicable Value Set(s) and Starter Set(s)

ICD-10-PCS is primarily a billing code used only in inpatient settings.
CPT and HCPCS are codes used to report procedures and services in outpatient procedures.
ICD-10-PCS is named in the 2015 Edition certification rules as an optional code set for procedures.
SNOMED CT U.S. Edition procedure codes can be used to describe treatment in any clinical setting and is not tied to billing but can be cross-mapped to corresponding ICD-10-PCS and CPT/HCPCS codes.

LOINC:

A Procedure Note records the indications for a non-operative procedure and, when applicable, post-procedure diagnosis, pertinent events of the procedure, and the patient's tolerance of the procedure.
A Pathology Report Narrative contains a consulting specialist's interpretation of the pathology report.

LOINC:
- Procedure Note (LOINC code 28570-0)

Comment

Submitted by mattreid on 2022-11-07

The CPT PLA and MAAA codes are for laboratory tests

The AMA asks that ONC move the following bullet under “Limitations, Dependencies, and Preconditions for Consideration” to Representing Laboratory Tests Ordered with the edit noted:

CPT Proprietary Laboratory Analyses (PLA) codes are published quarterly (1/1, 4/1, 7/1, and 10/1) and are available on the AMA website for representing laboratory tests.

The AMA asks that ONC move the following bullet under “Applicable Value Set(s) and Starter Set(s)” to Representing Laboratory Tests Ordered:

CPT:
- 80047 - 89398 - including Multianalyte Assays with Algorithmic Analyses (MAAA) codes 81490-81599
- Proprietary Laboratory Analyses (PLA) U codes
- MAAA administrative M Codes (0002M-0013M)

Submitted by gldickinson on 2020-10-23

Preserving Clinical Context

General Comments:

USCDI specifies lots of clinical data classes and data elements

Resolving to myriad de-coupled fragments
With vanishingly little focus on:
- Clinical context and vital inter-relationships, e.g., between problems, diagnoses, complaints, symptoms, encounters, history and physical findings, allergies, medications, vaccinations, assessments, goals/objectives, clinical decisions, orders, results, diagnostic procedures, interventions, observations, treatments/therapies, referrals, consults, outcomes, protocols, care plans and status...
- Elements and context + purpose of capture: e.g., blood pressure, its measurement (systolic, diastolic), its unit of measure (mm/Hg), its reason for capture, its context of capture (sampling site, sampling method, patient position, at rest/during/post exercise...

It is crucial to consider, determine and resolve how clinical content and context are bound together and preserved in USCDI. The ultimate end user (often a clinician) must be able to readily discern context and inter-relationships – otherwise USCDI places an undue (and often unresolvable) burden on this user. Only the source EHR/HIT system can structure clinical content and context properly. Once data is stuffed into the USCDI framework and related exchange artifact (e.g., FHIR resources) this opportunity is forever lost.

Submitted by cmcdonald on 2018-10-01

Have to be very careful with…

Have to be very careful with the scope of what is intended by procedures. Historically, HL7 distinguished surgical procedures from diagnostic procedures. Currently, all of the LRI and LOR require LOINC for the order and for the result. ISA specifies LOINC for the name of radiology tests. If a diagnostic test is defined as a procedure as below then there will be no way to verify that by comparing codes if the test ordered got results.

In the 4th bullet point under limitations, SNOMED CT is described as for coding treatments. That distinction regarding procedures should be made more broadly, so avoid the use of one code system to order a diagnostic study and another to report it.

Submitted by gdixon on 2018-09-12

New IHE Profile IHE [PCS] Paramedicine Care Summary

Be aware of and promote new profile. IHE [PCS] Paramedicine Care Summary maps the flow of the patient information from the ambulance patient record, commonly known as the electronic Patient Care Record (ePCR), to the hospital Electronic Medical Record (EMR).

From Profile - Currently, interventions and assessments are written into an ambulance electronic Patient Care Record (ePCR), and are either manually updated by the Emergency Medical Services (EMS) crew, or collected from electronic devices (e.g., hemodynamic monitor). The ePCR is updated with treatments and interventions that are administered during the transport. The hospital will not typically have access to paper or electronic versions of this patient information until the report is finished and signed in the ePCR and it is requested by the hospital. In this profile, the prehospital and paramedicine interventions and patient assessments are made available to the hospital/emergency room IT system electronically when the patient arrives, or in advance of patient arrival to the hospital. This informs medical decision making during the hospital treatment to improve patient care and to save lives

Submitted by mattreid on 2017-11-20

AMA comments on the 2018 ISA

On behalf of American Medical Association (AMA) I appreciate the ability to comment on the 2018 Interoperability Standards Advisory (ISA).

Comment:

Under “Limitations, Dependencies, and Preconditions for Consideration,” the AMA recommends that “CPT” be removed from the statement – “CPT/HCPCS are billing codes used for Outpatient Procedures.” The CPT code set is mandated and widely used for claims processing, but it also serves in various functions outside of billing, including medical care review guidelines, medical education, patient outcomes, health services, and quality research.

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