- Clinical Tests is a USCDI v2 data class representing non-imaging and non-laboratory tests performed on a patient that results in structured or unstructured (narrative) findings specific to the patient, such as electrocardiogram (ECG), visual acuity exam, macular exam, or graded exercise testing (GXT), to facilitate the diagnosis and management of conditions.
- Clinical Tests, like Laboratory and Diagnostic Imaging, should be represented by at least two components, the test and the results. For Clinical Tests, these components are:
- Clinical Test - The coded name of the non-imaging or non-laboratory test performed on a patient.
- Clinical Test Result/Report - Interpreted results of clinical tests that may include study performed, reason performed, findings, and impressions. Includes both structured and unstructured (narrative) components.
- The United States Core Data for Interoperability version 3 (USCDI v3) includes Clinical Tests as a data element used to capture and exchange data on a patient's non-imaging and non-laboratory tests. The value set included on this page is intended to guide development of the ability to capture this type of data in health IT.
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- USCDI Clinical Tests Minimum Set
- This value set represents a sampling of several specialty specific tests including cardiology and ophthalmology, and is not the entire universe of possible clinical test codes that may be needed for these or other specialties.
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Submitted by mattreid on 2022-09-26
Comment for Representing Non-imaging and Non-laboratory Clinical
Comment for Representing Non-imaging and Non-laboratory Clinical Tests The American Medical Association requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Non-imaging and Non-laboratory Clinical Tests. The CPT code set contains numerous codes for non-imaging and non-laboratory clinical tests, including, but not limited to:- Electroencephalography (EEG)
- Echocardiography (EKG)
- Cardiovascular and exercise stress tests
- Pulmonary function tests
- Electromyography (EMG)
- Electroretinography (ERG)
- Audiologic function tests
- Evoked potential tests
- Intraocular pressure measurement
- Visual acuity and function tests
- Allergy challenge tests
- Fetal monitoring
- Sleep studies
CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, laboratory, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.