Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions.

Data Element

Clinical Test
Description

The name of the non-imaging or non-laboratory test performed on a patient.

Applicable Vocabulary Standard(s)

Applicable Standards
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.70

Comment

Applicable vocabulary standards for Clinical Tests

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the applicable vocabulary standards for Clinical Tests – Clinical Tests. The CPT code set contains numerous codes for non-imaging and non-laboratory clinical tests. (See our previous comment on 4/17/2023 for a list of clinical tests and additional information.) The following are research examples where EHR data, including CPT clinical test codes, were used for the data analysis.

  • Kadambi P, Hart KW, Adeoye OM, Lindsell CJ, Knight WA 4th. Electroencephalography findings in patients presenting to the ED for evaluation of seizures. Am J Emerg Med. 2015 Jan;33(1):100-3. doi: 10.1016/j.ajem.2014.10.041. Epub 2014 Oct 30. PMID: 25468214; PMCID: PMC4847441.
  • Floris-Moore M, Edmonds A, Napravnik S, Adimora AA. Computerized Adjudication of Coronary Heart Disease Events Using the Electronic Medical Record in HIV Clinical Research: Possibilities and Challenges Ahead. AIDS Res Hum Retroviruses. 2020 Apr;36(4):306-313. doi: 10.1089/AID.2019.0036. Epub 2019 Sep 10. PMID: 31407587; PMCID: PMC7185364.
  • Shin CH, Grabitz SD, Timm FP, Mueller N, Chhangani K, Ladha K, Devine S, Kurth T, Eikermann M. Development and validation of a Score for Preoperative Prediction of Obstructive Sleep Apnea (SPOSA) and its perioperative outcomes. BMC Anesthesiol. 2017 May 30;17(1):71. doi: 10.1186/s12871-017-0361-z. PMID: 28558716; PMCID: PMC5450400.

Support to include CPT as an applicable vocabulary standard

The American Medical Association requests that the Current Procedural Terminology (CPT) code set be added to the Applicable Vocabulary Standards listed in Clinical Tests – 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, and sleep studies. The CPT code set was added in 2022 to the Interoperability Standards Advisory (ISA) vocabulary list for Representing Non-Imaging and Non-Laboratory Clinical Tests. In a 2022 study, CPT was identified as an important component needed to study the value of certain clinical tests performed preoperatively before cataract surgery. (Harris AHS, Bowe T, Kamal RN, Sears ED, Hawn M, Eisenberg D, Finlay AK, Hagedorn HJ, Mudumbai S. Frequency and costs of low-value preoperative tests for patients undergoing low-risk procedures in the veterans health administration. Perioper Med (Lond). 2022 Sep 13;11(1):33. doi: 10.1186/s13741-022-00265-0. PMID: 36096937; PMCID: PMC9469517.) The CPT code set is a comprehensive and regularly curated uniform language that provides reliable communication among users. It has an extremely mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders.

Response to Comment on Diagnostic studies and exams with results

There was much interest from the Task Force in adding clinical variables beyond laboratory to USCDI. This is a suggested starting set. We would suggest that users would not be required to use these specific codes listed under a given panel verbatim. They could drop codes that did not fit and add other LOINC codes as appropriate. This starter set should get the ball rolling to deliver richer clinical data that has been available for years and is in high demand by clinicians and patients.
2021 03 29 Some clinical measure tests panels available from LOINC just some to explore.docx

CMS agrees with the need to make this additional clinical data available via inclusion in the USCDI. We agree LOINC terminology is an appropriate applicable standard to accompany the data element. CMS identified some critical diagnostic studies/exams including cardiac exams (ejection fraction from echocardiography tests), and colonoscopy; many of these align with the exams provided in this document.

Non-lab variables to include

There was much interest from the Task Force in adding clinical variables beyond laboratory to USCDI. This is a suggested starting set. We would suggest that users would not be required to use these specific codes listed under a given panel verbatim. They could drop codes that did not fit and add other LOINC codes as appropriate. This starter set should get the ball rolling to deliver richer clinical data that has been available for years and is in high demand by clinicians and patients.

2021 03 29 Some clinical measure tests panels available from LOINC just some to explore.docx

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