An activity that is performed with or on a patient as part of the provision of care.

Data Element

Additional Information

Procedures

Applicable Vocabulary Standard(s)

Applicable Standards
  • Healthcare Common Procedure Coding System (HCPCS)
  • Current Procedural Terminology, Fourth Edition (CPT-4)
  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2019 Release
Optional:
  • USCDI v1 - International Classification of Diseases ICD-10-PCS 2020
Optional for technology which records dental procedures:
  • Code on Dental Procedures and Nomenclature (CDT), maintained and distributed by the American Dental Association, for dental services.

Comment

Rename for specificity

To delineate the element name from the class name, MedMorph suggests renaming the Procedures element to Procedure Code. This modification will more closely align with the USCDI definition of a Data Element ("A USCDI “Data Element” is the most granular level at which a piece of data is exchanged") as well as with US Core.

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