Activity performed for or on a patient as part of the provision of care.

Data Element

Additional Information

Procedures
Description
Activity performed for or on a patient as part of the provision of care.

Applicable Vocabulary Standard(s)

Applicable Standards
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2022 Release
  • Current Procedural Terminology (CPT®) 2022, as maintained and distributed by the American Medical Association, for physician services and other health care services, and Healthcare Common Procedure Coding System (HCPCS), as maintained and distributed by HHS.
  • For technology primarily developed to record dental procedures: Code on Dental Procedures and Nomenclature (CDT), maintained and distributed by the American Dental Association, for dental services.
Optional:
  • International Classification of Diseases ICD-10-PCS 2022

Comment

Lantana Consulting Group Comment

The Procedures data class is a broad category that captures medical and dental procedures and interventions that impact the physical person as captured by CDT, CPT, ICD-10-PCS and includes SDOH interventions and Reason for Referral.  We recommend clarifying the scope of the Procedures data class and considering the creation of an SDOH Data Class. Another gap in USCDI that is closely related to a Referral is a Transition of Care Summary. ONC’s 360X Project is testing the exchange of both referrals and a transition summary. Lantana recommends including both referrals and transition summaries under a Care and Treatment Plan data class.

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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