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

Data Element

Applicable Vocabulary Standard(s)

Procedures

  • 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.

Data Element

Applicable Vocabulary Standard(s)

Procedures

  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
  • Current Procedural Terminology (CPT®) 2021, 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 2021
SDOH Interventions

A service offered to a patient to address identified Social Determinants of Health concerns, problems, or diagnoses (e.g., Education about Meals on Wheels Program, Referral to transportation support programs). SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes.

  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
  • Current Procedural Terminology (CPT®) 2021, as maintained and distributed by the American Medical Association, for physician services and other health care services
  • Healthcare Common Procedure Coding System (HCPCS) Level II, as maintained and distributed by HHS.

Comment

Clarification needed on term "procedure"

A note to clarify what is meant by procedures would be helpful here because everything, lab tests, radiology studies, etc. could be considered procedures in some sense of the meaning. FHIR used “procedure” to mean surgical and similar invasive processes.  It is messy because CPT, for example, considers tests of all kinds as procedures, so some distinctions would be helpful.    

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