Activity performed for 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

Data Element

Applicable Vocabulary Standard(s)
Procedures

  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, January 2022 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:

  • 2022 International Classification of Diseases  ICD-10-PCS 
SDOH Interventions

Actions or services to address an identified Social Determinants of Health-related health concern, condition, or diagnosis (e.g., education about food pantry program, referral to non-emergency medical transportation program)
  • 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
  • Healthcare Common Procedure Coding System (HCPCS) Level II, as maintained and distributed by HHS
Reason for Referral

Explanation or justification for a referral or consultation.

Data Element

Applicable Vocabulary Standard(s)
Procedures

  • 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) 2022, maintained and distributed by the American Dental Association, for dental services.

Optional:

  • 2022 International Classification of Diseases  ICD-10-PCS 
SDOH Interventions

Actions or services to address an identified Social Determinants of Health-related health concern, condition, or diagnosis (e.g., education about food pantry program, referral to non-emergency medical transportation program)
  • 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
  • Healthcare Common Procedure Coding System (HCPCS) Level II, as maintained and distributed by HHS
Reason for Referral

Explanation or justification for a referral or consultation.

Data Element

Applicable Vocabulary Standard(s)
Procedures

Activity performed for or on a patient as part of the provision of care.
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2023 Release
  • Current Procedural Terminology (CPT®) 2023, 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, Tenth Revision, Procedure Coding System (ICD-10-PCS) 2023
Performance Time

Time and/or date a procedure is performed.

Examples include but are not limited to vaccine or medication administration times, surgery start time, and time ultrasound performed.
SDOH Interventions

Actions or services to address an identified Social Determinants of Health-related health concern, condition, or diagnosis.

Examples include but are not limited to education about food pantry program and referral to non-emergency medical transportation program.
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2023 Release
  • Current Procedural Terminology (CPT®) 2023, 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
Reason for Referral

Explanation or justification for a referral or consultation.
  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2023 Release
  • International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) 2023

Data Element

Applicable Vocabulary Standard(s)
Procedures

Activity performed for or on a patient as part of the provision of care.
  • SNOMED Clinical Terms® (SNOMED CT®) U.S. Edition, March 2024 Release
  • Current Procedural Terminology (CPT®) 2024, as maintained and distributed by the American Medical Association, for physician services and other healthcare services, and Healthcare Common Procedure Coding System (HCPCS), as maintained and distributed by HHS
  • Code on Dental Procedures and Nomenclature (CDT) 2024, maintained and distributed by the American Dental Association

Optional:

  • 2024 International Classification of Diseases, Tenth Revision, Procedure Coding System (2024 ICD-10-PCS)
Performance Time

Time and/or date a procedure is performed.

Examples include but are not limited to vaccine or medication administration times, surgery start time, and time ultrasound performed.
SDOH Interventions

Actions or services to address an identified Social Determinants of Health-related concern, condition, or diagnosis.

Examples include but are not limited to education about food pantry program and referral to non-emergency medical transportation program.
  • SNOMED Clinical Terms® (SNOMED CT®) U.S. Edition, March 2024 Release
  • Current Procedural Terminology (CPT®) 2024, as maintained and distributed by the American Medical Association, for physician services and other healthcare services
  • Healthcare Common Procedure Coding System (HCPCS) Level II, as maintained and distributed by HHS
Reason for Referral

Explanation or justification for a referral or consultation.
  • SNOMED Clinical Terms® (SNOMED CT®) U.S. Edition, March 2024 Release
  • International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) 2024

Data Element

Applicable Vocabulary Standard(s)
Procedures

Activity performed for or on a patient as part of the provision of care.
  • SNOMED Clinical Terms® (SNOMED CT®) U.S. Edition, March 2025 Release
  • Current Procedural Terminology (CPT®) 2025, as maintained and distributed by the American Medical Association, for physician services and other healthcare services, and Healthcare Common Procedure Coding System (HCPCS), as maintained and distributed by HHS
  • Code on Dental Procedures and Nomenclature (CDT) 2025, maintained and distributed by the American Dental Association

Optional:

  • 2025 International Classification of Diseases, Tenth Revision, Procedure Coding System (2025 ICD-10-PCS)
Performance Time

Time and/or date a procedure is performed.

Examples include but are not limited to vaccine or medication administration times, surgery start time, time ultrasound performed, and laboratory specimen collection time.
SDOH Interventions

Actions or services to address an identified Social Determinants of Health-related concern, condition, or diagnosis.

Examples include but are not limited to education about food pantry program and referral to non-emergency medical transportation program.
  • SNOMED Clinical Terms® (SNOMED CT®) U.S. Edition, March 2025 Release
  • Current Procedural Terminology (CPT®) 2025, as maintained and distributed by the American Medical Association, for physician services and other healthcare services
  • Healthcare Common Procedure Coding System (HCPCS) Level II, as maintained and distributed by HHS
Reason for Referral

Explanation or justification for a referral or consultation.
  • SNOMED Clinical Terms® (SNOMED CT®) U.S. Edition, March 2025 Release
  • International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) 2025

Data Element
Procedure Status

Comment

Submitted by joshualegler on

Procedure Date/Time

Consider adding a data element for the date/time a procedure was performed.

This comment is submitted on behalf of the National Emergency Medical Services Information System (NEMSIS) Technical Assistance Center.

Submitted by mrallins on

Procedures

The Regenstrief Institute applauds the addition of Reason for Referral as a data element in USCDI V3. We note that the association of Reason for Referral with the Procedures class can be confusing without having a clear definition for procedures as a data class. We also recommend including specific examples to clarify reason for referral concept so that the data element and the intent for its association with the procedures as a data class are clearly understood. Some examples of reason for referral include referral to social services, referral for pre-operative consultation. These examples will help the user understand the broad definition that procedures as a data class includes any type of activity that is performed with or on a patient as part of the provision of care.

Submitted by mrallins on

Patient Demographics

Logical Identifiers Names and Codes (LOINC) has an extensive set of concepts to express patient demographic data. We recommend including LOINC as a terminology standard to represent demographic data or to map to other demographic related code sets such as the CDC race and ethnicity code set.  

LOINC examples include:

76458-9 Patient Email address

21112-8 Birth date

46463-6 Race or ethnicity

Submitted by cmcdonald on

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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