Printer Friendly, PDF & Email

Procedures

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

Data Element

Applicable Standard(s)

Procedures

USCDI v1

  • Health Care Financing Administration 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.

Draft USCDI v2

  • Health Care Financing Administration Common Procedure Coding System (HCPCS)
  • Current Procedural Terminology (CPT), 2021
  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2020 Release

Optional:

  • International Classification of Diseases ICD-10-PCS 2021

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 Standard(s)

Procedures

USCDI v1

  • Health Care Financing Administration 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.

Draft USCDI v2

  • Health Care Financing Administration Common Procedure Coding System (HCPCS)
  • Current Procedural Terminology (CPT), 2021
  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2020 Release

Optional:

  • International Classification of Diseases ICD-10-PCS 2021

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

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.    

Log in or register to post comments