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

Data Element
Procedures

Applicable Vocabulary Standard(s)

Applicable Standards (*Please confirm or update this field for the new USCDI version*)
  • 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.

View guidance on Applicable Vocabulary Standards and versioning.

Comment

Submitted by CDC_DSMH_WG on

CDC comment on data element-Procedures

CDC recommends that ONC should expand the Procedures data class to include Procedure Body Site, representing the anatomical location where the procedure was performed, including laterality when applicable. Rationale: Body Site provides important clinical context about the specific anatomical location of a procedure. Including this element would improve alignment with FHIR/QI-Core and support accurate clinical care, quality measurement, and reporting.

FHIR path(s): Procedure.bodySite

Submitted by AndreaP on

Procedures

  1. Procedures. 
    1. In light of the comments on Lab Orders and given some HIT vendors are modeling Laboratory Orders as Procedure elements, it’s requested that clarity and guidance be provided that procedures are not laboratory orders.  It would help ensure that HIT vendors have appropriate functionality for laboratory orders and don’t inadvertently get certified for incorrect functionality for laboratory orders by calling them procedures. It would also help ensure that Laboratory Orders are encoded with LOINC and not SNOMED CT Procedure Hierarchy Codes.

Submitted by Lantana Consul… on

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.

Submitted by maria.michaels… on

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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Fig 5 A red triangle with exclamation mark indicator appears next to the “Return to saved Comment” button when draft comments are saved in the system.

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