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one that exists as part of the coded set.
defined after the fact. exp. coding burn between 3rd and 4th toes on L foot is generated by the data by combining terms form different axeses
Most commonly used controlled terminology
- ICD used mostly for diagnoses
- CMS requires its use on billing claims CM-clinical modification defined by US
the more popular set of teminologies in use today
- controled vocabularies - way to oganize knowledge for subsequent retreival, mandate the use of predefined authurised terms.
- .icd 9 and 10-internation classification of disease, created by WHO
- .AMA common procedural termionlogy
- .dignostic related group-used by CMS
- .NCD national drug codes-FDA
a specific data element-gender
value set M F
y or x chrom
semantic interoperability is still unattainable
group together diagnoses and procedures that are similar resources users for billing purposes
deals w/ ?'s concerning what entities exist or can be said to exist. how entities can be grouped, related w/in hierarchy and subdivided accord. to similarities and differences.
- practice and science of clasification
- Typically arranged in a hierarchical structure( parent-child relationships)
groupijng objects into a class or clases according to some common relatios or attributes. exp icd9 or icd 10, icpc
- a system of names or terms used in a prticular science or art consistent, systematic method of naming to denote classifications and avoid ambiguities
- names of anatomical structures or organs of the body are usuallu referred to as nomenclature. EXP-SNOMED..clinical healthcare teminology